Citation Nr: 1547780 Decision Date: 11/12/15 Archive Date: 11/25/15 DOCKET NO. 06-31 601 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to service connection for obstructive sleep apnea, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 2. Entitlement to service connection for a sleep disorder other than obstructive sleep apnea, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 3. Entitlement to service connection for muscle pain, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 4. Entitlement to service connection for anemia, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 5. Entitlement to service connection for headaches, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 6. Entitlement to service connection for edema of the lower extremities, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 7. Entitlement to service connection for cardiovascular disability, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 8. Entitlement to service connection for hypogonadism, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 9. Entitlement to service connection for hypothyroidism, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 10. Entitlement to service connection for chronic fatigue, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 11. Entitlement to service connection for fibromyalgia, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 12. Entitlement to service connection for peripheral neuropathy, to include as due to herbicide exposure and/or undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 13. Entitlement to service connection for arthritis, other than rheumatoid, of multiple joints. 14. Entitlement to service connection for pulmonary disability, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 15. Entitlement to service connection for gastrointestinal disability, including gastroenteritis and irritable bowel syndrome, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 16. Entitlement to service connection for skin disability, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 17. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Joel Ban, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran had active military service from January 1968 to October 1969, as well as, from November 1990 to May 1991. The Veteran served in the Republic of Vietnam during the Vietnam Era and in the Southwest Asia Theater of Operations during the Persian Gulf War. These matters initially came to the Board of Veterans' Appeals (Board) following a February 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah. In July 2007, the Veteran testified during a hearing before a Veterans Law Judge (VLJ) sitting at the RO. The Veteran and his spouse again testified before same VLJ at a videoconference hearing in May 2011. Transcripts of both hearings are in the Veteran's claims file. In a June 2015 letter, the Board informed the Veteran that the VLJ who performed his hearings is no longer employed with the Board and that if the Veteran did not respond to the letter within 30 days, requesting a new hearing, the Board would assume that he did not want another hearing and proceed with this matter. The Veteran did not respond to this letter and is thus presumed to not desire a new hearing. In February 2008, the Board remanded the Veteran's claims for additional development. In January 2012, the Board denied the above noted claims, as well as, claims for service connection rheumatoid arthritis and a disability manifested by burning semen. The Board also remanded claims for service connection for arthritis, other than rheumatoid, of multiple joints, and for a total disability rating based on individual unemployability. The Veteran further remanded claims for service connection for pulmonary disability, gastrointestinal disability (to include gastroenteritis and irritable bowel syndrome), and a skin disability - all of which were to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. The Veteran appealed the Board's January 2012 denial to the United States Court of Appeals for Veterans Claims (Court). In June 2013, the Court issued a memorandum decision upholding the denials of service connection for rheumatoid arthritis and a disability manifested by burning semen, and vacated the above noted issues for readjudication. The issues other than service connection for chronic fatigue and fibromyalgia are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War. 2. Resolving all doubt in favor of the Veteran, he has compensably disabling chronic fatigue syndrome (CFS). 3. Resolving all doubt in favor of the Veteran, he has compensably disabling fibromyalgia. CONCLUSIONS OF LAW 1. CFS is presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1117, 1131, 1154(a), 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2015). 2. Fibromyalgia is presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1117, 1131, 1154(a), 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As to the chronic fatigue and fibromyalgia claims, the Board is granting in full the benefits sought on appeal. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. Chronic Fatigue and Fibromyalgia Claims The Veteran contends that he developed chronic fatigue and fibromyalgia due to his service in Saudi Arabia during the Gulf War. The Board notes that service personnel records support the Veteran's contention that he served in Southwest Asia for three months in the early 1990s. A. Applicable Law Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. 