Citation Nr: 23023971 Decision Date: 04/26/23 Archive Date: 04/26/23 DOCKET NO. 16-04 259 DATE: April 26, 2023 REMANDED Service connection for a deterioration of the joints in the feet is remanded. Service connection for erectile dysfunction is remanded. Service connection for enlarged prostate is remanded. Service connection for a brittle nail disability is remanded. Service connection for loss of feeling in fingers of the left hand is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1968 to April 1972. These matters are before the Board of Veterans' Appeals (Board) on appeal from a May 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran presented testimony in July 2018 and January 2021 before two of the undersigned Veterans Law Judges (VLJs). As explained in the previous remand order, a panel of VLJs has been assigned to review this appeal. The Veteran was offered the opportunity to testify before a third VLJ at the January 2021 hearing; however, he waived this right on the record. Arneson v. Shinseki, 24 Vet. App. 379 (2011). The Board remanded the appeal in September 2018, May 2021, and June 2022 for further development. In July 2021, the RO granted service connection for idiopathic angioedema. In February 2023, the RO granted service connection for hypertension. Thus, those issues are no longer before the Board. As further discussed below, there has not been substantial compliance with the June 2022 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.902(c). 1. Service connection for a deterioration of the joints in the feet is remanded. 2. Service connection for erectile dysfunction is remanded. 3. Service connection for enlarged prostate is remanded. 4. Service connection for a brittle nail disability is remanded. 5. Service connection for loss of feeling in fingers of the left hand is remanded. The Veteran contends that his deterioration of the joints in the feet, erectile dysfunction, enlarged prostate, brittle nail disability, and loss of feeling in fingers of the left hand are secondary to medications taken to control his angioedema. See January 2021 Board hearing transcript at 12-14; see also March 2022 argument brief. The Veteran underwent VA contract examinations for the above conditions in October 2021. The examiner opined that the claimed conditions were less likely than not aggravated beyond their natural progression by medications used to treat the Veteran's angioedema with urticaria. The examiner explained that there was no objective evidence to suggest the claimed conditions were worsened or aggravated by medications used to treat the Veteran's angioedema with urticaria. He stated that the Veteran's brittle fingernails were likely aggravated by nutritional and mineral deficiencies; that the left ulnar nerve compression at the level of the elbow was caused by an anatomical compression of the left ulnar nerve; that the bilateral great toe conditions were caused by repeated physical trauma to both feet; that the enlarged prostate was caused by advanced age as prostatic enlargement is a natural part of every man's aging process; and that the enlarged prostate was likely the cause of his erectile dysfunction. In January 2022, an addendum opinion was obtained from the same examiner. The examiner stated that the claimed conditions were less likely than not aggravated beyond their natural progression by, or proximately due to, medications used to treat the Veteran's angioedema with urticaria. The rationale provided was identical to that in October 2021. In the June 2022 remand, the Board found that the examiner's rationale for causation and aggravation were identical and was primarily focused on proximate causation. The Board further noted that the limited rationale for aggravation (i.e., 'there was no objective evidence to suggest the claimed conditions were worsened or aggravated by medications used to treat the Veteran's angioedema with urticaria') did not provide the Board with sufficient information to make a fully informed decision on that particular aspect of the appeal. An addendum opinion on aggravation was requested. In July 2022, an addendum opinion was obtained from the same examiner. The examiner opined that the Veteran's claimed conditions were less likely than not proximately due to or the result of his service-connected idiopathic angioedema, including its medications. The examiner provided a nearly identical rationale as his prior opinions, and reiterated that there was no objective evidence to suggest the Veteran's service-connected idiopathic angioedema, including medications used to treat this condition, aggravated his claimed conditions. The primary purpose of the remand was to obtain an opinion on aggravation with rationale that differed from that on causation, and that provided more explanation other than noting that 'there was no objective evidence to show aggravation.' Atencio v. O'Rourke, 30 Vet. App. 74 (2018). Unfortunately, the examiner did not substantially comply with the previous remand directives. Stegall, 11 Vet. App. at 268. Further, there is no indication that the examiner reviewed the National Institutes of Health (NIH) article that the Veteran submitted in March 2022, which discussed the adverse effects of prednisone and its effect on the endocrine and central nervous systems. On remand, the RO must obtain an addendum opinion that is substantially compliant with the Board's remand directives. To the extent possible, the addendum opinion should be obtained from a medical professional other than the July 2022 examiner. The addendum opinion and rationale must reflect consideration of the NIH article on prednisone which the Veteran provided in March 2022. The matters are REMANDED for the following action: Obtain an addendum opinion from a VA examiner, different from the previous ones, for the claimed disabilities of deterioration of the joints in the feet, erectile dysfunction, enlarged prostate, a brittle nail disability, and loss of feeling in fingers of the left hand. The examiner must review the claims file, to include a copy of this Remand and the NIH article on the effects of prednisone provided by the Veteran in March 2022, in connection with authoring this opinion. For each claimed disability, the examiner is to opine as to whether it is at least as likely as not aggravated by medications used to treat the Veteran's service-connected idiopathic angioedema? The examiner is advised that 'aggravation' means any incremental increase in disability in a non-service-connected disability resulting from a service-connected disability. A fully-explained rationale must be provided for all opinions expressed. The rationale should reflect consideration of the treatise evidence (i.e., the NIH article discussing the adverse effects of prednisone) provided by the Veteran in March 2022. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Jake Choi, Attorney Advisor 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.