Citation Nr: 21073181 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 19-29 728 DATE: December 7, 2021 REMANDED Entitlement to service connection for sarcoidosis, to include neurosarcoidosis is remanded. Entitlement to service connection for a disability manifested by brain lesions and seizures is remanded. Entitlement to service connection for obstructive sleep apnea, claimed as a sleep disability is remanded. Entitlement to service connection for hypothyroidism is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1977 to September 1983 and from November 1986 to January 1996, to include service in the Persian Gulf from December 1992 to May 1992. His awards include combat action ribbon. This matter comes before the Board of Veterans' Appeals (Board) on appeal from Department of Veterans Affairs (VA) Regional Office (RO)'s rating decisions issued in August 2018. The Board previously remanded the issues for further development on April 18, 2020. One of the remanded issues, the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), was later vacated by a February 2021 Board decision due to a jurisdictional issue. However, the claim was granted in a March 2021 Board decision. During the appeal period, the Veteran's claim for entitlement to service connection for a psychiatric disability, including an unspecified anxiety disorder was granted in a June 2021 rating decision and rated as mild neurocognitive disorder. As this grant represents a full grant of the benefits sought, this issue is no longer on appeal. See Grantham v. Brown, 114 F.3d. 1156 (Fed. Cir. 1997). The rest of the remanded issues has now been returned to the Board for appellate review. The Veteran originally filed a claim for a "sleep condition." As noted above, the Veteran is now service-connected for neurocognitive disorder, and the rating for the disability includes chronic sleep impairment. See the June 2021 rating decision. However, he has another diagnosed sleep disability, obstructive sleep apnea. Therefore, the issue of service connection for a sleep disability has been recharacterized as that of obstructive sleep apnea. 1. Service connection for sarcoidosis, to include neurosarcoidosis 2. Service connection for a disability manifested by brain lesions and seizures A review of the evidence indicates that the Veteran has been diagnosed with both neurosarcoidosis and multiple nodules of the lung. An October 2015 VA treatment record indicates that a September 2015 consult reports by Mayo Clinic provided a diagnosis of "chronic inflammatory granulomatous disease with central nervous system (CNS) involvement likely sarcoidosis," "bilateral trigeminal nerve palsy and right facial nerve palsy, secondary to neurosarcoidosis," "seizure disorder," "extra central nervous system involvement, granulomatous, interstitial nephritis, pancreatitis, pulmonary nodules and lung interstitial disease," as well as "pituitary mass lesion (adenoma vs. sarcoid infiltrative lesion)." Moreover, an August 2018 VA examination reflects a diagnosis of "sarcoidosis, multi-system, to include CNS/neuro (with cranial nerve infiltration and possible seizure), pulmonary & renal involvement." Also, as noted by a March 2021 VA examiner, a September 2018 pulmonary consult reflects that sarcoidosis was diagnosed at Mayo Clinic and that biopsy showed sarcoidosis with multiorgan involvement. In light of the above, the Veteran has likely been primarily treated at Mayo Clinic for sarcoidosis involving nervous system as well as lungs. However, no treatment records from the clinic have been obtained. Upon remand, the Agency of Original Jurisdiction (AOJ) must obtain treatment records from Mayo Clinic with proper release authorization from the Veteran. Additionally, the Board finds that medical opinions concerning sarcoidosis, brain lesions, and seizure disorder that were obtained per the April 2020 remand are inadequate for rating purposes. The March 2021 examiner stated that sarcoidosis is a lung condition which is not related to seizures or brain lesions and that sarcoidosis is an inflammatory lung disease characterized by the formation of granulomas. This does not appear consistent with the facts found in the medical evidence above. The Veteran has been diagnosed with and treated for neurosarcoidosis involving multiple organs, to include the lungs, nervous systems, and kidneys. After the record development is complete, the AOJ must schedule a new VA examination for sarcoidosis, to include neurosarcoidosis, as well as for brain lesions and seizure disorder. A medical etiology opinion for these disabilities must be obtained. 