Citation Nr: 23014239 Decision Date: 03/09/23 Archive Date: 03/09/23 DOCKET NO. 15-12 279 DATE: March 9, 2023 REMANDED Service connection for a hyperparathyroidism disability to include as secondary to the service-connected nephrolithiasis (kidney stones) is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1989 to January 1990 and August 2000 to January 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2014 rating decision. This matter was most recently before the Board in February 2022 when it was remanded to obtain a medical opinion pursuant to 38 U.S.C. § 5109. Service connection for a hyperparathyroidism disability to include as secondary to the service-connected nephrolithiasis (kidney stones) is remanded. A review of the medical opinions obtained since the February 2022 Board opinion shows another remand is warranted because while the endocrinologist addresses causation, they failed to adequately address aggravation and secondary service connection. Service connection may be granted on a secondary basis for a disability which is proximately due to, the result of, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. Regarding this, three opinions were obtained pursuant to 38 U.S.C. § 5109 in September 2021 to determine the nature and etiology of the Veteran's hyperparathyroidism. In the first opinion from September 2021, the endocrinologist provides a negative opinion for direct service connection and secondary service connection causation. For their rationale, the endocrinologist notes hyperparathyroidism occurs when one or more of the parathyroid glands is overactive, and as a result, the gland makes too much parathyroid hormone (PTH). The endocrinologist indicates too much PTH causes calcium levels within the blood to rise too high, which can lead to health problems such as bone thinning and kidney stones; thus, when a person has kidney stones, it is very good practice to consider hyperparathyroidism as a cause. The endocrinologist concludes, "This excludes hyperparathyroidism as a cause of the [V]eteran's kidney stones" because "if the serum calcium is normal at 9.4, there is obviously no increased parathyroid hormone in the body, and no way that hyperparathyroidism could be a cause of the kidney stones." The endocrinologist observes, there "was a long history of kidney stones dating to 1997 with hyperparathyroidism not being diagnosed until 2013, 16 years later, when both calcium and the hormone from the parathyroid glands (PTH) were elevated." Thus, the endocrinologist further concludes, "This definitely demonstrates that the kidney stones were present many years before, and not causally related to hyperparathyroidism." In the second opinion from September 2021, the endocrinologist found the Veteran's hyperparathyroidism was not due to or aggravated by his service-connected nephrolithiasis. The endocrinologist notes nephrolithiasis does not cause or aggravate the development or progression of hyperparathyroidism. For their rationale, the endocrinologist states in this case, kidney stones are not due to or a cause of the hyperparathyroidism as they are independent conditions. The endocrinologist notes the development of hyperparathyroidism could add another reason for kidney stones; thereby, increasing the frequency of stone formation. The endocrinologist then indicates there is no mechanism by which kidney stones could cause or aggravate the development of hyperparathyroidism. The endocrinologist states kidney stones are the result of precipitation of calcium in the urine, which can happen because there is too much calcium within the urine or because there are other problems causing the stones to form. The endocrinologist notes hyperparathyroidism is one cause of there being too much calcium in the urine and concludes by stating, "nephrolithiasis is one cause of but never causes hyperparathyroidism." The Board observes although the endocrinologist addresses aggravation in the opinion, the opinion does not address aggravation sufficiently. Regarding this, the United States Court of Appeals for Veterans Claims (Court) held in the case of Ward v. Wilkie, 31 Vet. App. 233 (2019), that aggravation pursuant to 38 C.F.R. § 3.310 does not require a permanent worsening of the condition. Rather, the Court explained, "aggravation" is any incremental increase in disability attributable to the service-connected disability, i.e., any additional impairment of earning capacity that is above the degree of disability existing before the increase, regardless of its permanence. Id. The Board further observes it is unclear whether the rationale following the endocrinologist's finding that there is no mechanism by which kidney stones could cause or aggravate the development of hyperparathyroidism is for aggravation as it seems to address causation. Finally, there is an addendum opinion from December 2022. The endocrinologist provides much of the same information as the other two opinions, and a review of this opinion shows it does not adequately address aggravation. For aggravation, the endocrinologist found hyperparathyroidism was not aggravated by any service-connected condition. However, no further rationale or discussion is provided for aggravation by any service-connected condition. Furthermore, in addressing the Board's remand instructions directly, the endocrinologist notes hyperparathyroidism is not proximately due to or aggravated by his service-connected nephrolithiasis. However, no rationale is provided to support the conclusion. The Court has held causation and aggravation are independent concepts and should have separate findings and rationales. See Atencio v. O'Rourke, 30 Vet. App. 74 (2018). The matter is REMANDED for the following action: 1. Pursuant to 38 U.S.C. § 5109, obtain an independent medical expert opinion from an endocrinologist different than who provided the prior medical opinions in September 2021 and December 2022 as to whether the Veteran's hyperparathyroidism disability may be related to his service-connected nephrolithiasis. Prior to offering the opinions requested below, the expert is to review the Veteran's claims file, to include a copy of this remand. The expert is requested to provide an opinion as to whether the Veteran's hyperparathyroidism (i) was caused (in whole or in part) or (ii) aggravated (any incremental increase in disability or any additional impairment of earning capacity regardless of its permanence) by the Veteran's service-connected nephrolithiasis or any other service-connected condition. The examiner must provide separate opinions and rationales for secondary causation and secondary aggravation. Atencio, supra. In providing the requested opinion, the reviewing endocrinologist is to consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. A complete and detailed rationale for these opinions should be provided for every opinion requested by the examiner. DUSTIN L. WARE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Buck Denton 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.