Citation Nr: 21002833 Decision Date: 01/15/21 Archive Date: 01/15/21 DOCKET NO. 10-22 084 DATE: January 15, 2021 ORDER Service connection for hypothyroidism, to include as secondary to service-connected diabetes mellitus, type II, is denied. FINDING OF FACT The weight of the evidence is against finding that the Veteran’s service-connected diabetes mellitus, type II, caused or aggravated hypothyroidism; or is otherwise related to his active duty service. CONCLUSION OF LAW The criteria for service connection for hypothyroidism, to include as secondary to service-connected diabetes mellitus, type II, have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.310 REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1970 to January 1972, to include service in the Republic of Vietnam. The Veteran and his daughter testified before a Decision Review Office (DRO) in April 2011. A complete transcript is of record. This issue was previously before the Board in February 2015, July 2016, May 2017, and most recently in October 2018. Each Board decision of record remanded the Veteran’s service connection claim for new VA examination to address the etiology of his hypothyroidism. The October 2018 Board remand found that a July 2017 medical opinion and a December 2017 addendum opinion were inadequate because the evidence submitted by the Veteran was not adequately addressed. The Veteran was afforded a VA examination in July 2019 and the VA examiner provided a medical opinion which addressed the evidence provided by the Veteran. As such, the Board finds that there has been substantial compliance with the October 2018 Board remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection Service connection requires competent 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 disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disability which is aggravated by a service-connected disability. In order 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) competent evidence establishing that the service-connected disability caused or aggravated the nonservice-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995). Service connection for hypothyroidism, to include as secondary to service-connected diabetes mellitus, type II, is denied. The Veteran asserts that his hypothyroidism is either related to his exposure to Agent Orange or is secondary to his service-connected diabetes mellitus, type II. A review of the Veteran’s service treatment records (STRs) does not reveal any complaints, treatment, or diagnosis for thyroid problems, but the Veteran is service connected for diabetes mellitus, type II, and has been diagnosed with hypothyroidism. The Veteran was afforded VA examinations in September 2008, April 2015, October 2016, and July 2017. The respective VA examiners provided negative nexus opinions. The September 2008 examiner explained that 6 percent of the general population had hypothyroidism and acknowledged that hypothyroidism increased to 10 percent among people with diabetes. However, the examiner reported that the medical literature indicates that diabetes does not cause thyroid problems. The February 2015 Board decision found that the medical opinion was inadequate because it did not address whether diabetes aggravated hypothyroidism. The April 2015 VA examiner reviewed the Veteran’s claims file and found that the Veteran was diagnosed with hypothyroidism in approximately 1998, 26 years after his separation from the military and therefore was not related to his military service. In regard to secondary service connection, the examiner’s rationale was a reiteration of the September 2008 examiner’s opinion. The July 2016 Board decision found that the April 2015 examiner’s medical opinion was inadequate because they failed to address whether the Veteran’s diabetes aggravated his hypothyroidism. Pursuant to the Board’s July 2016 remand directives, an October 2016 medical opinion was obtained. The VA examiner provided a negative nexus opinion regarding whether diabetes caused or aggravated his hypothyroidism, but did not support their conclusion with any rationale. The May 2017 Board decision found that the October 2016 medical opinion was inadequate and remanded for a new VA examination. The Board remand directives directed the VA examiner’s attention to the statements made by the Veteran’s daughter at the 2011 DRO hearing and in a September 2014 letter and the medical articles provided by the Veteran in the January 2015 Appellate Brief. The Veteran’s daughter testified at the 2011 DRO hearing that he was diagnosed with hypothyroidism in 1998 and that his doctor mentioned that it was secondary to diabetes. The daughter reported in a September 2014 written statement that she had been a registered nurse for 4 years and saw clinical changes in her father that caused a gradual increase of an inability to function and perform activities of daily living. As a medical professional, the daughter is considered competent to discuss medical questions. The Veteran was afforded a VA examination in July 2017. The examiner was a nurse practitioner provided a negative nexus opinion, which acknowledged the daughter’s statements, but declined to address the medical literature cited to by the Veteran, stating that the evidence review was beyond the scope of the provider’s expertise and would require a specialist to review the merits, validity, and generalizability of the scholarly work cited to by the Veteran. An addendum opinion was provided in December 2017; however, it was provided by an unnamed examiner who identified himself as a, “clinical endocrinologist at a VA medical center, but was signed by