Citation Nr: 1308083 Decision Date: 03/11/13 Archive Date: 03/20/13 DOCKET NO. 00-06 750 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a skin disorder, including as due to an undiagnosed illness. 2. Entitlement to service connection for fatigue, including as due to an undiagnosed illness. 3. Entitlement to service connection for weight loss, leg cramps, dizziness and joint pains, including as due to an undiagnosed illness. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. J. N. Driever INTRODUCTION The Veteran served on active duty from January 1958 to January 1960 and from January 1991 to June 1991, including in the Southwest Asia theater of operations from February 1991 to May 1991, the latter period while in the National Guard. He also served in the National Guard from January 1972 to January 1978, including on periods of active duty for training from May 1972 to September 1972 and in July 1973, June 1974, July 1975, June 1976 and July 1977. These claims come before the Board of Veterans' Appeals (Board) on appeal of March 1996 and August 1997 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. In December 2007, the Board affirmed the RO's denial of service connection for a skin disorder, including as due to an undiagnosed illness, and service connection for posttraumatic stress disorder (PTSD). In addition, the Board remanded to the RO claims for service connection for, in pertinent part, a cardiovascular disorder, including as due to an undiagnosed illness, and fatigue, weight loss, leg cramps, dizziness and joint pains, including as due to an undiagnosed illness. The Veteran then appealed the December 2007 decision to the U.S. Court of Appeals for Veterans Claims (Court). By memorandum decision dated in October 2009, the Court affirmed the Board's denial of service connection for PTSD and set aside the Board's denial of service connection for a skin disorder, including as due to an undiagnosed illness. It remanded that claim to the Board for additional proceedings consistent with the memorandum decision. Specifically, the Court instructed the Board to provide a more adequate statement of reasons and bases for its finding that the clinical diagnoses assigned the Veteran's skin symptoms remove any skin disability from the purview of the "undiagnosed illness" presumptive provisions. The Court cited the various skin assessments of record, including xerosis (March 1997), sebhorrea dermatosis and dermatitis (1998 to 1999), neurodermatitis (September 2005), a comedone with a suspected superimposed fungal infection (May 2006), and atopic dermatitis (August 2006), and based on dictionary definitions, found that these conditions represented abnormal dryness of the skin, a skin disease not characterized by inflammation that results in excessive secretions, inflammation of the skin, a type of eczema presumed to be a cutaneous response to prolonged scratching thought by some to be psychogenic, a possible fungal infection, and a genetic predisposition toward hypersensitivity reactions against common environmental antigens. The Court indicated that these conditions constituted a cacophony of inconsistent and contradictory assessments and were medical descriptions of symptoms, rather than diagnoses, much less clinical diagnoses, of a skin condition or a determination of a disease that is causing the symptoms. The Court further indicated that there were no laboratory findings of record to confirm or rule out any diagnostic impression, including any allergies or fungal infections, and that such findings are a fundamental requirement of a clinical diagnosis. In decisions dated in April 2010 and February 2011, the Board again remanded to the RO claims for service connection for a cardiovascular disorder, including as due to an undiagnosed illness, and fatigue, weight loss, leg cramps, dizziness and joint pains, including as due to an undiagnosed illness. In February 2011, in response to the Court's memorandum decision, the Board also remanded to the RO the claim for service connection for a skin disorder, including as due to an undiagnosed illness. This Board asked the RO to afford the Veteran a VA skin examination by a dermatologist (he previously underwent general medical examinations, not an examination by a dermatologist specifically focusing on the skin), during which the examiner was to identify all current skin disorders and discuss the etiology of each. By rating decision dated in August 2012, the RO granted the Veteran service connection for cardiovascular disorders, including chronic obstructive pulmonary disease (COPD) and hypertension. This claim is thus no longer before the Board for appellate review. With regard to the fatigue portion of the claim for service connection for fatigue, the RO completed all requested development. With regard to the other portions of the claim, it did not. The Board has thus recharacterized the claim as two, as shown on the title page of this decision, one ready for appellate review. Additional evidence has been added to the record since the last supplemental statement of the case in August 2012. To the extent that any of the evidence is relevant and has not been reviewed by the RO, a remand, pursuant to 38 C.F.R. § 20.1304 is not necessary, as the Veteran waived RO jurisdiction over any new evidence in September 2012. The Board has advanced these claims on its docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Board addresses the claim of entitlement to service connection for weight loss, leg cramps, dizziness and joint pains, including as due to an undiagnosed illness, in the REMAND section of this decision, below, and REMANDS that claim to the RO via the Appeals Management Center in Washington, D.C. FINDINGS OF FACT 1. The Veteran served in the Southwest Asia theater of operations (SWA) during the Persian Gulf War. 2. The Veteran's skin symptoms have been attributed to known diagnoses, none of which is related to his active service. 