Citation Nr: 21071833 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 17-48 730 DATE: December 1, 2021 ORDER Entitlement to service connection for hyperthyroidism, claimed as Graves' disease (hereinafter referred to as "hyperthyroidism") is granted. FINDING OF FACT The Veteran's hyperthyroidism is etiologically related to service. CONCLUSION OF LAW The criteria for service connection for hyperthyroidism have been met. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1985 to August 2005. This matter comes to the Board of Veterans' Appeals (Board) from a February 2016 rating decision which denied the Veteran's petition to reopen his service connection claim for hyperthyroidism because no new and material evidence had been received. In June 2020, the Board found that new and material evidence had been received to reopen the service connection claim for hyperthyroidism and then remanded to obtain a VA medical opinion regarding the etiology of the Veteran's hyperthyroidism. The agency of original jurisdiction obtained this opinion on remand and, thus, substantially complied with June 2020 remand. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for hyperthyroidism is granted. The Veteran asserts that his hyperthyroidism is related to in-service job stress that is documented in his service treatment records. He further asserts that probative weight should be given to his specialist's positive nexus opinion and that the VA examiner did not consider whether his complaints of stress indicated an earlier onset of hyperthyroidism than the official date of diagnosis. Service connection may be granted on a direct basis for a disability that results from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Direct service connection generally requires (1) evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). As a preliminary matter, the Board will not restate the August 2017 VA medical examiner's negative nexus opinion because the June 2020 remand explained why this opinion was inadequate. A September 1984 enlistment examination identified no defects or abnormalities involving the endocrine system. The Veteran's service treatment records, to include August 1999 and September 2003, showed complaints and treatment for stress. At an April 2005 retirement examination, the provider noted that the Veteran had a lesion on his head, but did not appear to have performed a full examination. In 2009, the Veteran underwent a sleep study due to reports of excessive daytime somnolence. During the work-up for sleep apnea, medical providers noted the Veteran's complaints of feeling breathless while sitting still. A thyroid-stimulating hormone test showed a result of less than .01, where the normal range is .49 to 4.67. A thyroid ultrasound showed a left thyroid mass. Dr. C.R., an endocrinologist, diagnosed the Veteran with T3 thyrotoxicosis with left thyroid enlargement probably due to Graves' disease. In July 2017, Dr. R. opined that it was at least as likely as not that the Veteran's military service could have been the cause for Graves' disease. Dr. R. reviewed the Veteran's medical record and stated that it was clear that the Veteran was under significant stress during service. Dr. R. also stated that the Veteran had no family history for thyroid disease and that Graves' disease is usually precipitated by stress. In June 2020, Dr. R. restated this opinion. In a July 2020 VA opinion, Dr. K.F. opined that it was less likely than not that the Veteran's hyperthyroidism was related to service. Dr. F. stated that the Veteran was diagnosed with Graves' disease in 2009, four years after separation from service. Dr. F. stated that the medical literature shows that stressful events are associated with the development of Graves' disease within 12 months of diagnosis, but the literature does not support that Graves' disease is triggered by stressful events occurring more than 12 months before diagnosis. Dr. F. cited a study that evaluated patients who reported at least one stressful event before the onset of Graves' disease. Dr. F. also cited a study containing five patients who had a stressful life event in the 12 months preceding diagnosis of Graves' disease. After reviewing the conflicting evidence, the Board finds that the Veteran's current disability of hyperthyroidism is etiologically related to service. The Veteran was in sound condition at enlistment based on the September 1984 examination. The medical evidence shows that the Veteran has a current diagnosis of hyperthyroidism. The Board accords probative weight to Dr. R.'s opinion because it was based on a thorough review of the Veteran's record, and the Veteran's service treatment records documented reports of stress. Similarly, as an endocrinologist, Dr. R. has specialized expertise of the etiology of hyperthyroidism. The Board accords limited probative weight to Dr. F.'s opinion. While Dr. F. acknowledged a link between stress and hyperthyroidism, he stated that this link was limited to where the stressful event occurred within 12 months of the diagnosis of hyperthyroidism. The studies cited by Dr. F., however, do not support this opinion because they were limited to patients who had a stressful event within 12 months of the onset of hyperthyroidism. Thus, these studies do not exclude the possibility that hyperthyroidism could be related to stressful events that occurred more than one year before the onset of this disability. Moreover, Dr. F. erroneously conflated the onset of hyperthyroidism with its diagnosis because Dr. F. did not consider the Veteran's assertions that the onset of this disability began during service but was not diagnosed until four years after service. Accordingly, the Board concludes that the preponderance of the evidence supports the Veteran's claim and grants the claim of service connection for hyperthyroidism. TRACIE N. WESNER Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Ormson, 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.