Citation Nr: 22041008 Decision Date: 07/18/22 Archive Date: 07/18/22 DOCKET NO. 11-21 576 DATE: July 18, 2022 REMANDED Entitlement to a disability rating in excess of 30 percent from April 4, 2012 for hypothyroidism is remanded. Entitlement to an initial compensable disability rating for constipation associated with hypothyroidism is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from September 1995 until her honorable discharge in February 2009. These matters come before the Board of Veterans' Appeals (Board) on appeal from the July 2016 and August 2020 rating decisions by the Regional Office (RO) of the United States Department of Veterans Affairs (VA). In September 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ), sitting at the RO in St. Petersburg, Florida. A transcript of the hearing has been associated with the record on appeal. In a December 2020 decision, the Board denied the Veteran's claim for a disability rating in excess of 30 percent from April 4, 2012 for hypothyroidism. The Veteran subsequently appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a March 2022 Joint Motion Partial Remand (Motion), the Court remanded the case to the Board for readjudication. REMANDED As a preliminary matter, the Board reminds the RO of the principles against pyramiding. Specifically, that disabilities, including those arising from a single disease entity, are generally rated separately before ratings are then combined in accordance with 38 C.F.R. § 4.25. However, VA is prohibited from pyramiding (rating the same disability, or the same manifestation of a disability, under different diagnostic codes). 38 C.F.R. § 4.14. When disabilities have duplicative or overlapping symptoms, the rule against pyramiding prohibits VA from compensating the Veteran more than once for the same symptom or impairment. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017). In this regard, the Board directs the RO (and examiners) to note that the Veteran is currently service-connected, effective March 27, 2021, for depressive disorder with symptoms including anxiety, chronic sleep impairment, depressed mood, forgetting names, forgetting recent events, mild memory loss associated with migraine headaches, hypothyroidism, right hip degenerative arthritis of the left knee, lumbar sprain, painful scars, ganglion cyst of the left wrist, polycystic ovarian disease with hirsutism. See June 2022 VA examination, see also July 2022 Rating Decision; see also February 2021 Medical Treatment Record [mislabeled as from a government facility] (private opinion received on February 22, 2021). 1. Entitlement to a disability rating in excess of 30 percent from April 4, 2012 for hypothyroidism is remanded. The Board notes that during the Veteran's September 2018 Board hearing, she asserted that after her thyroid was removed, her heart slowed down. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In the present case, the record is unclear as to the onset of the Veteran's acquired psychiatric disability and the two February 2020 VA examinations (hypothyroidism and psychiatric) appear to be inconsistent. Furthermore, the opinion(s) in the prior VA examination(s) do not adequately address the disability in relation to the Veteran's assertions and a remand is required. The Board notes that the Veteran is competent to report symptoms of her disability, but not the etiology. See Davdison v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); see also Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (2007). 2. Entitlement to an initial compensable disability rating for constipation associated with hypothyroidism is remanded. Finally, because a decision on the remanded issue of entitlement to a disability rating in excess of 30 percent from April 4, 2012 for hypothyroidism could significantly impact a decision on the issue of entitlement to an initial compensable disability rating for constipation, the issues are inextricably intertwined. A remand of the claims for entitlement to an initial compensable disability rating for constipation is required. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for any and all private providers that have diagnosed and/or treated the Veteran for thyroid disabilities, muscular weakness, cardiovascular disabilities (including but not limited to bradycardia), cold intolerance, and sleep disabilities. Make two requests for the authorized records from all private providers that have diagnosed and/or treated the Veteran for thyroid disabilities, muscular weakness, cardiovascular disabilities (including but not limited to bradycardia), cold intolerance, and sleep disabilities; unless it is clear after the first request that a second request would be futile. 2. Obtain any/all of the Veteran's VA treatment records that are not already of record. 3. After any additional records are associated with the claims file, obtain an addendum opinion regarding the severity of the Veteran's hypothyroidism from April 4, 2012 to March 26, 2021 from a VA examiner(s). The entire claims file must be made available to and be reviewed by the examiner(s). If an examination is deemed necessary, it shall be provided. An detailed explanation for all opinions expressed must be provided. From April 4, 2012, does the Veteran's hypothyroidism at least as likely as not (50 percent probability or greater) manifest with the symptom(s) of muscular weakness, mental disturbance (dementia, slowing of thought, depression), weight gain, cold intolerance, cardiovascular involvement (including but not limited to hypotension, bradycardia (less than 60 beats per minute), and pericardial effusion), and/or sleepiness? The examiner must address the Veteran's September 2018 Board testimony that her heart slows down and specifically determine if her hypothyroidism has produced, at any point throughout the period on appeal bradycardia (less than 60 beats per minute). The examiner must address if the Veteran's hypothyroidism has produced, at any point throughout the period on appeal, a mental disturbance (dementia, slowing of thought, or depression). The examiner must address the apparent conflicting information between the February 2020 thyroid examination and February 2020 psychiatric examination. Specifically, the examiner must address the February 2020 VA psychiatric examination which found that the Veteran did not have nor has she ever been diagnosed with a mental disorder and the February 2020 VA thyroid examination which noted that the Veteran reported a history of mild depression and the examiner found that the Veteran had mental and psychological symptoms attributable to a thyroid condition. If the examiner finds that the Veteran's hypothyroidism manifests in a mental disturbance prior to March 26, 2021, the examiner must also specifically address if the Veteran's hypothyroidism produced a separate and distinct mental disability from her service-connected depressive disorder from March 26, 2021. For any of the above symptoms are not present throughout the period on appeal, it must be clearly stated. For any of the above symptoms that are present at any point throughout the period on appeal, it must be clearly identified for the onset (and if applicable, the resolution) of the symptom(s) and an etiology opinion on if it is at least as likely as not (50 percent probability or greater) due to the Veteran's hypothyroidism. A detailed rationale for all opinion(s) provided is required, including the onset (and/or resolution) of any of the above symptoms. 4. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issue of entitlement to an initial compensable disability rating for constipation. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and her representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Deemer, 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.