Citation Nr: 21014098 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 18-19 289 DATE: March 11, 2021 ORDER Entitlement to service connection for erectile dysfunction is granted. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a kidney disability is remanded. Entitlement to service connection for a right upper extremity neurological disability, to include diabetic peripheral neuropathy, is remanded. Entitlement to service connection for a left upper extremity neurological disability, to include diabetic peripheral neuropathy, is remanded. Entitlement to service connection for a right lower extremity neurological disability, to include diabetic peripheral neuropathy, is remanded. Entitlement to service connection for a left lower extremity neurological disability, to include diabetic peripheral neuropathy, is remanded. FINDINGS OF FACT 1. Service connection is currently in effect for diabetes mellitus and coronary artery disease. 2. It is at least as likely as not that erectile dysfunction is related to service-connected diabetes mellitus. CONCLUSION OF LAW The criteria for service connection for erectile dysfunction, secondary to diabetes mellitus, are met. 38 U.S.C. §§ 5107; 38 C.F.R. §§ 3.102, 3.310(a). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active service from January 1960 to January 1963 and from April 1963 to April 1966. The Veteran served in the Republic of Vietnam. Service Connection for Erectile Dysfunction The Veteran asserts that service connection for erectile dysfunction is warranted as the disability was incurred as the result of the service-connected diabetes mellitus. Service connection may be established for recurrent disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Service connection may also be established for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Service connection shall be established on a secondary basis under the provisions of 38 C.F.R. § 3.310(a) where it is demonstrated that a service-connected disability has aggravated a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection has been established for diabetes mellitus and coronary artery disease. A March 2016 evaluation from A. Smith, Jr., M.D., the Veteran’s treating primary care physician, states that the Veteran was diagnosed with erectile dysfunction secondary to diabetes mellitus. An October 2016 treatment record from Dr. Smith indicates that the Veteran was diagnosed with “uncontrolled Type 2 diabetes mellitus with complications with long-term current use of insulin.” An October 2018 treatment record from D. Iddings, D.O., states that the Veteran had a history of high glucose levels. The report of a July 2020 examination conducted for the Department of Veterans Affairs (VA) states that the Veteran was diagnosed with erectile dysfunction. The examiner concluded that “the claimed erectile dysfunction is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s disabilities, to include diabetes mellitus or coronary artery disease.” The doctor noted that the Veteran’s “medical record shows that his diabetes mellitus was well controlled and was not associated with any complications at the time of his erectile dysfunction diagnosis.” The examiner opined further that “the currently erectile dysfunction was less likely than not aggravated beyond its natural progression by the Veteran’s conditions to include diabetes mellitus or coronary artery disease” and “given the lack of medical evidence contained in his medical record to confirm the presence of his erectile dysfunction during service, it is speculative to estimate the level of impact that his diabetes mellitus or coronary artery disease had on his erectile dysfunction at the time of diagnosis.” The Board of Veterans’ Appeals (Board) observes that the examiner’s findings that the diabetes mellitus was historically well controlled is contradicted by the clinical documentation of record from his treating physician which shows that the diabetes mellitus was repeatedly found to be uncontrolled and productive of complications. Further, the examiner did not note or otherwise address the Veteran’s private treating physician’s opinion that the erectile dysfunction was related to the service-connected diabetes mellitus. Because of those deficiencies, the Board finds that the July 2020 examination report is of limited probative value. The Veteran has been diagnosed with erectile dysfunction by private physicians and VA examiners. The private treating physician has concluded that the erectile dysfunction is related to the service-connected diabetes mellitus. The Board finds that the evidence is in at least equipoise as to whether the diagnosed erectile dysfunction is related to the service-connected diabetes mellitus. Therefore, resolving reasonable doubt in the Veteran’s favor, the Board concludes that service connection is warranted for erectile dysfunction. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. The issue of entitlement to service connection for hypertension is remanded. A March 2016 hypertension evaluation from Dr. Smith, the Veteran’s treating primary care physician, states that the Veteran was diagnosed with hypertension secondary to the service-connected diabetes mellitus. The report of a July 2020 hypertension examination conducted for VA states that the Veteran was diagnosed with hypertension. The examiner concluded that “the claimed hypertension is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s disabilities, to include diabetes mellitus or coronary artery disease.” The doctor noted that “although both the Veteran’s service-connected diabetes mellitus and coronary artery disease are risk factors of hypertension, it is also well known in the medical community that hypertension is a common cause of coronary artery disease” and “given the lack of conclusive evidence to demonstrate etiological sequence of pathologic events leading up to his development of hypertension, it is unlikely for this provider to conclude that his coronary artery disease or diabetes mellitus played a role in the development of hypertension.” The examiner opined further that “the currently diagnosed hypertension related to the Veteran’s claimed hypertensive disability was less likely than not aggravated beyond its natural progression by the Veteran’s conditions to include diabetes mellitus or coronary artery disease;” “the Veteran’s medical record does not support the presence of his claimed hypertension condition during service, nor does it accurately depict a correlating progression of his hypertension with onset of his coronary artery disease and diabetes mellitus;” and “his medical record does show that his diabetes mellitus was well controlled and was not