Citation Nr: 1330507 Decision Date: 09/23/13 Archive Date: 09/30/13 DOCKET NO. 99-01 128 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for chronic fatigue syndrome, including as due to an undiagnosed illness. 2. Entitlement to service connection for arthralgia of the neck, back, knees, ankles, and feet. 3. Entitlement to service connection for gastroenteritis, also claimed as a digestive disability, including as due to an undiagnosed illness. 4. Entitlement to an initial rating in excess of 30 percent for the service-connected acquired psychiatric disorder, to include generalized anxiety disorder and related phobias, effective May 5, 1997. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A.M. Ivory, Counsel INTRODUCTION The Veteran served on active duty from February 1984 to February 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 1998 rating decision issued by the Department of Veterans Affairs' (VA) Regional Office (RO) in Montgomery, Alabama. In May 2007, June 2008, November 2011, and November 2012 the Board remanded multiple issues, including entitlement to service connection for multiple joint arthralgia, chronic fatigue syndrome, and gastroenteritis for further development. For the issue of entitlement to service connection for chronic fatigue syndrome, the requested development has been completed and no further action to ensure compliance with the remand directive is required. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In November 2012 the Board also remanded the issues of entitlement to service connection for vertigo and a lumbar spine disorder for further development. During the pendency of the appeal, a July 2013 rating decision granted service connection for vertigo with an initial rating of 10 percent effective May 5, 1997, and service connection for degenerative disc disease of the lumbar spine with an initial rating of 20 percent effective September 17, 1996. Thus, those issues are no longer before the Board. In November 2012 the Board granted the Veteran service connection for an acquired psychiatric disorder to include generalized anxiety disorder and related phobias. In a December 2012 rating decision the RO assigned an initial 30 percent disability rating effective May 5, 1997. In May 1999 the Veteran testified before a Decision Review Officer (DRO) at the RO. In April 2008, the Veteran testified before the undersigned Veterans Law Judge, via videoconference. Transcripts from both hearings have been associated with the Veteran's claims file. A review of the Virtual VA paperless claims processing system reveals VA treatment records that have been reviewed both by the RO in a September 2012 Supplemental Statement of the Case (SSOC) and the Board, the July 2013 rating decision, and the August 2013 brief by the Veteran's representative. The issues of entitlement to service connection for multiple joint arthralgia and gastroenteritis and the issue of an initial rating in excess of 30 percent for the service-connected acquired psychiatric disorder, to include generalized anxiety disorder and related phobias, are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT The preponderance of the evidence is against a finding that the Veteran currently suffers from chronic fatigue syndrome that is the result of a disease or injury in active duty service, including as due to an undiagnosed illness. CONCLUSION OF LAW Chronic fatigue syndrome was not incurred in or aggravated by active military service. 38 U.S.C.A. § 1110, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record that is necessary to substantiate the claim. The Veteran should be informed as to what portion of the information and evidence VA will seek to provide, and what portion of such the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, legally adequate notice was provided to the Veteran by a November 2005 letter. This letter detailed the elements of a service connection claim, described the evidence and information necessary to substantiate the claim, and set forth the respective responsibilities of VA and the Veteran in obtaining such. In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (hereinafter Court) held that, upon receipt of an application for service connection, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) also require notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, the RO informed the Veteran in the March 2006 letter. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters herein decided. Medical evidence associated with the claims file includes the Veteran's service treatment records and VA treatment records. Additionally of record and considered in connection with the claim are various statements provided by the Veteran, and by his representative, on his behalf. VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran was afforded a VA examination for his chronic fatigue syndrome in January 2010, December 2011, and June 2013. The Board finds that these VA examinations, specifically the most recent in June 2013, were sufficient since they were thorough and contemporaneous examinations of the Veteran that took into account records of pre-service treatment, service treatment records, and records of post-service examination and treatment. Lineberger v. Brown, 5 Vet. App. 367 (1993); Waddell v. Brown, 5 Vet. App. 454 (1993); Caffrey v. Brown, 6 Vet. App. 377 (1994). As noted above, the Veteran's claim of chronic fatigue syndrome has been remanded in May 2007, November 2011, and November 2012. In May 2007 the Board remanded in order for the Veteran to be afforded a hearing before the Board; the Veteran testified before the undersigned Veterans Law Judge in April 2008. In November 2011 the Veteran's claim was remanded in order for the Veteran to be afforded a VA examination and to obtain outstanding treatment records; the Veteran was afforded a VA examination in December 2011 and outstanding treatment records were obtained and associated with the Veteran's claims file. In November 2012 the Veteran's claim was remanded in order for the Veteran to be afforded a VA examination; the Veteran underwent a VA examination in June 2013. Thus, the Board finds that for the issue of entitlement to service connection for chronic fatigue syndrome, the May 2007, November 2011, and November 2012 Board remands requirements have been met. As the requested development has been completed, no further action to ensure compliance with the remand directive is required. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Also of record and considered in connection with the appeal is the transcript of the May 1999 DRO hearing, the transcript of the April 2008 Board hearing, and various written statements provided by the Veteran, and by his representative, on his behalf. The Board finds that no additional RO action to further develop the record in connection with the claim herein decided, prior to appellate consideration, is required. As for the DRO and Board hearings, it is noted that, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) (2012) requires that the individual (interpreted to include a Veterans Law Judge ) who chairs a hearing fulfill two duties to comply with the regulation: (1) to fully explain the issues; and, (2) to suggest the submission of evidence that may have been overlooked. Here, during the May 1999 DRO hearing and April 2008 Board hearing, the DRO and Veterans Law Judge identified the issues on appeal. The Veteran provided testimony regarding his chronic fatigue syndrome. The hearing transcripts also reflect appropriate exchanges between the Veteran, his representative, and the DRO/Veterans Law Judge pertaining to the Veteran's military service and the bases for denial of the claim. While the submission of specific, additional evidence was not explicitly suggested, any omission is this regard was harmless, as it did not in any way prejudice the Veteran. As such, the Board finds that, consistent with Bryant, the requirements of 38 C.F.R. 3.103(c)(2) have been met, and that both hearings were legally sufficient. In summary, the duties imposed by the VCAA have been considered and satisfied. The Veteran has been notified and made aware of the evidence needed to substantiate the claim herein decided, the avenues, through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with this claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter on appeal, at this juncture. See Mayfield, 20 Vet. App. at 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis Service connection may be granted for disability resulting from disease or injury incurred or aggravated during a veteran's active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to prevail on the issue of service connection there must be: medical evidence of a current disability; medical evidence, or in some cases lay evidence, of in-service occurrence or aggravation of a disease or injury; and, medical evidence of a nexus between an in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); Pond v. West, 12 Vet. App. 341, 346 (1999). Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). When such chronic diseases are at issue, the second and third elements for service connection may be established by showing continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a). Id. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran asserts that he has a current diagnosis of chronic fatigue syndrome that is related to his military service, specifically to his service in the Persian Gulf and to an undiagnosed illness as a result of that military service. Service connection may also be established 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. See 38 U.S.C.A. § 1117(a)(1) (West 2002); 38 C.F.R. § 3.317(a)(1) (2012). A 'Persian Gulf Veteran' is one who served in the Southwest Asia Theater of operations during the Persian Gulf War. See 38 C.F.R. § 3.317 (2012). The Persian Gulf War began on August 2, 1990. See 38 C.F.R. § 3.2(i) (2012). A 'qualifying chronic disability' includes: (A) an undiagnosed illness, (B) the following medically unexplained chronic multi symptom illnesses: chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, as well as any other illness that the Secretary of VA determines is a medically unexplained chronic multi-symptom illness; and (C) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. See 38 U.S.C.A. § 1117(a) (2) (West 2002); 38 C.F.R. § 3.317(a)(2)(i) (2012). Objective indications of a 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. See 38 C.F.R. § 3.317(a)(3) (2012). 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. See 38 C.F.R. § 3.317(b) (2012). 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. A disability referred to in this section shall be considered service-connected for the purposes of all laws in the United States. See 38 C.F.R. § 3.317(a)(2)(5) (2012). An 'undiagnosed illness' is defined as a condition that by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. See 38 C.F.R § 3.317(a)(1)(ii) (2012). In the case of claims based on undiagnosed illness, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. See Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). 