Citation Nr: 1212417 Decision Date: 04/04/12 Archive Date: 04/11/12 DOCKET NO. 09-39 722 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for diabetes mellitus claimed as secondary to service-connected sarcoidosis. 2. Entitlement to service connection for insomnia claimed as secondary to service-connected sarcoidosis. 3. Entitlement to service connection for restless leg syndrome claimed as secondary to service-connected sarcoidosis. 4. Entitlement to service connection for anemia claimed as secondary to service-connected sarcoidosis. 5. Entitlement to service connection for a chronic acquired psychiatric disorder to include posttraumatic stress disorder (PTSD) as secondary to service-connected. 6. Entitlement to service connection for chronic fatigue syndrome claimed as secondary to service-connected sarcoidosis. 7. Entitlement to service connection for a disorder manifested by cramping of the upper and lower extremities claimed as secondary to service-connected sarcoidosis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD G. A. Wasik, Counsel INTRODUCTION The Veteran had active duty service from September 1981 to September 1988 and from August 1990 to July 1991. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran testified at a Board hearing at the RO in September 2010. The issues on appeal were previously before the Board in April 2011 when they were remanded for additional evidentiary development. In addition to the issues on the title page, the Board also remanded claims of entitlement to an earlier effective date for the grant of service connection for sarcoidosis, entitlement to service connection for irritable bowel syndrome, entitlement to service connection for headaches, entitlement to service connection for a sinus disorder and entitlement to service connection for a kidney disorder for additional evidentiary development. In October 2011, the RO granted an earlier effective date for the grant of service connection for sarcoidosis and also granted service connection for headaches, nephropathy (claimed as kidney condition), irritable bowel syndrome and for a sinus condition. These issues are no longer on appeal. The issues of entitlement to service connection for a chronic acquired psychiatric disorder to include PTSD, for insomnia and for a disorder manifested by cramping of the upper and lower extremities are addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The preponderance of the competent evidence of record demonstrates that the Veteran does not have diabetes mellitus at any time during the appeal period. 2. The preponderance of the competent evidence of record demonstrates that the Veteran does not have restless leg syndrome at any time during the appeal period. 3. The preponderance of the competent evidence of record demonstrates that the Veteran does not have anemia at any time during the appeal period. 4. The preponderance of the competent evidence of record demonstrates that the Veteran does not have chronic fatigue syndrome at any time during the appeal period. CONCLUSIONS OF LAW 1. Diabetes mellitus was not incurred in or aggravated by the Veteran's active duty, may not be presumed to have been incurred in service, nor is it secondary to a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2011). 2. Restless leg syndrome was not incurred in or aggravated by the Veteran's active duty service nor is it secondary to a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2011). 3. Anemia was not incurred in or aggravated by the Veteran's active duty service nor is it secondary to a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2011). 4. Chronic fatigue syndrome was not incurred in or aggravated by the Veteran's active duty service nor is it secondary to a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations set forth certain notice and assistance provisions. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.156(a), 3.159 and 3.326(a). After reviewing the claims folder, the Board finds that the appellant has been notified of the applicable laws and regulations which set forth the criteria for entitlement to VA benefits. Specifically, the discussion in a July 2008 VCAA letter has informed the appellant of the information and evidence necessary to warrant entitlement to service connection for the issues adjudicated by this decision. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). The requirements of 38 C.F.R. § 3.159(b)(1) have been met. The Board finds that all notices required by VCAA and implementing regulations were furnished to the appellant and that no useful purpose would be served by delaying appellate review to send out additional VCAA notice letters. In this case, the RO's decision came after notification of the Veteran's rights under the VCAA. The VCAA notice was timely. