Citation Nr: 22016707 Decision Date: 03/23/22 Archive Date: 03/23/22 DOCKET NO. 18-51 882 DATE: March 23, 2022 REMANDED The issue of service connection for pituitary microadenoma is remanded. The issue of service connection for erectile dysfunction, to include as due to pituitary microadenoma is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from January 1982 to December 1987. This matter comes to the Board of Veterans' Appeals (Board) on appeal from the April 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2019, the Board denied the claims of service connection for pituitary microadenoma, adjustment disorder, and erectile dysfunction. The Veteran appealed the claim to the United States Court of Appeals for Veterans Claims (Court) and through a March 2021 Joint Motion for Partial Remand (JMPR), the claim was remanded for the Board to provide adequate reasons and bases for its findings. In November 2021, following the Court's decision, the Board remanded the claims and directed the RO to provide the Veteran VA examinations for his claims of service connection for pituitary microadenoma and psychiatric disability. The Veteran was afforded VA examinations in December 2021 for his claims. Thus, the Board finds that the AOJ substantially complied with the remand directives and no further action is necessary in this regard. Stegall v. West, 11 Vet. App. 268 (1998). Before the matter was certified to the Board, in a January 2022 rating decision, the RO granted service connection for adjustment disorder unspecified with an evaluation of 10 percent effective December 31, 2014, and a 30 percent evaluation effective December 11, 2021. The award of service connection constitutes a complete grant of the benefit sought on appeal. The record currently available to the Board contains no indication that the appellant has initiated an appeal with the effective date or initial ratings assigned. Thus, this issue is not before the Board. Cf. Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). 1. The issue of service connection for pituitary microadenoma As discussed above, the Veteran was afforded a VA examination in December 2021 for his claim of service connection for pituitary microadenoma. The December 2021 VA examiner, a nurse practitioner, opined that the Veteran's pituitary microadenoma was less likely than not incurred "by the claimed in service illness." The examiner added that "an opinion cannot be given without resorting to speculation" as the examiner "could not find the exact causes of pituitary microadenoma" "after review of medical literature." The examiner did not cite any literature that directly refuted the Veteran's contention that his pituitary microadenoma was caused by exposure to harmful fumes and toxic chemicals while aboard a ballistic missile submarine as a missile checkout technician, nor cite any other potential causes. Although the examiner stated that medical records after service "does show his pituitary disorder along with complications for the disorder," she effectively bases her decision on the lack of contemporaneous medical evidence as she stated that "there was no service records found correlating Veteran having claimed condition during service" and that "there has not been a nexus between the exposure to toxics and fumes and the diagnosis of pituitary microadenoma." The Board finds that the December 2021 VA examination to be inadequate. The examiner did not properly address the Veteran's contentions, only stating that there was no medical literature pointing to an "exact cause" rather than discussing the Veteran's contentions. See Moore v. Derwinski, 1 Vet. App. 401, 404 (1991) ("the Board must include in its decisions 'the precise basis for that decision ... [and] the Board's response to the various arguments advanced by the claimant'" (alterations in original) (quoting Gilbert v. Derwinski, 1 Vet. App. 49 (1990)). Moreover, the December 2021 VA examiner relied solely on the absence of contemporaneous medical evidence, which is an inadequate reason for a negative finding. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006) (holding that the Board cannot determine that lay evidence as to diagnosis and nexus lacks credibility merely because it is unaccompanied by contemporaneous medical evidence). When VA obtains an evaluation, the evaluation must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Thus, the claim is remanded for an addendum opinion. 2. The issue of service connection for erectile dysfunction, to include as due to pituitary microadenoma. Although the Veteran was afforded a VA examination in December 2021 for his claim of service connection for erectile dysfunction, the December 2021 VA examiner relied solely on the absence of service treatment records "correlating Veteran having claimed condition during service." The examiner did not opine whether pituitary microadenoma, or any other service-connected disability, could cause or aggravate erectile dysfunction. See Buchanan, 451 F.3d at 1337. The Board also notes that the issue of service connection for erectile dysfunction was found inextricably intertwined with the issue of service connection for pituitary microadenoma by the Court in March 2021. As such, consideration of the appeal regarding entitlement to erectile dysfunction will be deferred. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (noting that two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). The matters are REMANDED for the following action: 1. Request from Commander, Submarine Force, U.S. Atlantic Fleet, 1430 Mitscher Ave. Norfolk VA 23551 (Attn. Force Medical Officer) or other Navy Department agency technical information on the nature and frequency of the Veteran's claimed exposures to toxic chemicals and fumes as a typical junior missile technician aboard a new construction and operational Trident submarine and aboard a submarine tender from 1983-86. The claimed exposures included diesel oil, fuel, solvents, and missile solid rocket fuel and an opinion whether any chemical hazards associated with this Veteran's rating and duties are risk factors for pituitary microadenoma. 2. Obtain an addendum VA medical opinion regarding the Veteran's pituitary microadenoma from a clinician with the necessary medical expertise. Specifically, the examiner must opine whether it is at least as likely as not (50 percent or greater probability) that pituitary microadenoma was incurred in service. The examiner is advised that aggravation means any increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. A rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered, specifically the Veteran's contention of exposure to "hazardous or toxic materials" being the cause of his pituitary microadenoma after discharge. The examiner may not solely rely on the absence of contemporaneous medical evidence. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). The need for another examination is left to the discretion of the examiner offering the addendum opinion. 3. Obtain an addendum VA medical opinion regarding the Veteran's erectile dysfunction. Specifically, the examiner must opine whether it is at least as likely as not (50 percent or greater probability) that erectile dysfunction was caused by a service-connected disability. The examiner is advised that aggravation means any increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. (continued next page) A rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge, the record, or the examiner. The need for another examination is left to the discretion of the examiner offering the addendum opinion. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H.S. Yun, 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.