Citation Nr: 21022654 Decision Date: 04/16/21 Archive Date: 04/16/21 DOCKET NO. 16-61 941 DATE: April 16, 2021 REMANDED Entitlement to service connection for headache disorder is remanded. Entitlement to service connection for sleep disorder with memory loss is remanded. Entitlement to a compensable initial rating for epididymectomy is remanded. Entitlement to a compensable initial rating for hypertension is remanded. Entitlement to an initial rating in excess of 10 percent for right hip degenerative joint disease is remanded. Entitlement to a compensable initial rating for erectile dysfunction is remanded. Entitlement to a compensable initial rating for left ankle lateral collateral sprain is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from February 1992 to May 1992 and from October 1993 to March 2014. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in June 2015 by a Department of Veterans Affairs (VA) Regional Office. The Board previously remanded these claims for further development in a November 2018. The Board remanded the case for VA examinations to determine the etiology and the severity of the Veteran’s disabilities. In October 2019, the Agency of Original Jurisdiction (AOJ) sent a letter to the Veteran informing him that he would be contacted by the private facility to schedule the examinations. The claims file indicates that the VA examinations were cancelled because the Veteran was “unavailable”. The July 2020 supplemental statement of the case (SSOC) indicates that he was unavailable to attend the scheduled examinations because he stated he was currently deployed. Thus, he provided good cause for his inability to attend the VA examinations, but it is unclear how long he was being deployed or whether any attempt was made to reschedule the examinations after his return from deployment. Therefore, to ensure compliance with the Board’s remand directives, a remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: 1. Contact the Veteran, and, with his assistance, identify any outstanding records of pertinent medical treatment. Then take appropriate measures to obtain copies of any outstanding records identified by the Veteran, including treatment for headaches and a sleep disorder with memory loss, as discussed in his June 2015 notice of disagreement. The Veteran should be notified if any identified records are unavailable and given an opportunity to respond and submit any additional lay evidence or statements. 2. After obtaining any additional records to the extent possible, an examiner should review the entire claims file and provide the following opinions: (a.) Whether the Veteran has any current or previously diagnosed headaches; (b.) Whether it is at least as likely as not (i.e. a 50 percent or better probability) that any current or previously diagnosed headaches were incurred in the Veteran’s service; (c.) Whether the Veteran has any current or previously diagnosed sleep disorder with memory loss; and (d.) Whether it is at least as likely as not (a 50 percent or better probability) that any current or previously diagnosed sleep disorder with memory loss was incurred in the Veteran’s service. In rendering these opinions, the examiner should consider service treatment records discussing head injuries, including those dated July 2005 (noting “concussion [following] epididymectomy” with “no sequelae,” received 9/8/14, page 51 of 341), August 1997 (received 9/8/14, page 138 of 341), January 1996 received 9/8/14, page 298 of 341), and March 1994 (received 9/8/14, page 191 of 341). The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. All correspondence with the Veteran, including attempts made to schedule the Veteran for his examinations, should be documented in the Veteran’s claims folder. 3. After obtaining any additional records to the extent possible, provide an examination and obtain a medical opinion regarding the nature and severity of the Veteran’s service-connected right hip and left ankle disorders. The claims folder should be made available to the examiner for review prior to the examination and the examiner should acknowledge such review in the examination report. (a.) Full range of motion testing must be performed where possible. The joint involved should be tested in both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of the opposite undamaged joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain the basis for this decision. (b.) The examiner should determine whether the Veteran’s service-connected hip and ankle disorders are manifested by weakened movement, excess fatigability, incoordination, pain or flare-ups. These determinations should be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, pain or flare-ups. (c.) The examiner should also request the Veteran identify the extent of his functional loss during flare-ups and, if possible, offer range of motion estimates based on that information. If the examiner is unable to provide an opinion on the impact of any flare-ups on the Veteran’s range of motion, the examiner should indicate whether this inability is due to lack of knowledge among the medical community or based on the lack of procurable information. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and must state whether there is additional evidence that would permit the necessary opinion to be made. 4. After obtaining any additional records to the extent possible, an examiner should review the entire claims file and provide an opinion as to whether the Veteran’s erectile dysfunction or epididymitis, to include any residuals from the surgeries in connection thereof, constitute a distortion of the penis, either internal or external. The need for additional examination is left to the examiner’s discretion. The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. Sonja A. Mishalanie Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Edward G. Lent 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.