Citation Nr: 25005609 Decision Date: 04/24/25 Archive Date: 04/24/25 DOCKET NO. 19-32 781 DATE: April 24, 2025 REMANDED Entitlement to an increased evaluation for hypothyroidism, currently rated as 30 percent disabling, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1990 to May 1994. This case comes to the Board from a decision issued in July 2017 by the Agency of Original Jurisdiction (AOJ). In its decision, the AOJ reduced the disability rating for hypothyroidism from 30 percent to 10 percent, denied a request for a total disability rating for individual unemployability due to service-connected disorders (TDIU), and denied requests for increased ratings for service-connected hypertension, unspecified depressive disorder, sacroiliitis, and radiculopathy of both lower extremities. In her notice of disagreement (NOD), the Veteran appealed the rating issues concerning hypothyroidism, hypertension, and TDIU. In September 2019, the AOJ granted the request for a TDIU rating. In May 2022, the Veteran testified before the undersigned at a virtual hearing. A transcript of that hearing is of record. In July 2023, the Board denied a disability rating higher than 10 percent for hypertension and remanded the hypothyroidism claim for further development. Since the hypertension and TDIU issues were resolved, the hypothyroidism increased rating claim is the only remaining issue in this appeal. In July 2023, April 2024, and, most recently, in January 2025, the Board remanded the hypothyroidism claim to the AOJ for further development. In the January 2025 remand, the Board instructed the AOJ to obtain copies of missing medical records from health care providers in private practice whose treatment of the Veteran was arranged by her local VA Medical Center (VAMC) pursuant to the community care program, especially treatment records from a nephrologist in private practice. The AOJ satisfied this requirement by obtaining copies of these records and associating them with the electronic claims file. The Board also instructed the AOJ to arrange a new examination and to obtain an opinion from the examiner addressing four questions which are potentially significant in deciding whether the Veteran is entitled to an increased rating for her hypothyroidism. Specifically, the post-remand examiner was asked: (1) are the Veteran's claimed symptoms of cold intolerance, weight gain, insomnia, dry skin, and swelling of the legs and hands related to her hypothyroidism? (2) Is the Veteran's hyperparathyroidism related to her hypothyroidism? (3) If the examiner identified thyroid-related neurologic or psychological impairments, the instructions requested an opinion addressing whether these could be distinguished from potentially similar service-connected disabilities, such as the Veteran's sciatic nerve radiculopathy and/or her unspecified depressive disorder; (4) The Board asked the examiner to clarify conflicting statements in an earlier series of opinions prepared in September 2024. Some of the statements for which clarification was necessary attributed potentially relevant symptoms to the Veteran's nonservice-connected kidney disease. The January 2025 remand advised that, according to her medical records, the Veteran had a kidney transplant in September 2024. Accordingly, the Board asked the post-remand examiner, "Did any of the symptoms mentioned in these instructions (including cold intolerance, weight gain, insomnia, dry skin, swelling of the legs and hands, hyperparathyroidism, depression) resolve after the kidney transplant? Do any post-transplant changes in the Veteran's medical condition help resolve the question of whether kidney disease or hypothyroidism caused the relevant symptoms?" As requested, a physician examined the Veteran in February 2025 and prepared a questionnaire and a series of opinions. The examiner satisfied one part of the Board's remand orders by providing a clear report concluding that, in the examiner's opinion, hyperparathyroidism was not related to the Veteran's service-connected hypothyroidism. This report includes a thorough explanation of the medical reasons for the examiner's conclusion. Unfortunately, there is a contradiction between the examiner's response to the Board's first question and the information in the examination questionnaire. In one of his post-remand opinions, the examiner wrote, "[the Veteran's] previously described symptoms of 'cold intolerance, weight gain, insomnia, dry skin, and swelling of the legs and hands' are all related to hypothyroidism..." But in section III ("Thyroid: Findings, Signs, and Symptoms") of the February 2025 examination questionnaire, the examiner marked "no" in response to "Does the Veteran have any findings, signs, or symptoms attributable to a thyroid condition?" On the examination report form, there are boxes next to pre-printed text where the examiner would indicate, if appropriate, the presence of skin symptoms, neurological symptoms, or mental or psychological symptoms associated with