Citation Nr: 18116331 Decision Date: 07/05/18 Archive Date: 07/05/18 DOCKET NO. 15-19 475 DATE: July 5, 2018 ORDER Service connection for hypothyroidism, status post multinodular goiter and thyroidectomy (claimed as thyroid removal) is granted. Service connection for diabetes as secondary to hypothyroidism, status post multinodular goiter and thyroidectomy is granted. REMANDED Service connection for palpitations of the heart as secondary to hypothyroidism, status post multinodular goiter and thyroidectomy is remanded. Service connection for high cholesterol as secondary to hypothyroidism, status post multinodular goiter and thyroidectomy is remanded. Service connection for hypertension as secondary to hypothyroidism, status post multinodular goiter and thyroidectomy is remanded. FINDINGS OF FACT 1. The Veteran’s hypothyroidism, status post multinodular goiter and thyroidectomy, is at least as likely as not related to his military service. 2. The probative medical evidence of record indicates that the Veteran’s diabetes mellitus, type II, is proximately due to, or the direct result of, the service-connected hypothyroidism disability. CONCLUSIONS OF LAW 1. The criteria for service connection for hypothyroidism, status post multinodular goiter and thyroidectomy, are met. 38 U.S.C. § 110, 1131, 5107(b) (West 2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The Veteran’s diabetes mellitus, type II, is secondary to his service-connected hypothyroidism disability. 38 U.S.C. §§ 1110, 1112, 1116, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310, 3.313 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in-service. 38 C.F.R. § 3.303 (d). In order to establish service connection on a direct basis, the record must contain: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303 (b), an alternative method of establishing the second and third Shedden element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309 (a); however, a thyroid condition is not qualifying chronic diseases. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See id; Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or aggravated by, a service-connected disease or injury. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (b). The Veteran is seeking entitlement to service connection for a hypothyroidism, status post thyroidectomy. Specifically, he contends that he was exposed to radiation in service, which resulted in a large goiter and thyroidectomy which caused his hypothyroidism. Service connection for conditions claimed to be due to exposure to ionizing radiation in service can be established in three different ways. See Davis v. Brown, 10 Vet. App. 209, 211 (1997). First, some diseases are presumed to be service connected in radiation-exposed veterans under 38 U.S.C. § 1112 (c) and 38 C.F.R. § 3.309(d). A radiation-exposed veteran is defined by 38 C.F.R. § 3.309 (d)(3) as a veteran who, while serving on active duty or on active duty for training or inactive duty training, participated in a radiation-risk activity. The Veteran does not qualify as a “radiation-exposed veteran” as defined by 38 C.F.R. § 3.309 (d) as he did not participate in a radiation-risk activity as defined by 38 C.F.R. § 3.309 (b)(i), (ii) (2017). In addition, hypothyroidism is not listed as a disease presumed to be service connected in radiation-exposed veterans under 38 U.S.C. § 1112 (c) and 38 C.F.R. § 3.309 (d). Thus, he does not meet the criteria for establishing service-connection presumptively under 38 U.S.C. § 1112 (c) and 38 C.F.R. § 3.309 (d). 1. Service connection for hypothyroidism, status post multinodular goiter and thyroidectomy (claimed as thyroid removal). The Veteran is seeking entitlement to service connection for a hypothyroidism, status post multinodular goiter and thyroidectomy. Specifically, he contends that he was exposed to radiation in service, which caused a large goiter and thyroidectomy and thereafter caused his hypothyroidism. In the instant matter, the Veteran has a current diagnosis of hypothyroidism, which is not considered to be a “radiogenic disease” pursuant to 38 C F.R. § 3.311 (b)(2)(1). However, the Veteran testified during his April 2017 Board hearing that he was stationed at the Walter Reed Army Institute of Research during service for the purposes of conducting research involving animals. The Veteran recounted that this research involved exposure to radioactive iodine when it was injected into sheep. The Veteran’s DD-214 supports that he was stationed at the Walter Reed Army Institute of Research as a Veterinary Specialist. In addition, an August 1974 Army memorandum shows that experiments were conducted at Walter Reed Army Institute of Research which consisted of administering radioactive iodine to sheep. These experiments were conducted at the same time that the Veteran was stationed at Walter Reed Army Institute of Research. The Veteran has also submitted a May 2017 private treatment record which states that the Veteran underwent a total thyroidectomy in 1996. This thyroidectomy was necessitated by the development of a large multinodular goiter. The physician noted that exposure to radioactive iodine increases the future risk of development of thyroid nodules, typically several years or decades later. Therefore, he concluded that the goiter was likely related to radioactive iodine exposure. Notably, the May 2017 private treatment record is the only medical opinion of record addressing the question of whether the Veteran’s hypothyroidism is related to radiation exposure in service. In light of that fact and considering the opinion is supported by rationale with supporting medical explanation, the Board finds it is highly probative and persuasive in this matter. In summary, the preponderance of the evidence is in favor of a finding that the Veteran has a current diagnosis of hypothyroidism, status post multinodular goiter and thyroidectomy, that was caused or aggravated by service. Thus, the claim for service connection is granted. 2. Service connection for diabetes as secondary to hypothyroidism, status post multinodular goiter and thyroidectomy. The Veteran has claimed that his currently diagnosed diabetes mellitus, type II, was caused by his service connected hypothyroidism. As shown immediately above, the Veteran is now service connected for hypothyroidism. The Veteran does not content that his diabetes mellitus, type II, is directly related to service. Likewise, the evidence of record does not suggest that the current diabetes mellitus, type II, is directly related to service. Service treatment records are silent for complaints of, a diagnosis of, or treatment for diabetes mellitus, type II. Rather, the Veteran contends that his diabetes mellitus, type II, developed as a result of his service connected hypothyroidism. As such, the question before the Board is whether there is a causal relationship between the Veteran’s current diabetes mellitus, type II, and his hypothyroidism sufficient to award service connection on a secondary basis. Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 16-17. A May 2017 private treatment records show that the Veteran was diagnosed with diabetes mellitus, type II. A May 2017 private treatment record states that as a result of the Veteran’s 1996 thyroidectomy he developed rapid weight gain, which subsequently led to development of diabetes. The physician further stated that the thyroidectomy may have predisposed him to rapid weight gain and subsequent development of type II diabetes. The May 2017 private treatment record is the only medical opinion of record addressing the question of whether the Veteran’s diabetes mellitus, type II, was caused by his service connected hypothyroidism. In light of that fact and considering the opinion is supported by rationale with supporting medical explanation, the Board finds it is highly probative and persuasive in this matter. Based on the credible and probative medical opinion evidence of record, namely the May 2017 medical opinion, the Board finds sufficient evidence of a nexus between the Veteran’s service connected hypothyroidism, status post thyroidectomy, and his current diabetes mellitus, type II, to grant an award of secondary service connection. Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 16-17.   REASONS FOR REMAND 1. Service connection for palpitations of the heart as secondary to hypothyroidism, status post multinodular goiter and thyroidectomy is remanded. 2. Service connection for high cholesterol as secondary to hypothyroidism, status post multinodular goiter and thyroidectomy is remanded. 3. Service connection for hypertension as secondary to hypothyroidism, status post multinodular goiter and thyroidectomy is remanded. Upon review of the record, the Board concludes that further evidentiary development is necessary. Although the Board sincerely regrets this delay and is appreciative of the Veteran’s service to his country, a remand is necessary to ensure VA provides the Veteran with appropriate process and assistance in developing his claim prior to final adjudication. Under McClendon v. Nicholson, 20 Vet. App. 79, 81 (2006), a VA medical examination must be provided when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4)(i). The Veteran has submitted competent medical evidence of diagnoses hypertension, high cholesterol and heart palpitations. The Veteran is currently service connected for hypothyroidism and has submitted a June 2017 private medical opinion which states that his coronary artery disease is related to his hypothyroidism. However, the June 2017 opinion did not render an opinion regarding the Veteran’s hypertension, high cholesterol and heart palpitations. As the Veteran has not undergone a VA examination for these conditions, the Board finds that insufficient medical evidence exists to make a determination on the claim for service connection for hypertension, high cholesterol and heart palpitations. The matters are REMANDED for the following action: 1. Prior to obtaining any opinion, the Veteran’s assistance should be obtained to ensure that copies of any outstanding records of pertinent medical treatment are identified and added to the claims file. Contact the Veteran, and, with his assistance, identify any outstanding records of pertinent medical treatment from VA or private health care providers. With the Veteran’s assistance obtain copies of any pertinent records and add them to the claims file. Follow the procedures for obtaining the records set forth by 38 C.F.R. § 3.159 (c). If VA attempts to obtain any outstanding records which are unavailable, the Veteran should be notified in accordance with 38 C.F.R. § 3.159(e). 2. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his hypertension. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must provide an opinion, in light of the examination findings and the service and post-service evidence of record, as to whether it is at least as likely as not (50 percent or greater probability) that the hypertension was caused or aggravated by the Veteran’s military service, to include as due to exposure to ionizing radiation and service connected hypothyroidism. The examiner must specifically address the Veteran’s assertions and medical literature submitted that exposure to ionizing radiation caused his hypothyroidism, which led to the development of hypertension. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his heart palpitations. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must provide an opinion, in light of the examination findings and the service and post-service evidence of record, as to whether it is at least as likely as not (50 percent or greater probability) that the heart palpitations were caused or aggravated by the Veteran’s military service, to include as due to exposure to ionizing radiation and service connected hypothyroidism. The examiner must specifically address the Veteran’s assertions and medical literature submitted that exposure to ionizing radiation caused his hypothyroidism, which led to the development of heart palpitations. 4. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his high cholesterol. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must provide an opinion, in light of the examination findings and the service and post-service evidence of record, as to whether it is at least as likely as not (50 percent or greater probability) that the high cholesterol was caused or aggravated by the Veteran’s military service, to include as due to exposure to ionizing radiation and service connected hypothyroidism. The examiner must specifically address the Veteran’s assertions and medical literature submitted that exposure to ionizing radiation caused his hypothyroidism, which led to the development of high cholesterol. 5. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims must be readjudicated. If the claims remain denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2014). DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Nelson, Associate Counsel