Citation Nr: 21032463 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 16-00 072 DATE: May 27, 2021 ORDER 1. Entitlement to service connection for a skin disorder is denied. 2. Entitlement to an initial evaluation in excess of 20 percent for service-connected diabetes mellitus, type II, is denied. 3. Entitlement to a separate evaluation for right upper extremity diabetic neuropathy is granted. 4. Entitlement to a separate evaluation for left upper extremity diabetic neuropathy is granted. 5. Entitlement to a separate evaluation for right lower extremity diabetic neuropathy is granted. 6. Entitlement to a separate evaluation for left lower extremity diabetic neuropathy is granted. 7. Entitlement to an evaluation in excess of 20 percent for service-connected residuals of a gunshot wound to the right shoulder (right shoulder disability) is denied. REMANDED Entitlement to a separate evaluation for erectile dysfunction and/or special monthly compensation for loss of use of a creative organ is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran had a chronic skin disorder that began in service or is other etiologically related to in-service injury or disease, to include herbicide agent exposure. 2. The preponderance of the evidence demonstrates that the Veteran's service-connected diabetes mellitus, type II, did not require daily insulin or regulation of activities. 3. The preponderance of the evidence demonstrates that the Veteran's service-connected diabetes mellitus, type II, caused right and left upper and lower extremity neuropathy. 4. The Veteran's right shoulder (minor) disability, muscle group IV, is rated at the maximum schedular level for that disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a skin disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for an evaluation in excess of 20 percent for service-connected diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7913. 3. The criteria for a separate evaluation for right upper extremity diabetic neuropathy are met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7913. 4. The criteria for a separate evaluation for left upper extremity diabetic neuropathy are met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7913. 5. The criteria for a separate evaluation for right lower extremity diabetic neuropathy are met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7913. 6. The criteria for a separate evaluation for left lower extremity diabetic neuropathy are met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7913. 7. The criteria for an evaluation in excess of 20 percent for right shoulder (minor arm) disability have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 4.73, Diagnostic Code 5304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1967 to August 1969, with service in Vietnam. He was in receipt of a Purple Heart and a Combat Infantryman Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision by the Department of Veterans Affairs (VA) Montgomery, Alabama Regional Office (RO). In May 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. The Veteran died in September 2020 and the appellant is his surviving spouse. The appellant was properly substituted into the appeal, as noted in a January 2021 letter. In April 2020, the Board remanded the issues on appeal. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. The Board directed the RO to have the Veteran complete authorization forms for non-VA providers, to include Bayou Clinic, to obtain VA treatment records beginning in May 2019, to obtain an appropriate muscle examination for the right shoulder, and to readjudicate all the issues on appeal after significant evidence had been submitted to the Board after the last statement of the case. The RO sent the Veteran a letter requesting appropriate authorizations in May 2020. No response was received. VA treatment records dated through October 2020 were obtained. Although an examination for the right shoulder was scheduled, the Veteran died before it could be completed. Accordingly, the Board finds that there has been substantial compliance with the prior Board remand. Regarding the claim for service connection for a skin disorder, no VA examination was provided, but the Board find that none is required. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159. VA's duty to assist includes providing a medical examination when is necessary to decide on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The RO did not provide the Veteran with an examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Although there are current diagnoses and herbicide agent exposure is conceded, there is no "indication" that the skin disorders are due to service. The Veteran's testimony that his skin diagnoses are related to Agent Orange exposure is not competent as detailed below, he has not testified that there were continuous symptoms since service, and there is no medical evidence indicating that the disorders were due to herbicide agent exposure. Accordingly, the Board finds that no examination and opinion are required. Regarding the claim for an increased evaluation for the right shoulder disability, the Board finds the 2013 VA examination was not entirely adequate. In cases involving limitation of motion of joints, "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). In addition, assignment of a disability rating should take into account consideration of limitation of functional ability during flare-ups or when a joint is used repeatedly over a period of time. Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). The examination did not fully address flare-ups, address the left shoulder range of motion, passive motion, and weight-bearing versus non-weight-bearing. The Board finds, however, there is no prejudice to the appellant in proceeding with the adjudication of this claim. Specifically, at the VA examination, the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed by the examiner. The reports do not suggest that the findings on examination, in terms of range of motion (ROM), would change to the degree required for a higher rating during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record, to include the Veteran's lay statements. Moreover, as a general matter of course, active range of motion testing usually results in further limitation than passive range of motion testing. Massie v. Shinseki, 25 Vet. App. 123, 131 (2011). In short, the Board notes that there is no reason to suspect that passive range of motion would be any less than that of active motion absent a finding of such on examination or report of such by the Veteran, neither of which is present in this case. Furthermore, as the Veteran died in 2020, he is not available for additional examination or for additional information regarding flare-ups. 1. Entitlement to service connection for a skin disorder is denied. In a June 2013 submission, the Veteran asserted that his skin disorder was due to Agent Orange exposure. At the May 2019 Board hearing, the Veteran stated that his skin disorder began around four to 10 years prior. He described the symptoms as itching with dry, flaky skin. He also stated that no medical practitioner had related the skin disorder to service. The Board concludes that preponderance of the evidence is against finding that the Veteran had a chronic skin disorder that began in service or is other etiologically related to in-service injury or disease, to include herbicide agent exposure. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a), (d). A veteran who served in the Republic of Vietnam during the Vietnam era is presumed to have been exposed during to an herbicide agent, unless there is affirmative evidence to the contrary. 38 C.F.R. § 3.307(a)(6)(iii). The Vietnam era is the period beginning on February 28, 1961 and ending on May 7, 1975 for veterans who served in the Republic of Vietnam. 38 U.S.C. § 101(29)(A). The Veteran's DD-214 indicates one year of Vietnam service during the period from 1967 to 1969. Accordingly, he is presumed exposed to Agent Orange. For veterans presumed to have been exposed to herbicides, certain enumerated diseases shall be service connected even though there is no record of such disease during service, so long as the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307(a)(6)(iii) are met, and the rebuttable presumption provisions of 38 U.S.C. § 1113 and 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). The enumerated diseases which are deemed to be associated with herbicide exposure include chloracne, but no other skin disorder. 38 C.F.R. § 3.309(e). Although the Veteran's diagnosed skin conditions (e.g. seborrheic keratosis, dermatitis, and eczema) are not diseases presumptively associated with exposure to herbicide agents, 38 C.F.R. § 3.309(e), nonetheless, service connection may be established with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also McCartt v. West, 12 Vet. App. 164, 167-68 (1999) (providing that the provisions set forth in Combee are equally applicable in cases involving claimed Agent Orange exposure). In this case, although the Veteran had current diagnoses of seborrheic keratosis, dermatitis, and eczema, and evidence shows Agent Orange exposure, the preponderance of the evidence weighs against finding that any skin disorder began during service or is otherwise related to an in-service injury, event, or disease to include herbicide agent exposure. Treatment records show the Veteran was not diagnosed with keratosis, dermatitis, and/or eczema until at least 25 years after his separation from service. The Veteran's service treatment records (STRs) are silent for any skin disorder. In a February 1970 VA General Examination conducted shortly after discharge, there was a normal skin examination. Seborrheic keratosis was not noted until March 1999 in VA treatment records. Dermatitis was diagnosed in an October 2011 VA record. An April 2013 VA record diagnosed seborrheic keratosis. Private treatment records confirm a dermatitis diagnosis in October 2017. A December 2018 VA examination was conducted in relation to a skin cancer claim. The examiner determined there was no chloracne or skin cancer but noted diagnoses of eczema and seborrheic keratosis. At the 2019 Board hearing, the Veteran testified that his skin disorder did not begin until sometime in the 2000s. Thus, the lay and medical evidence does not support an in-service onset or continuity of symptomatology; rather, the evidence shows that any skin disorder began years after service. The Veteran has asserted that his skin disorders are related to his exposure to Agent Orange. The Veteran is not competent to provide a nexus opinion regarding this issue as it is medically complex - it requires knowledge of the relationship between chemical exposures and a decades-later development of skin conditions. Therefore, it is outside the competence of the Veteran because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Also as noted at the 2019 Board hearing, the Veteran stated that no medical practitioner had indicated his skin symptoms were due to Agent Orange exposure. Thus, there is not competent evidence indicating a possible relationship between his diagnosed skin disorders and herbicide agent exposure. Accordingly, the evidence does not demonstrate than any skin disorder is related to service. On balance, the weight of the evidence is against the claim. Accordingly, the claim is denied. There is no doubt to resolve. 38 U.S.C. § 5107(b). Increased Evaluations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2020). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2020). 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2020). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3 (2020). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2020). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev'd in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. at 509. Here, the date of claim regarding diabetes mellitus was in August 2012. The date of claim regarding the right shoulder was in June 2013. 