Citation Nr: 21029983 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 16-12 044 DATE: May 17, 2021 REMANDED Entitlement to an initial compensable rating for left testicle varicocele is remanded. REASONS FOR REMAND 1. Entitlement to an initial compensable rating for left testicle varicocele is remanded. The Veteran had active service from March 1991 to September 1994; January 2003 to June 2003; and September 2005 to September 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an October 2013 Department of Veterans Affairs (VA) Regional Office (RO) rating decision granting service connection for left testicle varicocele with a disability rating of 0 percent. This matter was before the Board in April 2020, and again in February 2021, at which time the Board remanded the Veteran's claim to obtain an addendum to an October 2020 VA medical opinion regarding the symptoms of his left testicle varicocele. A remand by the Board confers on the Veteran, as a matter of law, the right to substantial compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). A VA medical opinion was obtained in February 2021. As discussed further below, the Board finds that the February 2021 opinion is inadequate. Once VA undertakes the effort to provide an examination when developing a claim, the examination must be an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Accordingly, the Veteran's claim must be remanded again to obtain substantial compliance. The Veteran's varicocele is currently rated under Diagnostic Code 7120 for varicose veins. 38C.F.R. §4.104. The 0 percent rating requires a showing of an asymptomatic palpable or visible varicose vein. The criteria for higher ratings include, but are not limited to: intermittent edema with symptoms relieved by elevation or compression; persistent edema, with or without beginning stasis pigmentation or eczema; persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration; persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration; and/or massive board-like edema with constant pain at rest. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38C.F.R. §4.7. While VA has hitherto characterized the Veteran's varicocele as asymptomatic, the record reflects complaints by the Veteran, or clinical observation, of testicular, scrotal, or groin pain, tenderness to palpation, and/or swelling on the following occasions: February 2013 VA examination; May 2013 VA treatment note; November 2013 treatment note; February 2016 Notice of Disagreement to VA; May 2017 VA treatment note; October 2017 VA treatment note; May 2018 VA treatment note; June 2018 VA treatment note; February 2019 VA treatment note; and December 2019 hearing testimony. However, the overall disability picture is complicated by the Veteran's other disabilities, both service-connected and nonservice-connected. The record reflects that the Veteran has other symptoms and manifestations not contemplated by Diagnostic Code 7120, which are attributable to his varicocele. When a particular service-connected disability is not listed in the rating schedule, it may be rated by analogy to a closely related disease in which not only the functions affected, but also the anatomical location and symptomatology are closely analogous. 38C.F.R. §§4.20, 4.27. When it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. 38C.F.R. §3.102; Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). February 2013, May 2018, and February 2019 VA treatment notes reflect that infertility may be a symptom of the Veteran's varicocele. The most recent VA rating code sheet reflects that VA has associated the Veteran's infertility with his service-connected prostatitis, rated under Diagnostic Code 7527; however, infertility is not an element of the rating criteria for Diagnostic Code 7527, and the record does not reflect that the Veteran's prostatitis is rated under a hyphenated diagnostic code pursuant to 38C.F.R. §4.27. Moreover, the record reflects that the Veteran has also been diagnosed with bilateral hydrocele of the testicles, a disability that is not currently service-connected. In light of the foregoing, in April 2020 the Board directed that a VA medical opinion be obtained in order to determine the current severity of the Veteran's disability, as the last VA examination had been provided in February 2013. The Board also directed the examiner to "specifically identify all disability manifestations and symptoms, including but not limited to pain, swelling, and infertility, which are at least as likely as not attributable to the Veteran's left testicle varicocele." A VA medical examination was obtained in October 2020. However, the October 2020 VA examiner's report was limited to a physical examination of the Veteran's reproductive organs and documentations of associated clinical findings on the day of the examination, along with documentation of the Veteran's own report of his history and symptoms. The report included no independent medical analysis of which of the Veteran's various claimed symptoms, including the clinical observations documented on the day of the examination, were at least as likely as not attributable to the Veteran's left testicle varicocele. Thus, in February 2021 the Board remanded the Veteran's claim to obtain an addendum opinion that was adequately responsive to the April 2020 remand directives. An addendum opinion was obtained in February 2021. The VA examiner's response, in full, was as follows: "[P]ain, swelling, infertility secondary to chronic prostatitis and epididymitis based of treatment record dated [February 2019] and [January 2019]." On its face, this opinion is inadequate in that it is not responsive to the Board's directive that the examiner "specifically identify all disability manifestations and symptoms . . . which are at least as likely as not attributable to the Veteran's left testicle varicocele", instead only identifying symptoms which are purportedly not associated with the Veteran's left varicocele. Moreover, it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). A mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor's opinion. Stefl v. Nicholson, 21 Vet. App. 120, 125 (U.S. 2007). The probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. See Sklar v. Brown, 5 Vet. App. 140 (1993). Here, the examiner has not provided any rationale to support their opinion, but has only provided conclusory citations to two treatment notes associated with specific dates. Further, to the extent they are relevant at all, the Board finds that the treatment notes cited to by the examiner appear to contradict the examiner's conclusion. The February 2019 note is a urology follow up note that reflects the Veteran's report to the provider that a previous doctor told him that his left testicle pain may be the result of an infection, and that removal of the left epididymis was suggested. The February 2019 note does not reflect any discussion of the Veteran's prostatitis. The record includes two January 2019 treatment notes: a primary care note and a nursing note. Neither January 20198 note reflects any discussion of the Veteran's claimed symptoms of testicular pain and/or swelling, or infertility. Additionally, the February 2019 note characterizes the Veteran's left scrotal pains as questionably secondary to recurrent left varicocele, and a January 2017 note characterizes the Veteran's infertility as questionably secondary to left varicocele. The January 2017 note reflects that a varicocelectomy was considered as treatment for left testicle pain. Thus, contrary to the Board's April 2020 and February 2021 remand directives, there is still not yet of record a VA medical opinion that specifically identifies the symptoms associated with the Veteran's left testicle varicocele and evaluates the current severity of those symptoms. The matters are REMANDED for the following action: 1. Forward the claims file, including this remand, to the examiner who provided the February 2021 opinion. If the February 2021 VA examiner is unavailable, or is unable to offer the opinion sought, the requested opinions should be obtained from another appropriately qualified clinician. The examiner shall indicate in the addendum report that the claims file was reviewed. The need for an additional in person examination is left to the discretion of the medical professional offering the addendum opinion. (Continued on the next page) The examiner should specifically identify all disability manifestations and symptoms, including but not limited to pain, swelling, and infertility, which are at least as likely as not attributable to the Veteran's left testicle varicocele. After these symptoms have been identified, the examiner should evaluate their severity. If possible, the examiner should provide an evaluation of their severity for the period from February 2013 onward. A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner explain why an opinion cannot be provided and specifically state whether the inability to provide an opinion is due to the limits of the examiner's knowledge, the limits of medical knowledge in general, or there is additional evidence that would allow for an opinion on this matter. If due to the limits of the examiner's knowledge, then the RO should refer the claims file to an examiner with the requisite training and experience Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. C. Sametshaw 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.