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. See 38 C.F.R. § 3.317(a)(2)(ii) (2012). There are currently no diagnosed illnesses that have been determined by the Secretary to warrant a presumption of service connection under 38 C.F.R. § 3.317(a)(2)(C) (2012). Compensation shall not be paid under 38 C.F.R. § 3.317 if: (1) the undiagnosed illness was not incurred during active service in the Southwest Asia theater of operations during the Persian Gulf War; or (2) the undiagnosed illness was caused by a supervening condition or event that occurred between most recent departure from service in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or (3) the illness is the result of willful misconduct or the abuse of alcohol or drugs. See 38 C.F.R. § 3.317(c) (2012). Compensation may be paid under 38 C.F.R. § 3.317 for disability which cannot, based on the facts of the particular Veteran's case, be attributed to any known clinical diagnosis. The fact that the signs or symptoms exhibited by the Veteran could conceivably be attributed to a known clinical diagnosis under other circumstances not presented in the particular Veteran's case does not preclude compensation under § 3.317. See VAOPGCPREC 8-98. In cases where a Veteran applies for service connection under 38 C.F.R. § 3.317 but is found to have a disability attributable to a known diagnosis, further consideration under the direct service connection provisions of 38 U.S.C.A. § 1110 is then warranted. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). A threshold requirement for the grant of service connection for any disability is that the disability claimed must be shown present. See 38 U.S.C.A. §§ 1110, 1131 (West 2002). Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. § 1110 (West 2002). In the absence of proof of a present disability there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, though the Veteran has reported symptoms of fatigue the evidence does not support a finding that the Veteran has chronic fatigue syndrome. At a September 1993 VA examination the Veteran reported fatigue since discharge that became progressively worse and that he had to rest after one to two hours of work; the impression was a history of chronic fatigue syndrome, nonspecific. In November 1993 the Veteran was assessed with insomnia and fatigue; he was assessed with fatigue in January 1994. In May 1994 it was stated that he had questionable chronic fatigue syndrome and in July 1994 he reported that he was still fatigued and the impression was "? chronic fatigue syndrome". In March 1999 the Veteran complained that his chronic fatigue was getting worse. The January 2010 VA "Gulf" examiner diagnosed the Veteran with impaired glucose tolerance and noted that chronic fatigue was a problem associated with this diagnosis. The December 2011 VA examiner stated that though some of the Veteran's previous physicians have felt that he might have chronic fatigue syndrome he does not have sufficient symptoms to warrant a diagnosis of chronic fatigue syndrome. He stated that the Veteran's conditions of glucose intolerance, anxiety, and phobias would cause fatigue; as well as, recent financial and family losses. The June 2013 VA examiner stated that the Veteran did not meet the criteria for chronic fatigue syndrome but his fatigue was at least as likely as not related to his military service because the Veteran is "presently service-connected for Neurosis which in turn can lead to a variety of mental health symptoms to include anxiety, insomnia, and fatigue." The Board finds that service connection for chronic fatigue syndrome must be denied. The Veteran fails the threshold requirement for the grant of service connection since he does not have an actual diagnosis of chronic fatigue syndrome. 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. Here, however, though the Veteran has reported subjective symptoms of fatigue and there has been an indication of a possible diagnosis of chronic fatigue syndrome he has not been diagnosed with chronic fatigue syndrome; the December 2011 and June 2013 VA examiners relate the Veteran's fatigue as symptomatology to other conditions and not to a diagnosis of chronic fatigue syndrome. While he is competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge he is not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). In this case, the Veteran's subjective symptoms of chronic fatigue syndrome have not been confirmed by a medical diagnosis and any symptoms of fatigue have been associated with other diagnoses, i.e. his neurosis and/or his glucose intolerance. Thus, in this case lay evidence cannot competently and sufficiently to establish a diagnosis of chronic fatigue syndrome. Thus, the Board finds that to this day, a disorder manifested by chronic fatigue syndrome is not shown and without evidence of a diagnosis service connection cannot be granted. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (Court stated "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability," and held "[i]n the absence of proof of a present disability[,] there can be no valid claim"); Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). As the Veteran does not meet the criteria for a diagnosis of chronic fatigue syndrome, and indeed, no such diagnosis has been assigned, service connection for chronic fatigue syndrome, as a separate disease entity is not appropriate. In the absence of a present disability involving chronic fatigue syndrome there can be no valid claim. Service connection for chronic fatigue syndrome is therefore denied. ORDER Service connection for chronic fatigue syndrome is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Arthralgia The Veteran asserts that he has arthralgia of the neck, back, knees, ankles, and feet due to his military service, to include as due to undiagnosed illness. In January 2010 the Veteran underwent a VA Gulf War examination and was diagnosed with three, separate conditions upon examination - namely, impaired glucose tolerance, mild degenerative disc disease of the cervical spine, and lumbar facet syndrome. The VA examiner noted that fibromyalgia was