Citation Nr: 22016378 Decision Date: 03/22/22 Archive Date: 03/22/22 DOCKET NO. 14-31 081A DATE: March 22, 2022 ORDER Entitlement to service connection for erectile dysfunction, secondary to service-connected type II diabetes mellitus, on a causation basis, is granted. REFERRED The issue of entitlement to an increased rating for type II diabetes mellitus was raised by the Veteran in a March 2022 "Application for Disability Compensation and Related Compensation Benefits" form (VA Form 21-526EZ). This matter is referred to the agency of original jurisdiction (AOJ) for adjudication. FINDING OF FACT The evidence is at least evenly balanced as to whether the Veteran's erectile dysfunction is caused by his service-connected type II diabetes mellitus. CONCLUSION OF LAW With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for erectile dysfunction, as secondary to service-connected type II diabetes mellitus, on a causation basis, are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1965 to December 1967, which includes service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) from an August 2011 rating decision. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a March 2022 hearing. A transcript of the hearing has not yet been associated with the claims file. However, in light of the fact that the Board is awarding service connection for erectile dysfunction (thus reflecting a full grant of the benefit sought) and the fact that there is no information in the hearing transcript that will affect the decision herein, the transcript is not necessary at this time. As a final preliminary matter, the Board notes that during the March 2022 hearing, the Veteran raised the issue of entitlement to an effective date earlier than August 15, 2017, for the award of service connection for type II diabetes mellitus. Service connection for diabetes mellitus was awarded by the AOJ in a July 2020 decision. The Veteran did not appeal the July 2020 decision within one year of its issuance and new and material evidence was not received within that year. Therefore, the July 2020 decision became final as to the effective date assigned for the award of service connection for diabetes. The Board cannot address this issue at this time without a notice of disagreement as to the effective date having been filed. However, the Board points out that it appears that the AOJ assigned the August 15, 2017, effective date based on the date the Veteran was diagnosed as having diabetes mellitus, rather than the date that his service connection claim was received, without addressing the date entitlement arose as opposed to the date of diagnosis. It was discussed during the hearing that in the absence of an appeal within a year of the assignment of the effective date, a motion alleging clear and unmistakable error in the assignment of the effective date in the July 2020 decision can be filed. This matter is referred to the AOJ for any appropriate action. Entitlement to service connection for erectile dysfunction, secondary to service-connected type II diabetes mellitus Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, air, or space service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection is also warranted for disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310. The Veteran contends that he has current erectile dysfunction which is associated with his service-connected diabetes mellitus. The Board finds, for the following reasons, that the Veteran has current erectile dysfunction and that the evidence is at least evenly balanced as to whether the disability is caused by his service-connected type II diabetes mellitus. Medical records, including the report of a July 2019 VA male reproductive system conditions examination, indicates that the Veteran has been diagnosed as having erectile dysfunction. Therefore, current disability has been demonstrated. As for whether the Veteran's erectile dysfunction is caused by his service-connected diabetes mellitus, there are conflicting medical opinions. The Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the Veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The Board may favor one medical opinion over another, provided an adequate statement of reasons or bases is provided. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The physician who conducted a January 2011 VA genitourinary examination opined that the Veteran's erectile dysfunction was not due to his diabetes mellitus. The examiner reasoned that the Veteran's erectile dysfunction preceded his glucose intolerance by at least 15 years. Medical literature does not support that erectile dysfunction is an early precursor to diabetes. Also, the Veteran did not have diabetes mellitus. Rather, he only had induced glucose intolerance without elevation of HbgA1c. The physician who completed a September 2014 Diabetes Mellitus Disability Benefits Questionnaire (DBQ) indicated that the Veteran had erectile dysfunction which was likely ("at least as likely as not") due to his diabetes mellitus. The physician did not provide a specific explanation or rationale for this opinion, but noted on the DBQ that the Veteran had evidence of type II diabetes mellitus, as well as complications such as erectile dysfunction, since 2009. Private treatment records from the Millennium Physician Group LLC dated from October 2013 to January 2018 include numerous diagnoses of erectile dysfunction that is due to/associated with diabetes/diabetic peripheral neuropathy. There were no further explanations or rationales provided for these opinions. The examiner who conducted the July 2019 VA male reproductive system conditions examination opined that the Veteran's erectile dysfunction was not likely ("less than 50 percent probability") proximately due to or the result of his service-connected diabetes mellitus. The examiner reasoned that there was no objective clinical evidence of type II diabetes mellitus at the time of the July 2019 examination. Private medical records document that the Veteran was started on metformin for "metabolic syndrome" with an A1c of 5.8 percent and he reported symptoms consistent with hypoglycemia, rather than hyperglycemia. He did not meet the ADA criteria for a diagnosis of diabetes mellitus, since there were no A1c readings of record that were greater than 6.5 percent. Additionally, there was no objective clinical evidence of microvascular changes (no proteinuria/retinopathy) or complications of diabetes. The Veteran reported the onset of erectile dysfunction was in the 1970s (more than 40 years prior to being started on metformin for "metabolic syndrome") and private medical records document hypogonadism (low testosterone) as the cause of his erectile dysfunction. In July 2020, a VA physician reviewed the Veteran's claims file and explained, in pertinent part, that despite the Veteran's subjective claim and erroneous diagnoses or documentation by his private primary care physician that he had type II diabetes mellitus since 2009, the objective HgbA1c values documented over the previous 11 years showed that he only qualified to be diagnosed as having type II diabetes mellitus in August 2017, when his second HgbA1c value was 6.6, marking the second time it was objectively documented that the value was equal to or greater than 6.5. Since the Veteran had developed erectile dysfunction in 1992, it could not have been caused by his diabetes mellitus, as it had preceded the diabetes mellitus diagnosis by at least 25 years. In other words, his erectile dysfunction was not likely ("less likely than not"/"less than 50 percent probability") proximately caused by his service-connected type II diabetes mellitus. Moreover, the physician explained that the Veteran reported during the July 2019 examination that his erectile dysfunction started as early as the 1970s, at which time low testosterone was found. He reported that he had an MRI to check his pituitary gland and they found 2 small brain tumors, but that he did not require any surgery or any other treatment, and that the tumors had not grown at the time of a follow up scan 7 years later. He was never started on any testosterone replacement therapy, but was given some other medication that did not work. He reported that his testosterone remained low, that he tried Viagra in the 1980s which did not work, and that he tried Cialis 10 years prior to the July 2019 examination which worked a little bit. The Board acknowledges that the precise date of onset of erectile dysfunction is unclear, however, even if the Veteran did experience erectile dysfunction prior to being diagnosed with diabetes mellitus, with regard to service connection on a secondary basis under a causation theory, the primary disability (i.e., diabetes mellitus in this case) need not be service-connected, or even diagnosed, at the time the secondary condition is incurred. Frost v. Shulkin, 29 Vet. App. 131, 133 (2017). In light of the above opinions and diagnoses, the Board finds that the evidence is at least evenly balanced as to whether the Veteran's erectile dysfunction is caused by his service-connected diabetes mellitus. As the reasonable doubt created by the relative equipoise in the evidence must be resolved in favor of the Veteran, service connection for erectile dysfunction, secondary to service-connected type II diabetes mellitus, on a causation basis, is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Elwood, 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.