the nurse practitioner. The October 2018 Board decision found that the July 2017 opinion was inadequate because it did not address the medical literature provided by the Veteran; and the December 2017 addendum opinion was inadequate because it was provided by an unnamed endocrinologist and signed by the nurse practitioner who stated that the review of the medical literature cited to by the Veteran was beyond their clinical expertise. The October 2018 Board decision remanded for an addendum opinion to address both direct and secondary theories to service connection, which addressed the medical literature cited to by the Veteran and the statements made by the Veteran’s daughter. The Veteran was afforded a VA examination in July 2019. The examiner reported that she was a clinical endocrinologist at a VA medical center and had conducted clinical research in the past. She indicated having reviewed the Veteran’s claims file, to include the two articles cited to by the Veteran. The examiner explained that the two articles were not relevant to the current claim because the first article described thyroid hormone therapy in general and did not discuss diabetes and did not support any connection between the two diseases. The second article was not relevant because it discussed the effects hyperthyroidism had on diabetes; the examiner pointed out that the Veteran had hypothyroidism, not hyperthyroidism. The examiner acknowledged that there may be an association between diabetes and hypothyroidism, but did not imply causality because in clinical practice, there was no association between the development of hypothyroidism in the presence of diabetes mellitus, type II. The examiner report was signed by endocrinology physician. Here, the Board finds that the endocrinology physician provided adequate medical nexus opinions because she indicated a review of the Veteran’s claims file and provided a robust rationale to support their conclusions. The examiner also acknowledged the medical literature cited to by the Veteran. As such, the Board finds there has been substantial compliance with the remand directives of the October 2018 Board decision. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes that the Veteran, nor his representative has challenged the adequacy of the July 2019 VA examination. See Appellate Brief dated December 22, 2020. Here, service connection on a direct basis is not warranted because the April 2015 VA examiner reported that the Veteran was diagnosed with hypothyroidism in approximately 1998, 26 years after his separation from the military and found no basis to directly relate the condition to his military service. Regarding service connection on a secondary basis, the Board also finds that service connection is not warranted. The Board acknowledges the evidence provided by the Veteran, namely the medical literature that accompanied the January 2015 Appellate Brief and the Veteran’s daughter’s testimony and statements. The Board appreciates the evidence provided by the Veteran, but notes that medical articles without a positive nexus opinion provided by a competent medical professional cannot undermine a medical nexus opinion provided by a VA medical professional. Further, the Veteran’s daughter’s reports that the Veteran was informed by his treating physician that his hypothyroidism was secondary to diabetes and her statements indicating that she noticed clinical changes in her father that caused a gradual increase of an inability to function and perform activities of daily living does not constitute competent medical evidence that would establish service connection for hypothyroidism, or show that the Veteran’s hypothyroidism was aggravated by his diabetes mellitus. Based on the foregoing, the Board affords the submitted medical articles, and the statements made by the Veteran little probative weight. To the extent the Veteran’s daughter is a nurse, she is assumed to have some level of medical training, and would be considered competent to provide some medical opinions. However, her statements and experience must also be weighed against the opinion of an endocrinologist who would have a great deal more training and expertise to assess the etiology of hypothyroidism. The Board affords the July 2019 endocrinologist physician’s opinion great weight because she was able to review the Veteran’s medical records, and acknowledged the evidence presented by the Veteran. Unfortunately, the endocrinologist found that the articles provided by the Veteran were not relevant and did not indicate or suggest that diabetes caused or aggravated his hypothyroidism. To the extent that the Veteran believes that his hypothyroidism is secondary to his service-connected diabetes mellitus, type II, such a medical opinion requires medical expertise, and that determination cannot simply be made by lay observation alone; and the Veteran is not considered competent (meaning medically qualified by training or experience) to provide a medical opinion. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Given that the Veteran provided medical articles that purported to support his assertions, VA examinations were ordered to take into account the medical evidence of record, as well as the Veteran and his daughter’s statements and assertions. Unfortunately, the July 2019 VA examiner provided a negative nexus opinion, and this evidence is found to be the most probative in this case. As such, the weight of evidence is against the Veteran’s claim, and service connection for hypothyroidism is denied. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Fu, 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.