Citation Nr: 21031355 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 13-16 636 DATE: May 21, 2021 REMANDED Entitlement to service connection for residuals of vasectomy, to include scrotal pain, swelling and lop-sidedness, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1984 to June 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office. In April 2017, the Veteran and his wife testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the evidentiary claims file. The Board remanded this appeal in July 2018 and October 2020 to the agency of original jurisdiction (AOJ) for additional development and examination. Now the matter is returned to the Board. However, the Board finds that more development is necessary prior to final adjudication of the claim on appeal. The Veteran asserts that his current scrotum pain, swelling, and lop-sidedness is a residual of his in-service vasectomy performed in December 1995. At the April 2017 Board hearing, the Veteran testified that he experienced pain and swelling on the right side of the scrotum since a difficult vasectomy, where he recalled the doctor saying during the procedure, "oh, can't get...may have to come back in six months to do this." See April 2017 Board Transcript at 15. The Veteran further testified that the surgery was completed, but he had swelling and pain at his follow-up appointment and was prescribed Motrin. Id at 4. Moreover, the Veteran testified that his scrotum still appears swollen and is lop-sided, which occurred after the vasectomy. Id at 18-19. The Board remanded this appeal in July 2018 for additional development and examination to determine the nature and etiology of the Veteran's claimed vasectomy residuals, including pain and swelling on the right side. The Veteran was afforded a June 2019 VA examination, and an addendum opinion was obtained from the same examiner in February 2020. However, the examiner did not provide a direct opinion as requested in the July 2018 Board Remand directives. Moreover, the examiner identified that he did not have expertise in intrascrotal anatomy and surgery to analyze the details of the surgery. See February 2020 Addendum/Clarification Disability Benefits Questionnaire. The Board remanded this appeal in October 2020 for additional development. The Board requested a VA examination from an appropriate urologist to provide an opinion on the nature and etiology of the Veteran's vasectomy residuals. The decision noted the Veteran's testimony of continuing symptoms of scrotal pain and swelling since his in-service vasectomy and specifically advised the examiner to acknowledge and consider the Veteran's reports in formulating any opinion. Pursuant to the October 2020 Board Remand, in December 2020, a VA medical review and addendum opinion was conducted by a staff physician as step one of the two-step process implemented by the VA medical facility when examination requires specialty providers. The examiner noted that an extensive review of the Veteran's medical records was conducted and "medical evidence was accepted over anecdotal information" to provide the requested opinion. See December 2020 Compensation and Pension Exam, Medical Opinion. The examiner noted the Veteran's bilateral vasectomy was performed without difficulty in December 1995 and a follow-up a week later indicated swelling and a small hematoma on the right side, otherwise doing well. Thereafter, the review of the review of the record did not show genitourinary concerns until mid-2010 when prostate cancer was discovered. Thus, the examiner determined the Veteran's vasectomy was an uncomplicated procedure, except for the small right hematoma that resolved with no residuals in about six weeks. The examiner therefore opined that in the absence of an objective demonstrable finding, any symptoms the Veteran now experiences in the scrotum area are not and cannot be attributable to the 1995 procedure, after an interval of two plus decades. In February 2021, as the second step of a two-step process used by the VA medical facility when a specialty examination is required, the chief of urology reviewed all pertinent items in the claims file, including the medical opinion by the staff physician, to provide an addendum opinion. See February 2021 Medical Opinion Addendum/Clarification Disability Benefits Questionnaire. The chief urologist agreed with the December 2019 medical opinion that a vasectomy in 1995 is not likely to be related to any issues years later. The chief urologist speculated that the Veteran's pain could be caused by a hydrocele that can occur spontaneously or a hernia that can also cause intermittent groin pain. However, the chief urologist determined the vasectomy in 1995 would not lead to these issues years later. The Board notes it is undisputed that the Veteran's in-service vasectomy was difficult. Indeed, it is documented on the vasectomy postoperative screening as "complications: post [posterior] vas [deferens] on the right; difficult; slightly excessive bleeding." See December 14, 1995 Service Treatment Records. Therefore, the evidence of record contradicts the December 2020 VA examiner's finding that the vasectomy was performed without difficulty. Medical opinions based on an inaccurate factual premise are not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). As such, the Board finds the December 2020 VA medical opinion inadequate. In addition, the February 2021 VA neurologist reviewed and agreed with the December 2020 medical opinion. Of note, the chief neurologist was not provided the Veteran's entire claims file and medical records to review and formulate an opinion. Thus, the VA neurology addendum opinion was based on the December 2020 examiner's inaccurate factual premise that the in-service vasectomy was an uncomplicated procedure. In accordance with Reonal, the Board finds the February 2021 VA neurology addendum opinion inadequate. Id. Notably, the December 2020 VA medical opinion and February 2021 VA neurology addendum opinion did not address the Veteran's lay statements that he experienced pain, swelling, and appeared lop-sided as a residual of his in-service vasectomy, and the symptoms presently continue. Instead the examiners noted the gap in the record, with the December 2020 VA examiner specifically noting that medical evidence was considered over anecdotal information. A medical examiner is not free to simply ignore a Veteran's lay statements recounting symptoms or events. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Considering the above, the Board finds that while the AOJ made a good faith effort to further develop the claims, it has not "substantially complied" with the previous Board remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998). As such, the Board must remand for a medical addendum based on review of the entire evidentiary file that specifically considers and acknowledges the Veteran's reports of scrotal pain, swelling, and lop-sidedness since the in-service vasectomy and includes a rationale of any such rejection. Thus, this issue is once again being remanded to the AOJ to ensure compliance with the October 2020 Board remand directives. The matters are REMANDED for the following action: 1. The AOJ should obtain an addendum opinion from the same neurologist that conducted the February 2021 VA addendum medical opinion regarding the Veteran's claimed residuals of vasectomy, to include scrotal pain, swelling and lop-sided appearance. If the same examiner is not available, the request should be forwarded to another neurologist. If any examiner deems necessary, an in-person examination should be scheduled for the Veteran. The examiner must review the Veteran's complete claims file and a copy of this REMAND order before the examination and include a notation that a record review was performed. (a.) The examiner must opine whether the Veteran's claimed residuals of vasectomy, to include scrotal pain, swelling, and lop-sidedness are at least as likely as not (50 percent or greater probability) related to in-service vasectomy of December 1995 or otherwise had their onset in service. (b.) The examiner is specifically asked to consider the Veteran's April 2017 testimony of experiencing scrotal pain, swelling, and lop-sidedness since his in-service vasectomy performed in December 1995. See April 2017 Board Hearing Transcript. The examiner is advised that the Veteran is competent to report the onset, symptoms, and history, and such reports must be acknowledged and considered in formulating any opinion. See e.g., March 2013 RO Hearing Transcript. If the examiner rejects the Veteran's reports, an explanation for such rejection must be provided. (c.) The examiner must provide a complete written rationale for any opinion rendered. 2. The examiner must provide a complete written rationale for any opinion rendered. If the claims remain denied, the Veteran and his representative must be provided a Supplemental Statement of the Case and afforded the opportunity to respond. Thereafter, the appeal must be returned to the Board for appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Gipson, 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.