associated with any complications at the time of his hypertension diagnosis.” The Board observes again that the examiner’s findings that the service-connected diabetes mellitus had been well controlled is contradicted by the clinical documentation of record reflecting that the diabetes mellitus was repeatedly found to be uncontrolled and productive of complications. Further, the examiner did not note or otherwise address either that the Veteran’s private treating physician’s opinion that the hypertension was related to the service-connected diabetes mellitus or that the service-connected coronary artery disease is to be presumed to have been the result of the Veteran’s in service exposure to herbicide agents. Because of such deficiencies, the Board finds that the July 2020 VA examination report is of essentially no probative value. VA’s duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121 (1991). When VA obtains an evaluation, the evaluation must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that further VA hypertension evaluation is needed. Clinical documentation dated after July 2020 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran’s claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 2. The issue of entitlement to service connection for a kidney disability is remanded. Private physicians and VA examiners have diagnosed the Veteran with chronic kidney disorder, Stage III related to the diagnosed hypertension. Therefore, the issue of service connection for a kidney disability is inextricably intertwined with the issue of entitlement to service connection for hypertension being remanded and must also be remanded. 3. Entitlement to service connection for a right upper extremity neurological disability to include diabetic peripheral neuropathy; a left upper extremity neurological disability to include diabetic peripheral neuropathy; a right lower extremity neurological disability to include diabetic peripheral neuropathy; and a left lower extremity neurological disability to include diabetic peripheral neuropathy is remanded. A March 2016 physical evaluation from Dr. Smith states that the Veteran had been diagnosed with diabetes mellitus with polyneuropathy. The October 2018 treatment record from Dr. Iddings reports that the Veteran “has some neuropathy and that is not changing as his glucose levels were very high several years ago.” In February 2019 Remand instructions, the Board requested that the Veteran was to be scheduled for a VA neurological examination to assist in determining the current nature of any identified peripheral neuropathy and any relationship to active service and the service connected disabilities. The examiner was expressly requested to review the record, including Dr. Smith’s March 2016 evaluation, and to note that review in the report. The report of a July 2020 “Peripheral Nerves Conditions (Not Including Diabetic Sensory-Motor Peripheral Neuropathy)” examination conducted for VA states that the Veteran was diagnosed with “chemotherapy-induced peripheral neuropathy, bilateral lower extremities” unrelated to active service and the service connected disabilities. The examiner did not note or otherwise address Dr, Smith’s March 2016 evaluation. The Agency of Original Jurisdiction’s compliance with the Board’s remand instructions is neither optional nor discretionary. Stegall v. West, 11 Vet. App. 268 (1998). The Veteran therefore must be scheduled for further VA evaluation. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated him for any hypertension, kidney, upper extremity neurological, and lower extremity neurological disabilities after July 2020. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records dated after July 2020. 3. Schedule the Veteran for a VA hypertension examination conducted by a medical doctor who has not previously examined him, to assist in determining the current nature of the diagnosed hypertension and any relationship to active service or the service-connected disability. The examiner must review the record, including Dr. Smith’s March 2016 evaluation, and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all hypertensive disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified hypertensive disability had its onset during active service or is related to any incident of service, including presumed exposure to herbicide agents while in the Republic of Vietnam. (c) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified hypertensive disability is due to or the result of diabetes mellitus, or coronary artery disease, and the other service-connected disabilities. Reconcile the opinion with the other opinions of record, including from Dr. Smith. (d) Opine whether it at least as likely as not (50 percent probability or greater) that any hypertensive disability has been aggravated (increased in severity beyond the natural progress of the disorder) by diabetes mellitus, coronary artery disease, and the other service connected disabilities. Reconcile the opinion with the other opinions of record, including from Dr. Smith. 4. Schedule the Veteran for a VA examination conducted by a medical doctor who has not previously examined him, to assist in determining the current nature of any identified peripheral neuropathy and any relationship to active service and the service-connected disabilities. The examiner must review the record, including Dr. Smith’s March 2016 evaluation and the October 2018 treatment record from Dr. Iddings, and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all neurological disabilities of the upper and lower extremities. Conduct any necessary testing to properly diagnose neurologic disabilities. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified neurological disability of the upper and lower extremities had its onset during active service or is related to any incident of service, to include presumed exposure to herbicide agents during service. (c) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified neurological disability of the upper and lower extremities is due to or the result of diabetes mellitus and the other service-connected disabilities. Reconcile the opinion with the other opinions of record, including those from Drs. Smith and Iddings. (d) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified neurological disability has been aggravated (increased in severity beyond the natural progress of the disorder) by diabetes mellitus and the other service-connected disabilities. Reconcile the opinion with the other opinions of record, including from those from Drs. Smith and Iddings. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. T. Hutcheson, 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.