Citation Nr: 21021568 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 16-15 346A DATE: April 13, 2021 REMANDED Entitlement to service connection for erectile dysfunction (ED), claimed as secondary to service-connected major depressive disorder and irritability (MDD), is remanded. Entitlement to service connection for peripheral neuropathy (PN) of the left lower extremity, claimed as secondary to service connected MDD (with intermediary obesity), is remanded. Entitlement to service connection for peripheral neuropathy (PN) of the right lower extremity, claimed as secondary to service connected MDD (with intermediary obesity), is remanded. Entitlement to service connection for hypertension (HTN), claimed as secondary to service connected MDD (with intermediary obesity), is remanded. Entitlement to service connection for heart disease, claimed as secondary to service connected MDD (with intermediary obesity), is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1972 to June 1975. These matters initially came before the Board of Veterans' Appeals (Board) from July 2013 and February 2014 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for ED, PN of the left and right lower extremities, HTN, and heart disease. The appeals have been merged. In April 2016 the Veteran filed a substantive appeal (via VA Form 9). In August 2019 the Veteran testified during a videoconference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the claims file. In December 2019 the Board remanded the Veteran’s claims for additional development. Although that development was conducted, upon further review another remand is warranted to attempt to obtain private treatment records as discussed below. Entitlement to service connection for ED, PN of the left and right lower extremities, HTN, and heart disease, claimed as secondary to service connected MDD, is remanded. At a July 2016 hearing with a decision review officer (DRO) the Veteran’s attorney argued that the medication the Veteran took for his MDD caused his ED and weight gain which in turn caused his PN of the left and right lower extremities, HTN, and heart disease. At the August 2019 Board hearing the Veteran again testified that his ED is a side-effect of the antidepressants he takes for his MDD and that this medication caused him to gain weight which caused his PN of the left and right lower extremities, HTN, and heart disease. The Board notes that obesity is not a disability for purposes of VA benefits and it cannot be service connected on a direct basis. Marcelino v. Shulkin, 29 Vet. App. 155, 158 (2018). However, indirect secondary service connection can be granted with obesity acting as an "intermediate step." See VAOPGCPREC 1-2017 (Jan. 6, 2017). A grant is warranted (1) if the service-connected disability caused the Veteran to become obese; (2) if obesity was a substantial factor in causing a subsequent disability; and (3) if the subsequent disability would not have occurred but for obesity. See also Walsh v. Wilkie, 32 Vet. App. 300 (2020) (precedential panel decision) (holding that obesity as an "intermediate step" in a causal chain for service connection can be established on either a causation or aggravation basis). In a February 2018 letter, the chief executive officer for Psych Care Consultants indicated that the Veteran had been treated by a psychologist with the initials S.M. since July 13, 2011. On this letter, the date July 13, 2011 is crossed out and the date March 19, 2001 is handwritten in its place along with the Veteran’s initials. A July 2015 private physician noted that the Veteran underwent lap band surgery in May 2005 at St. Alexis Hospital which indicates he was obese prior to 2011. As the Veteran contends his psychiatric medication caused his weight gain, whether the Veteran was taking medication for his MDD from 2011 or as early as 2001 is relevant and necessary to make a fully informed decision in this case. The February 2018 letter from Psych Care Consultants is the only treatment record from this medical group in the Veteran’s claims file. Thus, it is unclear as to how long the Veteran has been treated for his MDD. As there might be outstanding treatment records from Psych Care Consultants which may prove or disprove a matter in issue, a remand is therefore warranted to allow VA to obtain authorization and request these relevant treatment records. The matters are REMANDED for the following action: 1. Ask the Veteran to identify the location and name of any VA or private medical facility where he has received treatment for MDD, specifically, Psych Care Consultants, to include the dates of any such treatment. Ask the Veteran to complete a VA Form 21-4142 for all records of his treatment for MDD. Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 2. After records development is completed, request an opinion from an appropriate clinician regarding the nature and etiology of the Veteran’s ED and related symptoms. The VA examiner must determine if the Veteran’s ED is at least as likely as not (1) caused by service-connected acquired psychiatric disorder, diagnosed as MDD (to include any medications taken for this disability); OR (2) aggravated by service-connected acquired psychiatric disorder, diagnosed as MDD (to include any medications taken for this disability). The physician should also address whether the Veteran’s service-connected MDD, to include any medications taken for this disability, caused him to become obese due to, inter alia, inactivity or immobility; if so, whether the obesity was a substantial factor in causing the Veteran’s claimed ED; and whether this disability would not have occurred but for the obesity. If an examination is deemed necessary, one should be conducted, to include via telehealth. 3. Request an opinion from an appropriate clinician regarding the nature and etiology of the Veteran’s PN of the right and left lower extremities and related symptoms. The VA examiner must determine if the Veteran’s PN of the right and left lower extremities are at least as likely as not (1) caused by service-connected acquired psychiatric disorder, diagnosed as MDD (to include any medications taken for this disability); OR (2) aggravated by service-connected acquired psychiatric disorder, diagnosed as MDD to include any medications taken for this disability). If an examination is deemed necessary, one should be conducted, to include via telehealth. The physician should also address whether the Veteran's service-connected MDD, to include any medications taken for this disability, caused him to become obese due to, inter alia, inactivity or immobility; if so, whether the obesity was a substantial factor in causing the Veteran's claimed PN of the right and left lower extremities; and whether this disability would not have occurred but for the obesity. If an examination is deemed necessary, one should be conducted, to include via telehealth. 4. Request an opinion from an appropriate clinician regarding the nature and etiology of the Veteran’s HTN and related symptoms. The VA examiner must determine if the Veteran’s HTN is at least as likely as not (1) caused by service-connected acquired psychiatric disorder, diagnosed as MDD (to include any medications taken for this disability); OR (2) aggravated by service-connected acquired psychiatric disorder, diagnosed as MDD (to include any medications taken for this disability). If an examination is deemed necessary, one should be conducted, to include via telehealth. The physician should also address whether the Veteran's service-connected MDD, to include any medications taken for this disability, caused him to become obese due to, inter alia, inactivity or immobility; if so, whether the obesity was a substantial factor in causing the Veteran's claimed HTN; and whether the HTN would not have occurred but for the obesity. If an examination is deemed necessary, one should be conducted, to include via telehealth. 5. Request an opinion from an appropriate clinician regarding the nature and etiology of the Veteran’s heart disease and related symptoms. The VA examiner must determine if the Veteran’s heart disease is at least as likely as not (1) caused by service-connected acquired psychiatric disorder, diagnosed as MDD (to include any medications taken for this disability); OR (2) aggravated by service-connected acquired psychiatric disorder, diagnosed as MDD (to include any medications taken for this disability). If an examination is deemed necessary, one should be conducted, to include via telehealth. The physician should also address whether the Veteran's service-connected MDD, to include any medications taken for this disability, caused him to become obese due to, inter alia, inactivity or immobility; if so, whether the obesity was a substantial factor in causing the Veteran's claimed heart disease; and whether the heart disease would not have occurred but for the obesity. If an examination is deemed necessary, one should be conducted, to include via telehealth. The clinician is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinion. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board James R. Miller, 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.