Citation Nr: 21004398 Decision Date: 01/27/21 Archive Date: 01/27/21 DOCKET NO. 18-06 779 DATE: January 27, 2021 ORDER Entitlement to service connection for low testosterone is granted. REMANDED Entitlement to service connection for a prostate disability, to include prostatitis and benign prostatic hyperplasia, and to include as due to radiation exposure, is remanded. Entitlement to service connection for hypothyroidism, to include as due to radiation exposure, is remanded. FINDING OF FACT The Veteran has a diagnosis of low testosterone that is etiologically related to his exposure to non-ionizing radiation in service. CONCLUSION OF LAW The criteria for service connection for low testosterone have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service from May 1987 to December 2007. This matter was previously before the Board in December 2018 and August 2020 and was remanded for further development in both instances. The matters have been returned to the Board for further adjudication. 1. Entitlement to service connection for low testosterone, to include as due to radiation exposure. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a) (2018). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Whenever there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107 (b). The Veteran contends he has low testosterone from being exposed to radiation as an air pilot in service. As noted in the Board’s August 2020 decision, exposure to non-ionizing radiation has been conceded. With regard to a current diagnosis, a June 2019 VA examination for male reproductive system conditions and private treatment records both show a diagnosis for hypogonadism, which is also known as having low serum or low testosterone. See https://www.healthline.com/health/hypogonadism. In determining whether the Veteran’s low testosterone is related to service, there are several medical opinions for consideration. Pursuant to the Board’s December 2018 remand directives, an examination and medical opinion were obtained to determine the etiology of the Veteran’s low testosterone disorder. Specifically, in an August 2019 VA medical opinion, the examiner found that the Veteran’s condition was less likely than not related to service since the Veteran did not have low testosterone in service. However, this opinion was found inadequate in the Board’s August 2020 decision since the examiner relied on the absence of a diagnosis in service. Notably, the absence of treatment or a diagnosis does not preclude service connection. As a result, a second VA opinion was obtained in September 2020 where a different examiner also found that the Veteran’s low testosterone was less likely than not related to service. In so finding, the examiner noted that ionizing radiation can result in diminished spermatogenesis and decreased testosterone production, and exposure to intense, direct amounts of non-ionizing radiation may result in damage to tissue due to heat. However, the examiner indicated that this is not common and mainly of concern in the workplace for those who work on large sources of non-ionizing radiation devices and instruments. The examiner further noted that non-ionizing radiation does not penetrate deep into the tissues but increases the risk of damage to the skin and eyes. Further, the examiner explained that the diagnosis of low testosterone was not confirmed until 2014, many years after the Veteran retired, and that low testosterone was likely caused by normal aging and obesity as both affect production and response to hormones. The examiner noted that on September 7, 2017, the Veteran was in the obese category. Alternatively, in a January 2017 private medical opinion, the Veteran’s private urologist opined that the Veteran’s condition was caused by radiation exposure as a pilot. In doing so, the examiner explained that the Veteran had no other known risk factors that may have participated to cause the Veteran’s current condition of testicular hypofunction. In considering the competing opinions, the Board finds the September 2020 VA opinion is inadequate for adjudicating the Veteran’s claim. Here, the examiner merely provided an example as to how non-ionizing radiation may result in damage to tissue for those who work on large sources of non-ionizing radiation devices and instruments; however, the examiner did not provide an opinion or rationale as to how this would negate the possibility, or support her finding that it was less likely than not, that the Veteran’s low testosterone could not have been caused by radiation exposure. Further, the examiner noted that a diagnosis of low testosterone was not confirmed until 2014, which was likely caused by normal aging and obesity. She specifically noted that the Veteran was in the obese category in September 2017. The Board notes, however, that even if the Veteran was deemed obese on this date, this was three years after his initial diagnosis in 2014; therefore, this conclusion is unsound. As the August 2019 and September 2020 VA medical opinions are inadequate, the Board finds the opinions are low in probative value. To that end, the Board finds the January 2017 private medical opinion is the most probative evidence of record. Although the opinion is not detailed, the examiner’s rationale is adequate, clear, and it was based on the Veteran’s medical history and the examiner’s past and current treatment of the Veteran. Moreover, the opinion is consistent with the medical literature cited above which indicates radiation exposure as a cause of hypogonadism. Therefore, the Board resolves all reasonable doubt in favor of the Veteran and finds the preponderance of evidence is in favor of granting the claim. Thus, service connection for low testosterone is granted. REASONS FOR REMAND 1. Entitlement to service connection for a prostate disability, to include prostatitis and benign prostatic hyperplasia, and to include as due to radiation exposure. Pursuant to the Board’s prior remand, a medical opinion was obtained to determine the etiology of the Veteran’s prostatitis. Specifically, in a September 14, 2020 medical opinion, the examiner found it less likely than not that the Veteran’s prostatitis was related to service. In so finding, the examiner noted that the Veteran did not have prostatitis in service; he was not seen for, diagnosed with or treated for prostatitis in service. She further indicated the more accurate diagnosis is benign prostatic hyperplasia (BPH), not prostatitis. The examiner explained that prostatitis refers to inflammation of the prostate gland and can be caused by traumatic injury to the prostate or by bacteria that gets into the prostate from urine or during sex, which is more likely to affect men ages 50 or younger. The examiner further explained that BPH causes a person to have an enlarged prostate and becomes more common as men age, which usually occurs in men over age 50. The examiner noted the Veteran is currently 56 years old. In a September 28, 2020 addendum opinion, the examiner addressed the Veteran’s lay statements in which he reported having symptoms as early as 2003. The examiner noted that records show the earliest history of prostatitis was