Citation Nr: 21008601 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 14-28 466 DATE: February 17, 2021 REMANDED Entitlement to a rating in excess of 10 percent for hypothyroidism, previously claimed as inhomogeneous echotexture of the thyroid gland with bilateral nodules, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1988 to December 1988, and from February 2003 to February 2004. In April 2015, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge at the RO. A transcript of the hearing is of record. In January 2020, the Board remanded the case for further development by the originating agency. The case has been returned to the Board for further appellate action. Entitlement to a rating in excess of 10 percent for hypothyroidism is remanded. Pursuant to the Board’s January 2020 remand, the Veteran was to be afforded a VA examination to assess the severity of his service-connected thyroid disability. The examiner was directed to provide a full description of the Veteran’s thyroid disability and to specifically address the presence or absence of cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance, bradycardia, sleepiness, weight gain, fatigability, and constipation. The examiner was also directed to specifically discuss whether muscular weakness and coronary artery disease, noted in the Veteran’s medical records, are manifestations of his service-connected thyroid disability. In March 2020, the Veteran was afforded a thyroid conditions examination, as well as VA muscle injury, chronic fatigue syndrome, intestinal conditions, heart conditions, endocrine systems, and mental disorders examinations. The Veteran was found to have no diagnosed mental disorder or intestinal condition, and no diagnosis of chronic fatigue syndrome. He was diagnosed with obesity, which the endocrine systems examiner opined is not related to his thyroid disability. He was also diagnosed with coronary artery disease, which the heart conditions examiner opined is related to his thyroid disability, and which he has since been granted service connection for. The VA muscle injuries examiner diagnosed muscle injuries, but the muscle injuries examiner did not provide an opinion as to whether any of the diagnosed muscle injuries are related to his service-connected thyroid disability. Furthermore, neither the thyroid conditions examiner nor any other examiner addressed the presence or absence of cold intolerance, bradycardia or sleepiness, as directed. For these reasons, the Board finds that another remand of this matter is warranted for a VA examination to fully assess the severity of the Veteran’s service-connected thyroid disability, considering all the evidence of record. The Board errs when it fails to ensure substantial compliance with a Board remand. Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order). Where the Board fails to ensure substantial compliance, remand is appropriate. Stegall, 11 Vet. App. at 271. The matters are REMANDED for the following action: 1. Updated treatment records should be obtained and added to the claims file/e-folder. 2. Following completion of the above, obtain an addendum opinion from an appropriate medical professional regarding the nature and severity of the service-connected thyroid disability. An in-person examination is not required unless deemed necessary by the clinician. The claims folder should be made available to the examiner for review in connection with the examination and the examiner should acknowledge such review in the examination report or in an addendum. Any indicated studies should be performed. All indicated tests and studies should be accomplished (with all findings made available to the examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The examiner should provide a full description of the Veteran’s thyroid disability, reporting all current manifestations, and the extent, frequency or severity of manifestations, specifically addressing the presence or absence of cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance, bradycardia, sleepiness, weight gain, fatigability, and constipation. The examiner should also specifically discuss whether muscular weakness, noted in the Veteran’s medical records, is a manifestation of his service-connected thyroid disability. A complete rationale should be given for all opinions and conclusions expressed, and a discussion of the facts and medical principles involved must be provided. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. 3. After completion of the above and any other development deemed necessary, review the expanded record, and readjudicate the claim for an increased rating. If the claim remains denied, the Veteran and his representative should be furnished an appropriate supplemental statement of the case, afforded an opportunity to respond, and the case should thereafter be returned to the Board for further appellate review, if in order. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board F. Yankey, 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.