any current thyroid condition. But the examiner did not mark any of these boxes. If, as the examiner's opinion suggests, the Veteran's insomnia, dry skin, and swelling of the legs and hands are related to her hypothyroidism, the examiner should have marked "yes" on part 3A of the questionnaire. Consistent with the thyroid questionnaire's instructions, the examiner should then complete the appropriate psychological, neurological, and/or dermatological questionnaires. The Board has considered the possibility that the examiner may have intended to indicate that the Veteran's hypothyroidism had previously caused her to experience insomnia, dry skin, etc. - but that those symptoms resolved before the February 2025 examination. But if this were true, the examiner should have given a complete answer to the Board's question asking whether any of the relevant symptoms resolved after the September 2024 kidney transplant. Instead, in response to the request to discuss the effects of the kidney transplant, if any, on the symptoms of the Veteran's hypothyroidism, the examiner merely repeated his conclusion that hyperparathyroidism was related to kidney disease and unrelated to hypothyroidism. When the Board remands an appeal, the claimant obtains a right to compliance with the remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Although the AOJ obtained some useful information by obtaining the community care medical records and an adequate opinion concerning hyperparathyroidism, the other reports from the February 2025 examiner failed to comply with the Board's instructions. Although the need for further delay is regrettable, the Board must remand the increased rating claim for hypothyroidism to seek a new medical opinion to correct these problems. The matter is REMANDED for the following action: 1. SCHEDULE THE VETERAN FOR AN IN-PERSON MEDICAL EXAMINATION WITH AN APPROPRIATE CLINICIAN to determine the current severity of her service-connected hypothyroidism. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the disability under the rating criteria. In addition to the information requested on the standard thyroid and parathyroid examination report form, the examiner must provide an opinion addressing these questions: (a) Please attempt to clarify a contradiction in the February 2025 examination reports and opinions. These include a thyroid conditions examination questionnaire and separate opinions responding to different parts of the Board's January 2025 remand orders. In one of these opinions, the examiner wrote, "[the Veteran's] previously described symptoms of 'cold intolerance, weight gain, insomnia, dry skin, and swelling of the legs and hands' are all related to hypothyroidism..." But on section III ("Thyroid: Findings, Signs, and Symptoms") of the February 2025 examination questionnaire, the examiner answered "no" in response to the question "Does the Veteran have any findings, signs, or symptoms attributable to a thyroid condition?" On the examination report form are boxes next to pre-printed text where the examiner would indicate, if appropriate, the presence of skin symptoms, neurological symptoms, or mental or psychological symptoms associated with any thyroid condition. But the examiner did not mark any of these boxes. Are the symptoms of cold intolerance, weight gain, insomnia, dry skin, and swelling of the legs and hands described by the Veteran related to her hypothyroidism? Why or why not? (b) According to the VAMC records, the Veteran received a kidney transplant in September 2024. Did any of the symptoms mentioned in these instructions (including cold intolerance, weight gain, insomnia, dry skin, swelling of the legs and hands, or depression) resolve after the kidney transplant? Do any post-transplant changes in the Veteran's medical condition help to resolve the question of whether kidney disease or hypothyroidism caused the relevant symptoms? (c) Because the Veteran filed her increased rating claim before the effective date of the amended version of the amendments to 38 C.F.R. § 4.119, Diagnostic Code 7903, the pre-amendment rating criteria, and not only the information on the current thyroid conditions questionnaire, are potentially relevant to this claim. At any time while this claim was pending (May 5, 2017, to the present) has the Veteran's hypothyroidism resulted in muscular weakness, mental disturbance and weight gain? At any time while this claim was pending (May 5, 2017, to the present) has her hypothyroidism resulted in cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute) and sleepiness? The examiner should provide a clear rationale thoroughly explaining the medical reasons for his or her opinions. 2. The AOJ must ensure that the requested examination report and opinions comply with the directives of this remand. If any report is deficient in any way, the AOJ should implement corrective procedures. DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Nye, 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.