Citation Nr: A23002997 Decision Date: 02/14/23 Archive Date: 02/14/23 DOCKET NO. 200719-99894 DATE: February 14, 2023 ORDER Entitlement to special monthly compensation (SMC) at the rate pursuant to 38 U.S.C. § 1114(t) is granted. Entitlement to service connection for erectile dysfunction, claimed as secondary to service-connected posttraumatic stress disorder (PTSD), is granted. Entitlement to SMC based on loss of use of a creative organ is granted. FINDINGS OF FACT 1. The Veteran is in need of regular aid and attendance for the residuals of traumatic brain injury (TBI), is not eligible for compensation under 38 U.S.C. § 1114(r)(2), and in the absence of such regular aid and attendance would require hospitalization, nursing home care, or other residential institutional care. 2. The evidence is in relative equipoise as to whether the Veteran's erectile dysfunction is proximately due to his service-connected PTSD. 3. The criteria for SMC due to loss of use of a creative organ are met. CONCLUSIONS OF LAW 1. The criteria for SMC at the (t) rate have been met. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. §§ 3.102, 3.350, 3.351, 3.352. 2. The criteria for service connection for erectile dysfunction as secondary to service-connected PTSD are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for SMC due to loss of use of a creative organ have been met. 38 U.S.C. §§ 1114(k), 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400, 3.350(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 2002 to July 2012. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated April 2020 and June 2020 of the Department of Veterans Affairs (VA) Regional Office (RO). In the April 2020 higher level review rating decision, the RO denied entitlement to SMC at a higher rate pursuant to 38 U.S.C. § 1114(t). In the June 2020 rating decision, the RO readjudicated and denied the Veteran's claim of entitlement to service connection for erectile dysfunction and denied entitlement to SMC based upon loss of use of a creative organ. The Veteran submitted a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), in July 2020 in which he expressly disagreed with the April 2020 and June 2020 rating decisions. He selected the evidence submission docket. Therefore, for the claim of entitlement to a higher rate of SMC, the Board may only consider the evidence of record at the time of November 2019 rating decision reviewed in the April 2020 higher level review rating decision, as well as any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the VA Form 10182. For the erectile dysfunction and SMC claim, the Board may only consider the evidence of record at the time of June 2020 rating decision, as well as any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. 1. Entitlement to a higher level of aid and attendance under 38 U.S.C. § 1114(t). The Veteran contends that he is entitled to a higher level of aid and attendance for his TBI under SMC(t). See the written argument of the Veteran and the VA Form 10182 dated July 2020. SMC is authorized in particular circumstances in addition to compensation for service-connected disabilities. See 38 U.S.C. § 1114; 38 C.F.R. §§ 3.350, 3.352. SMC is authorized under subsections (k) through (s), with the rate amounts increasing the later in the alphabet the letter appears (except for the "s" rate). SMC at the (k) and (l) rates are paid in addition to any other SMC rates, with certain monetary limits. SMC at the (k) rate is provided for loss or loss of use of certain body parts. 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350(a). SMC at the (l) rate is payable when the veteran, due to service-connected disability, has suffered the anatomical loss or loss of use of both feet or one hand and one foot, or is blind in both eyes, or is permanently bedridden or so helpless as to be in need of regular aid and attendance under the criteria set forth in 38 C.F.R. § 3.352(a). See 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). SMC at the (m) rate is warranted if the veteran, as a result of service-connected disability, has suffered the anatomical loss or loss of use of both hands, or of both legs at a level, or with complications, preventing natural knee action with prosthesis in place, or of one arm and one leg at levels, or with complications, preventing natural elbow and knee action with prosthesis in place, or has suffered blindness in both eyes having only light perception, or has suffered blindness in both eyes, rendering such veteran so helpless as to be in need of regular aid and attendance. 38 U.S.C. § 1114(m); 38 C.F.R. § 3.350(c). SMC at (n) rate is warranted if the veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of both arms at levels, or with complications, preventing elbow action with prostheses in place, has suffered the anatomical loss of both legs so near the hip as to prevent the use of prosthetic appliances. 