Citation Nr: 18161060 Decision Date: 12/28/18 Archive Date: 12/28/18 DOCKET NO. 16-15 672A DATE: December 28, 2018 REMANDED Entitlement to service connection for diabetes mellitus, type II, as secondary to service-connected status post partial thyroidectomy is remanded. Entitlement to service connection for obstructive sleep apnea, as secondary to service-connected status post partial thyroidectomy is remanded. Entitlement to service connection for hypertension, as secondary to service-connected status post partial thyroidectomy is remanded. Entitlement to service connection for erectile dysfunction, as secondary to service-connected status post partial thyroidectomy is remanded. Entitlement to service connection for bilateral upper extremity carpal tunnel syndrome, as secondary to service-connected status post partial thyroidectomy is remanded. Entitlement to service connection for bilateral upper and lower extremity peripheral neuropathy, as secondary to service-connected status post partial thyroidectomy is denied. REASONS FOR REMAND The Veteran served on active duty from July 1970 to August 1992. With regards to the Veteran’s diabetes mellitus claim, in a March 2012 private medical opinion, J.M., a registered nurse who noted that she specialized in the treatment of the endocrine system, opined that it was more likely than not that the Veteran’s diabetes mellitus, type II, was the result of his service-connected thyroid condition. Specifically, J.M. noted that the Veteran was continuously treated with synthetic thyroid medication following his partial thyroid removal and that the level of thyroid hormone controlled metabolism. She opined that the Veteran’s sustained level of synthetic thyroid at 0.2 mg over time had led to a steady increase in weight, which, in turn, led to the development of diabetes mellitus. The Veteran underwent VA examination in June 2013. Following examination, the examiner opined that the Veteran’s diabetes mellitus, type II, was less likely than not proximately due to or the result of the Veteran’s service-connected thyroid condition. The examiner noted that the Veteran had a family history of diabetes mellitus, type II, specifically his mother, and opined that the Veteran’s diabetes mellitus, type II, was hereditary. The examiner noted that the March 2012 private medical opinion did not consider a hereditary etiology or evidence that the Veteran’s thyroid condition was well-controlled on thyroid medication. The Board reflects that this opinion does not address the aggravation portion of secondary service connection, nor does it address whether the Veteran’s obesity. In a February 2016 VA medical opinion report, the examiner stated that there was no medical knowledge or study connecting the euthyroid state to diabetes mellitus, type II, or obesity. The examiner noted that although the Veteran underwent a partial thyroidectomy for a left side nodule during active duty, he had also received thyroxine continuously and had his serum levels regularly monitored. He found that the medical evidence of record showed that the Veteran has been physiologically euthyroid since the Veteran started taking oral thyroxine post-operatively. The examiner further described the function of the thyroid gland and stated that medication taken each day by mouth served the same purpose as the hormones naturally secreted by the thyroid. By occasionally measuring the hormone levels in the Veteran, and adjusting the medication dosage up or down as needed, the Veteran was kept in the euthyroid state without having a functional thyroid gland or only a partially-functional thyroid gland. The examiner stated that a change of 20 percent in the dosage of medication was more than appropriate when made in response to appropriate monitoring. Further, the examiner stated that euthyroidism was a natural/functional state that was not pathologic, and did not lead to and could not aggravate diabetes mellitus, type II. Therefore, the examiner opined that the Veteran’s diabetes mellitus, type II, was not proximately due to or aggravated by the Veteran’s service-connected thyroid condition. The Board reflects that, although the February 2016 VA examiner opined that the Veteran’s diabetes mellitus was not connected to his obesity, no rationale for that opinion was provided. Additionally, the February 2016 examiner explained in detail that the Veteran’s euthyroid state following treatment for his thyroid removal in service did not cause his diabetes mellitus, it is unclear the rationale for the conclusion that such need to synthetically treat his thyroid disability did not aggravate his diabetic condition. In any event, the February 2016 VA examiner did not address the main thrust of March 2012 private nurse’s opinion that the Veteran’s synthetic treatment for his thyroid condition led to his obesity which led to his diabetes. A remand is therefore necessary in order to obtain another VA examination and medical opinion that adequately addresses these aspects of the claim. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005) (a VA examination must be based on an accurate factual premise). The Board reflects that the Veteran’s hypertension, erectile dysfunction, and neurological disorders are intertwined with the remanded diabetes claim and therefore are also remanded. See Henderson v. West, 12 Vet. App. 11, 20 (1998); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Likewise, the Board reflects that the opinion with regards to the Veteran’s obesity that is being obtained also potentially affects the any opinion respecting the sleep apnea claim; that claim is therefore also remanded as intertwined in this case. See Id. On remand, the Board also finds that any outstanding VA treatment records should also be obtained. See 38 U.S.C. § 5103A(b), (c); 38 C.F.R. § 3.159(b); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016) (where the Veteran “sufficiently identifies” other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Obtain any and all VA treatment records not already associated with the claims file from the Columbia VA Medical Center, or any other VA medical facility that may have treated the Veteran and associate those documents with the claims file. 2. Ensure that the Veteran is scheduled for a VA examination with an endocrinologist or other appropriate specialist who has not previously participated in this case in order to determine whether his diabetes mellitus is related to service or secondary to his service-connected thyroid disability. The claims folder must be made available to and be reviewed by the examiner. All tests deemed necessary should be conducted and the results reported in detail. Following examination of the Veteran and review of the claims file, the examiner must opine whether the Veteran’s diabetes mellitus and/or any complications, to include hypertension, erectile dysfunction, and/or neurological disorders, at least as likely as not (50 percent or greater probability) began in or are otherwise related to his miliary service. Next, if the examiner does not find that the Veteran’s diabetes with attendant complications are directly related to military service, the examiner must opine whether his diabetes with attendant complications at least as likely as not are (a) caused by; or, (b) aggravated (i.e., chronically worsened) by the Veteran’s service-connected disabilities, particularly his thyroid disability. The examiner is reminded that he or she must address both prongs (a) and (b) above. In addressing the above, the examiner should additionally opine whether the Veteran’s service-connected disabilities, individually or combined, caused, in whole or in part, his obesity. In addressing this aspect, the examiner must specifically address the March 2012 opinion from J.M., which indicated that the Veteran’s synthetic treatment to control his thyroid disability caused him to gain weight, which in turn caused his diabetes. If the examiner finds that the Veteran’s service-connected disabilities caused him to become obese, either in whole or in part, then the examiner must opine whether (1) obesity was a substantial factor in causing or chronically worsening the Veteran’s diabetes mellitus, hypertension, and/or obstructive sleep apnea; and, (2) whether his diabetes, hypertension, and/or obstructive sleep apnea would not have occurred/chronically worsened if but for the obesity caused by his service-connected disabilities. Finally, the examiner should consider any of the Veteran’s lay statements regarding symptomatology during service and any continuity of symptomatology since discharge and/or since onset. The examiner should also consider any other pertinent evidence of record, as appropriate, including the other VA examiners’ findings and conclusions. All findings should be reported in detail and all opinions must be accompanied by a clear rationale. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Bristow Williams, Associate Counsel