Citation Nr: 21030421
Decision Date: 05/18/21	Archive Date: 05/18/21

DOCKET NO. 16-47 590
DATE: May 18, 2021

REMANDED

Entitlement to a rating in excess of 60 percent for hypothyroidism is remanded.

REASONS FOR REMAND

The Veteran served on active duty in the United States Army from October 1981 to June 1983 and from December 1984 to October 1991.  This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO).  The Board remanded the appeal in December 2018.

Unfortunately, remand is again necessary to obtain a medical opinion adequate for VA purposes.  When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate.  Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).  Here, the Veteran was afforded a VA examination in keeping with the December 2018 Board remand directives.  However, the opinion was not written so that the Board's evaluation of the claimed disability would be a fully informed one.  See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007).  As with the prior examination of record warranting the Board's 2018 remand, the 2020 VA examiner listed various symptoms in the history section of his report (e.g., cold intolerance and muscle weakness) but did not endorse those same symptoms in the findings section.  Moreover, no commentary or remarks were included to justify or explain the discrepancy, and the examiner did not complete separate examination reports for the musculoskeletal and psychological symptoms endorsed, though this action was specifically requested in the examination report.  October 2019 VA examination, 3A.  Therefore, another VA examination is needed to determine the current state of the Veteran's hypothyroidism.  Any outstanding treatment records should also be secured.

The matter is REMANDED for the following action:

1. Obtain any outstanding VA treatment records.

2. With any necessary assistance from the Veteran, obtain any outstanding relevant private treatment records.

3. Then schedule the Veteran for an examination with an appropriate clinician to determine the current severity of his hypothyroidism.  If there is a difference between the Veteran's reported symptoms and what you find on physical examination, commentary should be provided to explain this discrepancy.  If a symptom is endorsed that requires completion of an additional Disability Benefits Questionnaire (DBQ), please complete the same.

 

 

S. BUSH

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Z. Sloley, 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.