Citation Nr: 21021255 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 16-05 173 DATE: April 12, 2021 REMANDED Entitlement to a rating in excess of 10 percent for iatrogenic hypothyroidism is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Navy from June 1988 to June 2008. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a July 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). This issue was previously remanded by the Board in September 2018 and October 2020 for further development. It has since been returned to the Board for appellate review. Although the Board regrets the additional delay, further development is required before a decision may be made on the merits of the issue on appeal. 38 U.S.C. § 5103A. In October 2020, the Board remanded the issue of entitlement to a rating in excess of 10 percent for iatrogenic hypothyroidism to the RO to obtain any outstanding VA treatment records and obtain an addendum medical opinion from the examiner that conducted the October 2019 VA examination to determine whether the Veteran had myxedema, and, if so whether it had stabilized. The remand instructed the Agency of Original Jurisdiction (AOJ) to readjudicate the Veteran’s claim for an increased rating for iatrogenic hypothyroidism for the entirety of the appeal period, with consideration of evidence associated with the claims file since the issuance of the May 2020 rating decision. The remand further instructed that the AOJ should consider the old rating criteria for Diagnostic Code 7903 for the entirety of the appeal period. Pursuant to the October 2020 Board remand, an addendum medical opinion was obtained in November 2020 from the VA examiner that conducted the October 2019 VA examination. The VA examiner was asked to determine whether the Veteran had myxedema, and, if so, whether it had stabilized. The examiner opined that it was less likely than not that that the Veteran was suffering from hypothyroid related symptoms. He stated that the various symptoms, consisting of fatigue, memory difficulty, emotional instability, depression, tremors, and hot/cold intolerance, should be evaluated for etiology other than hypothyroidism. As rationale, the examiner explained that myxedema is a term for severely advanced hypothyroidism with symptoms consisting of confusion, low body temperature, swelling of body parts (especially the face, tongue, and lower legs), and often times, difficulty breathing. He stated that myxedema is not a term that should be used for hypothyroidism being treated with replacement thyroid hormone. The examiner also noted the Veteran’s July 2019 laboratory test results for thyroxine (T4) test and thyroid-stimulating hormone (TSH) test. He further noted that the Veteran continued to complain of fatigue, poor memory, some emotional instability, depression, tremors, and intolerance of both hot and cold weather, but opined that it is unlikely that each of these issues or any of these issues were caused by hypothyroidism. As rationale for said statement, he stated that treatment with daily replacement thyroid hormone (Synthroid) extinguished hypothyroidism by normalizing the Veteran’s thyroid hormone levels. He then explained that he would have liked to have seen a TSH and T4 within the last six months, but since that was not available, he based his opinion on the laboratory evidence of record available to him. The issue of entitlement to a rating in excess of 10 percent for iatrogenic hypothyroidism is remanded to correct duty to assist errors that occurred after the October 2020 Board remand but prior to the issuance of the December 2020 supplemental statement of the case (SSOC) that denied an increased rating for iatrogenic hypothyroidism. As noted above, in the November 2020 addendum medical opinion, the examiner indicated that TSH and T4 tests taken within six months prior to the examination would have aided him in rendering his opinion because it would have provided him with more recent results from tests that track the Veteran’s thyroid levels than those already in the claims file. Based on this statement from the examiner, the AOJ should have obtained new TSH and T4 tests for the Veteran, added them to the claims file, and then obtained an additional addendum medical opinion, preferably from the same examiner, that included review of the newly obtained TSH and T4 test results. Moreover, after the October 2020 Board remand but prior to the issuance of the December 2020 supplemental statement of the case (SSOC) that denied an increased rating for iatrogenic hypothyroidism, new medical records concerning the Veteran’s iatrogenic hypothyroidism (including TSH and T4 test results from December 2019) were added to the claims file; however, because these medical records were added after the November 2020 addendum medical opinion they have not yet been reviewed and addressed in an addendum medical opinion. See Medical Treatment Record – Non-Government Facility, received in December 2020. As such, the Board finds the opinion provided by the November 2020 examiner to be inadequate because it was based on incomplete information and incomplete claims file records. In light of the above, this case should be remanded to the AOJ for substantial compliance with the Board’s October 2020 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following action: 1. Make efforts to obtain all outstanding medical records in accordance with duties set forth in 38 C.F.R. § 3.159(c). 2. Schedule the Veteran for thyroxine (T4) and thyroid-stimulating hormone (TSH) tests. Associate the results of these tests with the claims file. 3. After the above development has been completed, forward a copy of the remand to the October 2019 and November 2020 VA examiner, if available, if not to another qualified clinician, to obtain an addendum medical opinion concerning the Veteran’s iatrogenic hypothyroidism. All pertinent evidence of record, including the October 2020 Board remand, the medical records added since November 2020, and the newly obtained TSH and T4 test results, must be made available to and reviewed by the examiner. If the examiner determines that another in-person examination is required to provide the below requested information, then such an examination should be scheduled. The examiner is asked to determine whether the Veteran has myxedema, and, if so, whether it has stabilized. The examiner is further asked to discuss the findings of the newly obtained TSH and T4 test results and what those results indicate. A full rationale must be provided for any opinion offered and a thorough explanation would be helpful for the Board. The Board recognizes the practical difficulties of scheduling an examination in view of the COVID-19 epidemic, and requests flexibility and understanding in affording the Veteran an opportunity for an examination. If a VA examination proves not feasible for any reason, including the Veteran not appearing for an examination, the claims file should still be reviewed by an appropriate professional for the purpose of providing the requested opinions. 4. After completing the above development, and any other development deemed necessary, readjudicate the issue on appeal. On remand, the AOJ should consider the old rating criteria for Diagnostic Code 7903 for the entirety of the appeal period. If any benefit sought on appeal remains denied, provide an additional supplemental statement of the case to the Veteran and her representative, and return the appeal to the Board for appellate review, after the Veteran and her representative have had an adequate opportunity to respond. B. G. LeMoine Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Fairlie, 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.