Citation Nr: A25020175 Decision Date: 03/05/25 Archive Date: 03/05/25 DOCKET NO. 240119-409299 DATE: March 5, 2025 REMANDED Entitlement to service connection for hyperthyroidism is remanded. REASONS FOR REMAND The Veteran served active duty from September 2005 until March 2010. This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2024 decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In the January 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the January 2024 agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. However, because the Board is remanding the claim, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii). Under the Appeals Modernization Act (AMA), the Board is bound by favorable findings by the AOJ unless rebutted by evidence of clear and unmistakable error. 38 C.F.R. § 3.104(c). With respect to the Veteran's claim of entitlement for hyperthyroidism, the RO made favorable findings that: (1) the Veteran has a current disability; and (2) he was exposed to environmental hazards during military service. Entitlement to service connection for hyperthyroidism is remanded. The Veteran contends he is entitled to service connection for hyperthyroidism due to his military service. Specifically, he notes it was discovered in 2011 that he had an enlarged thyroid and nodules on his right lobe and a large nodule on his left lobe. He noted while deployed in Afghanistan from May 2006 until June 2007 and December 2008 until January 2010, he was exposed to burn pits on a regular basis. See August 2023 VA 21-526EZ, Fully Developed Claim. Service connection may be granted for an injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. To establish service connection, the Veteran must show evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1167. Service connection may be granted for a Persian Gulf veteran with a qualifying chronic disability that became manifest to any degree at any time. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). A Persian Gulf veteran is defined as a veteran who served on active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e)(1). The Southwest Asia theater of operations refers to Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. Id. § 3.317(e)(2). The period of the Persian Gulf War is from August 2, 1990, through the present. See 38 C.F.R. § 3.2(i). The Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act, was enacted on August 10, 2022. Section 405 of the PACT Act reduces the threshold for establishing eligibility when considering presumptive service connection for Persian Gulf War veterans. Presumptive conditions under 38 C.F.R. § 3.317(a) and (b) may now manifest to any degree at any time. There is no longer a requirement for a chronic disability to manifest to a degree of 10 percent or more prior to December 31, 2026. The end date is no longer applicable and will be removed in a forthcoming regulation. Additionally, the PACT expanded the definition of a Persian Gulf veteran to include those who served in the countries of Afghanistan, Israel, Egypt, Turkey, Syria, and Jordan, along with those who served in the Southwest Asia theater of operations as defined in 38 C.F.R. § 3.317(e). The VA has a duty to assist veterans and must provide a medical examination or obtain a medical opinion when such an examination or opinion is necessary to decide the claim. 38 U.S.C. § 5103A(d)(1). The medical examination or opinion must also be adequate. A medical opinion is adequate when it is based upon consideration of the Veteran's prior medical history and examinations and describes the disability in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one. Barr v. Nicholson, 21 Vet. App. 303, 311. Here, the Veteran was afforded a VA examination in January 2024. The VA examiner opined the Veteran's hyperthyroidism was less likely than not caused by toxic exposure risk activities after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The examiner stated there is no pathophysiological link from toxic exposure from deployment and the development of subclinical hyperthyroidism and multinodular goiter. The VA examiner provided medical literature to support his rationale. The literature stated the pathophysiology, natural history, prevalence, risks and long-term outcome of subclinical hyperthyroidism are unknown. It is assumed that most elderly patients with subclinical hyperthyroidism have a multinodular goiter, but several other conditions should be considered in the differential diagnosis. The literature discusses TSH levels and stated the etiology of subclinical hyperthyroidism includes partially or insufficiently treated over hyperthyroidism, multinodular goiter, Graves' disease, iodine-associated hyperthyroidism, solitary autonomous adenoma and thyroiditis. The Board finds the January 2024 VA opinion is inadequate for the following reasons: (1) the VA examiner did not provide a direct service connection opinion; (2) the examiner's opinion did not discuss why the Veteran's claimed condition could not be related to exposure to burn pits while on deployment; (3) the examiner did not provide a rationale to connect his medical literature to his opinion as the literature provided stated pathophysiology and long-term outcome of subclinical hyperthyroidism are unknown; and (4) the literature provided does not discuss the connection or lack thereof to environmental hazards. As such, the Board finds it was a pre-decisional duty to assist error to rely on the January 2024 opinion. Thus, a remand is warranted. The matters are REMANDED for the following action: Provide the record, to include a copy of this Remand, to an appropriate clinician and obtain an addendum opinion regarding the Veteran's claim for hyperthyroidism. The need for additional examination is left to the discretion of the clinician. The examiner should opine on the following: Is it at least likely as not that the Veteran's hyperthyroidism had its onset or is otherwise related to his military service, including exposure to hazardous environment and burn pits? In addition, to an opinion on direct service connection, the examiner should address the synergistic, combined effect of all TERAs. The examiner should address the relevant lay statements of record. (Continued on the next page) ? Any opinion offered should be accompanied by a clear rationale. JIMMY L. BARDIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Bond, Tyana N. 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.