Citation Nr: 21032465 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 16-42 571 DATE: May 27, 2021 REMANDED Entitlement to service connection for diabetes mellitus is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to a disability rating in excess of 30 percent for multinodular goiter, status post thyroidectomy is remanded. REASONS FOR REMAND The Veteran had active duty service from August 1987 to November 1993, and from January 2001 to September 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). This appeal was previously remanded by the Board in December 2018. It has now been returned to the Board. 1. Entitlement to service connection for diabetes mellitus is remanded. 2. Entitlement to service connection for hypertension is remanded. 3. Entitlement to a disability rating in excess of 30 percent for multinodular goiter, status post thyroidectomy is remanded. The Veteran seeks service connection for hypertension and diabetes, both claimed as secondary to a service-connected multinodular goiter, status post thyroidectomy. She also seeks an increased rating for this service-connected disability. Unfortunately, this claim must again be remanded for additional development. In its prior December 2018 remand order, the Board requested the RO obtain the Veteran's updated private treatment records. She was sent a September 2019 letter requesting she complete VA Forms 21-4142, Authorization to Disclose Information to the VA, and 21-4142a, General Release for Medical Provider Information to the VA. According to a November 2019 report of contact, she stated she would obtain her private treatment records herself and submit them to VA. In December 2019, however, she faxed to VA several pages of private treatment records, as well as a completed VA Form 21-4142 listing five different private medical care providers. To date, review of the record does not indicate any efforts have been made by VA to obtain this relevant medical evidence from the identified private medical care providers. As such, remand is required in order to obtain this pertinent medical information. In the December 2018 remand, the Board also requested that a VA examiner provide an opinion on whether the Veteran's hypertension and/or diabetes was proximately due to her service-connected multinodular goiter, status-post thyroidectomy, or aggravated beyond their natural progression by this disability. In rendering an opinion, the examiner was asked to comment on the Veteran's assertion that her thyroid disorder caused her to gain weight which in turn caused or aggravated these disabilities. In a January 2020 opinion, a VA examiner stated that "it is less likely as not that the diabetes mellitus is . . . proximately due to her service-connected multinodular goiter status post thyroidectomy, as there are no direct pathophysiologic relationship between the diabetes mellitus condition and the multinodular goiter status post thyroidectomy condition, nor are there any records showing such a relationship exists." The same rationale was used when finding that diabetes was not aggravated beyond its natural progression by the service-connected multinodular goiter. Identical opinions were provided for the Veteran's hypertension claim. In a July 2020 addendum opinion, the examiner noted that although a thyroid condition can cause a patient to gain weight, "weight gain is not attributable to any one particular disease or vice versa since weight gain can be associated with diet, exercise, genetic, metabolic disorder, stress, depression, hormone disorder, lack of sleep, sleep apnea, etc." Thus, it is less likely that the thyroid disorder is related to her diabetes and/or hypertension. The examiner also stated that the Veteran's hypertension is most likely an idiopathic hypertension that "has no identifiable cause, most commonly affecting 95% of the patients" and tends to be familial and a consequence of interaction between environmental and genetic factors and not caused by any one particular disease. The VA examiner's opinion is unclear. Specifically, it is not clear whether the examiner was stating that the origin of weight gain could never be attributed to a single disease, or whether this Veteran's weight gain could not be attributed to her service-connected disability. In this capacity the Board notes that a June 2012 VA examination report indicated that the Veteran experienced weight gain that is attributable to her hypothyroid condition. This finding was not addressed in the addendum opinion. Another opinion is required. The matters are REMANDED for the following action: 1. Make two requests for the authorized records from the private medical care providers identified in the December 2019 VA Form 21-4142, unless it is clear after the first request that a second request would be futile. All attempts to obtain these records should be documented for the claims file. 2. After completing the action requested in item 1, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the diagnosed hypertension is at least as likely as not (a) caused by, or (b) aggravated by (worsened beyond natural progression) service-connected multinodular goiter, status post thyroidectomy. In offering the opinion, the examiner is asked to address (a) whether a service-connected disability or disabilities caused the Veteran to become obese or aggravated the Veteran's obesity, and if so, (b) whether the obesity or aggravation of obesity resulting from service-connected disability was a substantial factor in causing hypertension such that the hypertension would not have occurred but for the obesity caused or aggravated by service-connected disability. In offering the opinion, the examiner is asked to consider the Veteran's lay statements on weight gain and the February 2012 VA examination report indicating that the Veteran's weight gain is attributable to a hypothyroid condition. The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. 3. After completing the action requested in item 1, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the diagnosed type II diabetes mellitus is at least as likely as not (a) caused by, or (b) aggravated by (worsened beyond natural progression) service-connected multinodular goiter, status post thyroidectomy. In offering the opinion, the examiner is asked to address (a) whether a service-connected disability or disabilities caused the Veteran to become obese or aggravated the Veteran's obesity, and if so, (b) whether the obesity or aggravation of obesity resulting from service-connected disability was a substantial factor in causing diabetes mellitus such that the diabetes would not have occurred but for the obesity caused or aggravated by service-connected disability. In offering the opinion, the examiner is asked to consider the Veteran's lay statements on weight gain and the February 2012 VA examination report indicating that the Veteran's weight gain is attributable to a hypothyroid condition. The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Thomas D. Jones, 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.