Citation Nr: 20056762 Decision Date: 08/27/20 Archive Date: 08/27/20 DOCKET NO. 15-16 012 DATE: August 27, 2020 REMANDED Entitlement to service connection for hypothyroidism, to include as due to exposure to herbicide agents and as secondary to diabetes mellitus, is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from January 1969 to January 1972. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a June 2014 Department of Veterans Affairs (VA) rating decision. In March 2019, the matter was remanded for additional development. The March 2019 remand ordered a VA examination to obtain an opinion that addressed the likely etiology of the Veteran’s hypothyroidism (considering whether it was caused or aggravated by his service-connected diabetes, expressing agreement or disagreement with the opinions in the record, and commenting on the applicability of the literature submitted to the Veteran’s claim). In a November 2019 VA medical opinion addendum, the provider noted the Institute of Medicine (IOM) released a report in 2016 containing new research that found hypothyroidism is more strongly linked to Agent Orange exposure than previously thought. The Veteran served in Vietnam, and it is not in dispute that he was exposed to Agent Orange/herbicide agents in service. Although hypothyroidism is not a disease entitled to presumption of service connection based on exposure to herbicide agents under 38 U.S.C. § 1116 and 38 C.F.R. § 3.309 (e), he may nonetheless substantiate the claim under that theory of entitlement by competent evidence that the diseases are related to such exposure. See Combee v. Principi, 4 Vet. App. 78 (1993). While the November 2019 examiner opined that hypothyroidism is not related to service (noting it was diagnosed well after from service), he did not discuss his own observation that updated medical treatise shows a stronger association between hypothyroidism and exposure to Agent Orange. Additionally, in an opinion against the secondary service connection theory of entitlement, the provider noted there is no nexus in medical literature for diabetes and hypothyroidism per his review of the medical literature; the examiner does not address the applicability of the medical literature already in the record. Given the noted inconsistencies, development for a clarifying advisory medical opinion is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The matter is REMANDED for the following: Arrange for the Veteran’s record to be returned to the November 2019 examiner for re-review and an addendum opinion regarding the etiology of his hypothyroidism. [If that provider is unavailable or unable to provide the opinions sought, arrange for the claims file to be forwarded to another appropriate clinician for review and the opinions sought (and if in such circumstance further examination of the Veteran is deemed necessary, such should be arranged).] Upon review of the record, the consulting provider should: (a.) Opine whether is it at least as likely as not (a 50% or greater probability) that hypothyroidism is etiologically related to the Veteran’s service (to include as due to his exposure to Agent Orange/herbicide agents therein) OR was caused or aggravated by (increased in severity due to) his service-connected diabetes mellitus or by medication provided to treat the diabetes? [The opinion must address aggravation.] (b.) If hypothyroidism was not caused, but was aggravated, by service-connected disabilities, to the extent possible identify the degree of severity of the hypothyroidism (the extent of related impairment) that is due to such aggravation. (c.) If hypothyroidism is determined to be unrelated to service, and not caused to aggravated by a service-connected disability, identify the etiology for the hypothyroidism that is considered to be more likely (and explain why that is so). All opinions must include rationale. The rationale should include comment on the opinions and medical treatises already in the record in this matter, specifically discussing the VA consulting provider’s observation that recent studies suggest a stronger (than was previously thought) link between Agent Orange and hypothyroidism and literature submitted suggesting a link between diabetes and thyroidism. Express agreement or disagreement with the opinions, including rationale, and comment on the applicability of the literature submitted in support of the claim). GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Naumovich, 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.