1110, 1131 (West 2014); 38 C.F.R. 3.303(a) (2015). Because the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may also be established under 38 C.F.R. § 3.317. Service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. Unlike service connection on a direct basis, the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 do not require competent medical nexus of a link between the qualifying chronic disability and military service. Service connection is presumed unless there is affirmative evidence to the contrary. See 38 C.F.R. § 3.317(c); Gutierrez v. Principi, 19 Vet. App. 1 (2004). Persian Gulf Veteran means a veteran who, during the Persian Gulf War, served on active military, naval, or air service in the Southwest Asia theater of operations, which includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317 (d). For purposes of § 3.317, qualifying chronic disabilities include: (1) an undiagnosed illness; and (2) a medically unexplained chronic multi-symptom illness such as (but not limited to) chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders. 38 C.F.R. § 3.317(a)(2). An undiagnosed illness is defined as a condition that by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Further, lay persons are competent to report objective signs of illness. Gutierrez, 19 Vet. App. at 8-9. A medically unexplained chronic multi-symptom illness is one defined by a cluster of signs or symptoms, and specifically includes-but, importantly, is not limited to-chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders. A medically unexplained chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2). Objective indications of chronic disability include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). For purposes of 38 C.F.R. § 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Lastly, compensation shall not be paid under § 3.317 if there is affirmative evidence that an illness was not incurred during active military service in the Southwest Asia theater of operations during the Persian Gulf War; if there is affirmative evidence that an otherwise qualifying illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (The Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (Noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). B. Factual Background and Analysis For disability due to undiagnosed illness and medically unexplained chronic multisymptom illness (such as CFS and fibromyalgia), the disability must manifest either during active military service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2016. 38 C.F.R. § 3.317(a)(1) and (2). As such, service connection is warranted if the Veteran has CFS and/or fibromyalgia that has manifested to a degree of 10 percent or more, unless there is affirmative evidence that the qualifying chronic disability in question was not incurred during active service in Southwest Asia theater of operations during the Persian Gulf War; was caused by a supervening condition or event that occurred between the Veteran's most recent departure from service in the Southwest Asia theater of operations during the Persian Gulf war and the onset of the illness; or was the result of willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(a)(7). In the present case, the evidence of record is conflicting as to whether the Veteran has current diagnoses of either CFS or fibromyalgia. Prior to the current claim, a September 2005 VA examiner found neither CFS nor fibromyalgia. Rather, the Veteran had significant illnesses that could result in fatigue symptoms, including hypogonadism, hypothyroidism, monoclonal gammopathy and obstructive sleep apnea. Similarly, in conjunction with the current claim, an October 2009 VA examiner found that while the Veteran manifested 18 of 18 tender points consistent with fibromyalgia, neither that nor CFS could be diagnosed due to the Veteran's many other major underlying disorders, which included untreated disorders and suboptimally treated apnea. More recently, a September 2014 VA examiner found that the Veteran did not meet diagnostic criteria for CFS. She further found that the Veteran's fibromyalgia, but that it was not due to service. Multiple private medical records document diagnoses of both disorders. (March 2006 letter and private medical records from Dr. M.K.). Additionally, an April 2010 VA examiner (who actually also wrote the September 2005 VA examination) found that the Veteran had both CFS and fibromyalgia, as he the Veteran had multiple signs and symptoms that supported the diagnoses. Similarly, in January 2015, Dr. L.B. found that the Veteran meets the criteria for fibromyalgia by 1990 and 2010 criteria due to widespread pain, 14/18 tender points, and supported by fatigue, cognitive complaints and unrefreshing sleep. Sher further found that his history matched the onset and description of CFS, with flu like onset, followed by a fatigue with markedly limited function, post exertional malaise, cognitive impairment, unrefreshing sleep, myalgia, arthralgia, and other symptoms. She noted that the criteria for CFS are often thought to exclude patients with other chronic illnesses contributing to fatigue, but that was not the case if there is no alternate diagnosis to explain of the CFS symptoms. She reported that none of the Veteran's diagnoses could fully explain his multisystem illness manifestations. She opined that since no specialists have arrived at an umbrella diagnosis for his multisystem illness in spite of adequate diagnostic workup, nor produced any single diagnosis that completely explained his degree of debilitation, his illness was aptly described by the term "medically unexplained illness" and he met the 1994 Fukuda criteria for CFS. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). However, a medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board finds that, for the current appeal period, the diagnoses of CFS and obstructive sleep apnea are warranted based on the most probative medical evidence of record, the medical opinions on that matter made by the April 2010 VA examiner and Dr. L.B. Both L.B. and the April 2010 VA examiner are physicians, rather than physician assistants, like the October 2009 and September 2014 VA examiners. Moreover, they provided the most detailed explanations as to how each one came to his or her determination that the Veteran currently has CFS and fibromyalgia. As the Board has found that the Veteran has CFS and chronic fatigue, the question turns to whether either or both disabilities have manifested to a degree of 10 percent or more prior to December 31, 2016. As to CFS, such a disability is rated under 38 C.F.R. § 4.88b, Diagnostic Code 6354. A 10 percent disability rating is warranted for signs and symptoms of CFS that wax and wane but result in periods of incapacitation of at least one but less than two weeks total duration per year or the symptoms are controlled by continuous medication. Higher ratings can be warranted with nearly constant signs and symptoms that restrict routine daily activities by increasing percentages as to pre-illness level; or which wax and wane, resulting in periods of incapacitation of increasing weeks total duration per year. 38 C.F.R. § 4.88b, Diagnostic Code 6354. In the present case, the Veteran has reported constant fatigue that his limited his routine activities by at least 50 percent (April 2010 VA examination, January 2015 evaluation by Dr. L.B.). As such, the Veteran's CFS has manifested to a degree of 10 percent or more prior to December 31, 2016. As to fibromyalgia, it is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5025. Under Diagnostic Code 5025, a 10 percent rating is appropriate for symptoms that require continuous medication for control. A 20 percent rating is appropriate for symptoms that are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time. The highest rating of 40 percent rating is warranted for symptoms that are constant, or nearly so, and are refractory to therapy. The April 2010 VA examiner noted that the Veteran had been treated for fibromyalgia with numerous medications over the years, as well as various anti-inflammatories, with no effect. Given such findings, the Board finds that the Veteran's fibromyalgia likely manifested to at least a 10 percent disability rating. Given such diagnoses and adequate manifestation levels, service connection for both chronic fatigue syndrome and fibromyalgia is warranted, unless there is affirmative evidence that the qualifying chronic disability in question was not incurred during active service in Southwest Asia theater of operations during the Persian Gulf War; was caused by a supervening condition or event that occurred between the Veteran's most recent departure from service in the Southwest Asia theater of operations during the Persian Gulf war and the onset of the illness; or was the result of willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(a)(7). There is no evidence of willful misconduct or the abuse of alcohol or drugs. As to the questions of a supervening condition or affirmative evidence that either disorder was not incurred during active service in Southwest Asia theater of operations during the Persian Gulf War, the October 2009 and September 2014 VA examiners found that the Veteran did not have fibromyalgia or chronic fatigue syndrome as his symptoms were due to other disorders. Therefore, such opinions were not responsive to those questions. The only medical opinion of record addressing that question was from the April 2010 VA examiner, who noted the causes of these entities. The VA examiner noted that: rheumatologists believe that these two entities represent some form of an immunological disorder. Many other physicians believe that these conditions represent an underlying psychiatric condition. It is felt by those individuals who think it is an autoimmune disorder that the process is likely triggered by an infection, most likely a viral infection. It appears...[the Veteran] may have had such a viral infection some time in 2002 because that is when all of his symptoms began. There is no specific treatment for these disorders but time and support and some degree of physical therapy and exercises. While the April 2010 VA examiner found that the Veteran's chronic fatigue and fibromyalgia began almost a decade following service from an infection, even then he is unclear, noting that there are essentially two schools of thought on the cause of such disorders. Furthermore, the Board notes that VA itself as characterized both disorders as "a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms," indicating an ambiguity as to the cause of such disorders. Indeed, the October 2009 VA examiner noted that although the Veteran specifically denied having a family history of fibromyalgia during his VA examination, multiple private medical records documented the Veteran's prior reports of a sibling with fibromyalgia, further showing a lack of clarity as to the cause of such disorder. Given the above ambiguities and giving the Veteran the benefit of the doubt, the Board finds that there is no supervening condition or affirmative evidence that either disorder was not incurred during active service in Southwest Asia theater of operations during the Persian Gulf War. Resolving all reasonable doubt in the Veteran's favor, service connection for chronic fatigue and fibromyalgia is granted. ORDER Service connection for chronic fatigue is granted. Service connection for fibromyalgia is granted. REMAND As to the remaining claims of obstructive sleep apnea, sleep disorder other than obstructive sleep apnea, muscle pain, anemia, headaches, edema of the lower extremities, cardiovascular disability, hypogonadism, hypothyroidism, and peripheral neuropathy, the development directed by the Board in its last remand was not accomplished, as the September 2014 VA examination was not completely responsive to the Remand instructions. Furthermore, as to the claims of service connection for arthritis of multiple joints (other than rheumatoid), a gastrointestinal disorder, a pulmonary disorder, and a skin disorder, as well as, for TDIU, the development directed by the Board in the January 2012 remand (and again in the March 2014 Board remand) have also not been accomplished, including requests for VA medical opinions. The law mandates that where the remand orders of the Board or the Courts are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes that the claims for service connection could affect the determination of his claim for entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). The TIDU claim is inextricably intertwined and must be remanded. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Undiagnosed Illness Claims As noted by the Veteran's attorney in the March 2015 Response, the September 2014 VA examiner did not provide an adequate medical opinion that was fully responsive to the March 2014 Board remand, including failing to address the private physician's medical opinions from March 2005, May 2005, March 2006, February 2008, and December 2013. The Board also notes that a new January 2015 medical opinion has also been associated with a claims file. Furthermore, the September 2014 VA examination was only performed by a physician assistant. Also, given the Board's grants of service connection for chronic fatigue and fibromyalgia above, the examiner should note whether any of the claimed are actually part of such, now service-connected, disabilities, as opposed to separate disorders. Additionally, per the June 2013 Court's Memorandum Decision, there is no medical determination of record that clearly and thoroughly discusses whether the Veteran's complained-of symptoms, whether attributed to a known diagnosis or not, constitute a medically unexplained chronic multi-symptom illness as contemplated by 38 C.F.R. § 3.317(a)(2)(i)(B). The Board finds that an addendum VA medical opinion, by a VA physician, is necessary to address the remaining claims. Past Medical Evidence As reported in the March 2014 and January 2012 Board remands, relevant medical evidence of record consists of the Veteran's service treatment records, records of his post-service treatment with both private and VA treatment providers, the January 2015 report of Dr. L.B., and reports of VA examinations conducted in September 2005, October 2009, April 2010, September 2014. Review of the Veteran's service treatment records reveals that they are silent as to any complaints of obstructive sleep apnea or other sleep problems, muscle pain, anemia, headaches, edema of the lower extremities, a cardiovascular disability, hypogonadism, hypothyroidism, or peripheral neuropathy of the lower extremities or related symptomatology. Other records, including the Veteran's separation reports of medical history and examination, are silent as to any problems with claimed difficulties. Regarding the Veteran's claimed disabilities of a gastrointestinal disorder, a pulmonary disorder, and a skin disorder, service treatment records are silent as to any complaints of or treatment for such problems, and he was found to have normal gastrointestinal, pulmonary, and skin systems at his separation medical examination. He was treated in June 1981 for complaints of left knee pain, and was assigned a questionable diagnosis of meniscal tear at that time. No follow-up evidence is of record. The Veteran was also seen for right wrist tendonitis and for left shoulder and neck pain in September 1993, at which time he was diagnosed with muscle strain of the shoulder and neck. Post-service medical records reflect that the Veteran has complained on multiple occasions of pain and stiffness in various joints, including at a November 1999 treatment visit in which computed tomography study revealed mild degenerative disc disease in his thoracic spine. Additionally, the Veteran complained of pain in his knees and toes at a May 2004 treatment visit; however, no diagnosis was assigned. The Veteran underwent a left knee meniscectomy in May 2005. Radiological study conducted at that time revealed a normal right hip, although magnetic resonance imagery (MRI) study showed degenerative disc disease and degenerative joint disease in the Veteran's lumbar spine and osteoarthritis in the knees bilaterally. MRI study conducted in March 2009 and May 2010 confirmed the presence of degenerative disc disease of the cervical spine. Following complaints in December 2008 of pain in his right knee and hip, February 2009 radiological study and bone scan revealed degenerative changes in the Veteran's shoulders, knees, ankles, and sternoclavicular joints. In addition, a private treatment provider opined in March 2011 that the degenerative changes in the Veteran's lumbar spine, cervical spine, and knees were aggravated by the activities he engaged in while on active duty, which rendered him more likely to develop arthritis in the joints than his advancing age would alone. Private treatment providers have also identified the Veteran as suffering from a variety of gastrointestinal disorders, including irritable bowel syndrome, with which he was diagnosed in March 2006. In addition, the Veteran has complained of both diarrhea and constipation and was noted in July 2003 to have "mild gastrointestinal irritation" and in February 2008 to have a possible diagnosis of irritable bowel syndrome. Regarding the Veteran's claimed pulmonary disorder, the Veteran has been assigned a multitude of diagnoses, including recurrent pneumonia, pleural effusions, and sarcoidosis. Similarly, he was seen on multiple occasions for complaints of skin lesions on his shins, which were treated in June 2007, and leg eczema, with which he was diagnosed in July 2008. In addition, the Veteran was assigned diagnoses of hemangioma, actinic keratosis, and irritant dermatitis in February 