Citation Nr: 19166103 Decision Date: 08/27/19 Archive Date: 08/26/19 DOCKET NO. 16-50 875 DATE: August 27, 2019 REMANDED Entitlement to service connection for hypothyroidism (claim as a thyroid condition) is remanded. Entitlement to service connection for residuals of a stroke is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1971 to May 1974. This appeal comes before the Board of Veterans’ Appeals (Board) from a September 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. This case was remanded by the Board in December 2018 for additional development. For the reasons discussed below, another remand is necessary. 1. Entitlement to service connection for hypothyroidism (claim as a thyroid condition) is remanded. 2. Entitlement to service connection for stroke is remanded. Issues 1-2. The Veteran contends that his hypothyroidism and stroke (diagnosed as transient ischemic attacks (TIAs)) are related to service. Specifically, the Veteran argues that his hypothyroidism stems from in-service immunizations and his TIAs stem from exposure to herbicide agents. The Board notes that the Veteran has not explicitly argued that his TIAs are secondary to his service-connected diabetes mellitus; however, as explained below, the evidence of record has raised the argument. See Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009) (the Board must construe pleadings liberally and consider theories of entitlement that are independently raised by the record, even if they were not specifically asserted by the Veteran). Despite the December 2018 Board remand for VA medical opinions, the Board does not have sufficient evidence to render a decision in this case. Once VA provides an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In general, an adequate medical opinion must support its conclusion with an analysis that can be weighed against contrary opinions and be based upon prior medical history and examinations. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board’s duty to return an inadequate examination report “if further evidence or clarification of the evidence . . . is essential for a proper appellate decision”). The February 2019 VA medical opinions obtained pursuant to the December 2018 Board remand reflect that the Veteran’s hypothyroidism and TIAs are less likely than not incurred in or caused by service. For the hypothyroidism, the examiner noted that the Veteran was not diagnosed with the disability until 2001, 26 years after service, and that Agent Orange is not a cause of hypothyroidism. For the TIAs, the examiner initially noted that the Veteran has never actually been diagnosed with a stroke. It was further noted in the opinion that (1) Agent Orange does not cause strokes, (2) service-connected diabetes mellitus could be a potential contributor to the TIAs, but the Veteran developed diabetes mellitus in 2015, after his 2001 TIAs, and (3) neurology felt that his TIAs were likely secondary to his nonservice-connected hypertension. For reasons discussed below, the Board finds the February 2019 VA medical opinions to be inadequate for adjudicative purposes. Hayes v. Brown, 5 Vet. App. 60, 69 (1993). In determining the adequacy of a medical examination or opinion, an examination or opinion is considered adequate, “where it is based upon consideration of the veteran’s prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board’s ‘“evaluation of the claimed disability will be a fully informed one.’” Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991))). Therefore, when a medical examination or opinion is provided, the clinician must support conclusions with an analysis that is adequate for the Board to consider and weigh against contrary opinions. Id. at 124-25. First, the medical opinions are inadequate because there is little to no rationale for the clinician’s conclusions. In this case, the opinions reflect conclusions with supporting data, but no reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (noting that “a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two”). For instance, the opinions note the delayed onset of the Veteran’s hypothyroidism and TIAs and that Agent Orange does not cause these disabilities, but makes no attempt to provide a medical explanation connecting the two. Next, the TIA medical opinion notes diabetes mellitus as likely contributing to the TIAs, but then discards the theory because the Veteran was not diagnosed with diabetes mellitus until over a decade later from his first TIAs. Although the opinion found that diabetes mellitus did not cause the Veteran’s TIAs, it made no conclusive finding on whether the diabetes mellitus aggravates the TIAs. See Allen v. Brown, 7 Vet. App. 439 (1995) (additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability is also compensable under 38 C.F.R. § 3.310). Lastly, the Veteran’s contention that his hypothyroidism was caused by in-service immunizations was left unaddressed in the medical opinion, making it inadequate to fully address the Veteran’s contention. Unfortunately, there has not been substantial compliance with the Board’s previous remand directives as inadequate medical opinions were obtained for the Veteran’s service connection claims for hypothyroidism and stroke. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records for the period from September 2016 to the Present. 2. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s hypothyroidism and TIAs. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the examiner. The report of examination should, among other things, include a discussion of the (i) Veteran’s documented history and assertions, and (ii) February 2019 VA medical opinions. The clinician should provide a medical opinion that expressly addresses the following: (a) Whether the Veteran’s hypothyroidism at least as likely as not (a probability of 50 percent or greater) had its onset in service or is etiologically related to service, to include in-service immunizations? (b) Whether the Veteran’s TIA at least as likely as not (a probability of 50 percent or greater) had its onset in service or is etiologically related to service, to include in-service exposure to herbicide agents? (c) Whether the Veteran’s TIA is at least as likely as not (i) proximately due to service-connected diabetes mellitus, or (ii) aggravated beyond its natural progression by service-connected diabetes mellitus. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Griffey, Associate 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.