Citation Nr: 21008366 Decision Date: 02/16/21 Archive Date: 02/16/21 DOCKET NO. 17-15 856 DATE: February 16, 2021 ORDER Entitlement to service connection for residuals of pituitary injury, to include pituitary adenoma and hyperpituitarism (hyperprolactinemia), is granted. Entitlement to service connection for parathyroid disability is denied. REMANDED Entitlement to service connection for residuals of head and neck injuries, to include traumatic brain injury and a headache disorder, is remanded. Entitlement to an earlier effective date for the grant of service connection for posttraumatic stress disorder is remanded. FINDINGS OF FACT 1. The Veteran’s pituitary was injured in service. 2. Residuals of the pituitary injury include pituitary adenoma and hyperpituitarism (hyperprolactinemia). 3. A parathyroid disability did not manifest in service or within one year of separation and is not attributable to service. 4. A parathyroid disability is not proximately due to or aggravated by a service-connected disease or injury. CONCLUSIONS OF LAW 1. Residuals of pituitary injury, to include pituitary adenoma and hyperpituitarism (hyperprolactinemia), were incurred in service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for a parathyroid disability, to include migraine headaches, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran is not expected to have the expertise necessary to identify all disabilities. Consistent with our March 2019 remand, the AOJ has expressly addressed thyroid and pituitary disabilities. Based on the rationale provided in the April 2020 supplemental statement of the case (SSOC), the AOJ also appears to have implicitly considered parathyroid disabilities. See April 2020 SSOC (AOJ cited November 2019 negative nexus opinion to deny pituitary disability claim, but examiner gave negative opinions for parathyroid disabilities and positive opinions for pituitary disabilities). In light of the medical evidence of record, the Veteran’s claims have been recharacterized to explicitly include parathyroid disabilities as a separate issue. Service Connection Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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, the so-called “nexus” requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310. 1. Entitlement to service connection for residuals of pituitary injury, to include pituitary adenoma and hyperpituitarism (hyperprolactinemia), The Board remanded the Veteran’s pituitary disability claim in March 2019, because no VA examiner had opined whether the Veteran’s pituitary disabilities are related to service. In light of the opinions received since then, the Board finds service connection for pituitary adenoma and hyperpituitarism is warranted. As noted in our prior remand, the Veteran contends, or has presented evidence, that his pituitary disabilities are due to head and neck traumas incurred in service, to include an alleged February 1964 head injury. Alternatively, he contends alleged exposure to an herbicide agent (Agent Orange) is the cause of his disabilities. Treatment records and December 2019 VA examination reports confirm the Veteran has current pituitary disabilities. Furthermore, the Board finds the Veteran sustained head and neck injuries in service. Although service treatment records do not show treatment for a head or neck injury, the Veteran’s service medical records are limited to an entrance examination and a separation examination. The Agency of Original Jurisdiction (AOJ) has made a formal finding on the unavailability of complete service treatment records. See September 2012 VA memo. However, the AOJ has relied on the Veteran’s separation examination to verify a posttraumatic stress disorder (PTSD) stressor of a head injury in February 1964. See October 1964 separation examination (shows presence of a scalp scar, on right, which was not present on entrance examination). The Veteran is competent to report head and neck injuries. Accordingly, the Board finds credible the Veteran’s general assertion that he sustained head and neck injuries in service. Accordingly, we will not address the credibility of each specific injury allegation. Therefore, the remaining question is whether there is a nexus between service and the Veteran’s pituitary disabilities. The Veteran attended a VA endocrine system examination in November 2019, and the examiner opined the Veteran’s pituitary disabilities are at least as likely as not incurred in or caused by an injury in service. In support of this, the examiner noted the Veteran was punched in the head in service and further explained that a head injury “such as a punch can damage the pituitary gland with sequelae of fatigue, decreased stamina, increased anxiety and depression, which mimic the veterans symptoms.” See December 2019 opinion report addressing pituitary disability (noting pituitary adenoma); see also December 2019 opinion report addressing hyperprolactinemia (providing separate rationale related to trauma). Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current pituitary disabilities were incurred in service. Accordingly, the Board finds that service connection for residuals of pituitary injury, to include pituitary adenoma and hyperpituitarism (hyperprolactinemia) is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for parathyroid disability The Veteran contends any parathyroid disability is due to in service head or neck injuries, or due to alleged herbicide agent exposure. As noted above, in March 2019 the Board remanded the claim related to parathyroid disability because no VA examiner had opined whether the Veteran’s parathyroid disabilities are related to service. Treatment records and December 2019 VA examination reports confirm the Veteran has current parathyroid disabilities. The November 2019 VA examiner believed the Veteran was exposed to Agent Orange in service. The Board notes that in the grant of service connection for hypothyroidism, the notation includes Agent Orange, outside Vietnam. Additionally, the Board has found the Veteran sustained head and neck injuries in service. Therefore, the remaining issue is whether there is a nexus between service and the Veteran’s parathyroid disabilities. The Veteran attended a VA endocrine system examination in November 2019. After examining the Veteran, reviewing his record and medical literature, the examiner opined the Veteran’s parathyroid disabilities were less likely than not incurred in service or due to in-service injury or disease, including a head or neck injuries and exposure to an herbicide agent. The examiner explained, the “[m]ain cause associated with hyperparathyroidism is a parathyroid adenoma, medical literature search reveals most parathyroid adenomas do not have an identified cause. Conditions that can cause the parathyroid gland to increase in size are genetic disorders, taking the drug lithium and chronic kidney disease.” The examiner’s opinion is supported by adequate rationale and the evidence of record does not contain a contrary medical opinion. Therefore, the weight of the evidence is against finding any parathyroid disability was incurred in or due to service. The Board notes that there is no indication in the record that the Veteran takes or has taken lithium or has chronic kidney disease. The November 2019 examiner also noted that a small portion of patients with pituitary tumors have an inherited defective gene that can cause hyperparathyroidism, but “documentation per his endocrinologist, Dr [A.] show he tested negative for MEN 1”. See December 2019 opinion report addressing parathyroid adenoma. There is no evidence of aggravation of a parathyroid disability due to a service-connected disease or injury. Therefore, the weight of evidence is against finding a parathyroid disability is proximately due to or aggravated by a service-connected disease or injury.   