Citation Nr: 21012080 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 07-36 197 DATE: March 3, 2021 REMANDED Entitlement to service connection for a disability manifested by low testosterone levels, to include as secondary to service-connected disabilities or as due to an undiagnosed illness, is remanded. Entitlement to a service connection for a skin disability, to include as secondary to service-connected disabilities or as due to an undiagnosed illness, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1985 to January 1988 and from August 1988 to August 1993 with service in Southwest Asia. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2009 rating decision. In October 2015, the Veteran testified at a video-conference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing has been associated with the claims file. Most recently, the Board remanded these matters for further development in November 2020. Unfortunately, the Veteran’s claims for service connection must be remanded for further development. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran’s claims, so he is afforded every possible consideration. 1. Entitlement to service connection for a disability manifested by low testosterone levels, to include as secondary to service-connected disabilities or as due to an undiagnosed illness, is remanded. The Veteran’s claim for service connection was remanded in November 2020 to obtain an addendum medical opinion concerning whether his disability is proximately due to or aggravated by his service-connected chronic fatigue syndrome. A December 2020 medical opinion was obtained in response. However, since that time, additional VA treatment records have been obtained that warrant a further remand. Of note, the Veteran is service-connected, in pertinent part, for other specified trauma and stressor related disorder with other specified insomnia disorder; fibromyalgia; headaches associated with fibromyalgia; degenerative disc disease, lumbar spine; bilateral pes planus; and right knee strain. The Veteran’s recent VA treatment records show that his prescribed Selective Serotonin Reuptake Inhibitors (SSRIs) can cause sexual side effects. The June 2018 Mental Disorders (other than PTSD and Eating Disorders) –DMS-V Disability Benefits Questionnaire states that the Veteran’s current medications include Topiramate, Prazosin HCL Sertraline, and Zolpidem. A January 2020 VA treatment record provides that decreased sexual hormones is a side-effect of opioid use. A June 2019 VA treatment record provides that the Veteran complains of chronic joint pain and headaches that affect his sexuality. Therefore, an addendum medical opinion is warranted to consider whether the Veteran’s disability manifested by low testosterone is proximately caused by or aggravated by the above service-connected disabilities, including associated pain and medication used for treatment. 2. Entitlement to a service connection for a skin disability, to include as secondary to service-connected disabilities or as due to an undiagnosed illness, is remanded. The Veteran’s claim for service connection was remanded in November 2020, in part, to obtain an addendum medical opinion concerning whether his skin disability is proximately due to or aggravated by his service-connected acquired psychiatric disorder. A December 2020 medical opinion was obtained in response. For the reasons discussed below, the Board finds that the December 2020 medical opinion is inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding 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 December 2020 medical opinion does not contain a sufficient rationale in support of its conclusion. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion…must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”) In finding that the Veteran’s skin disability was not proximately due to or aggravated by his service-connected acquired psychiatric disorder, the examiner stated that literature has not shown a direct causal relationship between the Veteran’s mental health condition and his skin conditions. Additionally, the examiner provided that while the Veteran’s lay statement on the February 2020 Skin Diseases Disability Benefits Questionnaire noted a relationship between his service-connected mental health condition and the skin rash located on his bilateral shin area, the general medical community has not shown a direct causal relationship. The examiner did not cite to the literature or principle or findings of the general medical community that supports the above conclusions. Accordingly, the medical opinion does not form a sufficient foundation upon which to base a denial of entitlement to service connection. See Wilson v. Derwinski, 2 Vet. App. 614 (1992) (reflecting that the Board is free to assess medical evidence and is not obligated to accept a physician's opinion). Therefore, an addendum medical opinion is warranted to consider whether the Veteran’s skin disability is proximately caused by or aggravated by his service-connected acquired psychiatric disorder. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from November 2020 to the present. 2. After the above development is completed, forward the Veteran’s claims folder to the examiner who submitted the December 2020 medical opinion as to his disability manifested by low testosterone levels, his erectile dysfunction and/or hypogonadism, or a suitable substitute, for an addendum medical opinion. If any examiner determines that an additional physical examination of the Veteran is required, so schedule him. The examiner must review the Veteran’s claims folder. The examiner must: (a.) Opine whether the Veteran’s disability manifested by low testosterone levels, his erectile dysfunction and/or hypogonadism is at least as likely as not (50 percent probability or greater) proximately due to his service-connected disabilities (other specified trauma and stressor related disorder with other specified insomnia disorder; fibromyalgia; headaches associated with fibromyalgia; degenerative disc disease, lumbar spine; bilateral pes planus; right knee strain), including medication use for treatment of his service-connected disabilities. (b.) Opine whether the Veteran’s disability manifested by low testosterone levels, his erectile dysfunction and/or hypogonadism is at least as likely as not (50 percent probability or greater) aggravated, i.e., worsened beyond its natural progression, by his service-connected disabilities (other specified trauma and stressor related disorder with other specified insomnia disorder; fibromyalgia; headaches associated with fibromyalgia; degenerative disc disease, lumbar spine; bilateral pes planus; right knee strain), including medication use for treatment of his service-connected disabilities. In providing the above medical opinions, the examiner must consider: • The Veteran’s recent VA treatment records show that his prescribed Selective Serotonin Reuptake Inhibitors (SSRIs) can cause sexual side effects. The Veteran’s VA treatment records indicate that he has prescriptions for Sertraline and Prazosin. • The June 2018 Mental Disorders (other than PTSD and Eating Disorders) –DMS-V Disability Benefits Questionnaire states that the Veteran’s current medications include Topiramate, Prazosin HCL Sertraline, and Zolpidem. • A January 2020 VA treatment record provides that decreased sexual hormones is a side-effect of opioid use. The Veteran’s VA treatment records state that he is prescribed hydrocodone. • A June 2019 VA treatment record provides that the Veteran complains of chronic joint pain and headaches that affect his sexuality. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 3. Forward the Veteran’s claims folder to the examiner who submitted the December 2020 medical opinion as to his skin disability, or a suitable substitute, for an addendum medical opinion. If any examiner determines that an additional physical examination of the Veteran is required, so schedule him. The examiner must review the Veteran’s claims folder. The examiner must: (a.) Opine whether the Veteran’s skin disability is at least as likely as not (50 percent probability or greater) proximately due to his service-connected other specified trauma and stressor related disorder with other specified insomnia disorder. (b.) Opine whether the Veteran’s skin disability is at least as likely as not (50 percent probability or greater) aggravated, i.e., worsened beyond its natural progression, by his service-connected other specified trauma and stressor related disorder with other specified insomnia disorder. In providing the above medical opinions, the examiner must consider: • That during the current appellate period, the Veteran has been diagnosed with or recorded as having eczema, boils, lumps, lipomas, subcutaneous masses, and possible fatty tumors. • The February 2020DBQ indicating that an intermittent rash from 2010 to 2016 resolved coincident to treatment for anxiety. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sean Mussey, 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.