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Under these circumstances, the Board finds that all notification and development action needed to render a fair decision on the claim decided herein has been accomplished and that adjudication of the claim, without directing or accomplishing any additional notification and/or development action, poses no risk of prejudice to the appellant. See, e.g., Bernard v. Brown, 4 Vet. App. 384, 394 (1993). On March 3, 2006, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. See Dingess/Hartman, supra. In the present appeal, the Veteran was provided with notice of what types of information and evidence were needed to substantiate his claim as well as notice of the types of evidence necessary to establish an effective date and rating for the issues on appeal in the July 2008 VCAA letter. This information was again provided to the Veteran in a January 2010 letter. All the VCAA requires is that the duty to notify is satisfied, and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (harmless error). Furthermore, the Board finds that there has been compliance with the assistance provisions set forth in the new law and regulations. The record demonstrates that all VA, Social Security and private records have been obtained to the extent possible. The Veteran has been afforded appropriate VA examinations. The most recent VA examinations which were conducted in 2011 were based on a review of all the evidence in the claims file as well as the Veteran's statements. Opinions were provided as to the etiology of the various disabilities on appeal. The opinions were supported by adequate rationale. The evidence is sufficient for the Board to accurately adjudicate the claims. The requirements of 38 C.F.R. § 3.159(c)(4) have been met. No additional pertinent evidence has been identified by the appellant as relevant to the issues adjudicated by this decision. Under the circumstances of this particular case, no further action is necessary to assist the appellant. Competency and credibility The appellant can attest to factual matters of which he had first-hand knowledge,. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, the appellant as a lay person has not been shown to be capable of making medical conclusions; thus, his statements regarding causation are not competent. Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). Competent medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements or opinions. See Duenas v. Principi, 18 Vet. App. 512, 520 (2004). A layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997); see also Bostain v. West, 11 Vet. App. 124, 127 (1998). While the appellant is competent to report what comes to him through his senses, he does not have medical expertise. See Layno v. Brown, 6 Vet. App. 465 (1994). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that lay evidence is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself. The Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). This would include weighing the absence of contemporary medical evidence against lay statements. In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court indicated that varicose veins was a condition involving "veins that are unnaturally distended or abnormally swollen and tortuous." Such symptomatology, the Court concluded, was observable and identifiable by lay people. Because varicose veins "may be diagnosed by their unique and readily identifiable features, the presence of varicose veins was not a determination 'medical in nature' and was capable of lay observation." The Court found the veteran's lay testimony regarding varicose vein symptomatology in service represented competent evidence. In Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the Federal Circuit determined that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. The relevance of lay evidence is not limited to the third situation, but extends to the first two as well. Whether lay evidence is competent and sufficient in a particular case is a fact issue. Although the appellant is competent in certain situations to provide a diagnosis of a simple condition such as varicose veins, the appellant is not competent to provide evidence as to more complex medical questions and is not competent to provide opinions as to the etiology of any the disabilities on appeal with respect to whether they were secondary to the service-connected sarcoidosis as claimed by the Veteran. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). Service connection criteria Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Where there is a chronic disease shown as such in service or within the presumptive period under § 3.307 so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however, remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). This rule does not mean that any manifestations in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time as distinguished from merely isolated findings or a diagnosis including the word "chronic". When the disease entity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The Court has held that, in order to prevail on the issue of service connection, there must be medical evidence of a (1) current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v West, 12 Vet. App. 341, 346 (1999). Under section 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448; see also 38 C.F.R. § 3.310(b). In the absence of evidence of current disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The term "disability" means an impairment of earning capacity resulting from a disease or injury. Allen v. Brown, 7 Vet. App. 439, 448 (1995). "Injury" is defined as "damage inflicted on the body by an external force." Terry v. Principi, 340 F.3d 1378, 1384 (Fed. Cir. 2003) (citing Dorland's Illustrated Medical Dictionary 901 (29th ed. 2000)). "Disease" means "any