2010. The Veteran was given VA examinations in September 2005, October 2009 and April 2010 in conjunction with his service connection claims. Report of the September 2005 examination reflects that no arthritis was noted in any joints, and the Veteran was found to have normal range of motion in all joints without pain, tenderness, or swelling. At the October 2009 examination, the Veteran was noted to complain of pain in his back and right hip, as well as in his joints generally. He stated that he injured his right knee in service but that he did not seek any treatment at the time. The examiner diagnosed the Veteran with patellofemoral pain syndrome in the right knee and bursitis in the hips bilaterally and opined that these disabilities were not related to service, due to the lack of in-service injury or continuity of symptomatology. The Veteran also reported that his gastrointestinal complaints eased after his 2008 laparoscopic banding surgery. The examiner found the Veteran to have no diagnosis of irritable bowel syndrome or gastroenteritis, based on a colonoscopy conducted in April 2008 that returned normal results. In addition, the examiner noted that the Veteran had been seen for numerous pulmonary complaints in the years since service and carried a diagnosis of sarcoidosis, which the examiner stated was "felt to be new and not the cause of his earlier symptoms." However, no etiological opinion was provided. Finally, the examiner noted that the Veteran complained of having experienced intermittent rashes on his shins but found no skin disorder present at the time of the examination and therefore declined to assign a diagnosis of any skin disorder. Report of the April 2010 VA examination reflects that the examiner acknowledged the Veteran's complaints of pain in his right toe beginning in 1980, as well as pain in his fingers for the past five to six years and pain in his knees and ankles. In addition, the Veteran complained of pain in his shoulders and neck. The examiner diagnosed the Veteran with degenerative disc disease of the lumbar spine and cervical spine, as well as bilateral patellar chondromalacia. He opined in a May 2010 addendum that the Veteran's degenerative disc disease of the lumbar spine was not related to his time in service. The Veteran also complained of a "long history of lower abdominal pressure," as well as infrequent episodes of diarrhea and constipation. The examiner also noted the Veteran's "significant difficulty as related to his lungs," noting multiple diagnoses, including sarcoidosis. The examiner noted that, at the time of examination, the Veteran had no pulmonary complaints and that his "pulmonary problem has resolved completely." In addressing the Veteran's complaint of a skin disorder, the examiner noted that there was no indication on physical examination of any skin lesions or other skin disability and found him to have no diagnosed skin disorder. The examiner thus concluded that the Veteran had no symptomatology and no diagnoses related to his claimed gastrointestinal or skin disorders. Regarding the Veteran's pulmonary complaints, the examiner acknowledged a remote history of pneumonias and pleural effusions "likely secondary to infectious disease and possibly the sarcoidosis," although no definite diagnosis or etiological opinion was offered. Also, since service, the Veteran has sought treatment for complaints of sleep apnea, sleep disorder other than obstructive sleep apnea, muscle pain, anemia, headaches, edema of the lower extremities, cardiovascular disability, hypogonadism, hypothyroidism, and peripheral neuropathy from multiple VA and private treatment providers. The Veteran has been seen by both private and VA treatment providers beginning in 2000 for complaints of sleeping problems, muscle pain, headaches, and edema. He was first diagnosed with obstructive sleep apnea and insomnia in August 2000 and with hypothyroidism in March 2001; he has continued to seek treatment for those disabilities since that time. In addition, he was noted to have hypogonadism in 2004 and has continued to be treated for the disorder since that date. The Veteran has been noted to experience edema of the lower extremities on multiple occasions and was found to have anemia at a July 2007 private treatment visit. Multiple radiological and computed tomography scans of the Veteran's chest have revealed enlarged atria and ventricles, and he was diagnosed in February 2006 with cardiomyopathy secondary to hypertension. The Veteran has further been treated on multiple occasions since service for complaints of peripheral neuropathy. The Board notes that he was first diagnosed with peripheral neuropathy in May 2004 and was found to have peripheral neuropathy of the bilateral lower extremities of "questionable etiology" at a May 2005 nerve conduction study. At a June 2005 treatment visit, he was noted to have peripheral neuropathy that "might have a connection" to exposure to herbicide or to undiagnosed illness related to his time in the Persian Gulf. The Veteran underwent VA examinations in September 2005, October 2009, and April 2010 pursuant to his claims for service connection. Report of the September 2005 VA examination reflects the Veteran's complaints of chronic fatigue, headaches, and joint pain without redness or swelling of the joints. The examiner noted the Veteran's diagnoses of obstructive sleep apnea, hypogonadism, and hypothyroidism, as well as his report that he had been told he had peripheral sensory neuropathy in the lower extremities. The Veteran complained of intermittent mild tingling in the feet bilaterally. Physical examination revealed regular heart rate and normal range of motion in all joints but the lumbar spine. Neurological examination of the Veteran's lower extremities was normal, but some slight decrease to