on May 6, 2016, and that even if he had symptoms in 2003, it could have been due to cystitis, urethritis, epididymitis, etc. The examiner concluded that neither acute prostatitis nor chronic prostatitis with an onset in service can be confirmed and chronicity cannot be established. The Board finds both opinions are inadequate for several reasons. First, the examiner relied on the absence of treatment or a diagnosis in service, which does not preclude service connection. In addition, it appears the examiner did not review all of the Veteran’s records. Here, the examiner indicated the Veteran’s correct diagnosis is BPH and that the earliest history of prostatitis was in May 2016; however, this is incorrect. Private treatment records show diagnoses for acute prostatitis as early as April 2012 and BPH in April 2013. In addition, while the examiner indicated BPH usually occurs in men over 50, the Veteran was noted to be 48 years old at the time of his diagnosis. Furthermore, the addendum opinion was based on speculation when the examiner determined that the Veterans’ symptoms “could have been” related to other conditions, but she provided no other rationale to support this opinion. Based on the above, the Board finds the opinions are inadequate. When VA undertakes to provide a VA examination or obtain a VA opinion it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, the Board finds that a remand for a new examination and medical opinion as to the etiology of the Veteran’s prostatitis and BPH is warranted. The Board has expanded the Veteran’s claim to include both diagnoses pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009). 2. Entitlement to service connection for hypothyroidism, to include as due to radiation exposure. Pursuant to the Board’s prior remand, a new VA examination was obtained to determine the etiology of the Veteran’s hypothyroidism; however, the Board finds the opinion is inadequate. In a September 2020 medical opinion, the examiner found it less likely than not that the Veteran’s hypothyroidism was related to service. The examiner noted that the most common cause of hypothyroidism is an autoimmune disorder known as Hashimoto’s thyroiditis. The examiner also noted that radiation used to treat cancers of the head and neck can affect the thyroid gland and may lead to hypothyroidism, but that the Veteran was exposed to non-ionizing radiation. Based on the Board’s remand directives, the examiner was asked to submit an addendum opinion and to comment on medical literature that was submitted in a previous opinion. The literature concerned a study of military pilots and air crew from 2008-2017 and determined that “pilots flying for 56.6 minutes at 30,000 feet receive the same amount of UV-A [cancer-causing] radiation as that from a 20-minute tanning bed session. In an October 2020 addendum opinion, the examiner found that the literature supported her opinion as the study showed the incidence rate of thyroid disorders were more prevalent in females, members in the Air Force, and in healthcare personnel, which would not include the Veteran since he was a male who served in the Marines, and he was a pilot. The examiner indicated the literature was correlative in nature and that it did not change her initial medical opinion. The Board notes, however, that the examiner was specifically requested to provide a rationale as to why and how the literature applied to the Veteran given that he was discharged in 2007, prior to those service members the study focused on. However, the examiner did not provide an opinion as requested. In addition, although the Veteran served in the Marines, he also reported in his March 2017 Statement in Support of Claim that he had the most flight time in the F/A-18 when he retired, and that he had more than double the flight time of any retired Marine Fighter Pilot. It does not appear that the examiner considered this statement when rendering her opinion. Further, with regard to her September 2020 opinion, the examiner noted a cause of hypothyroidism and an instance involving ionizing radiation that could affect the thyroid gland; however, merely listing the cause or an example is not enough to support her conclusion. The examiner did not otherwise provide an explanation or opinion that would indicate that these causes would preclude or even make it less likely that that the Veteran’s hypothyroidism was not caused by his exposure to radiation in service. Given the above inadequacies, a new examination and opinion must be obtained before the Board can properly adjudicate the claim. In this regard, the Board notes that in his March 2017 Statement in Support of Claim, the Veteran contended that his hypothyroidism was aggravated by his diagnosed hypogonadism. As the Veteran has been service connected for low testosterone in the decision herein, an opinion on secondary service connection is also warranted. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate them with the Veteran’s claims folder. 2. Schedule the Veteran for a VA examination for his prostatitis and BPH with a urologist if one is available. If a urologist is unavailable, schedule the examination with an otherwise qualified VA physician, other than the September 2020 examiner. The examiner must review the entire claims file. All necessary studies or tests should be accomplished. The examiner should provide an opinion as to whether the Veteran’s prostatitis and/or BPH are at least as likely as not (50 percent probability or greater) related to service? The examiner must provide a complete rationale to support his/her opinion. The examiner is advised that the Veteran is competent to report his symptoms and history. Such reports, and all other lay evidence of record, including those of continuity of symptomatology, must be acknowledged and considered in formulating any opinion. 3. Schedule the Veteran for a VA examination with a qualified physician, other than the September 2020 examiner, to determine the nature and etiology of the Veteran’s hypothyroidism. The examiner must review the entire claims folder. All necessary studies or tests should be accomplished. a) The examiner should provide an opinion as to whether the Veteran’s hypothyroidism is at least as likely as not (50 percent probability or greater) related to service? b) The examiner should also provide an opinion as to whether the Veteran’s hypothyroidism was proximately caused or aggravated by his service-connected low testosterone disability? The examiner must provide a complete a rationale to support his/her opinion. The examiner is advised that the Veteran is competent to report his symptoms and history. Such reports, and all other lay evidence of record, including those of continuity of symptomatology, must be acknowledged and considered in formulating any opinion. 4. The AOJ should ensure that the examination report complies with this remand and the questions presented in this request. If the report is insufficient, it must be returned to the examiner for necessary corrective action, as appropriate. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Laffitte, Associate 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.