38 U.S.C. § 1114(n); 38 C.F.R. § 3.350(d). SMC at the (n) rate is also warranted if the veteran's service-connected disability has caused him to suffer anatomical loss of one arm and one leg so near the shoulder and hip as to prevent the use of prosthetic appliances, or to suffer blindness without light perception in both eyes. Id. SMC at the (o) rate is warranted if the veteran, as the result of service-connected disability, has suffered disability under conditions which would entitle such veteran to two or more of the rates provided in one or more of § 1114(l) through § 1114(n), no condition being considered twice in the determination, if the veteran has suffered the anatomical loss of both arms so near the shoulder as to prevent the use of prosthetic appliances, or bilateral deafness (and the hearing impairment in either one or both ears in service connected) rated at 60 percent or more disabling with service-connected total blindness with 5/200 visual acuity or less. SMC at the (o) rate is also warranted for total deafness in one ear or bilateral deafness (and the hearing impairment in either one or both ears is service connected) rated at 40 percent or more disabling and the veteran has also suffered service-connected blindness having only light perception or less. 38 U.S.C. § 1114(o); 38 C.F.R. § 3.350(e). Paralysis of both lower extremities together with the loss of anal and bladder sphincter control will entitle a veteran to the (o) rate of SMC, through the combination of loss of use of both legs and helplessness. The requirement of loss of anal and bladder sphincter control is met even though incontinence has been overcome under a strict regimen of rehabilitation of bowel and bladder training and other auxiliary measures. 38 C.F.R. § 3.350(e)(2). Determinations for entitlement to the (o) rate of SMC must be based upon separate and distinct disabilities. That requires, for example, that where a veteran who had suffered the loss or loss of use of two extremities is being considered for the maximum rate on account of helplessness requiring regular aid and attendance, the latter must be based on need resulting from pathology other than that of the extremities. 38 C.F.R. § 3.350(e). If the loss of use of two extremities or being permanently bedridden leaves the person helpless, increase is not in order on account of this helplessness. Under no circumstances will the combination of "being permanently bedridden" and "being so helpless as to require regular aid and attendance" without separate and distinct anatomical loss, or loss of use, of two extremities be taken as entitling the veteran to the maximum benefit. The fact, however, that two separate and distinct entitling disabilities, such as loss of use of both hands and both feet, result from a common etiological agent, for example, one injury or rheumatoid arthritis, will not preclude maximum entitlement. 38 C.F.R. § 3.350(e). 38 U.S.C. § 1114(p) provides for "intermediate" SMC rates between the different subsections based on anatomical loss or loss of use of the extremities or blindness in connection with deafness and/or loss or loss of use of a hand or foot. 38 U.S.C. § 1114(p); 38 C.F.R. § 3.350(f). In addition to the statutory rates payable under 38 U.S.C. § 1114 (l) through (n) and the intermediate or next-higher rate provisions set forth under 38 U.S.C. § 1114(p), additional single permanent disability or combinations of permanent disabilities independently ratable at 50 percent or more will afford entitlement to the next-higher intermediate rate, or if already entitled to the next-higher intermediate rate, then to the next-higher statutory rate under 38 U.S.C. § 1114, but not above the (o) rate. The disability or disabilities independently ratable at 50 percent or more must be separate and distinct and involve different anatomical segments or bodily systems from the conditions establishing entitlement under 38 U.S.C. § 1114 (l) through (n) or the intermediate rate provisions of 38 U.S.C. § 1114(p). 38 C.F.R. § 3.350(f)(3). Also, additional single permanent disability or combinations of permanent disabilities independently ratable at 100 percent apart from any consideration of individual unemployability will afford entitlement to the next-higher intermediate rate, or if already entitled to the next-higher intermediate rate, then to the next-higher statutory rate under 38 U.S.C. § 1114, but not above the (o) rate. The disability or disabilities independently ratable at 100 percent or more must be separate and distinct and involve different anatomical segments or bodily systems from the conditions establishing entitlement under 38 U.S.C. § 1114 (l) through (n) or the intermediate rate provisions of 38 U.S.C. § 1114(p). 38 C.F.R. § 3.350(f)(4). A veteran receiving SMC at the (o) rate, at the maximum rate under 38 U.S.C. § 1114(p), or at the intermediate rate between (n) and (o) plus SMC at the (k) rate, who is in need of regular aid and attendance or a higher level of care is entitled to an additional allowance during periods that he is not hospitalized at the United States Government's expense. Determination of this need is subject to the criteria of 38 C.F.R. § 3.352. 38 C.F.R. § 3.350(h). The regular or higher-level aid and attendance allowance is payable whether or not the need for regular aid and attendance or a higher level of care was a partial basis for entitlement to the maximum rate under 38 U.S.C. § 1114 (o) or (p), or was based on an independent factual determination. 38 C.F.R. § 3.350(h). The amount of the additional allowance payable to a veteran in need of regular aid and attendance is specified in 38 U.S.C. § 1114(r)(1) ("r1" rate). The amount of the additional allowance payable to a veteran in need of a higher level of care is specified in 38 U.S.C. § 1114(r)(2) ("r2" rate). The higher-level aid and attendance allowance authorized by 38 U.S.C. § 1114 (r)(2) is payable in lieu of the regular aid and attendance allowance authorized by 38 U.S.C. § 1114 (r)(1). 