2. Entitlement to an initial evaluation in excess of 20 percent for service-connected diabetes mellitus, type II. At the 2019 Board hearing, the Veteran asserted entitlement to a higher evaluation for diabetes mellitus, noting that he was no longer taking medication, but was being checked by his doctor regularly. He stated that he did not have other side effects that he knew of. The Board concludes that the preponderance of the evidence is against a rating in excess of 20 percent for the Veteran's service-connected diabetes mellitus, type II; he did not require daily insulin or regulation of activities. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7913. However, as explained later in this decision, the evidence warrants separate rating for associated disability as a complication of diabetes mellitus. Diagnostic Code 7913 provides a structured scheme of specific, successive, cumulative criteria. Each higher rating includes the same criteria as the lower rating plus distinct new criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). A 20 percent rating is warranted when diabetes requires one or more daily injection of insulin and restricted diet, or an oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted when it requires one or more daily injection of insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. A 60 percent rating is warranted when diabetes requires one or more daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100-percent evaluation. Noncompensable complications of diabetes are considered part of the diabetic process. 38 C.F.R. § 4.119, Diagnostic Code 7913 (Note 1). Because Diagnostic Code 7913 contains successive criteria, the criteria for the lower rating must be met before a higher disability rating may be awarded. A higher rating cannot be granted based on a finding that the Veteran's disability picture more nearly approximates the criteria for the next higher rating. However, reasonable doubt regarding the presence of a criterion may be resolved in the Veteran' favor. Johnson v. Wilkie, 30 Vet. App. 245 (2018). The question in this appeal is whether the Veteran's diabetes mellitus required one or more daily injections of insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. This criterion requires medical evidence. Camacho v. Nicholson, 21 Vet. App. 360, 364-65 (2007). The Board finds that the Veteran's diabetes mellitus required only restricted diet and an oral glycemic agent during the period on appeal, but not regulation of activities or insulin. In a July 2013 VA examination report, the examiner diagnosed non-insulin requiring DM, type II. The Veteran was prescribed an oral hypoglycemia agent but did not require regulation of activities or any other medications. A May 2018 VA medical record included a determination that the Veteran was no longer diabetic. A February 2019 VA medical clinician noted that upon review of the record, they did not find justification to support a diagnosis of diabetes. In a March 2019 VA examination, the examiner noted there was a diagnosis of DM, and that it was managed by restricted diet and no medications, to include insulin. The examiner further found that the Veteran's DM did not require regulation of activities. Thus, the medical evidence does not indicate insulin and/or regulation of activities. The Veteran is competent to report the circumstances of his disease and his reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the lay and medical evidence of record is against a finding that insulin and regulation of activities was required during the period on appeal. As such, the weight of the evidence is against assigning a rating in excess of 20 percent during the period on appeal. To this extent, the Veteran's claim for a higher rating for diabetes is denied. There is no reasonable doubt to resolve in this matter. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). However, as indicted above, the Board finds that the criteria are met to separate rating the Veteran's complications of diabetes. Separate evaluations may be assigned for various compensable complications of diabetes mellitus. See 38 C.F.R. § 4.119, Diagnostic Code 7913, Note 1. Although a July 2013 VA examination noted there were no conditions due to diabetes mellitus, a March 2019 VA Diabetes Mellitus examination determined the disability caused diabetic peripheral neuropathy. A separate March 2019 VA Diabetic Sensory-Motor Peripheral Neuropathy examination noted diagnoses of bilateral upper and lower extremity diabetic neuropathies. This examination showed potentially compensable evaluations as the examiner determined there was at least mild incomplete paralysis. Therefore, the Board finds that separate disability ratings are warranted for bilateral upper and lower extremity peripheral neuropathy as a complication of the Veteran's diabetes mellitus. Accordingly, separate evaluations are for assignment; the AOJ shall assign those in the first instance. 3. Entitlement to a rating in excess of 20 percent for service-connected residuals of a gunshot wound to the right shoulder. The Board concludes that the criteria for an evaluation in excess of 20 percent for right shoulder (minor arm) disability have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 4.73, Diagnostic Code 5304. The Veteran's disability is evaluated under DC 5304, which is the shoulder girdle and arm. 38 C.F.R. § 4.73. DC 5304 addresses Group IV, the function of which is the stabilization of shoulder against injury in strong movements, holding the head of humerus in socket, abduction, outward rotation, and inward rotation of the arm. It includes the intrinsic muscle of the shoulder girdle, including the supraspinatus, the infraspinatus and teres minor, the subscapularis, and the coracobrachialis. A 20 percent evaluation for the minor arm is assigned for severe residuals of a muscle injury and it is the maximum evaluation permitted. No higher schedular evaluation is available. 