Citation Nr: 21001248 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 12-11 613A DATE: January 7, 2021 REMANDED Entitlement to service connection for azotemia, to include as due to hypothyroidism is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1984 to April 1988, and from February 1990 to June 2002. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a February 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This appeal has been before the Board previously. In October 2017, the Board remanded the issue on appeal for an opinion as to whether it was at least as likely as not that the prescribed methimazole, or any other aspect of the Veteran’s treatment in the wake of his March 2009 thyroid ablation, caused azotemia or any other disorder. Additionally, in June 2020, the Board remanded the issues on appeal since it noted that the January 2019 VA examiner opined that it was less likely than not that the Veteran’s azotemia was a complication of the methimazole, the ablation, or the hypothyroidism; however, the examiner did not address aggravation. These matters have now returned to the Board for appellate consideration. Service Connection Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Where a disease is first diagnosed after discharge, service connection will be granted when all the evidence, including that pertinent to service, establishes it was incurred in active service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.30(d). Service connection requires evidence showing: (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 condition incurred or aggravated by service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Regulations provide that service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Further, a disability which is aggravated by a service-connected disorder may be service connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439, 449 (1995); 38 C.F.R. § 3.310(b). In order to establish entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; (3) medical evidence establishing a nexus between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). The Veteran is competent to report symptoms and experiences observable by his senses. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). In relevant part, 38 U.S.C. § 1154(a) requires that VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). 1. Service connection for azotemia, to include as due to hypothyroidism. The Veteran contends that his azotemia is related to or secondary to his Graves’ disease, hypothyroidism, and/or rhabdomyolysis. See 1/3/2010 VA Form 21-4138, at page 4; see also 1/13/2010 Administrative Decision; 3/17/2010 VA Form 21-4138; 9/12/2011 NOD; 12/9/2020 Third Party Correspondence. Additionally, the Veteran’s representative argued that medical research shows that azotemia may in fact occur because of hypothyroidism or treatment for hyperthyroidism. See 11/1/2019 Third Party Correspondence; see also 12/9/2020 Third Party Correspondence; 12/9/2020 Medical Treatment Record – Government Facility. Private treatment records showed a diagnosis of azotemia. See 6/7/2010 Medical Treatment Record – Non-Government Facility, at pages 3 and 13. As mentioned above, the June 2020 Board remand noted that the January 2019 VA examiner opined that it was less likely than not that the Veteran’s azotemia was a complication of the methimazole, the ablation, or the hypothyroidism. However, the examiner did not address aggravation and the Board found that an addendum opinion was warranted. The Veteran was afforded a VA examination in November 2020; however, the examiner determined that there was no objective evidence to warrant a diagnosis for azotemia. See 11/11/2020 C&P Examination. The Board finds this opinion inadequate. The reviewing clinician did not base his conclusion on the full claims record, since as mentioned above, the record shows a diagnosis for azotemia. As such, on remand, the RO should obtain an addendum opinion to determine if the diagnosed azotemia is aggravated by service-connected hypothyroidism and rhabdomyolysis. 2. A TDIU. With respect to the Veteran’s claim for a TDIU, the Board finds that this claim is inextricably intertwined with his pending service connection claim for azotemia. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a “significant impact’ upon another and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources the two claims are inextricably intertwined). The Veteran’s attorney representative has also argued that TDIU should be remanded due to pending decisions from VA. See 12/09/2020 Third Party Correspondence. Therefore, the adjudication of TDIU is deferred pending adjudication of the Veteran’s service connection claim for azotemia. These matters are REMANDED for the following actions: 1. Obtain all outstanding VA treatment records and associate them with the claims file. 2. After completion of step # 1, return the claims file to the reviewing clinician who authored the November 2020 hematologic opinion. The clinician is to review the virtual file, including a copy of this Remand. The examiner is to note that private treatment records showed a diagnosis of azotemia during the period on appeal (from February 2010) and this legally qualifies as a current disability even if as of 2021 there is no diagnosis. See 6/7/2010 Medical Treatment Record – Non-Government Facility, at pages 3 and 13. After a review of the claims file, the reviewing clinician must address: (a.) Whether it is at least as likely as not that the Veteran’s azotemia is aggravated (increased in severity beyond the natural progression) by a service-connected disability, to include but not limited to his service-connected hypothyroidism and/or rhabdomyolysis. (b.) If aggravation is found, please state, to the extent possible, the baseline level of disability prior to aggravation. **In doing so, please address the medical articles filed by the Veteran’s attorney representative to support the contention that medical research shows that azotemia, may in fact occur because of hypothyroidism or treatment for hyperthyroidism. See 12/9/2020 Medical Treatment Record – Government Facility.**   If the November 2020 reviewing clinician is no longer available, then the claims file and the November 2020 opinion should be forwarded to another examiner of at least equal qualifications to obtain the requested opinion. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Fuentes, 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.