Citation Nr: 21063527 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 17-61 576 DATE: October 14, 2021 ORDER Entitlement to service connection for erectile dysfunction (ED), as secondary to service-connected diabetes mellitus (DM), type II, is denied. REMANDED Entitlement to service connection for a heart disorder, to include coronary artery disease (CAD), is remanded. Entitlement to a total disability based upon individual unemployability (TDIU) is remanded. FINDING OF FACT The Veteran's DM did not cause or aggravate the Veteran's ED. CONCLUSION OF LAW The criteria for secondary service connection for ED have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from November 1965 to November 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision of an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). Issue 1: Entitlement to service connection for ED, as secondary to service-connected DM Secondary Service Connection Service connection on a secondary basis is merited if there is (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). Merits In July 2021, a VA examiner diagnosed the Veteran with ED, noting the Veteran had ED since the 1980s. This satisfies the first prong of a secondary service connection claim. VA has service connected the Veteran's DM. It has rated it as 20 percent disabling since February 5, 2018. This satisfies the second prong of a secondary service connection claim. The appeal turns on the third prong of a secondary service connection claim medical nexus. For the Veteran's understanding, secondary service connection nexus may be found upon one of two independent bases causation or aggravation. The Board will address these separately. For causation, three medical opinions are relevant. First, in December 2014, Dr. P.Y., M.D., in a private nexus statement, opined that the Veteran's DM caused his ED, but did not explain why. Second, in January 2015, a VA examiner opined that the Veteran's DM did not cause his ED because the DM predated the ED. Third, in September 2021, a VA examiner opined that the Veteran's DM did not cause his ED because the DM predated the ED. In considering these opinions, the Board finds Dr. P.Y.'s December 2014 opinion has no probative weight because he did not support his conclusion, nor did he explain how DM could have caused the ED given the unrefuted evidence that the ED predated the DM by many years. As such, the Board finds, based on the two VA examination opinions, that it is less likely than not that the DM caused the ED. For aggravation, only two of the three medical opinions above are relevant, as Dr. P.Y. did not address aggravation in his December 2014 opinion. First, in January 2015, a VA examiner opined that the Veteran's DM did not aggravate his ED because there was "no evidence" to support aggravation. Second, in September 2021, a VA examiner opined that the Veteran's DM did not aggravate his ED because was there "not enough evidence" to support aggravation. Moreover, he added "there has been no change in the symptoms. ED continues to be present, [the Veteran] responds to meds as prescribed." The examiner further found he could not determine a baseline of severity for the ED, a requirement for establishing aggravation. As such, the Board finds, based on the two VA examination opinions, that it is less likely than not that the DM aggravates the ED. Based on the foregoing, the Board finds the Veteran has not satisfied the third prong of service connection for this claim on either a causation or aggravation basis. Because the Veteran has not satisfied all three prongs of his secondary service connection claim, the Board must deny the appeal. REASONS FOR REMAND Remand is warranted for the heart disorder and TDIU issues. Heart Disorder Two matters warrant discussion for this issue the Veteran's private cardiologist and the nature of the Veteran's claimed disability. The Board considered this issue in April 2019, remanding it for additional development. In 2019, the Board said: The Veteran is seeking service connection for a heart disorder and for PTSD, as well as seeking an increased rating for diabetes mellitus and for his service-connected other specified trauma and stressor-related disorder. The Veteran's statements and his VA clinical records refer to private healthcare providers that primarily treat these disorders. A June 2017 VA clinical record refers to the Veteran's private cardiologist, Dr. L., and his non-VA primary care physician, Dr. B. Another June 2017 record shows the Veteran reported having an upcoming appointment with his private cardiologist in September. A June 2017 clinical note related to his diabetes includes mention that a discussion was had related to starting medication for his diabetes, but he wanted to talk to his private provider. More recently, a July 2018 clinical note includes coronary artery disease on his problem list and a notation that he has a private endocrinologist. [The Board has bolded the above language for emphasis.] For the reader's understanding, "Dr. L." is Dr. Lynch, whose first name is unavailable from the claims file. The Board remanded to give the Veteran the opportunity to submit records from "Dr. L." and to have a new cardiac examination. The AOJ, attempting to comply with the directives, invited the Veteran to submit the requested records and scheduled him for an exam in August 2020. Unfortunately, the Veteran misconstrued the Board's discussion and noted, in a March 2020 submission, treatment by a Dr. Anthony Lugo, who was "no longer in practice." The examination did not occur because the Veteran was in quarantine due to the Covid-19 pandemic. Nevertheless, a medical professional reviewed the claims file and stated: According to Kettering Network Primary Care Notes dated May 8, 2019, a diagnosis of coronary artery or ischemic heart disease is not documented. The Veteran Medical Treatment Records from Kettering Health Network dated Feb. 26, 2019 documents a diagnosis of Coronary Artery Disease. The date of diagnosis is not recorded. Medical Records in VBMS dated 12/02/2014 by Dr. [Y.] documents that the Veteran has ischemic heart disease however supporting documentation was documented on the Veteran's prior C&P IHD DBQ exam on Jan 28, 2015. Current CPRS and JLV Records does not support a diagnosis of Ischemic Heart Disease. The Veteran has a list of diagnoses regarding his heart from 01/2019 however the actual reports and results of these procedures are not of this record. If the Veteran does not have current evidence regarding his heart conditions in VBMS or with him at his upcoming appointment, he will be required to have an echo and EKG done at the time of his visit. The appeal returned to the Board in June 2021. The Board did not address the Veteran's misunderstanding of "Dr. L." It remanded for a new VA examination, which occurred in July 2021. The Veteran had an echocardiogram at the July 2021examination. The examiner opined that the echocardiogram did not show a heart disorder, and by extension, that the Veteran did not then have, nor had he ever had, a heart disorder. The appeal has now returned to the Board. The Board highlights these matters because the Veteran is representing himself. Given this, and what appears to be ongoing treatment by Dr. Lynch, the Board finds the Veteran should have one more opportunity to submit records from Dr. Lynch. If VA receives these records, the Board will order an addendum medical opinion. TDIU The TDIU issue is inextricably intertwined with the CAD issue. Therefore, the Board will defer adjudication until the CAD issue is resolved. The matters are REMANDED for the following action: 1. Assist the Veteran in attempting to obtain the treatment records from Dr. Lynch, his private cardiologist. Notify the Veteran that he may a) submit the treatment records from Dr. Lynch to VA directly, or b) provide the AOJ with a completed release form so that the AOJ can attempt to obtain the records on his behalf. 2. Only if VA receives the records from Dr. Lynch, then obtain an addendum opinion from the medical professional who examined the Veteran in July 2021 for his heart disorder claim. If that person is not available, arrange for a qualified medical professional to review the file and provide the addendum opinion. The reviewer should opine: a) Does the Veteran have a diagnosis of a heart disorder that falls under the diagnostic umbrella of "ischemic heart disease?" If yes, identify the diagnosis. b) If the answer to (a) is no, does the Veteran have a non-ischemic heart disorder? If yes, the examiner is requested to answer the following questions: a. Is it at least as likely as not (50 percent probability) that the heart disorder began during, or was otherwise caused by service, to include exposure to herbicide agents? b. Is it at least as likely as not (50 percent probability) that the Veteran's service-connected DM CAUSED his heart disorder? Why or why not? c. Is it at least as likely as not (50 percent probability) that the Veteran's service-connected DM AGGRAVATES his heart condition? Why or why not? Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Sopko, 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.