Here, there is no proof of a parathyroid disability during service or within one year of separation. There is no proof relating the disorder to potential herbicide exposure and the disorder is not an herbicide exposure presumptive disability. The preponderance of the evidence is against the claim and there is no doubt to be resolved. REASONS FOR REMAND 1. Entitlement to service connection for residuals of head and neck injuries, to include traumatic brain injury and a headache disorder, is remanded. Upon review of the evidence of record, the Board finds remand is warranted for additional examination and opinions. The Board remanded the Veteran’s TBI claim in March 2019 in part due to an inadequate opinion provide by a VA examiner in June 2015 that failed to distinguish between the Veteran’s reports of daily headaches beginning in the 1970s and migraines beginning in 1967. See March 2019 Board decision, pages 14-15. The November 2019 examiner relied in part on 2015 examination opinion that the Board previously found to be inadequate. The November 2019 examiner similarly erred in that the examiner highlighted the 2015 report’s notation that the Veteran reported daily headaches beginning in the 1970s, while apparently overlooking that the Veteran reported at the same examination that his current migraines headaches began in 1967. The November 2019 examiner also stated that there was no service treatment records found that support a traumatic brain injury (TBI) diagnosis, but did not explain this conclusion or address the Veteran’s separation examination (scar evidencing head injury and reported history of frequent or severe headaches that was not noted at induction). Similarly, the examiner stated without explanation that there are no signs, findings or symptoms to support a diagnosis of TBI, despite current headaches and prior medical opinions indicating a possible TBI. Although there is no reasons-or-bases requirement imposed on examiners, examiners must support their conclusions with an analysis that the Board can consider and weigh against contrary opinions. See Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In light of the above, remand is warranted for additional examination and opinions. The Veteran has expressed his belief that he had a TBI and suffers from certain symptoms of the TBI, e.g. headaches. As noted above, the opinion provided was inadequate, but was consistent with other opinions in that it raises the possibility that alleged TBI symptoms are due to other etiologies including the herein service-connected pituitary adenoma. See June 2015 headaches examination report (head pain is relieved by a “muscle relaxant, which would indicate that his poorly localized head pain is due to his neck injury and cervicalgia and not a headache syndrome. His head pain could also be due to the development of his pituitary adenoma.”) Therefore, the Board has taken an expansive view of his claim to include his alleged symptoms of his alleged TBI and have recharacterized his claim accordingly. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009). 2. Entitlement to an earlier effective date for the grant of service connection for posttraumatic stress disorder is remanded. Upon review of the evidence of record, the Board finds remand is warranted to ensure compliance with the March 2019 remand directives. The March 2019 remand directed the AOJ to determine if a VA Form 21-526e, dated November 6, 1964, was a valid claim for service connection for a psychiatric disorder, and if so schedule the Veteran for a pertinent examination. A review of the April 2020 supplement statement of the case (SSOC) reveals the AOJ merely adjudicated a claim of entitlement to an earlier effective date for the grant of service connection for posttraumatic stress disorder. There is no indication the VA Form 21-526e was considered as required by the March 2019 remand. To the contrary, the form is not even listed as evidence in the SSOC, whereas a December 2010 informal claim is listed as evidence. The AOJ did not substantially comply with the Board’s March 2019 remand directives. A remand by the Board confers on an appellant, as a matter of law, the right to compliance with the terms of the remand order and imposes upon VA a concomitant duty to ensure compliance with those terms. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In light of the above, remand is warranted to ensure substantial compliance with the Board’s remand. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to opine whether it is at least as likely as not the Veteran sustained a TBI in service, and if he has residuals thereof. For the purpose of this opinion, the examiner should assume the Veteran was punched in the head while in service, as described by the Veteran. The examiner should also solicit the Veteran’s headache history and attempt to reconcile differences from prior reporting. The examiner must ask the Veteran to clarify what symptoms he believes to be due to a TBI, e.g. headaches. If the examiner opines the Veteran did not suffer a TBI in service, then for each symptom the Veteran believes to be due to a TBI, provided opinions on the following: a) Whether the claimed symptom is at least as likely as not a disability and if so, whether the disability is at least as likely as not related to an in-service injury or disease, to include head or neck injuries?   b) Whether the claimed symptom is at least as likely as not a disability, and if so, whether the disability is at least as likely as not proximately due to service-connected disease or injury? c) Whether the claimed symptom is at least as likely as not a disability, and if so, whether the disability was at least as likely as not aggravated, i.e., worsened beyond its natural progression, by service-connected disease or injury? 2. Review the service records received April 8, 2013, including the VA Form 21-526e, dated November 6, 1964. The AOJ must determine if this was a valid claim for service connection for a psychiatric disorder. See 38 C.F.R. § 3.1(r). In doing so, the AOJ must explicitly address the VA Form 21-526e and VA Memo dated September 24, 2012 (PIES responded that a prior claim was filed upon Veteran's separation). If the 21-526e was a valid claim for service connection for a psychiatric disorder, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder exhibited during the pendency of the Veteran’s November 1964 potential claim.   After undertaking any additional development deemed appropriate, adjudicate the November 1964 potential claim. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Gregory T. Shannon, 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.