38 C.F.R. § 3.350(h)(3). SMC at the (r)(2) rate requires a showing that the Veteran required daily personal health care services by a medical professional, or under the supervision of such, without which institutional care would be required. 38 C.F.R. § 3.350(h)(2). Special monthly compensation provided by 38 U.S.C. § 1114(t) is payable where a veteran, as the result of service-connected disability, is in need of regular aid and attendance for the residuals of TBI, is not eligible for compensation under subsection (r)(2), and in the absence of such regular aid and attendance would require hospitalization, nursing home care, or other residential institutional care. A Veteran entitled to this benefit shall be paid, in addition to any other compensation under this section, a monthly aid and attendance allowance equal to the rate described in subsection (r)(2). An allowance authorized under this subsection shall be paid in lieu of any allowance authorized by subsection (r)(1). Essentially, this type of special monthly compensation is warranted for veterans who need regular aid and attendance for the service-connected residuals of TBI, but are not eligible for a higher level of aid and attendance, and would require hospitalization, nursing home care, or other residential institutional care in the absence of regular aid and attendance. 38 U.S.C. § 1114(t). During the appeal period, the Veteran has been in receipt of the following ratings for his service-connected disabilities: PTSD with adjustment disorder, mixed anxiety, and depression and TBI at 100 percent disabling; post-concussive headaches at 50 percent; lumbar strain at 40 percent, right leg sciatic radiculopathy at 20 percent, left leg sciatic radiculopathy at 20 percent, mucous retention cyst (sinus) at 10 percent, and allergic rhinitis at 10 percent. In an October 2018 rating decision, the Veteran was awarded SMC under 38 U.S.C. § 1114(l), on account of being so helpless as to be in need of regular aid and attendance while not hospitalized at U.S. government expense, effective September 27, 2018. In July 2019, the Veteran submitted additional evidence in support of his contention that he is entitled to a higher rate of SMC. A November 2019 rating decision denied entitlement to a higher level of compensation under 38 U.S.C. § 1114. In January 2020, the Veteran requested higher level review of the November 2019 rating decision and specifically asserted entitlement to SMC under 38 U.S.C. § 1114(t). An April 2020 higher level review decision denied entitlement to a higher level of care pursuant to 38 U.S.C. § 1114(t). The Veteran appealed the denial in the July 2020 VA Form 10182. For the reasons set forth below, the Board finds that entitlement to SMC under 38 U.S.C. § 1114(t) is warranted. In a letter dated September 2018, the Veteran's VA treatment provider, M.W., M.D., reported that the Veteran "has problem[s] with severe depression and has had episodes of suicidal ideation. He has TBI with memory impairment. He also had cervicobrachial syndrome and brain injury with concussion and posttraumatic headaches that [are] so severe." M.W., M.D., further opined, "[t]his medical condition makes this patient not physically and emotionally capable of holding meaningful work for a living." The Veteran submitted a September 2018 examination for aid and attendance/housebound, which was completed by a private treatment provider. The provider indicated that the Veteran is able to prepare his own meals but requires nursing care because he "forgets to take his pills, important dates, and turn [off] the stove." The Veteran also requires medication management. The provider stated that the Veteran "describes frequent episodes of dizziness at least five episodes per day, lasting five seconds or more. Constant tinnitus. He reports on and off episodes of memory loss. Forgets important dates, names, and phone numbers." The provider further noted that the Veteran "usually stays at home, but sometimes he goes to the gym, supermarket, and fishing trip[s] with his caregiver." The Veteran uses assistive devices for locomotion. In a July 2019 private examination for housebound status and permanent need for regular aid and attendance, the treatment provider indicated that the Veteran has the following disabilities: post-concussive headaches (migraines), residuals of head trauma/TBI, posttraumatic stress with TBI, and lumbar strain. The private provider indicated that the Veteran is unable to prepare his own meals; specifically, he "forgets to prepare is own meal, by doing so he forgets to turn off the stove [and it] caught on fire, for safety, his caregiver prepares his meals." The provider reported that the Veteran needs assistance with bathing and tending to other hygiene needs. The provider explained, "[d]ue to his memory loss, [the Veteran] forgets on bathing and taking care of his personal hygiene." The provider indicated that the Veteran's chronic depression also impairs his ability to tend to personal hygiene. The provider indicated that the Veteran requires nursing home care for "grooming, dressing, bathing. Patient uses assistive devices such as cane, back brace, knee brace." The private provider reported that the Veteran requires medication management because he forgets to take his