Citation Nr: 21031012 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 14-40 655 DATE: May 20, 2021 REMANDED Entitlement to a rating in excess of 10 percent for status-post Graves' disease with hypothyroidism is remanded. Entitlement to an increased evaluation for eye residuals of status-post Graves' disease with hypothyroidism, presently evaluated as exophthalmos and dry eye syndrome, both eyes with a 20 percent disability rating, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1981 to August 2001. This matter came before the Board of Veterans' Appeals ("Board") on appeal from July 2014 rating decision of the Department of Veterans Affairs ("VA") Regional Office ("RO"). 1. Entitlement to a rating in excess of 10 percent for status-post Graves' disease with hypothyroidism is remanded. The Board remanded this matter in November 2020 and directed the RO to obtain an addendum VA opinion on the current severity and manifestation of the Veteran's service-connected status-post Graves' disease with hypothyroidism. Pursuant to the Board's November 2020 remand, the RO obtained a medical opinion in January 2021. However, the Board finds the January 2021 opinion inadequate for deciding the issue on appeal. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Regrettably, the Board finds that further remand is necessary in this matter. In November 2020 remand, the Board directed the clinician to render an addendum opinion as to the severity of the Veteran's disorder when discounting the ameliorative effects of medication, and address his weight gain, elevated thyroid stimulating hormone (TSH) levels and the Veteran's contentions regarding claimed symptoms and manifestation of hypothyroidism. Pursuant to the November 2020 Board's remand, a medical opinion was obtained in January 2021, where the examiner opined that it was not possible to say whether myxedema would manifest, without the ameliorating effects of thyroid medication. The examiner explained that the Veteran's highest TSH in the recent years had been 23.92 on November 3, 2009. Also, the biologically active hormone free T4 value was 0.909, which was normal at the time. Thus, when the free T4 is normal, there is normal body function and reported abnormal symptoms are not attributed to hypothyroidism. This means myxedema is not expected with an elevated TSH of that level with normal free T4. Other elevated TSHs were associated with normal or near normal free T4 as well, which would not manifest with significant symptoms or as myxedema. According to the examiner, it is not known what the Veteran's TSH and free T4 would be now without the ameliorating effects of thyroid medication. What symptoms, including myxedema, he might manifest now, without the ameliorating effects of thyroid medication, is not known, without pure speculation. Regarding weight gain, the examiner opined that it was less likely than not that there had been weight gain due to hypothyroidism. Throughout the past 11 years, the Veteran had several elevations in TSH, however, his weight remained stable between 190 and 192 lbs., which was within the range of variability and not significant weight gain. During the times he had elevated TSH, his free T4 had been normal or near normal, this would not be expected to cause significant weight gain. Furthermore, the examiner supported the rendered opinion on weight gain by enlisting the Veteran's past reported values of TSH and T4 and compared with contemporaneously noted weights. The examiner concluded that any weight gain at the time of elevated TSH and normal or near normal free T4 would be less likely than not due to hypothyroidism and due to another cause. The examiner also addressed November 2015 and September 2020 statements of the Veteran's wife regarding claimed symptoms, and explained that the Veteran had been on levothyroxine 0.2 mg since 2015 with normal or below normal TSH and/or normal free T4. The examiner concluded that when the TSH is normal or the free T4 is normal, symptoms are not due to hypothyroidism. The Board finds the above January 2021 opinion adequate in addressing the questions regarding the ameliorative effects of medication, weight gain, and elevated TSH levels. The examiner explained why it was not possible to say whether or not myxedema would manifest, without the ameliorating effects of thyroid medication. However, the Board finds the examiner did not address the Veteran's contentions regarding symptoms of his thyroid condition, specifically his December 2020 statement indicating that his primary physician told him that his hypothyroidism was turning into hyperthyroidism. Consequently, a remand is warranted to obtain an addendum opinion as to whether the Veteran's hypothyroidism has become hyperthyroidism, and whether it is a continuation or progression of his service-connected hypothyroidism. 2. Entitlement to an increased evaluation for eye residuals of status-post Graves' disease with hypothyroidism, presently evaluated as exophthalmos and dry eye syndrome, both eyes with a 20 percent disability rating, is remanded. The Board notes that the Veteran is currently receiving separate compensable rating for "exophthalmos and dry eye syndrome, both eyes associated with status-post Graves' disease with hypothyroidism," with an evaluation of 20 percent from March 31, 2014. Diagnostic Code 7903 for evaluating hypothyroidism provides 100 percent rating for Hypothyroidism manifesting as myxedema (cold intolerance, muscular weakness, cardiovascular involvement (including, but not limited to hypotension, bradycardia, and pericardial effusion), and mental disturbance (including, but not limited to dementia, slowing of thought and depression)). 