Citation Nr: 21003519 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 13-23 858 DATE: January 21, 2021 REMANDED Entitlement to service connection for a bladder disorder is remanded. Entitlement to service connection for stricture of the urethra is remanded. Entitlement to service connection for a prostate disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from November 1963 to September 1965. This case comes before the Board of Veterans’ Appeals (Board) on appeal from June 2012 and June 2013 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The Veteran testified at a Board videoconference hearing before the undersigned Veterans Law Judge in January 2017. A transcript of the proceeding has been associated with the record. In May 2017, the Board remanded the appeal for additional development. In August 2019, the Board denied the Veteran’s claims for service connection, on appeal. The Veteran appealed the denials to the United States Court of Appeals for Veterans Claims (Court). In July 2020, the parties filed a Joint Motion for Remand (Joint Motion or JMR) which requested that the Board’s decision be vacated and remanded. A July 2020 Court Order granted the motion, and remanded the claim for readjudication consistent with the terms of the Joint Motion. 1. Entitlement to service connection for a bladder disorder is remanded. 2. Entitlement to service connection for stricture of the urethra is remanded. 3. Entitlement to service connection for a prostate disorder is remanded. The July 2020 Joint Motion states that the Veteran testified before the undersigned Veterans Law Judge of the Board in January 2017. At that time, the Veteran testified that he sought treatment for urinary symptoms for 3 – 4 years after his separation from service. The Joint Motion noted that, in May 1996, the Veteran submitted a VA Form 21-4142 (Authorization and Consent to Release Information to the Department of Veterans Affairs), wherein the Veteran authorized VA to obtain treatment records from Dr. C., dated 1965 to 1970, and found that VA did not adequately follow-up to an initial records request. Likewise, the Joint Motion noted that the Veteran’s claims file showed that the Veteran reported treatment by Dr. R and Scripps Mercy Hospital in 2016, but the most recent treatment records from Dr. R were dated in 2008, and no records from Scripps Mercy Hospital had been associated with the claims file. The Joint Motion stated that the Board erred by not ensuring that VA fulfilled its duty to assist, and directed the Board to obtain these records, as well as any other outstanding private treatment records. See 38 U.S.C. § 5103A(b)(1); 38 C.F.R. § 3.159. See also Golz v. Shinseki, 590 F.3d 1317, 1322 (Fed. Cir. 2010). The Board observes that VA must make all necessary efforts to obtain relevant records in the possession of a Federal agency. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Bell v. Derwinski, 2 Vet. App. 611 (1992). Any remaining, available VA treatment records related to the Veteran’s claimed disabilities on appeal should be associated with the Veteran’s claims file. In addition, the Joint Motion found that the Board relied on an inadequate VA examination in its August 2019 of the Veteran’s denial of the Veteran’s claims of service connection for bladder and prostate disorders. In this regard, the Joint Motion found that the May 2019 VA examination was inadequate because the May 2017 Board remand requested that the VA examiner consider and discuss the Veteran’s report of symptoms since service, and the May 2019 VA medical opinion failed to address the Veteran’s contentions. The Joint Motion noted that the May 2017 Board remand directed the VA examiner to address the Veteran’s credible hearing testimony, as well as his contentions regarding his symptoms, such as treatment for urinary incontinence since service, and pointed out that the May 2019 VA examiner opined that Veteran’s diagnosed bladder neck obstruction due to benign prostatic hypertrophy was not related to the Veteran’s service based on a lack of continuity of care and the absence of service treatment records reflecting an injury or illness likely to result in bladder neck obstruction. The Joint Motion found that the Board failed to ensure compliance with its own May 2017 remand directives, and remanded the Veteran’s claims to the Board so that the Board could obtain a new VA examination and/or opinion. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (noting that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The matters are REMANDED for the following action: 1. Contact the Veteran and request that he identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated him for the claimed disabilities on appeal. The Veteran should be requested to sign any necessary authorization for release of medical records to VA, and appropriate steps should be made to obtain any identified records. Upon receipt of proper authorization for the release of medical records, the RO must obtain all available treatment records from Dr. C, Dr. R, and Scripps Mercy Hospital, including any surgical and/or hospitalization reports. The RO must make two requests for the authorized records from any identified private treatment provider, unless it is clear after the first request that a second request would be futile. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. If the records are unavailable, notify the Veteran in accordance with 38 C.F.R. § 3.159. 2. After completion of the above, schedule the Veteran for an appropriate VA genitourinary examination to assess the nature and etiology of his claimed bladder, prostate, and urethral disorders. Any and all studies, tests, and evaluations deemed necessary by the examiner, should be performed. The examiner is requested to review all pertinent records associated with the claims file, and include discussion of the Veteran’s documented medical history and assertions. The VA examiner should indicate whether it is as least as likely as not (50 percent probability or more) that any current bladder, prostate, and/or urethral disorder, including bladder neck obstruction and benign prostatic hypertrophy are related to any event, illness, or injury during service and/or are consistent with the circumstances of the Veteran’s service. The VA examiner must discuss, with specificity, the Veteran’s credible assertions of symptomatology during and in the years since his active service. The examiner is advised that the Veteran is competent to report symptoms, treatment, and diagnoses and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinion.   The examiner must provide a complete rationale on which his/her opinion is based, and must include a discussion of the medical principles as applied to the medical evidence and facts used in establishing his or her opinion. 3. After completing all indicated development, the RO should readjudicate the Veteran's claims for service connection for a bladder disorder, prostate disorder, and stricture of the urethra. If any of the claims remain denied, the Veteran should be furnished with a supplemental statement of the case and afforded a reasonable opportunity for response. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Hallie E. Brokowsky, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.