vibratory sense was noted in the toes. The examiner concluded that the Veteran had "significant illnesses that could result in fatigue, including hypogonadism, hypothyroidism, monoclonal gammopathy and obstructive sleep apnea and these are the likely causes" of the Veteran's symptoms of fatigue. No anemia or arthritic changes in any joint were found. In an addendum, the examiner further diagnosed the Veteran with tension headaches linked to stress. He finally stated that although the Veteran complained of aches in all his joints, physical examination was completely normal in all joints, with no specific complaints of muscle tenderness or weakness. Report of the October 2009 examination reflects that that the Veteran stated that he first experienced health problems in 2002 after experiencing flu-like symptoms. The Veteran reported that shortly thereafter he was diagnosed with hypothyroidism and hypogonadism and began experiencing overwhelming fatigue and peripheral neuropathy. The examiner noted the Veteran's complaints of extreme fatigue, generalized muscle aches, and weakness, as well as his diagnosis of obstructive sleep apnea. The Veteran further complained of consistent aching joint pains that were "not necessarily migratory" and of intermittent headaches. Regarding the Veteran's fibromyalgia claim, the examiner noted his report of waxing and waning symptoms with episodic worsening following exercise. The examiner found, however, that "his fatigue cannot be described as unexplained given that he has multiple issues that contribute to fatigue," in particular obstructive sleep apnea that was under suboptimal control. Hypothyroidism and hypogonadism were noted to be controlled by medication, and the examiner noted that the Veteran's headaches were attributable to stress and obstructive sleep apnea. Regarding the Veteran's claim for paresthesia or peripheral neuropathy, the examiner opined that the Veteran's paresthesia, as well as his anemia, was more likely related to sleep apnea and resulting hypoxemia. The examiner also related the Veteran's anemia to chronic renal insufficiency and hypertension. The Veteran reported that he had not experienced edema of the lower extremities since having laparoscopic surgery in 2008 to address his obesity. The examiner related the prior edema to obesity and obstructive sleep apnea. Upon review of the Veteran's treatment records, the examiner diagnosed him with cardiomyopathy. Physical examination revealed tenderness along the lumbar muscles and some limitation of motion with pain. Trigger points were noted to be tender in all areas, as well as some generalized muscle tenderness. No neurological abnormalities were noted, although some decreased sensation was found in the feet. The examiner diagnosed the Veteran with sensory peripheral neuropathy of the lower extremities, insomnia, tension headaches, hypotestosteronism, cardiomyopathy, hypothyroidism, myalgias, anemia of chronic disease, and obstructive sleep apnea. The examiner also linked the Veteran's complaints of muscle and joint aches to his poorly-controlled sleep apnea, which causes hypoxia. The examiner also linked the symptoms to the Veteran's obesity. The examiner further concluded that the Veteran's obstructive sleep apnea and insomnia developed secondary to his obesity and a narrowed airway and were not likely linked to service. Similarly, the examiner concluded that the Veteran's hypogonadism and hypothyroidism were not likely linked to service, given the length of time between his separation from service and the onset of the disorders. The examiner further found the Veteran's cardiomyopathy to be secondary to his obstructive sleep apnea and obesity. The Veteran again underwent VA examination in April 2010. Report of that examination reflects that the Veteran complained of low back pain radiating to his right lower extremity that pre-dated his service but was worsened during active duty. The Veteran also complained of pain in his fingers, toes, and ankles, as well as bilateral knee pain that began in the 1980s when he would run. The examiner also noted the Veteran's complaints of chronic fatigue syndrome and fibromyalgia that began in 2002 following a flu-like episode. The Veteran stated that headaches, muscle aches, and sleep problems began at that time, and complained of tingling in his feet that began in the late 1980s. The examiner found no evidence of anemia or edema, noting that the Veteran stated he had not experienced edema for years. The examiner noted that the Veteran had a diagnosis of obstructive sleep apnea and reported being fatigued in the mornings despite treatment, although he reported that his insomnia had decreased. The examiner noted the Veteran's complaints of headaches and his diagnoses of hypogonadism and hypothyroidism. Physical examination revealed no cardiovascular abnormalities. Mild decreased vibratory sensation was noted in his toes; otherwise, neurological examination was normal. The examiner diagnosed the Veteran with poorly controlled obstructive sleep apnea and headaches secondary to stress and depression. The examiner assigned the Veteran diagnoses of both chronic fatigue syndrome and fibromyalgia, noting the reported acute onset of symptoms following a low-grade fever and flu-like symptoms in 2002. However, the examiner found the Veteran to have no peripheral neuropathy or cardiomyopathy. The examiner further opined that the Veteran's hypogonadism and hypothyroidism were both primary in nature and not related to service. The examiner opined that the only disorder related to the Veteran's time in service, including to his service in the Persian Gulf, was his degenerative disc disease of the lumbar spine (which is already service-connected). In so finding, the examiner noted that no symptoms of any other diagnosed disorder