Citation Nr: 21066119 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 12-06 165 DATE: October 28, 2021 REMANDED Service connection for a thyroid disability is remanded. Service connection for a gastrointestinal disability is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1987 to October 1987 and from December 1990 to May 1991 in the U.S. Air Force with additional service in the National Guard. This matter comes before the Board of Veterans' Appeals (Board) from a September 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. Jurisdiction of the case has subsequently transferred to the RO in Detroit, Michigan. In a March 2020 decision, the Board denied entitlement to service connection for a thyroid disability and a gastrointestinal disability. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In a February 2021 Joint Motion for Remand (JMR), the parties agreed to vacate and remand the March 2020 Board decision. This matter was most recently before the Board in June 2021, at which time the issues on appeal were remanded for further development consistent with the terms of the JMR. This case has now returned to the Board for appellate consideration. Thyroid Disability A VA medical opinion was obtained in July 2021. The physician opined that the Veteran's thyroid condition unequivocally was not caused or aggravated by the Veteran's hysterectomy. However, the Board finds that the opinion is inadequate because it focused on the causation of the Veteran's thyroid disability and did not provide a separate rationale for aggravation. To be adequate, a VA opinion must provide separate rationales for both causation and aggravation. Atencio v. O'Rourke, 30 Vet. App. 74 (2018). Additionally, the Board finds that the opinion is conclusory and relied on previous inadequate opinions. As such, remand is warranted to obtain a new VA opinion. Additionally, the Veteran also contends that her thyroid disability is related to her underlying gynecological issues that resulted in her hysterectomy. See e.g., March 2013 Hearing Testimony. The Board cannot make a fully-informed decision on the issue of service connection for a thyroid disability because no VA examiner has opined whether it is related to the Veteran's in-service treatment for gynecological issues. As such, this should be addressed on remand. Finally, the Veteran also contends that her thyroid disability is related to exposure environmental hazards while serving in the Gulf War; however, no VA examiner has opined whether the Veteran's thyroid disability is related to her service in the Gulf War on a direct basis. As such, this should be addressed on remand. Gastrointestinal Disability The July 2021 VA medical opinion stated that the Veteran's thyroiditis and treatment may have impacted gastrointestinal tract as the Veteran's lactose intolerance correlates with the diagnosis of thyroiditis. As such, the claim for service connection for a gastrointestinal disability is inextricably intertwined with the Veteran's claim for service connection for a thyroid disability. Therefore, the appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricable intertwined claim. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: Obtain an opinion from an appropriate physician to determine the nature and etiology of the Veteran's thyroid disability. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the physician. The opinions must include a notation that that this review took place. It is up to the discretion of the physician whether a physical examination of the Veteran is needed to answer the questions below. The physician should identify each diagnosis related to the Veteran's claimed thyroid disability. For each diagnosis, the reviewing physician should answer the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's thyroid disability had its onset during active service or is otherwise etiologically related to any in-service injury, event, or disease, to include (1) diagnosis and treatment for gynecological issues, including amenorrhea, endometriosis, menometrorrhagia, and dysmenorrhea or (2) exposure to environmental hazards in the Gulf War on a direct basis? The physician should consider whether the Veteran's symptoms of a thyroid disability had its onset during active service with continuity of symptoms. (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's thyroid disability was caused by her service-connected hysterectomy with bilateral salping oophorectomy, to include as secondary to any medication or treatment? (c.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's thyroid disability was aggravated by her service-connected hysterectomy with bilateral salping oophorectomy, to include as secondary to any medication or treatment? For purposes of this opinion, the physician is advised that any degree of worsening of a condition by a service-connected condition is sufficient to establish aggravation. (d.) If the physician finds that the Veteran's thyroid disability was not the result of her active-duty service or related to her service-connected hysterectomy with bilateral salping oophorectomy, the physician is requested to provide an opinion as to its etiology. In rendering these opinions, the reviewing physician is advised that the Veteran is competent to report her symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the physician rejects the Veteran's reports, he or she must provide an explanation for such rejection. The physician is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. The complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved must be provided. The physician must consider the medical articles cited by the Veteran in June 2011 and November 2018 supporting a relationship between hysterectomy and thyroid cancer. Additionally, the physician must refer to the Veteran's own medical history in the rationale rather than merely referencing a previous opinion and statistical analysis studies. If an opinion cannot be provided without resorting to mere speculation, the physician must provide a complete explanation for why an opinion cannot be rendered. In so doing, the physician must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). JOHN Z. JONES Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Kernen, 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.