Citation Nr: 22012209 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 16-51 617 DATE: March 2, 2022 REMANDED Entitlement to service connection for hypertension, to include as due to exposure to herbicides, is remanded. Entitlement to service connection for erectile dysfunction (ED) is remanded. REASONS FOR REMAND The Veteran had active service from March 1968 to December 1969. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In June 2019, the Veteran testified at a hearing before a Veterans Law Judge. A transcript of the hearing has been associated with the record. This case was previously before the Board in September 2020 and July 2021, at which time the issues currently on appeal were remanded for additional development. The case has now been returned to the Board for further appellate action. Service Connection - Hypertension The Veteran contends that his hypertension is related to exposure to herbicide agents while serving in the Republic of Vietnam. The Veteran alternatively argues that his hypertension is secondary to ischemic heart disease (IHD) or diabetes. The Veteran was provided both entrance and exit examinations during his time in service. At the entrance examination in September 1967 the Veteran's blood pressure was shown to be 118/60. In December 1969, the Veteran had an elevated blood pressure reading of 130/84. At the December 1969 exit examination, the Veteran's blood pressure was found to be 126/88. This represents two elevated blood pressure readings prior to his separation from service. The Veteran was diagnosed with hypertension in 1983 and was placed on medication to control it at that time. The Veteran also has IHD, has suffered multiple heart attacks, and has had numerous stents placed. As of the October 2020 VA examination the Veteran was taking Lisinopril and Metoprolol for his hypertension. The Veteran was provided VA examinations in October 2020 and October 2021. Neither examiner mentioned the Veteran's elevated blood pressure upon separation from service. Based upon this failure to discuss the Veteran's in service elevated blood pressure readings the Board finds the October 2021 VA medical opinion inadequate for rating purposes. As this opinion does not provide information sufficient to make an informed decision on the issue another opinion is warranted. Service Connection - Erectile Dysfunction The Veteran contends that his ED is caused by his various medications. The Veteran specifically points to his medication for hypertension. The Veteran also has argued that his ED is secondary to his diabetes mellitus (DM). The Veteran's medical history for ED includes a June 2004 medical appointment where the Veteran complains of the ED worsening over the past few months. He believes that this worsening coincides with a change in medications for the Veteran's cardiovascular issues. The notes to this visit indicate that the ED is likely a result of the multiple medications the Veteran was on. No specifics or explanation were provided. The Veteran testified regarding the nature and etiology of his ED at the June 2019 hearing. The Veteran noted that no doctor had advised him that his ED was related to his diabetes. He testified that the ED began in 2000. He was asked if the doctor provided an explanation but answered that he was not informed of a cause. The September 2020 Board remand required that the Veteran be provided a VA examination to determine the nature and etiology of the ED. The Veteran was afforded a VA examination in October 2020. At this examination the Veteran claimed to have developed ED after being placed on medication to treat his hypertension in 1983. This onset would be 17 years earlier than he testified to during his June 2019 hearing. The examiner also noted that the Veteran found his condition unchanged since being diagnosed with CAD, diabetes, or upon the prescription of different medications. This is again at odds with the Veteran's June 2004 record in which he complained of a worsening of his ED. The examiner diagnosed the Veteran with ED and noted the etiology was antihypertensive medication side effect. The examiner then finds it less likely than not that the Veteran's ED is related to his time in service. This explanation works as long as the Veteran's hypertension remains not service connected. The most recent Board remand in July 2021 discussed the possibility that the Veteran's ED could be related to his hypertension and/or the hypertension medication. The issue was remanded for a new VA examination related to the Veteran's hypertension as well as a discussion of the Veteran's ED as it relates to the hypertension and hypertension medication. The Veteran's most recent VA examination occurred in October 2021. The Board remand only required the examiner to discuss ED if hypertension was found to be related to service. However, the examiner found a negative nexus for the Veteran's hypertension, but still provided further explanation on the Veteran's ED. The examiner found that the Veteran had numerous risk factors for ED. These include being over 50, having a BMI greater than 32, having sleep apnea, being an ex-smoker, having BPH, hyperlipidemia, and hypogonadism. All of these factors make it more likely that the Veteran would have ED. Given the Veteran's history and risk factors the examiner found that the proximate cause of the Veteran's ED was hypogonadism. There is no indication of when the Veteran first began to experience hypogonadism. There is a brief note in the Veteran's file from February 2013 when the Veteran was prescribed pain medication that one possible side effect was hypogonadism. Further, the examiner noted that with these myriad of risk factors the Veteran's hypertension and medication for that would play only a minor role if any role at all. Taking a look at the Veteran's record as whole there are three points of confusion that need clarity before the Board can come to a fair conclusion. First, there is the issue of when the Veteran began experiencing ED symptoms. At his June 2019 hearing he stated that his ED symptoms began in 2000. This is contradicted by the note from the October 2020 VA examiner who found that the Veteran self-reported ED symptoms as early as 1983 following the prescription of hypertension medication. This same October 2020 examiner also stated that the Veteran had not used any ED medication to date. Prior medical records indicate that the Veteran was provided a prescription for Viagra. Finally, the October 2021 examiner found hypogonadism to the proximate cause of the Veteran's ED, but no timeline was given as to when the Veteran was diagnosed or began experiencing hypogonadism. These issues need to be clarified before proceeding. The matters are REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA and/or private treatment records and associate them with the claims file. 2. Then, return the claims file to the VA examiner who conducted the October 2021 VA examination or a VA examiner with sufficient expertise for an addendum opinion to determine the nature and etiology of the Veteran's hypertension. The claims file must be made available to and reviewed by the examiner. If a new VA examination is required, then one should be scheduled. Based on a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that the Veteran's hypertension is etiologically related to his active service, to include conceded exposure to herbicides. The examiner must discuss the Veteran's two elevated blood pressure readings in December 1969. Additionally, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that the Veteran's hypertension was caused or aggravated (chronically worsened) by his service-connected IHD or DM. The rationale for all opinions expressed must be provided. 3. Then, return the claims file to the VA examiner who conducted the October 2021 VA examination or a VA examiner with sufficient expertise for an addendum opinion to determine the nature and etiology of the Veteran's ED. The claims file must be made available to and reviewed by the examiner. If a new VA examination is required, then one should be scheduled. Based on a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that the Veteran's ED is etiologically related to his active service. Additionally, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that the Veteran's ED was caused or aggravated (chronically worsened) by his service-connected IHD or DM, or nonservice-connected hypertension, to include any prescribed medications for such. The examiner should reconcile any conflicting dates regarding the onset of the Veteran's ED. Further, the examiner must clarify the onset of any disabilities found associated with the Veteran's ED, to include hypogonadism. The rationale for all opinions expressed must be provided. 4. Confirm that all medical opinions provided comport with this remand and undertake any other development determined to be warranted. 5. Then, readjudicate the appeal. If the decision remains adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. D. Ware Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Andrew Ledman II 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.