medications. The provider stated that the Veteran "reports frequent episodes of headaches, back pain, memory loss, [and] dizziness. Constant tinnitus. He forgets important dates, phone numbers. Patient usually stays at home or [attends] medical appointment[s] with his caregiver." The provider further noted that the Veteran "reports he leaves his home one to two times a week for medical appointments or [goes to the] store with his caregiver." VA treatment records show that the Veteran applied for the Program of Comprehensive Assessment for Family Caregivers (PCAFC). A caregiver support assessment was performed in April 2019. The Veteran reported that his aunt is no longer his caregiver due to his explosive temper. His caregiver is now his father. The Veteran indicated that he requires assistance with dressing and personal hygiene due to his back and hip issues. The Veteran reported that his caregiver keeps track of his medical appointments. The Veteran endorsed suicide attempts in 2014 and 2018. He reported that his memory is okay, but indicated that his doctor said he might have dementia. He is unable to prepare his own meals because he becomes distracted. He reported that his father/caregiver manages his medications; however, the treatment provider indicated that the Veteran seems to be aware of his medication and might also manage his medication. The Veteran reported that he becomes aggressive towards others, but is not socially inappropriate. He explained, "I was getting aggressive towards my aunt. I sometimes hit people, I hit the wall, the door and sometimes I yell. My aunt could not control me. My dad keeps me in check." The treatment provider noted that the Veteran's father works 20 hours a week. When the Veteran's father is not there, the Veteran is on his own or is looked after by his mother or sister. The Veteran lives with his mother and father. He reports that his father assists him with his activities of daily living. VA treatment records dated in May 2019 show that the Veteran's PCAFC application was based upon a determination that he does "not require a caregiver to assist with your daily management of personal care functions either physically or related to supervision and protection." VA treatment records dated in May 2019 noted the Veteran's report that he has been thinking of moving out on his own, but his parents do not think it is a good idea. The Veteran stated that they think he sleeps too much. He explained that he does stay in bed a lot due to back pain. VA treatment records dated in July 2019 noted the Veteran's report that he almost died from a vehicular accident yesterday because he fell asleep at the wheel. At the time that he filed his VA Form 10182, the Veteran submitted a July 2020 statement from his father, who reported that the Veteran's TBI causes him to become frustrated, aggravated, and act impulsively. He indicated that, when he is attempting to de-escalate the Veteran, the Veteran sometimes does not know who he is. The Veteran's father reported that the Veteran's headaches and dizziness are his most severe TBI symptoms. He reported that the Veteran has been living with him since 2017 because the Veteran is unable to take care of himself. The Veteran's father explained that he must watch the Veteran, help him shower, and encourage him to eat. The Veteran's father stated that "[i]f we, his family, were not here to take care of him, he would be in a facility that could take care of the things we do for him. He would definitely be worse without his family." The Veteran also submitted a July 2020 neurology consultation from R.T., M.D., a neurologist, who reviewed the Veteran's medical history and determined, "[t]here is nothing in the Veteran's records that say or mention malingering, symptom exaggeration, [or] feigning symptoms. [The Veteran's] statements and complaints of his continuing impaired condition are credible and supported in his medical record." Dr. R.T. determined that it is more likely than not that the Veteran is in need of regular aid and attendance for residuals of TBI and it is more likely than not that, in the absence of such regular aid and attendance, the Veteran would require hospitalization, nursing home care, or other residential institutional care due to his residuals of TBI. Dr. R.T. explained that the "Veteran's family members provide the aid and assistance he needs for daily living activities due to TBI." Dr. R.T. noted that the Veteran "has demonstrated inability to dress or undress himself or to keep himself ordinarily clean and presentable." He reported that the Veteran has demonstrated physical or mental incapacity "which requires care or assistance on a regular basis to protect [him] from hazards or dangers incident to his daily environment." Dr. R.T. explained that the Veteran is unable "to live independently and, absent the aid and attendance provided by his family, in this instance, turning off the stove and providing him supervision, the Veteran would require hospitalization, institutional care, or other care to provider for his safety and well-being." Here, the evidence of record does not reflect that the Veteran requires personal health-care services provided on a daily basis in his home by a person who is licensed to provide such services or who provides such services under the regular supervision of a licensed health-care professional. It is well documented that the