3. The Veteran's fatigue has been attributed to COPD, a known diagnosis, and is contemplated as a symptom of COPD, i.e., not a separate disability, in the rating assigned that service-connected disability. CONCLUSIONS OF LAW 1. A skin disorder was not incurred in or aggravated by active service and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1117, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2012). 2. Fatigue, other than that which is part of the Veteran's service-connected COPD, was not incurred in or aggravated by active service and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1117, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist Upon receipt and prior to consideration of most applications for VA benefits, VA is tasked with satisfying certain procedural requirements outlined in the Veterans Claims Assistance Act of 2000 (VCAA) and its implementing regulations. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The United States Court of Appeals for Veterans Claims (Court) has mandated that VA ensure strict compliance with the provisions of the VCAA. Quartuccio v. Principi, 16 Vet. App. 183 (2002). A. Notice The VCAA and its implementing regulations provide that VA is to notify a claimant and his representative, if any, of the information and medical or lay evidence not previously provided to the Secretary that is necessary to substantiate a claim. As part of the notice, VA is to specifically inform the claimant and his representative, if any, of which portion of the evidence the claimant is to provide and which portion of the evidence VA will attempt to obtain on the claimant's behalf. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012). These notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of disability; (3) a connection between service and disability; (4) degree of disability; and (5) effective date of disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006). Notice under the VCAA must be provided a claimant prior to an initial unfavorable decision by the agency of original jurisdiction. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 119-20 (2004). The RO in this case sent the Veteran letters dated in August 1995, November 1996, June 2003, May 2009, July 2009, October 2009, May 2010 and July 2012, which satisfy the content requirements of the VCAA. These letters informed the Veteran of the evidence needed to substantiate his claims, identified the type of evidence that would best do so, notified him of VA's duty to assist and indicated that it was reviewing his claims pursuant to this duty. They included all necessary information on disability ratings and effective dates. They identified the evidence the RO had requested and/or received in support of the Veteran's claims and the evidence it was responsible for securing. They noted that the RO would make reasonable efforts to assist the Veteran in obtaining all outstanding evidence provided he identified its source(s), but that it was the Veteran's responsibility to ensure VA's receipt of all pertinent evidence. In an Appellant's Post-Remand Brief dated in December 2012, the Veteran's representative acknowledged his understanding of the elements needed to establish service connection on both direct and presumptive bases. It is thus clear the Veteran, through his representative, has received all essential notice and had a meaningful opportunity to participate in the development of his claims. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). The RO sent some of the notice letters after initially deciding the Veteran's claims; they are thus untimely. The RO cured this timing defect later, however, by readjudicating the Veteran's claims in a supplemental statement of the case issued in August 2012. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007).. B. Assistance VA is also to assist a claimant in obtaining evidence necessary to substantiate a claim, but such assistance is not required if there is no reasonable possibility that it would aid in substantiating the claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012). The RO attempted to obtain all evidence the Veteran identified as being potentially pertinent to his claims, including service treatment and personnel records and post-service VA and private treatment records. The RO also afforded the Veteran VA examinations, during which examiners addressed the etiology of the Veteran's skin complaints and fatigue. II. Analysis The Veteran seeks a grant of service connection for a skin disorder and fatigue on the basis that both have their origin in his service in Southwest Asia. He asserts that he has a skin disorder, which manifests as itchiness on his entire body or in certain areas such as his left elbow, legs, ankles, upper back and head. He believes that this disorder is related to his service in the Persian Gulf War and has caused him to lose his hair. He also asserts that he began experiencing severe fatigue in Saudi Arabia during the Persian Gulf War. Allegedly, since discharge, the Veteran has received treatment, including emergency care, for skin problems and fatigue and no medical professional has attributed these symptoms to a particular disease or disorder. He contends that these conditions have been aggravated. The Veteran has submitted lay statements in support of this appeal, which establish that he had medical problems while serving in the Persian Gulf War, but none of these statements specifically mention skin symptoms or fatigue. Rather, they focus primarily on the Veteran's emotional problems and hypertension. The Board acknowledges the Veteran's assertions, but considering them in conjunction with the medical evidence of record, they do not support a grant of service connection for a skin disorder or fatigue, including on a direct or presumptive basis. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). To prevail on the issue of service connection, there must be competent evidence of (1) a current disability, (2) in-service occurrence or aggravation of a disease or injury; and (3) a nexus between the in-service injury or disease and the current disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Once evidence is determined to be competent, its credibility must be evaluated. Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency, a legal concept focusing on whether testimony may be heard and considered, and credibility, a factual determination focusing on the probative value of the evidence). Subsequent manifestations of a chronic disease in service, however remote, are to be service connected, unless clearly attributable to intercurrent causes. For the showing of 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 diagnosis including the word "chronic." Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. 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) (2012). To establish service connection based on continuity of symptomatology, the claimant must have one of the chronic diseases enumerated at 38 C.F.R. § 3.303(a). Walker v. Shinseki, __ F.3d __ , No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). Service connection may be granted for any disease diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Service connection may be presumed for certain conditions, including fatigue and unexplained rashes or other dermatological signs or symptoms, under 38 U.S.C.A. § 1117, based on service during the Persian Gulf War. More specifically: (a)(1) The Secretary may pay compensation under this subchapter to a Persian Gulf veteran with a qualifying chronic disability that became manifest (A) during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War; or (B) to a degree of 10 percent or more during the presumptive period prescribed under subsection (b). (a)(2) For purposes of this subsection, the term "qualifying chronic disability" means a chronic disability resulting from any of the following (or any combination of any of the following): (A) An undiagnosed illness; (B) A medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms; (C) Any diagnosed illness that the Secretary determines in regulations prescribed under subsection (d) warrants a presumption of service connection. (b) The Secretary shall prescribe by regulation the period of time following service in the Southwest Asia theater of operations during the Persian Gulf War that the Secretary determines is appropriate for presumption of service connection for purposes of this section. * * (f) For purposes of this section, the term "Persian Gulf veteran" means a veteran who served on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War. 38 U.S.C.A. § 1117 (West 2002). The regulation implementing the foregoing statute provides, in relevant part, that except as provided otherwise, VA shall pay compensation in accordance with chapter 11 of Title 38, United States Code, to a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability, provided that such disability (I) became manifest either during active duty in the South West Asia theater of operations during the Gulf War, or to a compensable degree no later than December 31, 2011, and (ii) by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1) (2012). "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) (2012). Disabilities that have existed for at least six months and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered "chronic." 38 C.F.R. § 3.317(a)(4) (2012). The law and regulations pertinent to the Veteran's claims changed during the course of this appeal. Effective March 2002, VA revised the term "chronic disability", then in effect, to "qualifying chronic disability," and expanded the definition of "qualifying chronic disability" to include: (a) an undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 68 Fed. Reg. 34,539 (June 10, 2003). Effective October 2010, VA made technical revisions to 38 C.F.R. § 3.317 to remove a potential source of confusion and to implement more effectively Congress's intent as expressed in 38 U.S.C.A. § 1117. 75 Fed. Reg. 194 (Oct. 7, 2010). Specifically, VA amended § 3.317(a)(2)(i)(B) to clarify that chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome are examples of medically unexplained chronic multisymptom illnesses and do not reflect an exclusive list of such illnesses. Additionally, VA removed § 3.317(a)(2)(i)(B)(4), which reserved to the Secretary the authority to determine whether additional illnesses are "medically unexplained chronic multisymptom illnesses" as defined in paragraph (a)(2)(ii). VA did so to provide adjudicators the authority to determine on a case-by-case basis whether additional diseases meet the criteria of paragraph (a)(2)(ii). As well, VA added diabetes and multiple sclerosis to § 3.317(a)(2)(ii) as examples of chronic multisymptom illnesses of partially understood etiology and pathophysiology that are not considered medically unexplained chronic multisymptom illnesses. 75 Fed. Reg. 59,970 (Sept. 29, 2010); 75 Fed. Reg. 61,356 (Oct. 5, 2010); 75 Fed. Reg. 61,997 (Oct. 7, 2010). These amendments are applicable to claims pending before VA on October 7, 2010, such as the Veteran's, and provide definitional clarification in this case. According to DD Forms 214 of record and other service personnel records, the Veteran served on active duty from January 1958 to January 1960 and from January 1991 to June 1991, including in the Southwest Asia theater of operations from February 1991 to May 1991, the latter period while in the National Guard. The previously noted presumptive provisions are therefore applicable to his claim. A. Skin The Veteran does not allege, nor do his service treatment records show, that he had any issues with his skin during either of his periods of active service. He did not report any skin complaints and no medical professional noted any skin abnormalities. The Veteran underwent multiple medical evaluations during these time periods and on each occasion, he denied having had any type of skin disease, rash, skin infection or sores. During these evaluations, including one conducted in April 1991 for the purpose of redeployment, examiners consistently noted normal clinical evaluations of the skin. Approximately three years after discharge, in July 1994, the Veteran first expressed a complaint pertinent to his skin. He reported itchiness and a small mass on the left side of his neck of three days' duration. Since then, the Veteran has continued to report and receive treatment for skin complaints affecting his scalp (accompanied by a loss of hair), face, arms, back, legs, ankles, neck and buttocks. Medical professionals have diagnosed these complaints as, or attributed these complaints to: xerosis, male pattern alopecia and a sebaceous cyst of the scalp (March 1997); a comedone and seborrhea dermatosis (May 1998, July 1998, April 2010 and October 2010); dermatitis and pruritis (January 1999, March 2000, November 2001, March 2002, June 2010 and August 2010); neurodermatitis (September 2005, December 2005, August 2006, July 2007, May 2010 and September 2010); a comedone with a suspected superimposed fungal infection (May 2006); nostalgia paresthetica, atopic dermatitis, ichthyosis vulgaris, acanthoma, an epidermal cyst and neurodermatitis (August 2006); Schamberg's disease, lichen simplex chronicus, tinea (cured), stasis dermatitis and tinea incognito (August 2009); tinea corporis and nummular dermatitis (December 2009 and October 2010); and xerosis, xerotic eczema, androgenetic alopecia and post-inflammatory hyperpigmentation (June 2011). The question is whether any current skin problem is related to the Veteran's active service, including in the Persian Gulf. According to the Court, it is questionable whether these assessments/diagnoses represent actual clinical diagnoses, rather than just skin findings such as abnormal dryness (xerosis), excessive secretions of the sebaceous glands (seborrhea dermatosis), inflammation (dermatitis), a cutaneous response to scratching thought to be psychogenic in nature (neurodermatitis), a noninflammatory lesion of acne vulgarus (comedone), and hypersensitivity to environmental antigens (atopic dermatitis). However, dermatologists have also diagnosed the Veteran with known diseases, which would explain the skin symptoms, including ichthyosis vulgaris, a common skin disorder passed down through families that leads to dry, scaly skin, and nostalgia paresthetica, hereditary, localized pruritis. See www.ncbi.nlm.nih.gov. They have also diagnosed the Veteran with acanthoma, lichen simplex chronicus, Schamberg's disease, and tinea of various sorts. During the course of this appeal, medical professionals have attributed the pruritis to the Veteran's anxiety symptoms (August 2007), the dermatitis on his lower legs to peripheral vascular disease, venous (November 2001), the androgenetic alopecia to heredity (June 2011), and the xerosis or dryness, xerotic eczema and post-inflammatory hyperpigmentation to the natural aging process. In June 2011, a VA examiner specifically found the Veteran's skin symptoms unrelated to military service based on the fact that they are hereditary and due to the natural aging process. There is no evidence in the claims file suggesting that the Board should question the VA examiner's credibility. His opinion is thus competent and credible on the question of whether the Veteran's skin conditions are related to the Veteran's active service. The Veteran has not submitted a medical opinion refuting that of the VA examiner. The Veteran's assertions relating his skin conditions to service thus represent the only evidence of record of a nexus. The Veteran is competent to report and describe the nature of certain skin symptoms such as dryness and itchiness as these symptoms are capable of lay observation. He does not, however, possess a recognized degree of medical knowledge to link these symptoms to his active service, including in the Southwest Asia theater of operations. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (a layperson is not competent to offer an opinion regarding a medical question when that question may not be resolved through lay observation). In the absence of competent and credible evidence of a nexus between the Veteran's skin disorder, however diagnosed, and his active service, the Board concludes that such disorder was not incurred in or aggravated by such service. The Board further concludes that the Veteran's skin symptoms may not be presumed to have been incurred in service as medical professionals have attributed them to known diagnosed illnesses. A claimant is responsible for presenting evidence in support of his claim for benefits under laws administered by VA. VA is responsible for considering all such evidence, lay and medical. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA is to give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In this case, the evidence is not in relative equipoise. Rather, the preponderance of the evidence is against the claim. The benefit-of-the-doubt rule is thus not for application. B. Fatigue The Veteran first reported weakness/fatigue in February 1991, during service in the Persian Gulf. During that visit and the next, examiners discussed the weakness and fatigue in conjunction with reported shortness of breath. During the April 1991 redeployment examination, the Veteran reported that he was undergoing medical evaluations "due to breathing difficulties (fatigue)". Approximately three years later, in 1994, the Veteran began frequently reporting fatigue. In March 2004, he indicated that, since a few years prior to the visit, he had been having progressive fatigue when an upper respiratory process occurred. Again, medical professionals discussed this symptom in conjunction with reported shortness of breath as well as bronchitis. In June 1994, one indicated that it was necessary to rule out heart disease. Since then, the Veteran has continued to report and receive treatment for fatigue. In 2004, a physician first diagnosed COPD. During treatment visits for this condition, the Veteran reported that he had been a mild smoker for several years, but had begun to experience shortness of breath in the Gulf, from contamination. In 1997, a physician attributed the Veteran's fatigue to an alterated respiratory pattern. Since 2008, medical professionals have occasionally noted fatigue, general malaise and weakness and some have attributed these findings to the Veteran's COPD. None has indicated that the fatigue is due to any disorder other than the COPD, which is already service connected, or otherwise related to the Veteran's active service. In June 2009, a VA examiner specifically indicated that the Veteran did not meet the criteria for chronic fatigue syndrome and had other medical conditions that caused weakness. In August 2009 and June 2011, VA examiners elaborated that the Veteran had COPD, a debilitating condition that caused weakness and a loss of stamina. They found that the Veteran's weakness was not a consequence of the Persian Gulf War or other environmental conditions, but rather a consequence to prolonged smoking. They concluded that the condition was less likely than not related to service. There is no evidence in the claims file suggesting that the Board should question the VA examiners' credibility. Their opinions are thus competent and credible on the question of whether the Veteran's fatigue is related to the Veteran's active service. Based on the foregoing, the Board finds that the preponderance of the evidence shows that the Veteran does not have any chronic fatigue syndrome as a result of military service. The Veteran is competent to report that he has continued to experience fatigue symptoms since service. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007) (holding that lay testimony is competent to establish the presence of observable symptomatology); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). However, he is not competent to attribute his complaints to a diagnosis of chronic fatigue syndrome. The Veteran also has submitted no competent medical evidence to show that he has a current chronic fatigue syndrome. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements, or opinions). While the service treatment records note complaints of fatigue associated with shortness of breath or difficulty breathing, he was not diagnosed with a chronic fatigue syndrome in service or any time thereafter. His complaints were attributed instead to bronchitis, COPD, and smoking. In sum, the Veteran has not been diagnosed as having a current chronic fatigue syndrome related to military service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. In addition, there are no objective indications of a qualifying chronic disability. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. The Veteran has not submitted a medical opinion refuting that of the VA examiners and, as previously indicated, his assertions relating the fatigue to service are incompetent and insufficient to establish the necessary nexus in this case. The Veteran's fatigue has been attributed as a symptom of his COPD, a known diagnosis, and is contemplated in the rating assigned that service-connected disability. Fatigue is not a separate disability warranting service connection, but is rather a symptom of his already-service connected COPD and is therefore not entitled to separate compensation. The evidence in this case is not in relative equipoise. Rather, the preponderance of the evidence is against the claim and the benefit-of-the-doubt rule is not for application. As such, after weighing and balancing the evidence of record, the Board finds that the preponderance of the evidence of record is against a finding that the Veteran has a current fatigue disorder related to his service to include his service in the Persian Gulf War. Accordingly, the Board finds that the criteria for service connection for a chronic fatigue disorder are not met and the claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. See 38 U.S.C.A. § 5107(b). However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). ORDER Service connection for a skin disorder, including as due to an undiagnosed illness, is denied. Service connection for fatigue, other than that which is considered a symptom of his COPD, is denied. REMAND Prior to adjudicating the claim of entitlement to service connection for weight loss, leg cramps, dizziness and joint pains, including as due to an undiagnosed illness, additional development is necessary. See 38 C.F.R. § 19.9 (2012). By Remands dated in April 2010 and February 2011, the Board instructed the RO to afford the Veteran VA examinations in support of the claim for service connection for fatigue, weight loss, leg cramps, dizziness and joint pains, including as due to an undiagnosed illness. The Board instructed the RO to ensure that the examiner offered an opinion as to whether any disability manifested by the fatigue, weight loss, leg cramps, dizziness and/or joint pains had its onset during active service, or is otherwise related to any in-service disease or injury. The RO partially complied by affording the Veteran two VA examinations and obtaining an addendum opinion, but the reports of these examinations and the addendum opinion are inadequate to decide this claim. In each case, the examiner discussed only the Veteran's fatigue, not the other claimed conditions. Later, the RO denied the claim on the basis that it had reviewed the treatment records, which show that the claimed conditions are due to other diagnosed disabilities. A Board remand imposes upon VA a duty to ensure compliance with the terms of the remand. When the RO fails to comply with the Board's directives, the Board must ensure subsequent compliance by returning the claims file for completion of the previously requested action. Stegall v. West, 11 Vet. App. 268 (1998). In this case, because the examiner did not provide all requested information, an addendum opinion must be obtained. This claim is REMANDED to the RO for the following action: 1. Return the claims file to a VA examiner for an addendum opinion. Provide the examiner with the Veteran's claims file for review and ask the examiner to confirm in his written report that he conducted such a review. Following the review, the examiner should: a) note whether the Veteran has objective indications of weight loss, leg cramps, dizziness and/or joint pains; b) if so, opine whether these symptoms are due to a specific disease entity; c) for each symptom found to be due to a specific disease entity, opine whether the entity is at least as likely as not etiologically related to the Veteran's period of active service; d) for each symptom not shown to be due to a specific disease entity, indicate whether it represents an objective indication of chronic disability resulting from an undiagnosed illness related to the Veteran's Persian Gulf War service, or a medically unexplained chronic multisymptom illness, such as fibromyalgia, which is defined by a cluster of signs or symptoms; e) if any symptom represents an objective indication of chronic disability resulting from an undiagnosed illness or a chronic multisymptom illness, also describe the extent to which the illness has manifested; f) provide detailed rationale, with specific references to the record, for the opinions expressed; and g) if an opinion cannot be expressed without resort to speculation, discuss why such is the case and whether there is additional evidence that would aid in providing such opinion. 2. Review the addendum opinion to ensure that it complies with these instructions. If it does not, return it to the examiner for correction. 3. Readjudicate the Veteran's claim based on all of the evidence of record. If the benefit sought on appeal is denied, furnish the Veteran a supplemental statement of the case. 4. Thereafter, subject to current appellate procedure, return this case to the Board for further consideration. The Veteran has the right to submit additional evidence and argument on the remanded claim. Kutscherousky v. West, 12 Vet. App. 369, 372 (1999). This claim must be afforded expeditious treatment, see 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). As it is advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012), it also necessitates expedited handling. _________________________ SARAH B. RICHMOND Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs