Citation Nr: 21006573 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 13-19 418 DATE: February 4, 2021 REMANDED Entitlement to a separate rating for urinary incontinence as a possible neurological manifestation of the service-connected lumbar spine disability is remanded. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from May 2004 to May 2008. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from a May 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). By way of procedural background, this matter was previously before the Board in October 2017, March 2018, and May 2020. In October 2017, the claim was remanded to schedule the Veteran’s Board hearing. In March 2018, the Board granted a rating of 40 percent for the service-connected lumbar spine disability and remanded for an additional VA examination based on the Veteran’s assertion of worsening. In May 2020, the Board denied a rating higher than 40 percent for the low back disability and granted a separate 10 percent rating for right lower extremity radiculopathy and 20 percent for left lower extremity radiculopathy. The claim was then remanded for further examinations to determine if a separate rating for erectile dysfunction or urinary incontinence as neurological manifestations of the low back disability were warranted. While on remand, the RO granted service connection for erectile dysfunction secondary to the low back disability. As this is a full grant of the benefit sought on appeal, this claim is no longer before the Board. However, the RO denied a separate rating for urinary incontinence and denied entitlement to a TDIU. These claims have been returned to the Board for further appellate consideration. In January 2018, the Veteran testified before the undersigned Veterans Law Judge via videoconference hearing. A copy of the hearing transcript is of record and has been reviewed. 1. Entitlement to a separate rating for urinary incontinence as a possible neurological manifestation of the service-connected lumbar spine disability is remanded. Unfortunately, the claim for a separate rating for urinary incontinence must be remanded again to obtain an adequate medical opinion as to whether it is a neurological manifestation of the service-connected low back disability. A November 2020 VA addendum opinion was obtained per the Board’s May 2020 remand directives. The examiner, a nurse practitioner, concluded that it would be mere speculation to determine if a neurogenic bladder was a neurological manifestation of the low back disability because the Veteran had not yet been evaluated by a urologist to confirm a current diagnosis and to rule out other possible causes. This opinion is inadequate. When an examiner is asked to render an opinion and determines that he or she cannot do so without resorting to speculation, the Board may not rely on such an opinion unless the record in its entirety, including the examination and the opinion itself, shows that “‘the examiner [did] not invoke the phrase ‘without resort to mere speculation’ as a substitute for the full consideration of all pertinent and available medical facts.” Jones v. Shinseki, 23 Vet. App. 382 (2010). Here, the examiner noted that it would be mere speculation for this examiner to provide an etiology opinion as directed but clearly identified another specialist that should be able to provide such an opinion. Instead of either scheduling the Veteran for another VA examination or obtaining an addendum medical opinion from a urologist, the RO denied the claim and returned it to the Board. Once VA provides the Veteran with a VA examination or obtains a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). On remand, the Veteran should be afforded another VA examination with a urologist this time, and medical opinion should be obtained to determine whether the Veteran’s urinary incontinence symptoms are a neurological manifestation of the low back disability. 2. Entitlement to a TDIU is remanded. Entitlement to a TDIU is inextricably intertwined with the claim being remanded, as the outcome may impact the TDIU claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on a Veteran’s claim for the second issue). Thus, adjudication of this claim is deferred. The matters are REMANDED for the following action: 1. Obtain any outstanding pertinent VA treatment records and associate them with the claims file. Then, schedule the Veteran for a VA examination with a urologist, if at all possible, to determine the nature and etiology of the urinary incontinence symptoms. The claims file, and a copy of this Remand, must be made available to and be reviewed by the examiner. **Telehealth or other alternative method to a physical in-person examination should be considered, if a physical examination is not possible given the circumstances surrounding the recent pandemic. Nevertheless, if none of these methods of examination are possible, refer the claim to a VA urologist for a thorough review of the record and medical opinion, if an addendum opinion can be provided without a physical examination. After a complete review of the claims file, the examiner must provide an opinion as to whether the urinary incontinence was (1) caused by or is (2) aggravated by the service-connected low back disability. *If it is determined the urinary incontinence is due to a non service-connected disability (i.e. TBI, primary urological disability, etc.) and/or it is not aggravated by the service-connected low back disability, provide a thorough rationale to support this conclusion. (Continued on the next page)   *The examiner is also reminded that if a veteran is diagnosed with multiple disabilities of the same body part or system, and it is unclear which symptoms are attributable to each distinct disability, the Board is precluded from differentiating between the symptomatology of the disabilities and the symptom will be attributed to the service-connected disability. See Mittleider v. West, 1 Vet. App. 181, 182 (1998). 2. Readjudicate the claims on appeal to include entitlement to a TDIU. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Harper, 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.