Citation Nr: 21031136 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 18-28 411A DATE: May 20, 2021 REMANDED Entitlement to an initial evaluation in excess of 10 percent for residuals of prostate cancer is remanded. REASONS FOR REMAND The Veteran had active service from June 1965 to December 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2014 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). This matter, entitlement to an initial evaluation in excess of 10 percent for residuals of prostate cancer, was previously before the Board. Specifically, in July 2019, the Board denied the claim. The Veteran appealed the Board's July 2019 denial of the claim to the United States Court of Appeals for Veterans Claims (Court). In an Order dated in June 2020, the Court granted a June 2020 Joint Motion for Remand (JMR) of the parties (the Secretary of VA and the Veteran), vacated the Board's July 2019 decision, and remanded the case to the Board for readjudication consistent with the JMR. The Board, in part, remanded the claim in November 2020. It now returns for appellate review. 1. Entitlement to an initial evaluation in excess of 10 percent for residuals of prostate cancer is remanded. The June 2020 JMR found an April 2014 VA examiner noted the Veteran had "cancer of urethra" and further noted the Veteran had undergone "urethral surgery, radiation, and chemotherapy." The June 2020 JMR also found the August 2016 VA examiner stated that Veteran's urethral cancer was "likely from the prostate," and that a urethral resection surgery "seemed to be metastasis in retrospect." The June 2020 JMR also found the August 2016 examination noted erectile dysfunction, with an etiology of cancer of the prostate with resection and radiation treatment. The June 2020 JMR found that the Board erred by failing to consider whether this evidence related to Veteran's service-connected prostate cancer and warranted an increased rating or separate compensable ratings. Following the June 2020 JMR, the Board granted service connection for erectile dysfunction in November 2020. However, as to the Veteran's cancer of the urethra, as identified in the June 2020 JMR, the Board is unclear whether this disability is secondary to the Veteran's prostate cancer, and if so, whether it may be contributing to his voiding dysfunction or is resulting in any non-voiding and non-renal residuals. Bailey v. Wilkie, No. 19-2661, 2021 U.S. App. Vet. Claims LEXIS 13 (Jan. 6, 2021). In this regard, in an attachment to a June 2018 VA Form 9, substantive appeal, the Veteran's representative argued, as to the Veteran urethral cancer, he should receive a separate rating for this condition or its compensable residuals should be factored into the rating for his prostate cancer residuals. However, the Veteran's representative did not identify any specific manifestations related to the Veteran's cancer of the urethra. Also, during the January 2021 VA examination, the Veteran reported his prostate cancer spread to the regional lymph nodes, urethra, and bladder. Accordingly, an addendum opinion is necessary to determine whether the Veteran has residuals of cancer of the regional lymph nodes, cancer of the urethra, and/or cancer of bladder as secondary to his prostate cancer, and if so, what are the manifestations of such disability. In addition, in light of the remand for the above matter, updated VA treatment records and private medical records should be obtained. In this regard, the Board recognizes the Veteran was provided with a VA Form 21-4142, Authorization and Consent to Release Information to VA, in February 2021. However, as his private medical records were last obtained in June 2018, and as the record, such as a December 2020 VA treatment record, documented the Veteran was followed by a private urologist for his prostate cancer and bladder cancer, providing the Veteran with another opportunity to identify or submit relevant private medical records is warranted. The matters are REMANDED for the following actions: 1. Obtain any of the Veteran's updated VA treatment records, from January 2021 to the present. 2. Ask the Veteran to complete a VA Form 21-4142 for outstanding records for any relevant private medical providers, to include outstanding records of private urological treatment and any records from Lima Memorial Health System since June 2018. Make two requests for the authorized records from any identified medical providers, unless it is clear after the first request that a second request would be futile. 3. Obtain an addendum opinion from an appropriate clinician addressing whether the Veteran has residuals of cancer of the regional lymph nodes, cancer of the urethra, and/or cancer of bladder as secondary to service-connected prostate cancer, and if so, what are the manifestations of such disability. The examiner should address the following: (a.) Whether the Veteran has/had cancer of the regional lymph nodes, cancer of the urethra, and/or cancer of bladder which is at least as likely as not (1) proximately due to service-connected prostate cancer, or (2) aggravated (any increase in disability) by service-connected prostate cancer. Please explain. The clinician should consider that the August 2016 VA examiner stated that Veteran's urethral cancer was "likely from the prostate," and that a urethral resection surgery "seemed to be metastasis in retrospect." (b.) If residuals of cancer of the regional lymph nodes, cancer of the urethra, and/or cancer of bladder are found to be secondary to prostate cancer, please describe such residuals in detail. 4. Thereafter, readjudicate the issue on appeal. If the benefit sought is not granted, furnish the Veteran and his representative with a supplemental statement of the case and afford them an opportunity to respond before the record is returned to the Board for further review. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Espinoza, 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.