Citation Nr: 21070390 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 09-01 569 DATE: November 23, 2021 REMANDED Entitlement to service connection for multinodular goiter, to include as due to herbicide agents and/or radiation, is remanded. Entitlement to service connection for osteoporosis, to include as secondary to herbicide agent exposure, radiation and/or a service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from April 1968 to April 1972. These matters come to the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The appeal was remanded in October 2020 for additional development. It has since been returned to the Board for further appellate consideration. In a June 2021 rating decision, the RO granted service connection for residual disability, bladder cancer, in remission associated with herbicide exposure, effective June 20, 2007. The RO noted that this was a considered a full grant of the benefits sought on appeal, and the issue is no longer in appellate status. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). The claims for service connection for osteoporosis and service connection for multinodular goiter remain before the Board and will be addressed below. 1. Entitlement to service connection for multinodular goiter, to include as due to herbicide agents and/or radiation, is remanded. Remand is again necessary because the RO has not complied with the prior remand directives. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. The October 2020 Board remand directed the RO to obtain an addendum opinion. The Board indicated that the fact that thyroid condition is not a not a disability presumed to be related to herbicide agent exposure is not sufficient to serve as a rationale for a negative opinion. Also, the Board instructed that the examiner address the medical article submitted by the Veteran. Following the Board's October 2020 remand, VA obtained a January 2021 VA addendum opinion. The examiner opined that the Veteran's multinodular goiter is less likely than not due to service to include herbicide exposure. The examiner reasoned there is no VA presumptive or medical evidence that supports an association between a normal functioning thyroid gland with benign nodules and Agent Orange exposure. The examiner explained that the only diagnosis for multinodular goiter was in 2007, it is not a VA presumptive illness, and the Veteran has not required thyroid treatment. The examiner noted that the Veteran is monitored for change but thus far he has a normal thyroid function. The examiner explained the etiology for multinodular goiter is iodine deficient, familial, or not otherwise specified (NOS) factors only. First, the examiner seems to rely on the fact that thyroid condition is not a disability presumed to be related to herbicide agent exposure as rationale to support the negative opinion. As noted above, the prior Board remand indicated this is not sufficient to serve as rationale in this case. Next, the examiner noted review of the Veteran's claims file. The examiner however failed to address the medical literature submitted in December 2019 (see 12/20/2019 Web / HTML Documents) summarizing an Institute of Medicine study that suggested an upgrade from the category of insufficient evidence to limited or suggestive evidence of a link for bladder cancer and hypothyroidism based on a compellingly suggestive large study of Korean War Veterans who also served in Vietnam. As such, the Board finds that a remand is necessary for an addendum opinion. 2. Entitlement to service connection for osteoporosis, to include as secondary to herbicide agent exposure, radiation and/or a service-connected disability, is remanded. This issue must be remanded as it is inextricably intertwined with the issue of entitlement ot service connection for multinodular goiter. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). In a June 2021 VA examination, the examiner noted a diagnosis of osteoporosis and associated it with the Veteran's multinodular goiter disorder. Accordingly, it is intertwined with the resolution of that issue. The matters are REMANDED for the following action: 1. Obtain all updated records (i.e., those not already of record) of VA and adequately identified private treatment the Veteran has received for the disability on appeal. 2. Following the receipt of any outstanding records, obtain an addendum opinion to determine the nature and likely cause of any diagnosed thyroid disorders and/or residuals present since August 2007. The Veteran's entire claims file, to include a copy of this remand, should be provided to the examiner. Following a complete review of the record, the examiner is asked to provide the following opinion: Is it as least as likely as not (a 50 percent or greater probability) that the Veteran's thyroid condition is related to his active service or is caused by or aggravated by military service, to include exposure to herbicide agents? In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms and inservice exposure to herbicide agents. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. The fact that thyroid condition is not a disability presumed to be related to herbicide agent exposure is not sufficient to serve as a rationale in this case. If a negative opinion is offered based primarily on the length of time between separation and the current diagnosis the examiner should explain the medical significance of this fact, i.e., why this is indicative that thyroid condition is not related to service. In providing the above opinions, the examiner MUST address relevance of the medical article submitted by the Veteran reporting an upgrade to limited or suggestive evidence of a link between hypothyroidism and herbicide exposure. See Web/HTML Documents December 2019. (Continued on the next page) A complete rationale must be provided for each opinion. The opinion and rationale must go beyond a generalized statement that a review of medical literature does not support the Veteran's claim. The rationale should reflect the specific facts and medical principles specific to the Veteran's claim. 3. If upon completion of the above action the issues of multinodular goiter or osteoporosis remains denied, the case should be returned to the Board after compliance with appellate procedures. David Gratz Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Braxton, 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.