Citation Nr: A21020203 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 211105-195956 DATE: December 17, 2021 ORDER Entitlement to service connection for erectile dysfunction is granted. REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for a skin condition (claimed as chloracne) is remanded. FINDING OF FACT The Veteran's erectile dysfunction is at least as likely as not caused or aggravated by his service-connected hypertension. CONCLUSION OF LAW The criteria for entitlement to service connection for erectile dysfunction have been met. 38 U.S.C. §§ 1131; 38 C.F.R. § 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from November 1963 to December 1971, with service in the Republic of Vietnam. This matter comes before the Board of Veterans Appeals (Board) on appeal from a decision by a Department of Veterans Affairs (VA) Regional Office (RO). The RO issued a rating decision under the legacy system in May 2013, and the Veteran submitted a timely notice of disagreement (NOD). In March 2020, the agency of original jurisdiction (AOJ) issued a supplemental statement of the case (SSOC). The Veteran opted the claims into the modernized review system, also known as the Appeals Modernization Act (AMA), by submitting a March 2020 Form 10182, Decision Review Request: Board Appeal, identifying the March 2020 SSOC. This matter was then remanded by the Board in May 2021, to obtain VA medical examinations regarding the claimed conditions. A rating decision was issued in July 2021, and the Veteran submitted a VA Form 10182 Notice of Disagreement in October 2021, requesting Direct Review by a Veterans Law Judge. Service connection for erectile dysfunction Service connection may be granted for a disability on either a direct or secondary basis. Establishing secondary service connection requires competent medical or lay evidence of: (1) a current disability that is not already service connected; (2) at least one service-connected disability; and (3) a nexus between the current disability and the service-connected disability, showing that the current disability was either proximately due to or the result of the service-connected disability or that the current disability was aggravated beyond its natural progression by the service-connected disability. 38 C.F.R. § 3.310(a).; Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran's medical records show a current diagnosis of erectile dysfunction, and he is currently service connected for multiple disabilities, including hypertension. The first and second elements of secondary service connection are therefore met. In March 2020, the Veteran underwent a VA examination to determine the etiology of his erectile dysfunction. The examiner found it less likely than not that the Veteran's erectile dysfunction was directly related to his military service. However, the examiner found it at least as likely as not that the Veteran's erectile dysfunction was related to a service-connected condition; specifically, his hypertension. The examiner explained that a medication prescribed to control the Veteran's hypertension, and antihypertensive medications generally, was "known to cause erectile dysfunction," and was at least as likely the cause in this case. Because the March 2020 opinion is supported by adequate reasoning, medical basis, and reference to the Veteran's medical history, the Board finds that it merits probative weight. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Entitlement to service connection for erectile dysfunction is granted. REASONS FOR REMAND Unfortunately, a second remand is necessary, as the Board finds that the most recent VA medical examinations regarding the Veteran's sleep apnea and skin condition are inadequate. VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). If an examination is inadequate, VA has a duty to provide a new examination or, at least, explain why such an examination will not be provided. Failure to provide an adequate medical examination constitutes a pre-decisional duty to assist error on the part of the RO, and is grounds for remand. See 38 C.F.R. § 20.802(a); 38 U.S.C. § 5103A(g). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl, 21 Vet. App. at 123. The medical opinion also must support its conclusions with data and reasoning that the Board can follow. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301-304 (2008). Sleep apnea The June 2021 VA examination found that the Veteran's sleep apnea was less likely than not related to his in-service sleep problems, and based this conclusion primarily on the fact that sleep apnea cannot be diagnosed based on snoring alone. The lay statement submitted by the Veteran was considered, however it is insufficient to establish an etiology for the sleep apnea due to service. While the Veteran is deemed competent to report a history of symptomatology, he is not capable of diagnosing those symptoms or establishing an etiological basis for the symptoms. The history of snoring is not diagnostic of obstructive sleep apnea. Snoring can be related to other disorders associated with nasal and septal defects which are independent of obstructive sleep apnea. Snoring is also diagnosed as a separate sleep disorder when the condition does not meet the diagnostic criteria for obstructive sleep apnea. The Veteran had a 2011 sleep study with a diagnosis of obstructive sleep apnea, approximately 40 years post service. There is no established medical nexus incurred in service or otherwise medically related to service. It is true that a layperson is not competent to diagnose his own symptoms, or determine the etiology of a complex medical condition. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). It is the job of the VA examiner to make those determinations, based on the Veteran's testimony and other available evidence; the June 2021 examination failed to do so. The June 2021 examination report heavily emphasized that snoring and other sleep problems are not in of themselves sufficient to diagnose sleep apnea, but this is answering the wrong question. The Board did not ask about the general likelihood that any random snorer has sleep apnea. The Veteran does have sleep apneahe may have been diagnosed "approximately 40 years post service," but he has been diagnosed, nevertheless. The question of whether sleep apnea can be diagnosed in the first place purely based on snoring is not the same question as whether, given that the Veteran has a diagnosis of sleep apnea, his sleep apnea is at least as likely as not linked to his history of snoring (and other sleep interruptions). On remand, the next examiner should better analyze this point andif they still find that the Veteran's sleep apnea was less likely than not incurred in serviceexplain the most likely etiology of his sleep apnea. Skin condition The Veteran was also given a VA examination in June 2021 for his claimed skin condition. The examiner found it less likely than not that the Veteran had a skin disability linked to service: A thorough review of the Veteran's STRs [service treatment records] and medical records shows that the Veteran has been seen by the Staten Island VAMC Dermatology Clinic for nevi (moles) and freckles (macules) since 2012. Both skin conditions are benign and related to the effects of sun exposure and aging. A review of the Veteran's medical records does not support an onset in service. A review of the medical literature does not support an etiology related to service, to include herbicide exposure The Veteran testified in the BVA Hearing in April 2015 that he has noted an intermittent rash on his hands, which was more prevalent during the summer months. The Veteran is deemed competent to report a history of symptomatology. However, he is not capable of diagnosing those symptoms or of establishing an etiology basis for the symptoms. The medical exams during service and since separation from service are silent for any chronic skin condition caused by herbicide exposure, such as chloracne, or other skin conditions (aside from moles and freckles treated since 2012). Again, the examiner states that the Veteran is not capable of diagnosing or establishing an etiology for symptoms, but there is no explanation for why the examiner cannot do either of these things. The Board was capable in May 2021 of reviewing the Veteran's medical records and seeing that a diagnosis of a skin condition (other than moles and freckles) had not been made at the time; the matter was remanded so that a VA examiner could determine whether another diagnosis was appropriate. Since this was not done, another remand is necessary. The matters are REMANDED for the following action: 1. Obtain an opinion from an appropriate clinician, who has not already provided an opinion in this case, regarding the nature and etiology of the Veteran's obstructive sleep apnea. If the clinician believes an in-person or telehealth examination is necessary, one should be scheduled. After reviewing the entire claims file, including a copy of this remand, the examiner should answer the following: (a) Is it at least as likely as not (50 percent probability or greater) that the Veteran's sleep apnea had its onset during active service? (b) If the Veteran's sleep apnea did not have its onset during active service, is it at least as likely as not that the Veteran's sleep apnea is related to any event, injury, or disease that was incurred during active service? (c) Is it at least as likely as not that the Veteran's sleep apnea was caused or aggravated by a service-connected disability, to include hypertension and PTSD? (d) If the Veteran's sleep apnea is unrelated to his active service or any service-connected disability, what is its likely etiology? A complete and fully explanatory rationale must be provided for any opinion offered, citing any record evidence or medical literature relied upon. The examiner must give due weight to the Veteran's lay testimony. If an opinion cannot be rendered without resorting to speculation, the examiner must explain why. 2. Obtain an opinion from an appropriate clinician, who has not already provided an opinion in this case, regarding the nature and etiology of the Veteran's skin condition(s). If the clinician believes an in-person or telehealth examination is necessary, one should be scheduled. After reviewing the entire claims file, including a copy of this remand, the examiner should answer the following: (a) In the examiner's opinion, what skin conditions does the Veteran currently have? (b) Are the rashes described by the Veteran in his April 2015 Board hearing attributable to any diagnosable skin condition, or can their etiology be otherwise determined? (c) For any skin condition the Veteran has, is it at least as likely as not (50 percent or greater probability) that the condition is related to any event, injury, or disease that was incurred during active service, to include exposure to herbicide agents? A complete and fully explanatory rationale must be provided for any opinion offered, citing any record evidence or medical literature relied upon. The examiner must give due weight to the Veteran's lay testimony. If an opinion cannot be rendered without resorting to speculation, the examiner must explain why. 3. This case has been Advanced on the Docket. The Agency of Original Jurisdiction (AOJ) must review the examination reports and opinions to ensure they are adequate and comply with the Board's specific remand directives herein. If an opinion is deficient in any manner, the AOJ must undertake immediate corrective action before returning the case to the Board. Mary E. Rude Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Shermila Sundquist 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.