Citation Nr: 22016292 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 16-55 683 DATE: March 21, 2022 REMANDED Entitlement to service connection for erectile dysfunction, to include as due to service-connected diabetes mellitus and posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1966 to July 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2021, the Veteran testified at a hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. The undersigned agreed to keep the record open for 30 days to allow the Veteran additional time to submit nexus evidence to support his claim. See November 2021 Hearing Transcript, page 4. The Board notes that the 30 day period has elapsed, and no such evidence has been received. By way of background, this matter was previously before the Board in November 2018. At that time, the Board reopened the Veteran's claim of entitlement to service connection for erectile dysfunction and remanded the issue for additional development. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected diabetes mellitus and PTSD, is remanded. In November 2018, the Board remanded the Veteran's service connection claim to obtain an addendum medical opinion regarding the etiology of his diagnosed erectile dysfunction. Specifically, the Board asked the examiner to proffer an opinion as to whether it was at least as likely as not that the Veteran's erectile dysfunction was caused or aggravated by a service-connected diabetes mellitus and PTSD, to include as due to medications prescribed to treat the latter condition. To this end, the Board advised the examiner that secondary service connection was not barred merely because the Veteran's erectile dysfunction was diagnosed prior to diabetes mellitus or PTSD. See November 2018 BVA Decision. After a review of the record, the Board notes that VA obtained an addendum medical opinion in January 2019. However, the Board finds that the January 2019 VA examiner did not substantially comply with the November 2018 Board remand, and as such, additional development is needed before the Veteran's claim can be decided. Stegall v. West, 11 Vet. App. 268, 271 (1998). As noted above, VA obtained an addendum medical opinion in January 2019. After performing a review of the evidence of record, the examiner opined that it was less likely than not that the Veteran's erectile dysfunction was proximately due to or the result of his service-connected diabetes mellitus, PTSD, or medications used to treat the latter condition. In support of her opinion, the examiner noted that the Veteran developed symptoms of erectile dysfunction before he was diagnosed with diabetes mellitus and before he began taking medications to treat PTSD. However, the examiner indicated that the Veteran had a 30 year history of hypertension and explained that such was a chronic condition known to adversely affect sexual functioning. The examiner further noted that literature from up to date and the New England Journal of Medicine revealed that hypertension was a common cause of sexual dysfunction in the elderly population. As such, the examiner found that the Veteran's long history of hypertension combined with the normal aging process was the most likely cause of decline in his sexual functioning. See January 2019 C&P examination. The Board finds that the January 2019 VA examiner did not proffer an opinion as to whether it was at least as likely as not that the Veteran's diagnosed erectile dysfunction was aggravated beyond its natural progression by his service-connected diabetes mellitus and PTSD or by medication he took to treat his service-connected disability. Thus, the Board finds that VA did not substantially comply with the November 2018 remand directives. Based on the foregoing, the Board finds that a remand is warranted to obtain an addendum medical opinion for full compliance with the Board's previous remand instructions. The matter is remanded for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. After completion of the above development, obtain an opinion by an appropriately qualified examiner to determine the nature and etiology of the Veteran's diagnosed erectile dysfunction. It is up to the discretion of the examiner as to whether an in-person examination is necessary. The examiner should provide the following opinions: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed erectile dysfunction was aggravated by his service-connected diabetes mellitus? Please explain why or why not. (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed erectile dysfunction was aggravated by his service-connected PTSD, to include as due to side effects from his psychiatric medications? Please explain why or why not. The examiner should observe that permanent aggravation is not required. If aggravation is found, the examiner should identify, to the extent possible, the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the Veteran's service-connected diabetes mellitus and/or PTSD. The examiner is advised that if a negative opinion is provided for the secondary service connection claim, the rationale provided must go beyond noting that the Veteran's erectile dysfunction symptoms manifested before he was diagnosed with diabetes mellitus and before he began taking medications to treat his service-connected PTSD as there is no requirement in VA regulation that the primary disability must be diagnosed prior to the secondary disability in order to establishment entitlement to service connection on a secondary basis. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Justis, 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.