3. Service connection for obstructive sleep apnea, claimed as a sleep disability An April 2021 VA examination provided a diagnosis of obstructive sleep apnea. Pursuant to the April 2020 remand, a medical opinion was obtained in March 2021. The Board finds that this medical opinion is inadequate for rating purpose because it only provided an opinion for a nexus between sleep apnea and sarcoidosis or psychiatric disability. Moreover, this opinion did not consider the effects of medications the Veteran has been taking for his service-connected disabilities, to include diabetes, chronic kidney disease, migraine headaches, and psychiatric disability, even though such consideration was requested by the April 2020 remand. Stegall v. West, 11 Vet. App. 268, 271 (1998). Therefore, the AOJ must obtain an addendum opinion for the Veteran's obstructive sleep apnea that considers the evidence of record and provides sufficient rationales. 4. Service connection for hypothyroidism An April 2021 medical opinion states that the Veteran's hypothyroidism is unrelated to service-connected disabilities, including chronic kidney disease because they have different pathologies. Then, citing to a Mayo Clinic article, the examiner continued to explain that the most common cause of hypothyroidism is an autoimmune disorder known as Hashimoto's thyroiditis. The Board does not find this rationale persuasive. First, it is widely known that Hashimoto's thyroiditis is only one of the causes for hypothyroidism. See, e.g., Mayo Clinic, Hypothyroidism (underactive thyroid), https://www.mayoclinic.org/diseases-conditions/hypothyroidism/symptoms-causes/syc-20350284. Indeed, the article cited indicates that medications and pituitary disorder could be a cause. Rather, the evidence of record indicates that his thyroid level decreased relatively recently and the clinicians made such a finding during the course of treatment for other disabilities such as diabetes and chronic kidney disease. Pertinent to this, an article in UpToDate states that "[e]pidemiologic data suggest that predialysis patients with chronic kidney disease have an increased risk of hypothyroidism" and that "[t]he kidney normally plays an important role in the metabolism, degradation, and excretion of several thyroid hormones." UpToDate, Thyroid function in chronic kidney disease, https://www.uptodate.com/contents/thyroid-function-in-chronic-kidney-disease. This indicates a potential connection between kidneys and thyroid that was not considered or explained in the April 2021 medical opinion. In sum, in addition to failing to comply with the April 2020 Board directive to discuss the impact of medications for his service-connected disabilities on hypothyroidism, the April 2021 medical opinion does not adequately consider the Veteran's hypothyroidism in light of his complex situation with various medical disabilities, some of which are service-connected. As such, the AOJ must schedule a new VA examination and obtain a medical etiology opinion that considers the evidence fully and provides sufficient rationales. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for Mayo Clinic. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile. 2. After the record development is complete, schedule the Veteran for a VA examination for his sarcoidosis, to include neurosarcoidosis, brain lesions, seizure disorder, and hypothyroidism. The examiner must review the claims file. For each diagnosed disability, the examiner must provide an opinion, with sufficient rationales, for the following: (a) Whether the disability is at least as likely as not related to service, to include his service in the Persian Gulf; and (b) Whether the disability is at least as likely as not proximately due to or aggravated beyond its natural progression by a service-connected disability. Consideration must include impacts of medications he takes for his service-connected disabilities. 3. After the record development is complete, obtain an addendum opinion, with sufficient rationales, for obstructive sleep apnea as to: (a) Whether the disability is at least as likely as not related to service, to include his service in the Persian Gulf; and (b) Whether the disability is at least as likely as not proximately due to or aggravated beyond its natural progression by a service-connected disability. Consideration must include impacts of medications he takes for his service-connected disabilities. 4. After the development requested has been completed, the examination reports should be reviewed to ensure that they are in complete compliance with the directives of this REMAND. If any report is deficient in any manner, corrective procedures should be implemented. 5. Readjudicate the claims. Emily Tamlyn Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Y. Taylor 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.