Veteran's father, mother, and sister assist the Veteran with his activities of daily living, including grooming, bathing, preparation of meals, transportation, and medication management. The record does not reflect that the Veteran is in need of personal health-care services on a daily basis in his home that require a licensed health-care professional to perform. Although the type of care rendered by the Veteran's family satisfies the definition of regular aid and attendance under 38 C.F.R. § 3.352(a), it does not demonstrate the need for higher level care defined in 38 C.F.R. § 3.352(b)(3). In other words, while the family members may be implementing standard care recommended or required by a medical professional, close regular supervision to do so is not needed. Consequently, the Veteran's TBI does not warrant a higher compensation under 38 U.S.C. § 1114(r)(2). However, the evidence of record shows that, absent regular aid and attendance care provided by his family, the Veteran would not be able to reside on his own and care for his own needs. The medical and lay evidence demonstrates that the Veteran's residuals of his TBI have impaired his physical and mental functioning. The Veteran's family members ensure that the Veteran eats, maintains his personal hygiene, assist him with transportation and medical appointments, and provide housing and other assistance for his daily needs. He requires assistance to administer and manage his medications, prepare meals, and perform daily activities as a result of his significantly impaired memory and concentration. The evidence demonstrates that the Veteran has been consistently unable to maintain his independence throughout the appeal period. The Board affords significant probative value to the statement of the Veteran's father, who is his current caregiver, as well as to the July 2020 consultative opinion from Dr. R.T. This evidence demonstrates that the Veteran relies on caregivers to support his health and well-being, perform personal functions required in everyday living, and ensure that he remains safe from hazards of dangers incident to his daily environment. Considering the inherent risks associated with the failure to take medication as prescribed, prepare and consume meals, and perform household tasks and daily hygiene without supervision, the Board finds that the Veteran would require hospitalization or institutional residential care absent the regular aid and attendance provided by his father, mother, and sister. While the Veteran does not need regular aid of a licensed healthcare professional, the evidence indicates that he would not be able to reside on his own and would need to be placed in a nursing home or a similar living arrangement, which is consistent with the opinion of the July 2020 from the consultative neurologist, Dr. R.T. Accordingly, resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran is in need of regular aid and attendance due to residuals of TBI and in the absence of such regular aid and attendance would require hospitalization, nursing home care, or other residential institutional care. Entitlement to SMC pursuant to 38 U.S.C. § 1114(t) is therefore warranted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for erectile dysfunction. In order to prevail on the issue of service connection for any particular disability, there must be evidence of a current disability; evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence, or in certain circumstances, lay evidence, of a nexus between an in-service injury or disease and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Disability which is proximately due to or the result of a service-connected disease or injury shall also be service connected. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Medical evidence is generally required to establish a medical diagnosis or to address questions of medical causation; lay assertions of medical status do not constitute competent medical evidence for these purposes. Lay assertions, however, may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. In this matter, the Veteran asserts entitlement to service connection for erectile dysfunction as secondary to his service-connected PTSD. See the Veteran's supplemental claim dated June 2020. For the reasons set forth below, the Board finds that service connection is warranted. At the outset, the Board recognizes that the Veteran's service treatment records (STRs) do not document any complaints of, or treatment for, erectile dysfunction during his active duty service. The Veteran is service-connected for PTSD with adjustment disorder, mixed anxiety, depressed mood, and TBI. See the rating decision dated December 2014. VA treatment records dated in September 2017 indicate that the Veteran is prescribed Vardenafil for migraine headaches, which can cause erectile dysfunction. VA treatment records dated in October 2017 indicate that the Veteran has had erectile dysfunction and a low libido for five years. Private treatment records dated in November 2017 indicate that the Veteran has erectile dysfunction secondary to his PTSD medication. In an April 2018 private disability benefits questionnaire (DBQ), A.M., M.D., reported that the Veteran is diagnosed with erectile dysfunction. Dr. A.M. reported that the "[o]nset of erectile dysfunction has been gradual since [the Veteran] started using psychiatric medication such as