38 C.F.R. § 4.119, Diagnostic Code 7903. Hypothyroidism without myxedema is rated at 30 percent. Id. Notes (1) and (2) provide that the 100 percent and 30 percent ratings respectively shall continue for six months beyond the date that an examining physician has determined crisis stabilization (for 100 percent rating) or after initial diagnosis (for 30 percent rating). Id. Thereafter, the adjudicator is to rate residuals of hypothyroidism or medical treatment under the most appropriate diagnostic codes under the appropriate body system (e.g., eye, digestive, mental disorders). Id. Note (3) provides that if eye involvement, such as exophthalmos, corneal ulcer, blurred vision, or diplopia, is also present due to thyroid disease, also separately evaluate under the appropriate diagnostic code(s) in § 4.79, Schedule of Ratings - Eye (such as diplopia (DC 6090) or impairment of central visual acuity (DCs 6061-6066)). Id. Since the evidence of record indicates that the Veteran's eye condition is a complication associated with service-connected disability of status-post Graves' disease with hypothyroidism, the Board concludes that the issue of entitlement to increased rating for an eye condition is also on appeal as part and parcel of the claim of increased rating for status-post Graves' disease with hypothyroidism under Diagnostic Code 7903. 38 C.F.R. § 4.119, Diagnostic Code 7903. Hence, the Board is characterizing the issue as described above to include all potential eye conditions that could be manifested as complications of service-connected status-post Graves' disease with hypothyroidism, and to allow for the most favorable review of the evidence and the claim. See Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009); see also Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). The Board also notes that the last VA examination for an eye condition was provided in June 2014, however, three VA examinations for thyroid condition have been provided since then. Therefore, a new examination is warranted to ascertain the current severity of "exophthalmos and dry eye syndrome, both eyes" and to determine if the Veteran has any other eye condition as a complication of his service-connected status-post Graves' disease with hypothyroidism. Agency of original jurisdiction ("AOJ") should consider whether a higher and/or separate compensable evaluation beyond the 20 percent currently assigned for exophthalmos and dry eye syndrome, both eyes, is warranted for any eye disability that represents a residual of the thyroid condition. The matters are REMANDED for the following action: 1. Forward the claims file, and a copy of this remand to the examiner who rendered the January 2021 medical opinion, or to an appropriate clinician if the January 2021 examiner is unavailable, to obtain an addendum opinion on the severity and manifestation of the Veteran's service-connected status-post Graves' disease with hypothyroidism. Further in-person examination of the Veteran is left to the discretion of the clinician providing the opinion. If the clinician deems a new examination is necessary for providing an opinion, then such an examination should be scheduled. 2. After reviewing the claims file, the examiner is asked to opine whether the Veteran's hypothyroidism has become hyperthyroidism, and whether it is a continuation or progression of his service-connected status-post Graves' disease with hypothyroidism. The examiner should provide a full description of the disability and report all signs, symptoms, and their functional impacts necessary for evaluating the disability under the rating criteria. In providing the above opinion the examiner should address the Veteran's contentions and treatment record in the documents associated with the claims file, with entries dated: (i) 01/12/2021, titled "Medical Treatment Record Government Facility," page numbers 23 and 27 noting higher than normal value of thyroxine free in August 2020, and March 2020 respectively; (ii) 01/12/2021, titled "Correspondence," which includes Veteran's contentions indicating that his doctor advised him that his hypothyroidism was turning into hyperthyroidism. 3. Schedule the Veteran for a new VA examination to determine all the current diagnosis and severity of the Veteran's eye conditions, including exophthalmos and dry eye syndrome of both eyes, which could be potential complications of service-connected status-post Graves' disease with hypothyroidism. The examiner should provide a full description of the disability and report all signs, symptoms, and their functional impacts necessary for evaluating the Veteran's eye conditions which could be related to service-connected status-post Graves' disease with hypothyroidism under the rating criteria. The examiner must consider and discuss the Veteran's lay statements and notation of blurry vision in May 2020 treatment record associated with the claims on 01/12/2021 in the document titled "Medical Treatment Record Government Facility," page number 47 of 56. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If the examiner is unable to provide an opinion without resorting to mere speculation, then the examiner must state this and provide any information needed to make an opinion, if possible. 4. Thereafter, readjudicate the claims on appeal. If the benefit sought remains denied, issue the Veteran and his representative a supplemental statement of the case and provide a reasonable opportunity to respond before returning the matter to the Board for further appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Tariq, Nadeem, 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.