manifested until ten years after the Veteran left service and that all symptoms he complained of were attributable to known diagnostic entities. In an addendum, the examiner clarified that the Veteran's chronic fatigue syndrome and fibromyalgia were attributable, not to service, but to a viral infection that the Veteran experienced in 2002, which the Veteran pinpointed as the date of onset of all his symptomatology. The examiner specifically stated that the disorders were not linked to the Veteran's time in service. A September 2014 VA examination and January 2015 private medical record by Dr. L.B. have also since been associated with the claims file and addresses the claimed disorders. The Veteran has also submitted letters from his private treating physicians addressing his multiple complaints. To that end, the Board notes that, in a letter submitted in March 2005, the Veteran's private physician opined that there was a "very high likelihood that [the Veteran] has Gulf War Syndrome." However, no explanation was offered for this opinion. The Veteran's private cardiologist similarly submitted a letter in March 2005, in which he noted the Veteran's complaints of cardiomegaly, fatigue, dyspnea, and chest pressure. The cardiologist assigned the Veteran a diagnosis of hypertensive heart disease. In a letter dated in May 2005, a second physician noted that the Veteran reported his onset of symptoms in 2002, when he began to notice increased fatigue. The physician noted the Veteran's diagnoses of hypothyroidism, hypogonadism, and sleep apnea and diagnosed the Veteran with sleep apnea, mild renal insufficiency, hypogonadism, hypothyroidism, a thickened left ventricle, and "multi-organ system abnormality." No etiological opinions were offered in the letter. In a March 2006 letter, the Veteran's family practitioner identified the Veteran's multiple diagnoses and stated that the Veteran had reported that his medical problems began following his deployment to the Persian Gulf. However, no etiological opinion was offered in the letter. The family practitioner submitted a similar letter in February 2008 indicating that the Veteran experiences "possible Gulf War Syndrome." Similarly, an internist submitted a letter dated in July 2007 in which he assigned the Veteran a diagnosis of dilated cardiomyopathy and recommended a second opinion to ascertain etiology. Similarly, in a letter submitted in April 2008, a private pulmonologist opined that the etiology of the Veteran's "underlying disease process remains elusive." In addition, a private physician submitted a letter in December 2013. In the letter, the physician (who did not examine the Veteran) pointed out multiple abnormal nerve conduction studies, as well as abnormal blood and cardiac findings, and concluded that the Veteran's "conditions are caused by his military service and constitute manifestations of Gulf War Illness." In so finding, the physician relied on both "medical literature and common sense" in opining that "toxic exposures, stress hormones, and other unknowns will affect the immune system" and cause symptoms such as those experienced by the Veteran. The Veteran testified before a Veterans Law Judge and has submitted multiple written statements concerning his claims. At his July 2007 and May 2011 hearings, the Veteran contended that he has experienced symptoms of the claimed disorders, which he attributes to his time in the Southwest Asia theater of operations. He has repeated these contentions in multiple written statements. In view of the foregoing, the case is REMANDED for the following actions: 1. The Veteran must be sent a letter requesting that he provide sufficient information and, if necessary, authorization to enable VA to obtain any additional pertinent evidence not currently of record. The agency of original jurisdiction (AOJ) must explain the type of evidence VA will attempt to obtain as well as the type of evidence that is the Veteran's ultimate responsibility to submit. 2. As to the claim for arthritis, other than rheumatoid, of multiple joints, after all records and/or responses received from have been associated with the claims file, obtain a joints VA examination by a VA examiner. The entire claims file, to include a complete copy of the REMAND and pertinent records from the paperless, electronic Virtual VA/VBMS file must be made available to the individual designated to examine the Veteran, and the examination report should include discussion of the Veteran's documented history and assertions. All indicated tests and studies should be accomplished (with all results made available to the requesting examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The VA medical opinion provider should offer an opinion on the following: (i) Does the Veteran currently have arthritis, other than rheumatoid? If so, please note the diagnosed joints with such disorder. (ii) Is it at least as likely as not that any such arthritis was incurred in or was caused by the Veteran's active service? The examiner should consider the Veteran's reports of chronic and intermittent ankle pain since that time. (December 2009 Board hearing). The reviewer's attention is called to the Veteran's reported medical history, including in particular his contention that he first experienced right knee pain in service and has continued to experience pain since that time. The examiner must also consider the March 2011 opinion from his private treatment provider in the context of any negative opinion. (iii) Is it at least as likely as not that any currently diagnosed arthritis (if found) developed, to a compensable degree, within one year following his discharge from service (i.e., May 1991)? The examiner should indicate whether the type and degree of any arthritis findings shown on examination are consistent with arthritis having developed a year following service. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. For each joint found to have arthritis, other than rheumatoid, a fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The VA medical opinion provider should discuss the particulars of this Veteran's medical history and relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. 3. The claims file and a full copy of this REMAND must be made available to an appropriate physician to render a medical opinion on the remaining claims of (i) obstructive sleep apnea, (ii) sleep disorder other than obstructive sleep apnea, (iii) muscle pain, (iv) anemia, (v) headaches, (vi) edema of the lower extremities, (vii) cardiovascular disability, (viii) hypogonadism, (ix) hypothyroidism, (x) peripheral neuropathy Claims, (xi) gastrointestinal disorder - for the periods both before and after his lap band surgery, (xii) pulmonary disorder, and (xiii) skin disorder. The physician shall note in the examination report that the claims folder and the REMAND have been reviewed. The examiner(s) must review the entirety of the claims file (in particular, the Veteran's service medical records, the reports of the September 2005, October 2009, April 2010, and September 2014 VA examinations, as well as the multiple letters from private physicians concerning the etiology of the Veteran's complaints - such records are briefly summarized in the REMAND portion above, though the VA medical opinion provider should perform his/her own review of the evidence). The need for an additional examination of the Veteran is left to the discretion of the physician selected to write the addendum opinion. (If any opinion/examination is deemed necessary by a specialist, such as a cardiologist, orthopedist, neurologist, etc., such an examination should be scheduled and the specialist should be asked to address the same questions.) (a) The examiner should determine if there is objective evidence of any pertinent signs and symptoms of any of the above noted complaints: (i) obstructive sleep apnea, (ii) sleep disorder other than obstructive sleep apnea, (iii) muscle pain, (iv) anemia, (v) headaches, (vi) edema of the lower extremities, (vii) cardiovascular disability, (viii) hypogonadism, (ix) hypothyroidism, (x) peripheral neuropathy, (xi) gastrointestinal disorder - for both the period before and after his lap band surgery, (xii) pulmonary disorder, and (xiii) skin disorder. (b) The examiner should opine as to whether or not such signs and symptoms can be attributed to known clinical diagnoses, to include medications, (i) a functional gastrointestinal disorder (excluding structural gastrointestinal diseases), or his now service-connected (ii) chronic fatigue syndrome and/or (iii) fibromyalgia. Please be clear as to whether a diagnosis can be partially or fully explained in terms of etiology. (c) If any signs and symptoms can be verified and can be attributed to a known clinical diagnosis [other than to functional gastrointestinal disorder (excluding structural gastrointestinal diseases), or his now service-connected chronic fatigue syndrome and fibromyalgia] the VA medical opinion provider should offer an opinion for EACH such known clinical diagnosis as to whether it is at least as likely as not (50% probability or higher) related to the Veteran's military service (January 1968 to October 1969 and November 1990 to May 1991). The VA medical opinion provider should also provide an opinion as to whether each diagnosed disability has a conclusive pathophysiology or etiology. Please be clear as to whether a diagnosis can be partially or fully explained in terms of etiology. (d) If the VA medical opinion provider finds that there is no evidence of any claimed signs and symptoms, he/she should so state. (e) If the VA medical opinion provider finds that there is objective evidence of claimed signs and symptoms which cannot by history, physical examination, and laboratory tests be attributed to a known diagnosis, the examiner should so state. (f) The VA medical opinion provider must provide a comprehensive discussion as to whether each of the Veteran's complained-of problems, whether attributed to a known diagnosis or not, constitute a "medically unexplained chronic multi-symptom illness." (Such an illness is one that is without conclusive pathophysiology or etiology, which is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. The service-connected chronic fatigue and fibromyalgia are included in that category, as is a functional gastrointestinal disorder (excluding structural gastrointestinal diseases).) The examiner(s) should be aware that illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered "medically unexplained." 38 C.F.R. § 3.317.) (g) The VA medical opinion provider must also opine as to whether there is affirmative evidence that any illness is due to a supervening event. A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The VA medical opinion provider should discuss the particulars of this Veteran's medical history and relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. A full explanation should include a discussion of the opinions of the Veteran's private physicians in March 2005, May 2005, March 2006, February 2008, December 2013, and January 2015 (briefly summarized in the Remand body above, though the VA medical opinion provider should perform his/her own review). 4. When the development requested has been completed, the case should again be reviewed by the AOJ on the basis of the additional evidence. The AOJ should perform any additional development it deems warranted. If a benefit sought is not granted, the AOJ should furnish the Veteran a supplemental statement of the case and a reasonable opportunity to respond before returning the record to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs