Citation Nr: 21021876 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 17-39 452 DATE: April 14, 2021 REMANDED Service connection for multinodular goiter (a thyroid disability) is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1985 to June 1990. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. In November 2018 and May 2020, the Board remanded the case to the RO for further evidentiary development, to including obtaining additional information about the Veteran’s claimed exposure to ionizing radiation. Nonetheless, the Board regrets further delay, as additional developments are necessary before a decision may be rendered on this issue on appeal. In January 2016, the Veteran was afforded a VA examination for thyroid and parathyroid conditions. In the VA examination report, the examiner noted that although the Veteran has a diagnosis of a thyroid or parathyroid condition, and specifically, “euthyroid multinodular goiter”, the Veteran was uncertain about the date of the diagnosis. Additionally, at the VA examination, the Veteran reported that she was undergoing treatment for her goiter condition with a private endocrinologist. The VA examiner opined that the Veteran’s claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As the rationale for this opinion, the VA examiner reasoned that “there exists insufficient medical evidence to substantiate the [Veteran’s] contention for service connection regarding the multinodular goiter condition[,] per the available medical evidence.” The VA examiner also reasoned that there is no documentation of a diagnosis in the Veteran’s service treatment records (STRs), or that the Veteran sought treatment for this condition in the STRs, or in proximity to her separation from service, “which portends against any existence of condition of STR and does not support a nexus back to any [in-service] condition for which there is no record on file.” Pertinently, the VA examiner stated that there is no record of civilian medical care. However, this opinion is not based on all of the medical evidence, given that the VA examiner was unable to determine the onset of the Veteran’s disability, and additionally, presumed that there is no record of civilian medical care, even though the VA examiner acknowledged that the Veteran was under the private care of an endocrinologist for her condition. See January 2016 Disability Benefits Questionnaire (VA examination Report). After this VA examination, the Veteran submitted additional pertinent evidence to support her claim. Specifically, for example, she submitted relevant medical treatment records, which directly address the history of treatment for her condition, and describes the June 2017 surgical procedure that involved a total thyroidectomy with isthmusectomy and left upper parathyroid gland removal. See e.g. June 2017 Nursing Note; see also September 2019 Endocrinology Note; see too, September 2020 Correspondence from the Veteran. Additional evidence also includes the Veteran’s lay statements, in which she described the nature of her service in Germany, at the time of the 1986 Chernobyl Nuclear Power Plant disaster, as well as numerous articles and treatises addressing the association between the nuclear radiation fallout from Chernobyl and the subsequent development of various health conditions. See September 2020 Correspondence with Supporting Medical Articles and Treatises. Thus, as the Board is prohibited from exercising its own independent medical judgment, additional medical review of this evidence and medical opinion is required prior to its adjudication of the claim on appeal. Additionally, the evidence reflects that the Veteran has a non-malignant thyroid nodular disease, which is defined and listed as a “radiogenic disease”, under 38 C.F.R. § 3.311(b)(2)(xvii). See e.g. December Gastroenterology Attending Note (noting that the Veteran’s active problems, include and are not limited to, non-toxic multinodular goiter and a thyroid nodule). Moreover, and based on her lay statements, the Veteran has provided sufficient details about her ionizing radiation exposure, for the AOJ to undertake a dose assessment. Id. Thus, in summary, a remand is required for the AOJ to undertake an assessment of the size and nature of the radiation dose or doses, to determine the degree of the Veteran’s exposure to ionizing radiation during her active service in Germany; and to obtain a supplemental VA opinion on her non-malignant thyroid nodular disease. Finally, although the Veteran reported that she has a history of total thyroidectomy with isthmusectomy and left upper parathyroid gland removal, see September 2020 Correspondence, and medical treatment records reflect pre and post-surgical notes about the Veteran’s surgery, it appears that additional treatment records, especially including, the June 21, 2017 surgery report/notes/summary, are still outstanding and have not been associated in the claims file. Thus, on remand, the AOJ must obtain all outstanding and/or updated treatment records and associate them with the claims file. The matters are REMANDED for the following action: 1. Obtain the requisite authorization and release, and update the Veteran’s claims file with all outstanding treatment records, including and not limited to, the June 21, 2017 treatment note or surgical report about the Veteran’s total thyroidectomy, as well as the most recent private and VA treatment records. 2. Also, based on the details the Veteran has provided about her exposure to ionizing radiation during her active service in Germany, undertake all developments, pursuant to 38 C.F.R. § 3.311, for radiogenic diseases. 3. Thereafter, obtain a supplemental opinion from a VA examiner who has not yet evaluated the Veteran, for a clarification of her multinodular goiter. The VA examiner must review the claims file and must note that review in the report. A copy of this REMAND must be made available to the VA examiner. The VA examiner must undertake the following: a. Opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s multinodular goiter is reflective of symptoms that were incurred in service; is the result of an in-service injury, illness, disease, or event; and/or is otherwise related the Veteran’s active service, including her exposure to ionizing radiation. b. In rendering an opinion, consider all lay statements from the Veteran and any other witness about onset and symptomatology. (Continued on the next page)   c. Additionally, the VA examiner must consider and discuss all medical treatises and articles that the Veteran submitted, in support of her claim. See September 2020 Correspondence. d. A detailed explanation is requested for all opinions provided. If an opinion cannot be provided without resort to speculation, provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be rendered. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board V-N. Pratt 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.