deviation from or interruption of the normal structure or function of a part, organ, or system of the body." Id. at 1384 (citing Dorland's at 511). The Board notes that in McClain v. Nicholson, 21 Vet. App. 319, 321-323 (2007), the Court stated that the requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim . . . even though the disability resolves prior to the Secretary's adjudication of the claim." (Emphasis added).] Analysis Direct service connection Initially, the Board notes that the Veteran is claiming all the disabilities addressed in this decision were secondary to his service-connected sarcoidosis. The Veteran has not alleged that any of the disabilities on appeal were incurred in or aggravated by his active duty service, and the evidence of record does not support a finding that any of the issues on appeal were incurred in or aggravated by active duty service. Service connection is not warranted on a direct basis for any of the issues adjudicated by this decision. Entitlement to service connection for diabetes mellitus claimed as secondary to service-connected sarcoidosis. The Board finds that service connection is not warranted for diabetes mellitus as the preponderance of the competent evidence of record demonstrates that the Veteran does not have the disability and did not have it at any time during the appeal period. There is some medical evidence indicating that the Veteran has diabetes. An April 2008 VA clinical record includes an assessment of diabetes which was diet controlled. Additionally, there are VA clinical records which include assessments of borderline diabetes. In March 2009, the Veteran informed a clinician that he was diabetic. There is also some medical evidence which links claimed diabetes mellitus to the Veteran's service-connected sarcoidosis. In September 2010, a private physician, C.C., M.D., wrote that the Veteran was being treated for diabetes which was related to his lung transplant and immunosuppressive medications. Outweighing the probative value of the evidence in support of the claim is the evidence which indicates that the Veteran does not have diabetes mellitus at any time during the appeal period. A VA diabetes mellitus examination was conducted in April 2009. It was noted the Veteran was diagnosed with sarcoidosis in 1989 and had been taking prednisone as treatment. The examiner reviewed the medical evidence in the claims file including glucose readings. The examiner found that there was no evidence in the claims file to support a diagnosis of diabetes. This was based on fasting glucose criteria greater than 125 or any post-prandial value greater than 200. The Veteran's glucose values were observed to be between 64 and 158. The examiner noted that, whether the values were fasting or non-fasting, they did not meet the criteria for diabetes. At the time of an April 2011 VA examination, it was noted that the Veteran had a conflicting diagnosis of diabetes. VA records were referenced as including assessments of borderline diabetes and hyperglycemia and it was noted that a civilian physician diagnosed diabetes mellitus. The examiner found that there was no evidence in the records to support a fasting glucose greater than 125 or any postprandial value greater than 200. The Veteran tried to maintain a restricted diet. He was not receiving any treatment for diabetes. The pertinent diagnosis was that there was no definitive evidence to show that the Veteran is diabetic. Current laboratory results showed that the Veteran's readings were normal for A1C's and a nonfasting value of 175 would still not meet the criteria for diagnosing diabetes. The Board finds the probative value of the reports of the VA examinations outweigh the medical evidence which supports the Veteran's claim. The reports of the VA examinations specifically included determinations that there was no clinical evidence of the presence of diabetes mellitus. The private physician who affirmatively diagnosed the presence of diabetes mellitus did not include any clinical records which document the presence of diabetes mellitus symptomatology. Clinical records from the physician's employer (the University of Pittsburgh Medical Center) do not contain evidence of the presence of diabetes mellitus. The failure of the private medical evidence to include any pertinent clinical findings to support the diagnosis negates the probative value of the private physician's opinion. The Court has held on a number of occasions that a medical opinion premised upon an unsubstantiated account is of no probative value. See, e.g., Reonal v. Brown, 5 Vet. App. 458, 460 (1993); Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996); Swann v. Brown, 5 Vet. App. 229, 233 (1993). A bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999). Also, a medical opinion is inadequate when unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). Finally, a medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Outweighing the probative value of the private medical opinion are the two reports of the VA examinations which support their findings via citations to the lack of pertinent clinical findings pertaining to diabetes mellitus in the claims file. The opinions were supported by adequate rationale. The private health care provider merely made a general statement that the Veteran was being treated for diabetes mellitus but did not provide any rationale for why this determination was made. The citations in the clinical records to the presence of borderline diabetes mellitus does not outweigh the probative value of the reports of the two VA examinations. There is no clinical evidence of diabetes mellitus included with any of these records which include an assessment of borderline diabetes mellitus. No citations to the presence of pertinent glucose testing, etc. were made. The failure of these records to include any clinical evidence supporting a diagnosis of diabetes mellitus, negates the probative value of this evidence. Some of the clinical records include the annotation that the Veteran had diabetes mellitus, apparently based on the Veteran's self-reported medical history which is not backed up by any clinical records. This does not constitute competent evidence of the current existence of diabetes mellitus. A bare transcription of lay history, unenhanced by additional comment by the transcriber, is not competent medical evidence merely because the transcriber is a health care professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). The only other evidence which indicates that the Veteran experience diabetes mellitus at any time during the appeal period which is etiologically linked to his sarcoidosis is the Veteran's own allegations. The Veteran testified before the undersigned in September 2010 that, once someone undergoes a lung transplant, they are very susceptible to diabetes mellitus. The Veteran indicated he came out of lung transplant surgery requiring insulin. The Veteran got himself off the insulin after the transplant. He also testified that the long term use of prednisone and other corticosteroids increases the probability of diabetes. When asked if he was still currently diagnosed and being treated for diabetes, the Veteran responded that it was correct that he was still on prednisone. Current treatment for the diabetes was restricted diet and exercise. He reported that VA personnel found that the diabetes was obviously associated with the lung transplant. As set out above, the Board finds the Veteran is a lay person. His opinion as to the existence and etiology of the diabetes mellitus is without probative value as this is a complex medical determination. The Board finds the Veteran is competent to report that a health care provider had found the Veteran had diabetes mellitus which was associated with the lung transplant. This allegation is accorded some probative weight as there is no indication that the Veteran is being less than truthful when advancing the claim. The probative value of this statement, however, is completely outweighed by the lack of any clinical evidence documenting the presence of diabetes mellitus at any time during the appeal period. The probative value of the statement is also outweighed by the findings included in the two reports of VA examinations which both affirmatively found no evidence of diabetes mellitus. These reports, as set out above, are afforded significant probative weight. This probative weight is greater than that assigned to the Veteran's allegation of being informed by a VA clinician that he had diabetes mellitus due to his sarcoidosis. Based on the above, the Board finds the preponderance of the competent probative evidence of record demonstrates that the Veteran does not have diabetes mellitus at any time during the appeal period. Without the current existence of diabetes mellitus, service connection cannot be granted. Should diabetes subsequently be clinically established, appellant can reopen the claim. Entitlement to service connection for restless leg syndrome claimed as secondary to service-connected sarcoidosis. The Board finds that service connection is not warranted for restless leg syndrome as the competent evidence of record demonstrates that the Veteran does not experience the disorder at any time during the appeal period. The only evidence of record which supports the Veteran's allegation of having restless leg syndrome is the Veteran's own allegations and testimony. The Veteran testified before the undersigned in September 2010 that he experienced cramping which was medication induced. It was better at the time of the hearing but he was still experienced Charlie horse type cramping. The symptoms started after the lung transplant. He still experienced periodic tremors and shaking. The Board finds the Veteran is competent to report on leg cramping symptomatology he experiences. He is not competent, however, to link this symptomatology to a diagnosis of restless leg syndrome nor is he competent to link the symptomatology to a service-connected disability. The Board finds this is a complex medical determination for which the Veteran is not qualified to provide an opinion. There is competent evidence of record indicating that the Veteran does not have restless leg syndrome at any time during the appeal period. On VA examination in April 2011, the Veteran reported he was diagnosed as having restless leg syndrome. The examiner noted it was diagnosed by clinical symptoms without any diagnostic workup. The diagnosis was made in 2007 after a lung transplant. The Veteran reported that, once he was off immunosuppressive medications from the lung transplant, the symptoms decreased. He had the condition daily, lasting four or five hours. The pertinent diagnosis was restless leg syndrome not found. The examiner noted that, although the Veteran did have shaking of the extremities as he described, he did not meet the clinical criteria for restless leg. The examiner noted the prior diagnosis was given without any medical work up. The examiner opined it is less likely that the condition was present and that it was secondary to sarcoidosis. The Board finds the report of the April 2011 VA examination should be accorded significant probative value. The examiner had access to and reviewed the claims file. The examiner provided a diagnosis of a lack of restless leg syndrome and supported the diagnosis with the rationale that the Veteran did not meet the clinical criteria for a diagnosis of restless leg syndrome. This diagnosis was made based on the Veteran's self-reported symptomatology. The Board finds the probative value of the report of the April 2011 VA examination outweighs the Veteran's allegations of having restless leg syndrome. The fact that the clinical records associated with the claims file are devoid of complaints of, diagnosis of or treatment for restless leg syndrome also supports the Board's determination that the Veteran did not have restless leg syndrome at any time during the appeal period. Without competent evidence of the presence of restless leg syndrome at any time during the appeal period, service connection cannot be granted for restless leg syndrome. Entitlement to service connection for anemia claimed as secondary to service-connected sarcoidosis. The Board finds that service connection is not warranted for anemia as secondary to the service-connected sarcoidosis as there is no competent evidence of record of the existence of anemia at any time during the appeal period. The clinical records are silent as to complaints of, diagnosis of or treatment for anemia. The only evidence of record which indicates that the Veteran has anemia at any time during the appeal period is the Veteran's submission of the claim which instigated the current appeal. To the extent that this claim is read as indicating that the Veteran had anemia at the time the claim was filed or at any time during the appeal period, the Board finds no probative weight should attack to the allegation. As set out above, the Veteran is a lay person. The Board finds the determination as to whether the Veteran has anemia is a complex medical determination which requires clinical testing. The Veteran is not competent to provide an opinion as to the existence of anemia. There is competent evidence of record which demonstrates that the Veteran did not have anemia at any time during the appeal period. At the time of an April 2011 VA examination, the Veteran reported he was informed he had sarcoid in his bone marrow, which the examiner noted does result in primarily low platelets at times. The pertinent diagnosis, however, was anemia not found. The examiner determined that there was no current evidence of anemia. The Board finds this examination report should be accorded probative weight. The examiner reviewed the evidence in the claims file and determined that the clinical records do not support a finding that the Veteran had anemia. The determination was supported by citations to the clinical records (and the lack of pertinent clinical findings.) Based on the above, the Board finds that the preponderance of the competent medical evidence of record demonstrates that the Veteran does not have anemia at any time during the appeal period. Without a competent diagnosis at any time during the appeal period, service connection cannot be granted for anemia. Entitlement to service connection for chronic fatigue syndrome claimed as secondary to service-connected sarcoidosis. The Board finds that service connection is not warranted for chronic fatigue syndrome as secondary to the service-connected sarcoidosis as the preponderance of the competent evidence of record demonstrates that the Veteran does not have chronic fatigue syndrome at any time during the appeal period. There is a reference in the clinical records to the presence of chronic fatigue syndrome. A July 1997 private clinical record included chronic fatigue syndrome under the heading of Past Medical History. The Board finds this record does not constitute competent evidence of the existence of chronic fatigue syndrome. It is not apparent upon what basis the annotation was made other than via a self-reported history by the Veteran. The Court has held that a bare transcription of lay history, unenhanced by additional comment by the transcriber, is not competent medical evidence merely because the transcriber is a health care professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). Significantly, the rest of the medical evidence of record does not support a finding that the Veteran had chronic fatigue syndrome at any time during the appeal period. There were no actual diagnoses of chronic fatigue syndrome in the claims file. The Board finds that there is competent evidence of record which demonstrates that the Veteran did not have chronic fatigue syndrome at any time during the appeal period. At the time of an April 2011 VA examination, the Veteran reported he had chronic fatigue syndrome secondary to sarcoidosis. He reported he had not officially been diagnosed with the disorder. He reported he began having symptoms of fatigue in 1988 when the sarcoidosis was first diagnosed. He did not have acute onset. He did not have low grade fever. His lymph nodes were occasionally palpable or tender. He denied generalized muscle aches. He did not report migratory joint pains. The pertinent diagnosis was that the Veteran did not meet the criteria for chronic fatigue syndrome. The examiner opined that the Veteran did have fatigue which was, as likely as not, secondary to the sarcoidosis and its treatment. The Board finds this examination report should be afforded significant probative weight. The examiner reviewed the evidence in the claims file, interviewed the Veteran and conducted a physical examination. The examiner determined that the Veteran did not meet the diagnostic criteria for chronic fatigue syndrome based on the symptoms reported by the Veteran. The Board finds the rationale provided by the examiner is adequate. The Veteran's own response at the time of the examination that he had never been diagnosed as having chronic fatigue syndrome supports the Board's determination. The only other evidence which indicates that the Veteran experiences chronic fatigue syndrome is the Veteran's own allegations and testimony. The Veteran testified before the undersigned in September 2010 that he was diagnosed as having chronic fatigue syndrome all the way back to 1988. One of the main presentation features of sarcoid is chronic fatigue. He was not being treated for the condition. To the extent that the Veteran has alleged he was diagnosed as having chronic fatigue syndrome back in 1988, the Board finds some probative weight should attach as the Board finds no reason to question the Veteran's veracity in this regard. Significantly, other than the Veteran's allegation, there is no medical evidence which supports the Veteran's allegation. The Board finds the probative value of the Veteran's report of having been diagnosed with chronic fatigue syndrome in 1988 is outweighed by the probative value of the lack of pertinent clinical records from that time period forward and is also probatively outweighed by the conclusions included in the report of the April 2011 VA examination. As set out above, the Board finds significant probative weight is to be attached this examination report. The Board finds the preponderance of the competent evidence of record weighs against a finding that the Veteran had chronic fatigue syndrome at any time during the appeal period. Without evidence of a current diagnosis at any time during the appeal period, service connection cannot be granted for chronic fatigue syndrome. ORDER Entitlement to service connection for diabetes mellitus is not warranted. The appeal is denied. Entitlement to service connection for restless leg syndrome is not warranted. The appeal is denied.. Entitlement to service connection for anemia is not warranted. The appeal is denied. Entitlement to service connection for chronic fatigue syndrome is not warranted. The appeal is denied. REMAND The Veteran has claimed entitlement to service connection for an acquired psychiatric disorder to include PTSD as secondary to the service-connected sarcoidosis. To support the Veteran's claim, VA arranged to have a psychiatric examination which was conducted in April 2011. The examiner determined that the Veteran had depressive disorder not otherwise specified which was not linked to the service-connected sarcoidosis. The examiner noted the Veteran had reported that the onset of his depression occurred in 2001, coinciding with the breakup of the Veteran's marriage. The examiner opined that the Veteran's medical condition may have exacerbated the existing stressors, but it was not clear that it was the primary precipitant of the mood disorder. It was noted that the Veteran reported he began seeing a private health care professional in 2001 but the examiner found these records were not contained in the claims file. Significantly, the Board's review of the claims file demonstrates that several private medical records dated from 2001 to 2003 pertain to treatment for mental health complaints. The Court has held that an examination that does not take into account the records of prior medical treatment is neither thorough nor fully informed. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). The Court has also held that a medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). As it appears that at least part of the rationale for the determination that the depressive disorder was not linked to active duty was the lack of records from the private mental health care providers beginning in 2001, the Board finds a remand is required to allow the examiner to review the pertinent evidence and see if it changes his etiology opinion. The Veteran has claimed entitlement to insomnia as secondary to his service-connected sarcoidosis. The only time the Veteran was afforded a VA examination for compensation and pension purposes which pertained to his insomnia claim was in April 2011. Under the heading of chronic fatigue syndrome, the Veteran reported he could go several days without sleep. He was unable to report on what his average level of sleep was. He did best with ten to eleven hours of sleep per night. He usually took an Ambien to help him sleep. The pertinent diagnosis was insomnia not found at this time. The Board finds this opinion is deficient. The examiner did not provide a rationale for why it was determined that the Veteran did not have insomnia at the time of the examination especially in light of the fact that the Veteran alleged problems with his sleep. Furthermore, it is not apparent if the examiner provided an opinion as to whether the Veteran had insomnia at any time during the appeal period. At the time of the September 2010 travel Board hearing conducted by the undersigned, the Veteran testified that a private health care provider had opined that the Veteran had insomnia which was due to his sarcoidosis. A statement to this effect has not been associated with the claims file. The Veteran should be informed that he should obtain, in writing, a statement from the physician which links insomnia to the sarcoidosis which is supported by an adequate rationale, if possible. The Veteran has claimed entitlement to service connection for disorders manifested by cramping of the upper and lower extremities. A report of an April 2011 VA examination included the pertinent diagnosis of muscle cramping of the upper and lower extremities by Veteran's report only. The examiner found the Veteran did not have any definitive diagnosis for primary muscle cramping without joint involvement. The examiner then wrote that, without additional evidence, there is no sufficient evidence to diagnose a disorder manifested by muscle cramping. The Board finds this etiology opinion is deficient. The qualification of the opinion with regard to a lack of additional evidence negates the probative value of the opinion. The examiner did not set out what additional evidence would be sufficient to diagnose the pertinent disorder. It is not apparent to the Board if this additional evidence would consist of clinical records (or the lack thereof) or could be provided by additional medical testing which was not conducted at the time of the examination. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that he obtain, to the extent possible, a written statement from the health care provider he referenced at the time of the September 2010 hearing, which links insomnia to the service-connected sarcoidosis. 2. Return the claims file to the examiner who conducted the April 2011 VA PTSD examination and request that he prepare an addendum to the examination report which addresses the following: After review of the private health care records dated from 2001 to 2003 which are marked in the claims file, please indicate whether this evidence changes the prior opinion concerning the nature and etiology of the mental disorder which was diagnosed at the time of the April 2011 VA examination. The examiner should reconcile the opinion with all other clinical evidence of record. A complete rationale should be provided for any opinion expressed. The rationale must be supported, to the extent possible, by citations to the medical evidence in the claims file. If any opinion cannot be provided without resort to speculation, the examiner should so state and provide a rationale for why the opinion would require resort to speculation. If the examiner who conducted the April 2011 VA PTSD examination is not available, arrange to have the Veteran examined by a suitably qualified health care professional who should be tasked with answering the following inquiries: a.) Does the Veteran currently have an acquired psychiatric disorder now or at any time since service. b.) If the examiner diagnoses the presence of an acquired psychiatric disorder, is it at least as likely as not (a 50 percent or greater probability) that the acquired psychiatric disorder was inquired in or aggravated by the Veteran's active duty service? c.) If the examiner diagnoses the presence of an acquired psychiatric disorder, is it at least as likely as not (a 50 percent or greater probability) that the acquired psychiatric disorder was secondary to a service-connected disability to include sarcoidosis or aggravated by a service-connected disability? If the examiner determines that another examination of the Veteran is required, this should be scheduled. The claims file must be made available prior to completion of the evaluation. The examiner must annotate the examination report to indicate review of pertinent evidence in the claims file. The examiner must be informed that the term "at least as likely as not" does not mean merely 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 causation as it is to find against it. The examiner should reconcile the opinion with all other clinical evidence of record. A complete rationale should be provided for any opinion expressed. The rationale must be supported, to the extent possible, by citations to the medical evidence in the claims file. If any opinion cannot be provided without resort to speculation, the examiner should so state and provide a rationale for why the opinion would require resort to speculation. 3. Return the claims file to the examiner who conducted the April 2011 VA insomnia examination and request that he prepare an addendum to the examination report which addresses the following: a.) Is it at least as likely as not (a 50 percent probability or better) that the Veteran has insomnia at any time since June 2008? b.) If it is determined that the Veteran has had insomnia at any time since June 2008, is it at least as likely as not (a 50 percent probability or better) that the insomnia was incurred in or aggravated by active duty? c.) If it is determined that the Veteran has had insomnia at any time since service, is it at least as likely as not (a 50 percent probability or better) that the insomnia was secondary to a service-connected disability to include sarcoidosis? d.) If it is determined that the Veteran does not have insomnia at any time since service, please provide a rationale which supports this opinion. The examiner must be informed that the term "at least as likely as not" does not mean merely 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 causation as it is to find against it. If the examiner who conducted the April 2011 VA insomnia examination is not available, arrange to have the Veteran examined by a suitably qualified health care professional who should be tasked with answering the inquiries set forth above. If the examiner determines that another examination of the Veteran is required, this should be scheduled. The claims file must be made available prior to completion of the evaluation. The examiner must annotate the examination report to indicate review of pertinent evidence in the claims file. The examiner should reconcile the opinion with all other clinical evidence of record. A complete rationale should be provided for any opinion expressed. The rationale must be supported, to the extent possible, by citations to the medical evidence in the claims file. If any opinion cannot be provided without resort to speculation, the examiner should so state and provide a rationale for why the opinion would require resort to speculation. 4. Contact the examiner who conducted the April 2011 VA examination for cramping of the upper and lower extremities and request that he prepare an addendum to the examination report which addresses the following: The report of the April 2011 VA examination indicates the examiner was unable to diagnose a disorder manifested by cramping in the upper and lower extremities "without additional evidence." Please identify what additional evidence would be required in order to make this determination. If the examiner who conducted the April 2011 VA examination for cramping of the upper and lower extremities is not available, arrange to have the Veteran examined by a suitably qualified health care professional who should be tasked with answering the following inquiries: a.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran has a disorder manifested by cramping of the upper and/or lower extremities at any time since service? b.) If the examiner determines that the Veteran had a disorder manifested by cramping of the upper and/or lower extremities at any time since service, it at least as likely as not (a 50 percent or greater probability) that the cramping of the upper and/or lower extremities was incurred in or aggravated by active duty? c.) If the examiner determines that the Veteran had a disorder manifested by cramping of the upper and/or lower extremities at any time since service, it at least as likely as not (a 50 percent or greater probability) that the cramping of the upper and/or lower extremities was secondary to a service-connected disability to include sarcoidosis? If the examiner determines that another examination of the Veteran is required, this should be scheduled. The claims file must be made available prior to completion of the evaluation. The examiner must annotate the examination report to indicate review of pertinent evidence in the claims file. The examiner must be informed that the term "at least as likely as not" does not mean merely 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 causation as it is to find against it. The examiner should reconcile the opinion with all other clinical evidence of record. A complete rationale should be provided for any opinion expressed. The rationale must be supported, to the extent possible, by citations to the medical evidence in the claims file. If any opinion cannot be provided without resort to speculation, the examiner should so state and provide a rationale for why the opinion would require resort to speculation. 5. Thereafter, please review the claims folder to ensure that the foregoing requested development has been completed. In particular, review the examination reports to ensure that they are responsive to and in compliance with the directives of this remand and, if not, implement corrective procedures. See Stegall v. West, 11 Vet. App. 268 (1998). 6. After completing any additional development deemed necessary, readjudicate the claims. If any benefit requested on appeal is not granted to the Veteran's satisfaction, the Veteran and his representative should be furnished a Supplemental Statement of the Case, which addresses all of the evidence obtained after the issuance of the last Supplemental Statement of the Case, and provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if in order. By this remand, the Board intimates no opinion as to any final outcome warranted. The appellant and his representative have 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 Supp. 2011). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs