Citation Nr: 21025317 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 18-04 349 DATE: April 27, 2021 ORDER Entitlement to service connection for insomnia is granted. Entitlement to service connection for low testosterone treatment, including as secondary to service-connected prostate cancer residuals or an erectile dysfunction disability, is denied. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran’s insomnia is related to his military service. 2. The evidence is insufficient to show that the Veteran’s low testosterone condition had its onset in service, is otherwise related to his military service, or was caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for insomnia have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for low testosterone treatment, including as secondary to service-connected prostate cancer residuals or erectile dysfunction disabilities, have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Air Force from July 1964 to May 1968. This matter returns to the Board of Veterans’ Appeals (Board) from a previous Board remand in October 2020 (Board Remand) to obtain addendum medical opinions for the claimed issues. This matter originally came before the Board on the Veteran’s appeal of a May 2017 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO), which is the agency of original jurisdiction (AOJ). This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c); 38 U.S.C. § 7107(a)(2). Service Connection Entitlement to service connection for a claimed disability may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Establishing service connection on a secondary basis requires evidence sufficient to show that (1) a current disability exists and (2) the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 48 (1995) (en banc). Neither insomnia, nor conditions related to low testosterone, are a “chronic disease” listed under 38C.F.R. §3.309(a), and therefore, the presumptive provisions at 38 C.F.R. § 3.303(b) do not apply Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed or experienced, and which are within the realm of his or her personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159 (a). However, without specialized medical training a lay witness is not competent to either diagnose or make a nexus opinion concerning most medical conditions. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, “VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to.” Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). 1. Entitlement to service connection for insomnia. The Veteran seeks entitlement to service connection for insomnia. He contends that he experienced frequent sleep problems which began during his period of military service which continued for the rest of his adult life, or that it is a result of a service-connected disability. VA acknowledges that the Veteran has a currently diagnosed disability of insomnia. See VA Mental Disorder Disability Benefits Questionnaire (DBQ), December 14, 2017. Giving the benefit of any reasonable doubt to the Veteran, the Board finds that the evidence is at least in equipoise in favor os his claim and, therefore, finds that his insomnia began in and as a result of his military service. In our October 2020 Board Remand, the AOJ was asked to obtain an addendum medical opinion whether the Veteran’s insomnia condition is at least as likely as not related to his service as the VA examiner stated in his September 2019 that he was unable to provide this opinion without resorting to mere speculation. The Board found that opinion to be inadequate as the VA examiner did not take into consideration certain evidence, including evidence the Board thought may be favorable to the Veteran’s claim. The VA examiner had previously provided a December 2017 medical opinion that the Veteran’s insomnia was less likely than not proximately due to or the result of the Veteran’s service-connected disability and provided a rationale for that opinion. In the new January 2021 addendum opinion, the same VA examiner stated that after review of the Veteran’s records there was no additional information to clarify the onset, cause, or the degree to which his sleep difficulty in the service accounts for his insomnia diagnosis and that the speculative notion to provide an opinion is maintained as to whether his sleep disturbance beginning during service or is etiologically related to his active duty service. Despite this the VA examiner stated that given the life-long sleep problems described by the Veteran, it appears as likely as not (50 percent or greater) the sleep problems described during service were similar to the current sleep problems described in the VA examination in which he was diagnosed with insomnia. The Veteran’s military service treatment records (STRs) do show that in the February 1968 “Report of Medical History,” which is part of his separation physical, he indicated that he experienced frequent trouble sleeping. This medical condition was not stated in the Veteran’s military entrance physical examination records of June 1964. The Board finds the Veteran to be both competent and credible in his description of sleep related problems, including when they began, their frequency and duration, and that they continued on a consistent basis immediately after he separated from the military. The Board finds nothing in the record which impugns his credibility on those matters, and the record does contain other evidence which corroborates his testimony. Therefore, as the Board must resolve any reasonable doubt in the Veteran’s favor, the claim for entitlement to service connection for insomnia is granted. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for a low testosterone condition and treatment. The Veteran seeks service connection for a low testosterone condition and treatment and contends that the condition was caused in-service or is due to a service-connected disability. VA concedes that the Veteran does have a current diagnosis of a low testosterone condition for which he receives treatment. The Veteran is service connected for prostate cancer in a January 2018 rating decision, and for erectile dysfunction in an August 2020 rating decision, secondary to and as aggravated by his prostate cancer. In its October 2020 decision the Board remanded the issue of entitlement to service connection for the Veteran’s low testosterone condition as he was granted service connection for his erectile dysfunction condition after the previous Board Remand in June 2019, and there were no medical opinions whether his low testosterone condition, also stated to be hypogonadism, was caused or aggravated by his erectile dysfunction disability. In the October 2020 Board Remand the AOJ was asked to obtain an addendum medical opinion whether the Veteran’s low testosterone/hypogonadism condition is at least as likely as not related to service connected prostate cancer residuals or erectile dysfunction associated with prostate cancer residuals/proximately due to service-connected disabilities/aggravated beyond its natural progression by service-connected disabilities. It also instructed the examiner to address whether it was at least as likely as not related to service if it were not secondary to a service-connected condition. The VA examiner prepared the requested addendum opinion in November 2020, in which the Veteran’s low testosterone/hypogonadism condition stated to be less likely than not (less than 50% probability) proximately due to or aggravated as the result of the Veteran’s service-connected conditions. This was based on the rationale that Veteran was diagnosed with a low testosterone condition in February 2008, and his service connected disabilities of erectile dysfunction diagnosed in 2003 and prostate cancer in 2014; and etiologically that the Veteran’s hypogonadism/low testosterone is not related to his prostate gland or aggravated beyond natural progression by his service-connected prostate cancer. Also, medical literature has established that low testosterone causes hypogonadism, therefore prostate cancer is less likely to cause or aggravate hypogonadism. Further, since the low testosterone/ hypogonadism condition was not a result of his service connected erectile dysfunction or prostatae cancer, the VA examiner also stated that it was less likely than not (less than 50% probability) incurred in or aggravated in-service as the Veteran’s STRs had no complaints or diagnosis of hypogonadism/low testosterone during his military service from 1964 to 1968, his separation exam of February 1968 showed a normal genito-urinary examination, and he was not diagnosed with low testosterone until 2008. The Veteran’s STRs do not show any complaints, treatment, or diagnosis for a low testosterone condition. A February 2008 letter from the Veteran’s VA medical provider advised the Veteran of his low testosterone condition and that his low testosterone condition could be contributing to his erectile dysfunction. See February 2008 VA treatment record. The Veteran was diagnosed with prostate cancer in November 2014. The VA examiner for the Veteran’s October 2018 VA examination for prostate cancer recorded a diagnosis of erectile dysfunction with an etiology of hypogonadism. By way of background, the prostate is a male gland which contributes to the production of seminal fluid for reproduction. Dorland’s Illustrated Medical Dictionary (hereinafter Dorland’s), 1553 (31st ed. 2007). Hypogonadism is “a condition resulting from abnormally decreased gonadal function.” Id., page 915. Dorland’s defines a gonad as “a gamete-producing gland; an ovary, testis or ovotestis.” Id. page 808. Testosterone is a hormone produced “by the interstitial cells of the testes.” Id. page 1929. The Board notes that generally, low testosterone is not a disability in and of itself for which VA compensation benefits are payable. While low testosterone may be a sign of a separate disability, standing alone it is a laboratory finding. Laboratory findings are not disabilities in and of themselves for VA purposes. The term “disability” for VA purposes refers to a condition which has been deemed to result in impairment to the claimant’s earning capacity. See 38 C.F.R. § 4.1. In this instance, the Board accepts that the Veteran’s current low testosterone could be consider a disability, as he has been found to have physical manifestations from this disorder and receives treatment for it, and the Board’s prior remands have accepted that this is a disability for which separate service connection could theoretically be granted. In this case, the preponderance of the probative medical evidence does not demonstrate that the Veteran has a low testosterone/hypogonadism disorder, separate from those disorders that have already been granted service connection, which is related to service or that has been caused or aggravated by a service-connected disorder. The medical evidence does indicate that the Veterans’ low testosterone has contributed to the onset of erectile dysfunction, and it has also been related to his prostate cancer residuals. The Veteran has already been awarded service connection for prostate cancer residuals and erectile dysfunction, so to the extent that low testosterone/hypogonadism has contributed to erectile dysfunction, which is a residual of prostate cancer, this disorder has been compensated, and cannot be separately service connected again under a different diagnosis name. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994) (VA may not assign multiple ratings for duplicative or overlapping symptomatology.). No medical opinions were received which stated that the Veteran’s low testosterone/hypogonadism was caused or aggravated by his service-connected disabilities or that it developed in or caused by his military service. The Veteran, as a lay witness, is not shown to have the requisite medical training to provide a competent medical opinion concerning the cause of his low testosterone condition or its relationship – nexus – to his military service or a service connected disability. Layno, 6 Vet. App. at 470. The Board finds the opinions of the VA examiner to be highly probative. They are based on review of the Veteran’s file and supported with a detailed medical analysis which is consistent with other medical evidence of record. That being the February 2008 letter from the Veteran’s VA medical provider which advised the Veteran his low testosterone condition could be contributing to his erectile dysfunction, and the etiology stated for his erectile dysfunction to be low testosterone as recorded in his October 2018 prostate cancer VA examination. Both of these records indicate that his erectile dysfunction was caused by his low testosterone condition, not the other way around. Also, the medical definitions which affirm that the prostate is not involved in the production of testosterone which is instead produced in the testes. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert, 1 Vet. App. at 55-57. The claim for entitlement to service connection for the Veteran’s low testosterone condition/ hypogonadism and treatment thereto, is denied. Mary E. Rude Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Bannach, 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.