Citation Nr: 18131192
Decision Date: 08/31/18	Archive Date: 08/31/18

DOCKET NO. 13-35 612
DATE:	August 31, 2018
Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted.
Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected disabilities, is remanded.
Entitlement to an evaluation in excess of 10 percent for scars, mid-thoracic area and L1 level, is remanded.
Entitlement to an evaluation in excess of 20 percent for scars, neck region, is remanded.
Entitlement to a compensable evaluation for a headache disorder is remanded.
The Veteran’s service-connected disabilities preclude substantially gainful employment. 
The criteria for an award of TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16.
The Veteran had active military service from June 1973 to September 1973, January 1988 to June 1988, and February 2003 to September 2004.
The Veteran seeks entitlement to TDIU. The Veteran contends that his service-connected neck and carpal tunnel disabilities limit his movement so much that he can no longer perform his job as a marine engineer. 
To establish entitlement to TDIU due to service-connected disabilities, there must be impairment so severe that it is impossible for the average person to secure and follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. Consideration may be given to the Veteran’s level of education, special training, and previous work experience when arriving at this conclusion, but factors such as age or impairment caused by non-service-connected disabilities are not to be considered. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993).
During the entire period on appeal, the Veteran has met the schedular criteria for TDIU.  38 C.F.R. § 4.16 (a). The Veteran is in receipt of service-connected benefits for a cervical spine disability, carpal tunnel syndrome of the left and right upper extremities, scars of the neck region associated with cervical spine surgery, scars of the mid-thoracic and L1 level associated with cervical spine surgery, and a chronic headache disorder associated with traumatic degenerative disease of the cervical spine. 
Records regarding an application for Social Security Administration (SSA) disability benefits indicate that the Veteran had a primary diagnosis of arthropathies.
In the Veteran’s Application for Increased Compensation Based on Unemployability dated in June 2018 the Veteran reported that he was unable to work due to his migraines, cervical spine, and carpal tunnel syndrome. The Veteran reported that he last worked in March 2013, that he had an education level through college, and had earned a Master’s degree in business.
The Veteran was afforded a VA examination regarding his headache disability in July 2018. The examiner found that the Veteran’s headache condition impacted the Veteran’s ability to work. The examiner reported that the headache condition caused considerable loss of function during migraine episodes. The Veteran reported that he had to lie down for extended periods of time in a dark, cool room for symptoms on a routine basis. He reported daily headache related to pain and fatigue that frequently (every two to three days) exacerbated into prostrating migraine that required medication administration.
The Veteran was afforded a VA examination regarding his cervical spine disability in July 2018. The examiner found that the cervical spine disability impacted the Veteran’s ability to work. The examiner noted that the functional impact of each condition was reduced range of motion noted with flexion and extension of the neck. Moderate pain with neck movement, bending, turning, and related movement. Moderate to severe pain at sleep and interrupted sleep cycle causing increased daytime fatigue.
The Veteran was afforded a VA examination regarding his carpal tunnel syndrome disabilities in July 2018. The examiner found that the disabilities impacted the Veteran’s ability to work. The impact of the peripheral neuropathy on the Veteran’s ability work was moderate pain with decreased manual dexterity. He had difficulty with picking up and holding objects. 
The Board finds that the Veteran’s service-connected disabilities render the Veteran unable to secure and follow a substantially gainful occupation. The examiners have noted that the Veteran’s service-connected headaches impair his ability to work during migraine episodes; that the cervical spine disabilities impair his ability to work by reducing movement and causing sleep impairment, and; the carpal tunnel syndrome impairs his ability to work due to reduced manual dexterity. At the hearing the Veteran reported that he could no longer maneuver in close areas of ships to make determinations necessary for his work. In addition, he had trouble climbing ladders as required with his work. As the Veteran meets the schedular criteria for award of a TDIU and as the Veteran’s service-connected disabilities preclude employability, entitlement to a TDIU is granted. 
The Board has recharacterized the claim of service connection for “sexual deficiency due to loss of testosterone” as service connection for “erectile dysfunction” to consider all possible claims raised by the record. Brokowski v. Shinseki, 23 Vet. App. 79 (2009).
Medical opinions to date are inadequate because they do not address all diagnoses or theories.  In a VA medical opinion dated in March 2018, the examiner responded to the question whether the Veteran’s low testosterone was due to chronic pain or opiod-induced androgen deficiency.  The examiner opined that the medical record indicates that the Veteran was diagnosed with decreased libido and erectile dysfunction in 2005 and had a normal testosterone level at that time. Chronic pain and opioids can cause decreased libido, erectile dysfunction, and opiod-induced androgen deficiency by decreasing testosterone levels. The examiner concluded that since the Veteran’s testosterone level was documented to be normal at the time of diagnosis of decreased libido and erectile dysfunction, low testosterone is less likely than not to be the cause.    
The examiner did address the likely etiology of the erectile dysfunction itself, to include whether it is related to a service-connected disability or related medication.  As such, the claim must be remanded for another medical opinion. 
The Veteran was most recently afforded a VA examination regarding his scars in March 2017. Upon examination the scars were not noted to be painful. At a June 2018 hearing before the undersigned the Veteran reported that his scars constantly bother him and that they hurt. One scar in particular was reportedly painful in an unusual way; that is, the scar covers the implant of a stimulator and leaning on that scar is very uncomfortable. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of the service-connected scar disabilities.
The Veteran also Veteran reported that he received treatment from Keesler Air Force Base (AFB). Review of the claims file does not reveal treatment records from Keesler AFB dated since April 2014. On remand, after obtaining any necessary authorization, attempts must be made to obtain additional treatment records regarding the Veteran from Keesler AFB.
The Veteran receives treatment from VA. The most recent VA treatment records associated with the claims file are dated in February 2018. On remand, attempts must be made to obtain complete VA treatment records regarding the Veteran dated since February 2018. 
The matters are REMANDED for the following action:
1. Ask the Veteran to complete a VA Form 21-4142 for treatment records from Keesler AFB dated since March 2014. Make two requests for the authorized records from Keesler AFB, unless it is clear after the first request that a second request would be futile. 
2. Obtain the Veteran’s VA treatment records for the period beginning February 2018.
3. Thereafter, obtain a VA addendum opinion from a VA examiner regarding whether the likely etiology the Veteran’s claimed erectile dysfunction.  
The examiner should opine as to whether is it at least as likely as not that the Veteran’s erectile dysfunction (i) was incurred in service; (ii) is caused by service-connected disabilities or related pain medication, or; (iii) is aggravated by (defined as any increase in disability) service-connected disabilities or related pain medication.  
The claims file and all pertinent medical records must be made available to the examiner for review. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for an examination. 
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 Complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made.
4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected scar disabilities.  The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria.
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Robert J. Burriesci, Counsel 

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