a problem associated with these diagnoses but confusingly stated that there were no "findings to warrant a diagnosis for fibromyalgia at this time." Subsequently, in December 2011, the Veteran underwent a new VA examination where the examiner stated that there was evidence of muscle and joint pain arthralgia, diagnosed as generalized osteoarthritis. The examiner opined, "[The] Veteran does not have an unexplained pattern of disability and his complaints are not related to a specific exposure event experienced by the Veteran in [Southwest] Asia... [The] Veteran's conditions have a specific diagnosis or there is no pathology and are not related to a specific exposure event experienced by the Veteran in [Southwest] Asia." The Board then remanded the Veteran's claim in order for him to be afforded a new VA examination to clarify the above opinion. In June 2013 the VA examiner found that the Veteran did not have a diagnosis of fibromyalgia. He stated that the Veteran's symptoms/condition of arthralgia of neck, back, knees, ankles, and feet were due to bony degenerative conditions noted on plain film x-ray studies and that since fibromyalgia was a diagnosis of exclusion he does not meet the criteria for a diagnosis of fibromyalgia. The Board finds that the Veteran's claims file must be sent to the June 2013 VA examiner for an addendum opinion on whether the Veteran's bony degenerative conditions is at least likely as not due to his military service, to include his service in Southwest Asia. Also, whether the Veteran's arthralgia of neck, back, knees, ankles, and feet due to any aspect of his military service, to include his service in Southwest Asia. Gastroenteritis The Veteran also asserts that his gastroenteritis is largely attributable to his service in the Southwest Asia Theater of operations during the Persian Gulf War or directly related to his military service. The December 2011 VA examiner stated that there was no evidence of gastroenteritis. At the June 2013 VA examination the examiner stated that during the Veteran's active military service he developed nausea, vomiting, and frequent diarrhea with abdominal cramping; however, once the Veteran returned stateside he was treated with oral medications and three years ago he had an appendectomy and his symptoms have since resolved. However, the Veteran's representative asserts in the August 2013 brief that the Veteran's abdominal symptoms began in service and continued episodically until his 2007 appendectomy and that his symptoms could be related to chronic appendicitis and/or as a side effect of his medications. The Veteran's representative cited Chronic and recurrent appendicitis are Uncommon Entities Often Misdiagnosed, http://www.ncbi.nlm.nih.gov/pubmed/8149038 and Chronic Appendicitis: Bases for Varied Clinical Manifestation, http://radiology.rsna.org/content/5/2/152.abstract. The Board notes that the requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Thus, the Board finds that the Veteran's claim of entitlement to service connection for gastroenteritis must be sent to the June 2013 VA examiner for an addendum opinion. The VA examiner must discuss the Veteran's representative's theory of chronic appendicitis in relation to this Veteran; he/she should opine if the Veteran had any gastrointestinal disability prior to his appendicitis; and he/she should opine if any gastrointestinal disability prior to his appendicitis was at least likely as not related to the Veteran's military service. Service-Connected Acquired Psychiatric Disorder In November 2012 the Board granted the Veteran service connection for an acquired psychiatric disorder to include generalized anxiety disorder and related phobias. In a December 2012 rating decision the RO assigned an initial 30 percent disability rating effective May 5, 1997. However, in the August 2013 brief the Veteran's representative filed a Notice of Disagreement (NOD) on the initial rating assigned. The Veteran has not been furnished a Statement of the Case (SOC) that addresses the issue of entitlement to an initial rating in excess of 30 percent for the service-connected acquired psychiatric disorder to include generalized anxiety disorder and related phobias. Consequently, the Board must remand to the RO to furnish an SOC and to give the Veteran an opportunity to perfect an appeal of such issue by submitting a timely substantive appeal. See Manlicon v. West, 12 Vet. App. 238 (1999). The Board points out to the RO that in the August 2013 brief the Veteran's representative asserted that his fatigue should be part of the symptomatology associated with his service-connected acquired psychiatric disorder to include generalized anxiety disorder and related phobias. Thus, the RO should discuss the Veteran's fatigue in connection with his current 30 percent disability rating for service-connected acquired psychiatric disorder to include generalized anxiety disorder and related phobias. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file all updated VA and private treatment records. 2. The Veteran's claims file should be sent to the June 2013 VA examiner for an addendum opinion of the nature and etiology of the Veteran's arthralgia. If the June 2013 VA examiner is not available then it must be documented and the Veteran must be scheduled for a new VA examination. The entire claims file, including a copy of THIS remand, must be made available to the examiner for review. The examiner should discuss the Veteran's medical history and his assertions regarding whether his condition is due to service. If required by the examiner, provide the Veteran with a new VA examination. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. The VA examiner should review all pertinent records associated with the claims file, specifically including any medical opinions, and the Veteran's written and verbal accounts of his arthralgia of neck, back, knees, ankles, and feet. The VA examiner should determine whether it is at least as likely as not (50 percent or greater probability), that the Veteran's bony degenerative conditions are due to his military service, to include his service in Southwest Asia. The VA examiner should determine whether it is at least as likely as not (50 percent or greater probability), that the Veteran's arthralgia of neck, back, knees, ankles, and feet are due to any aspect of his military service, to include his service in Southwest Asia. If it is not possible to provide the requested opinion without resort to speculation, the examiner should state why speculation would be required in this case (e.g., if the requested determination is beyond the scope of current medical knowledge, actual causation cannot be selected from multiple potential causes, etc.). If there are insufficient facts or data within the claims file, the examiner should identify the relevant testing, specialist's opinion or other information needed to provide the requested opinion. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. The Veteran's claims file should be sent to the June 2013 VA examiner for an addendum opinion of the nature and etiology of the Veteran's gastroenteritis. If the June 2013 VA examiner is not available then it must be documented and the Veteran must be scheduled for a new VA examination. The entire claims file, including a copy of THIS remand, must be made available to the examiner for review. The examiner should discuss the Veteran's medical history and his assertions regarding whether his condition is due to service. If required by the examiner, provide the Veteran with a new VA examination. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. The VA examiner should review all pertinent records associated with the claims file, specifically including any medical opinions, the below cited medical evidence, and the Veteran's written and verbal accounts of his gastroenteritis. The VA examiner should determine whether it is at least as likely as not (50 percent or greater probability), that the Veteran had chronic appendicitis due to his military service. The VA examiner should state whether the Veteran had any gastrointestinal disability prior to his appendicitis. (Specifically, during the pendency of this appeal, September 17, 1996, to his appendectomy in 2007) If the Veteran had any gastroenteritis symptoms during the pendency of the appeal, were they at least likely as not due to his military service, to include his service in Southwest Asia. The VA examiner should determine if whether the Veteran's appendectomy in 2007 was at least likely as not related to the Veteran's military service. If it is not possible to provide the requested opinion without resort to speculation, the examiner should state why speculation would be required in this case (e.g., if the requested determination is beyond the scope of current medical knowledge, actual causation cannot be selected from multiple potential causes, etc.). If there are insufficient facts or data within the claims file, the examiner should identify the relevant testing, specialist's opinion or other information needed to provide the requested opinion. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The VA examiner must specifically discuss the two articles cited by the Veteran's representative in the August 2013 brief: Chronic and recurrent appendicitis are Uncommon Entities Often Misdiagnosed, http://www.ncbi.nlm.nih.gov/pubmed/8149038 and Chronic Appendicitis: Bases for Varied Clinical Manifestation, http://radiology.rsna.org/content/5/2/152.abstract. 4. The RO shall furnish the Veteran a Statement of the Case that addresses the issue of entitlement to an initial rating in excess of 30 percent for the service-connected acquired psychiatric disorder to include generalized anxiety disorder and related phobias. The RO shall return this issue to the Board only if the Veteran files a timely substantive appeal. The Board points out to the RO that in the August 2013 brief the Veteran's representative asserted that his fatigue should be part of the symptomatology associated with his service-connected acquired psychiatric disorder to include generalized anxiety disorder and related phobias. Thus, the RO should discuss the Veteran's fatigue in connection with his current 30 percent disability rating for service-connected acquired psychiatric disorder to include generalized anxiety disorder and related phobias. 5. The RO should review the claims file to ensure that all the foregoing requested development is completed, and, thereafter, arrange for any additional development indicated. The RO should then readjudicate the claims on appeal. If any benefit sought remains denied, the RO should issue an appropriate SSOC (Supplemental Statement of the Case) and provide the Veteran and his representative the requisite time period to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. No action is required of the appellant unless he is notified. The purposes of this remand are to ensure notice is complete, and to assist the Veteran with the development of his claims. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the appellant until further notice. The Board takes this opportunity to advise the appellant that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claims, including reporting for any scheduled VA examination, is both critical and appreciated. The appellant is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655. 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. 2012). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs