Citation Nr: 21031003
Decision Date: 05/20/21	Archive Date: 05/20/21

DOCKET NO. 14-35 122A
DATE: May 20, 2021

REMANDED

Entitlement to an initial rating in excess of 30 percent for hypothyroidism is remanded.

REASONS FOR REMAND

The Veteran served on active duty with the United States Air Force from December 1991 to September 1999, and with the United States Army from November 2004 to April 2006, from May 2006 to August 2007, and from July 2008 to September 2009.  The Veteran also had inactive service in the Army National Guard.  For his service, the Veteran was awarded (among other decorations) the Army Commendation Medal, the Air Force Achievement Medal, and the Iraq Campaign Medal.

This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).

This matter was previously before the Board in November 2018 and June 2020 when it was remanded for further development.

Entitlement to a rating in excess of 30 percent for hypothyroidism is remanded.

Although the additional delay is regrettable, the Board finds an additional remand is required before a decision can be made on the Veteran's claim.

In accordance with the June 2020 remand order, the Veteran underwent an additional VA examination in July 2020 to assess the nature and severity of his hypothyroidism. Following a review of the Veteran's claims file, the examiner noted that the Veteran's records did not show a diagnosis or findings consistent with myxedema, mental disturbance, or any complications as the Veteran's condition was well-treated with TSH. The examiner indicated that the Veteran did not currently have any findings, signs, or symptoms attributable to a thyroid condition, hyperthyroid condition, thyroid enlargement, or a hypothyroid condition. The examiner also noted that a review of the record did not show any residuals of the Veteran's treated hypothyroidism that involves other body systems, noting that the Veteran's symptoms of fatigue and sleep disturbance are multifactorial and associated with many of his other unrelated medical conditions (the Veteran was under treatment for hypogonadism, diabetes, hypertension, and mood disorder). 

However, the Veteran's medical records, including June 2010 and April 2014 VA treatment records, indicate that the Veteran reported blurred vision, which may suggest a residual eye condition. In addition, a November 2010 VA treatment record reflects that he complained of alternating loose stool and constipation and other records note a diagnosis of constipation which may suggest digestive problems. The Veteran has also reported symptoms of mental disturbance and, in his October 2014 VA Form 9, he reported that he was on medication for depression. Thus, it is unclear whether the Veteran's reported symptoms were adequately considered and remand for a new VA examination is required. Furthermore, as the examiner noted that an in-person examination was not conducted, the Board requests an in-person examination or telehealth interview be provided on remand so that the Veteran can report his current symptomatology.

The matters are REMANDED for the following action:

Schedule the Veteran for an in-person examination or a telehealth interview to determine the nature and severity of his hypothyroidism. The examiner is specifically asked to detail the nature of the findings, signs, and symptoms of the disease. The examiner should specifically discuss whether the Veteran's hypothyroidism has manifested as myxedema at any point during the appeal period. 

The examiner should separately examine the Veteran for any residual effects of hypothyroidism within the appropriate body system (e.g., eye, digestive, and mental disorder) and report all findings in detail. 

 

 

Evan M. Deichert

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	S. Jiggetts, 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.