Citation Nr: 21015698 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 20-18 401 DATE: March 18, 2021 ORDER Entitlement to service connection for a disability of the thyroid to include Graves' disease with hyperthyroidism, hypothyroidism, and Hashimoto's thyroiditis is granted. FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam during the Vietnam War era. 2. The Veteran experiences current hypothyroidism/Hashimoto’s thyroiditis. 3. The Veteran’s current Graves’ disease with hyperthyroidism is related to his Agent Orange exposure in service. CONCLUSION OF LAW The criteria for service connection for a disability of the thyroid, to include Graves’ disease with hyperthyroidism, hypothyroidism, and Hashimoto’s thyroiditis are met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from March 1968 to October 1969, which includes service in the Republic of Vietnam. His awards include the Combat Infantryman Badge and Army Commendation Medal. This matter comes before the Board of Veterans’ Appeals (Board) from a May 2018 rating decision. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a March 2021 hearing. A transcript of the hearing has not yet been associated with the claims file. However, in light of the fact that the Board is awarding service connection for a disability of the thyroid as broadly as possible, to include Graves’ disease with hyperthyroidism, hypothyroidism, and Hashimoto’s thyroiditis (thus reflecting a grant of the benefits sought in full), and the fact that there is no information in the hearing transcript that will affect the decision herein, the transcript is not necessary at this time. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A veteran, who, during active military service, served in the Republic of Vietnam during the period beginning in January 1962 and ending in May 1975, is presumed to have been exposed to herbicide agents, including Agent Orange. 38 U.S.C. § 1116 (f); 38 C.F.R. § 3.307 (a)(6)(iii). Service “in the Republic of Vietnam” includes service both on the landmass of Vietnam and the waters that are no more than 12 miles offshore of Vietnam. 38 U.S.C. § 1116A (a). If a veteran was exposed to an herbicide agent (to include Agent Orange) during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307 (a)(6) are met, even if there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307 (d) are also satisfied: AL amyloidosis; chloracne or other acneform disease consistent with chloracne; Type 2 diabetes; Hodgkin’s disease; ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal’s angina); all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia); multiple myeloma; non-Hodgkin’s lymphoma; Parkinson’s disease; early-onset peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma). 38 U.S.C. § 1116(a)(2); 38 C.F.R. § 3.309 (e). Moreover, the National Defense Authorization Act for Fiscal Year 2021, Pub. L. No. 116-283, amended 38 U.S.C. § 1116(a)(2) and added Parkinsonism, bladder cancer, and hypothyroidism as additional diseases which are presumed to be associated with exposure to herbicide agents (including Agent Orange). Although this law did not contain an effective date and has not yet been codified, in the absence of such guidance it must be presumed that the law became effective upon its January 1, 2021 enactment. See Gozlon-Peretz v. United States, 498 U.S. 395, 404 (1991) (“It is well established that, absent a clear direction by Congress to the contrary, a law takes effect on the date of its enactment”) Entitlement to service connection for Graves' disease, hypothyroidism, and Hashimoto's thyroiditis The Board finds, for the following reasons, that the Veteran is presumed to have been exposed to herbicide agents (including Agent Orange) during service, that he has a current diagnosis of hypothyroidism/Hashimoto’s thyroiditis that is presumptively service-connected, and that he has a current diagnosis of Graves’ disease which is related to his Agent Orange exposure. Medical records, including a February 2018 examination report from A. Varanasi, M.D. and a February 2019 letter from P. Ojha, M.D., indicate that the Veteran experiences current Graves’ disease and hypothyroidism/Hashimoto’s thyroiditis. Thus, current thyroid disability has been demonstrated. Moreover, as the Veteran served in Vietnam during the Vietnam War era, he is presumed to have been exposed to herbicide agents, including Agent Orange. 38 U.S.C. § 1116; 38 C.F.R. § 3.307 (a)(6)(iii). As the Veteran has current hypothyroidism/Hashimoto’s thyroiditis and is presumed exposed to herbicide agents in Vietnam, service connection for hypothyroidism/Hashimoto’s thyroiditis is warranted on a presumptive basis. As for the diagnosed Graves’ disease, Dr. Varanasi opined in the February 2018 examination report that “[a]fter considering his constellation of symptoms, it is likely that the [Veteran’s] Graves’ disease is related to his Agent Orange exposure.” There was no further explanation or reasoning provided for this opinion. In a letter received in February 2019, a VA physician (V.T.S.) explained, in pertinent part, that although Graves’ disease per se is considered to have “inadequate or insufficient evidence to determine an association” with Agent Orange exposure, there have been several cases in which VA has granted service connection for Graves’ disease that developed many years after separation from service. In this instance, the constellation of the Veteran’s Graves’ disease raised the concern of whether the original toxin (i.e., Agent Orange) exposure altered his immune system to enable the development of the disease. There is one study abstract that reported data suggesting that veterans with Agent Orange exposure had about a 3 times increased risk of developing Graves’ disease. Therefore, the physician opined that the Veteran’s Graves’ disease was “as likely as not to be related to Agent Orange exposure.” In her February 2019 letter, Dr. Ojha explained, in pertinent part, that the Veteran was diagnosed as having hyperthyroidism and was subsequently found to have Graves’ disease, which is an autoimmune thyroid disease which causes hyperthyroidism. The Veteran carries two antibodies, TS1 (typically associated with Graves’ disease) and TP0 (typically associated with hypothyroidism/Hashimoto’s thyroiditis). In recent years, a subset of patients like the Veteran who have autoimmune thyroid disease have been found to have both antibodies. When a patient has both antibodies present, the symptoms displayed depend on which antibody is the dominant higher level. Hyperthyroidism prevails when the TS1 antibody is relatively more elevated than the TP0 antibody. The converse occurs (hypothyroidism) when the TP0 antibody is relatively more elevated than the TS1 antibody. Dr. Ojha cited medical literature which revealed that there is a nearly 3 times increased risk of Graves’ disease in veterans who were exposed to Agent Orange, when compared to veterans not exposed to Agent Orange. Therefore, Dr. Ojha opined that the Veteran’s Graves’ disease development was “at least as likely as not to even high likely related to his previous Agent Orange exposure.” The February 2019 opinions are based upon a review of medical literature and consideration of the Veteran medical history, and they are accompanied by specific rationales that are consistent with the evidence. Thus, the February 2019 opinions are entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). Although Dr. Varanasi’s February 2018 opinion is not accompanied by any specific explanation or rationale, the physician provided the opinion based upon treatment of the Veteran and consideration of his reported history. This opinion is therefore entitled to some probative weight. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner “did not explicitly lay out the examiner’s journey from the facts to a conclusion,” did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). In sum, the above evidence, to include the medical opinions, support the conclusion that the Veteran has current Graves’ disease with hyperthyroidism, hypothyroidism, and Hashimoto’s thyroiditis, and that these disabilities are caused by his exposure to Agent Orange in service. There is no medical opinion contrary to this conclusion. Accordingly, service connection for a thyroid disability, to include Graves’ disease, hypothyroidism, and Hashimoto’s thyroiditis is warranted. The Board notes that the medical evidence reflects that the Veteran’s disability is unique and fluctuates and the grant of service connection is intended to take account of all thyroid-related disabilities regardless of how they are characterized. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Elwood, 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.