Sertraline for his service-connected PTSD." Dr. A.M. opined that the Veteran's current erectile dysfunction is secondary to medication prescribed to treat his PTSD. The Veteran was afforded a VA examination in May 2018 at which time the examiner confirmed a diagnosis of PTSD. The examiner determined that the Veteran's erectile dysfunction is less likely than not caused by his service-connected PTSD. The examiner explained that the Veteran "first began complaining of erectile dysfunction [to] his VA providers (primary and mental health) around May 2017. His mental health provider immediately stopped his Sertraline and began Bupropion instead." The examiner continued, "[s]everal notes indicate poor compliance with psychiatric medications." The examiner noted that the Veteran was evaluated by endocrinology and it was indicated that the Veteran had a pituitary tumor, which "could affect hormone levels." The Veteran was afforded another VA reproductive examination in December 2019 at which time the examiner reported that the Veteran has erectile dysfunction, which is most likely secondary to SSRI (Sertraline). In a March 2020 medical opinion, R.C., M.D., opined that the Veteran's claimed erectile dysfunction is at least a likely as not secondary to the medication prescribed to treat his service-connected PTSD. Dr. R.C. explained, "VA treatment records, private medical records, and military treatment records were reviewed. Records show that patient served in the Army for 10 years. STRs were negative for the diagnosis or treatment of erectile dysfunction." Dr. R.C. noted that the Veteran was subsequently diagnosed with PTSD and "[p]rivate medical records showed that the patient has been treated with Vardenafil HCL 200 mg." Dr. R.C. stated that the Veteran has also been under drug therapy for PTSD, that includes Sertraline 50 mg. and Mirtazapine 30 mg. He explained that erectile dysfunction is a common side effect of these medications. As indicated above, the Veteran filed a supplemental claim of entitlement to service connection for erectile dysfunction; a June 2020 rating decision readjudicated and denied the Veteran's claim. The Veteran initiated this appeal by filing a VA Form 10182 in July 2020 and selecting the evidence submission docket. Along with the VA Form 10182, the Veteran also submitted a July 2020 medical opinion from C.E., Psy. D., who determined that it is more likely than not that the Veteran's erectile dysfunction is a result of his service-connected PTSD. Dr. C.E. reviewed the Veteran's medical history and pertinent medical literature. She provided the following rationale: In summary, it is more-likely-than-not that [the Veteran's] erectile dysfunction (ED) is a result of his service-connected diagnosis of PTSD. The Veteran has a longstanding, documented history of PTSD, as well as treatment for sexual dysfunction. There is extensive research evidence of a clear relationship between PTSD and ED, as well as depression and ED, specifically among military veterans, including young military veterans. In addition, it should be noted that the association between ED and depression is significant, even when controlling for other potential contributing factors to ED such as age, smoking, alcohol consumption, hypertension, regular exercise, fasting blood sugar level, and total cholesterol. According to the research, veterans who are not prescribed psychotropic medications for PTSD are still at risk for male sexual dysfunction. Therefore, although [the Veteran] has been taking psychotropic medications to treat and alleviate his symptoms, ED is not necessarily a consequence or side effect of the medication since ED occurs among veterans with PTSD in the absence of psychotropic medications. PTSD increases the risk of sexual dysfunction, independent of psychiatric medication. Due to abundant evidence of this association, it is more-likely-than-not that [the Veteran's] ED is a consequence of his service-connected PTSD. Critically, the evidence must be persuasively against the claim in order to warrant a denial and that is not the case here; the negative evidence is not more persuasive or of greater evidentiary weight. Accordingly, in light of the multiple positive nexus opinions of record including the July 2020 opinion from C.E., Psy.D., described above, the Board finds that the evidence is at least in equipoise as to whether the Veteran suffers from erectile dysfunction that was caused by his service-connected PTSD. The benefit-of-the-doubt rule is therefore for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Board will resolve the reasonable doubt in the Veteran's favor and find that the evidence supports the grant of service connection for erectile dysfunction. See 38 U.S.C. § 5107. 3. Entitlement to SMC based upon loss of use of a creative organ. SMC is payable at a specified rate if the Veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of a creative organ. See 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350(a). Given the foregoing finding that the Veteran has the condition of erectile dysfunction secondary to a service-connected disability, the additional requirements for SMC based on loss of use of a creative organ are met. The claim for SMC based upon loss of use of a creative organ is granted. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. K. Buckley, 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.