38 C.F.R. § 4.73, Diagnostic Code 5304. All potentially applicable diagnostic codes have been considered. Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991) (holding that the Board must consider all potentially applicable regulatory provisions). Regarding other muscle groups of the shoulder girdle and arm, the evidence of record does not demonstrate severe disability related to Group I (upward rotation of scapula, elevation of arm above shoulder level); Group II (depression of arm from vertical to hanging at side, downward rotation of scapula, and the forward and backward swing of arm); or Group III (elevation and abduction of arm to level of shoulder, acting in the forward and backward swing of arm). 38 C.F.R. § 4.73, Diagnostic Codes 5301, 5302, 5303. In an August 2013 VA shoulder joints examination, the examiner found there was mild functional limitation. In particular, examination showed movement of the arm above shoulder level, even considering additional functional loss, with flexion to 150 degrees and abduction to 125 degrees. Repetitive use did not cause any additional limitation of motion and there was 5/5 muscle strength without guarding. Testing for rotator cuff conditions was negative, and there was no history of mechanical symptoms or recurrent dislocation. There was negative crank apprehension, cross body adduction, and relocation testing. There was no acromioclavicular (AC) joint condition or other impairment of the clavicle or scapula. There was tenderness on palpation on the AC joint. The evidence thus does not support an increased evaluation under these diagnostic codes. Additionally, the evidence does not show severe disability of Group V (elbow supination, flexion of elbow), and Group VI (elbow extension). Accordingly, other muscle groups of the shoulder girdle and arm do not provide for an increased evaluation. 38 C.F.R. § 4.73, DCs 5305, 5306. Regarding orthopedic disability of the shoulder joint, a 20 percent evaluation is the highest awarded for impairment of the clavicle or scapula. 38 C.F.R. § 4.71a, DC 5203. Additionally, an August 2013 VA examiner found there was no shoulder ankylosis. At the 2019 Board hearing, the Veteran did not report ankylosis. See 38 C.F.R. § 4.71a, DC 5200. Furthermore, regarding other impairment of the humerus, the 2013 VA examination did not show fibrous union of the humerus, false flail joint, or flail shoulder. See 38 C.F.R. § 4.71a, DC 5202. Regarding limitation of motion, a maximum 30 percent evaluation is assigned for flexion and/or abduction limited to 25 degrees from the side of the minor arm. 38 C.F.R. § 4.71a, DC 5201. The Veteran reported shoulder pain throughout the treatment records. At the 2019 hearing, he testified that he was left-handed and that he could move his arm past shoulder level, but that he could not keep it in that position, and it caused increased pain. He also reported weakness. But in the August 2013 VA examination, the examiner found flexion to 150 degrees and abduction to 125 degrees, both without objective evidence of painful motion. Upon repetitive use testing, there was no change in the limitation of motion. The examiner opined that there was no loss of function with repetitive use, except as noted. Additionally, the examiner could not determine the extent of functional loss due to flareups or repetitive use limited functional ability without speculation. Additionally, there was 5/5 muscle strength, no guarding, and no rotator cuff or AC joint conditions. The Veteran reported worsened pain during cold or rainy weather, and lack of strength. The range of motion would need to be limited an additional 100 or 125 degrees for a higher evaluation. But these functional limitations and symptoms do not indicate such a severe worsening, to include due to full strength and no additional limitation of motion upon repetitive use. Thus, even considering additional functional loss, the right arm was not limited to 25 degrees from the side. Accordingly, an increased evaluation is not warranted. As such, the Veteran's claim is denied. There is no reasonable doubt to resolve in this matter. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). REASONS FOR REMAND Entitlement to a separate evaluation for erectile dysfunction or SMC due to loss of use of a creative organ is remanded. The Board finds that remand is warranted for an addendum opinion addressing whether erectile dysfunction is related to service-connected diabetes mellitus. As noted above, separate evaluations may be assigned for various complications of diabetes mellitus. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note 1. Additionally, special monthly compensation is warranted for loss of use of a creative organ due to service-connected disability. 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350(a); 38 C.F.R. § 4.115b, Diagnostic Code 7522. VA treatment records dated as early as 2007 noted treatment for erectile dysfunction. A July 2013 VA examination noted there were no conditions due to DM. The examiner opined that the claims file showed pre-existing erectile dysfunction without any evidence of worsening beyond natural progression because of diabetes mellitus. In a March 2019 VA Diabetes Mellitus examination report, however, the examiner opined that diabetes caused erectile dysfunction, but did not address the prior opinion or treatment records. Accordingly, remand is required for a clarifying opinion. The matters are REMANDED for the following action: 1. Obtain an addendum retrospective opinion from an appropriate clinician to address whether the Veteran's ED was at least as likely as not proximately due to or aggravated by service-connected diabetes mellitus, type II. (a.) The clinician should review and comment on the opinions provided in the 2013 and 2019 VA examination reports. (b.) An adequate medical opinion will identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). 2. Ensure that the VA medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.M., 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.