Citation Nr: 1751096 Decision Date: 11/08/17 Archive Date: 11/17/17 DOCKET NO. 12-00 488 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a left hip disability, to include as secondary to a left knee disability. 2. Entitlement to service connection for a disorder manifested by fatigue, to include as due to undiagnosed illness. 3. Entitlement to an increased disability rating for service-connected undiagnosed illness manifested by diarrhea, currently rated 10 percent disabling. 4. Entitlement to an increased disability rating for service-connected undiagnosed illness manifested by joint pain, currently rated 10 percent disabling. REPRESENTATION Appellant represented by: Brendan B. Garcia, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The appellant is a Veteran who had active military service from July 1987 to July 1992, and from March 1993 to September 1993; he also had additional periods of Reserve service. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The claim of service connection for left hip disability arises from a February 2010 RO rating decision. The other issues on appeal arise from an October 2009 RO rating decision. In June 2014, the Veteran testified at a VA Central Office hearing before the undersigned Veterans Law Judge. A transcript of the proceeding is of record (in Virtual VA). This case was previously before the Board in September 2014, when the Board dismissed a number of issues withdrawn by the Veteran; the Board remanded the issues remaining on appeal to the RO for additional development of the evidentiary record. The case has now returned to the Board for further appellate review. The Board finds that there has been substantial compliance with the directives of the September 2014 remand with regard to the issues on appeal resolved by this Board decision. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board remand instructed that the AOJ should contact the Veteran to obtain information and authorizations regarding his receipt of pertinent treatment. The AOJ sent a letter to the Veteran in December 2014 in accordance with the remand directives, but the Veteran did not provide the requested information in response. A number of follow-up contacts by the RO are documented in the claims-file, with the Veteran repeatedly indicating that he intended to submit or had already submitted new documentation, but the record reflects that the requested information was never received by VA. The documentation in the claims-file shows significant efforts on the part of AOJ personnel through much of 2015 to offer the Veteran alternative means of submitting documents to VA, exhausting all reasonably available options; AOJ personnel repeatedly informed the Veteran that, despite his assertions of submitting documents, the documents had not been received by VA. The Board observes that the claims-file further shows that the Veteran has previously asserted that he was cooperating with VA requests in instances where documentation persuasively indicates that he had not done so, including as described in a February 2013 VA examination report. (The February 2013 VA examination report discusses that the Veteran stated that he had reported as requested for X-ray imaging, but VA determined that he had not done so; the February 2013 VA examination report also discusses that the Veteran stated that he would provide documentation of pertinent private medical treatment, but that he did not do so.) The Board concludes that the AOJ completed all reasonably available steps to request pertinent information from the Veteran and to assist the Veteran in these regards in substantial compliance with the directives of the September 2014 Board remand. The Board finds that all evidence and information actually provided by the Veteran has been included in the claims-file and is available to review at this time. To the extent that the Board's September 2014 remand directed efforts to obtain records of (1) the Veteran's reported 1991 treatment at the Army Medical Hospital associated with Fort Bliss, Texas, (2) the Veteran's reported 1992 treatment at Walter Reed Army Medical Hospital, and (3) the Veteran's medical treatment (in service treatment records) from the Veteran's Reserve and ACDUTRA service, efforts undertaken by the AOJ to determine the availability of these records are documented in the claims-file, but the resolution of these efforts is not clear. However, the issues of entitlement to service connection for a left hip disability and entitlement to an increased rating for a disability manifested by diarrhea are resolved by the Board at this time on bases that permit resolution without regard to the contents of these medical records from the remote past. Both of these issues are resolved with reference to information concerning pertinent periods that do not overlap with the time of the records sought from U.S. federal government sources; the outstanding records pertain to periods that are not pertinent to the resolution of the issues in this Board decision. (As explained below, the left hip disability issue is resolved on the basis of finding no left hip disability has existed during the pendency of the claim, and the diarrhea rating issue is resolved on the basis of the evidence of the severity of symptoms during the period on appeal. Any outstanding records from the 1990s would not be reasonably expected to pertain to either of these determinations.) To the extent that resolution of the efforts to determine the availability of these records is needed for the issues addressed in the remand section of this decision, this is reflected in the remand directives set out below. The Board notes that there has been some confusion in this case with regard to discrepancies between the Veteran's contentions presented at the June 2014 Board hearing and the issues currently perfected for appeal. The Veteran's contentions appeared to raise or suggest claims for entitlement beyond the issues currently in appellate status. For instance, this appeal formally features an issue of entitlement to service connection for a left hip disability, but some of the Veteran's testimony during the Board hearing appears to assert that a right hip disability has been medically diagnosed and attributed to his altered gait shifting his weight away from his painful left leg. Although the Veteran's representative eventually redirected attention to the Veteran's left hip service connection claim, the Veteran's testimony described that a VA medical doctor showed him X-ray imaging and explained that they revealed significant degeneration of the "hip" due to the Veteran's altered gait; it is apparent that the Veteran was describing the right hip at this time because he states that the VA doctor "said the left hip was fine," and also because the Veteran's explanation of the cause of the hip disability appears to be that he shifts his weight away from his painful left knee to overburden his right side. The Board observes that the February 2013 VA examination report shows no diagnosed disability for the left hip while providing a diagnosis for the right hip (trochanteric bursitis). Although the Veteran's testimony at the June 2014 Board hearing referenced the left hip, amid some apparent confusion on the matter, the Board views the record and the Veteran's testimony together as raising a claim of entitlement to service connection for a right hip disability as well. The Veteran's statements at the June 2014 hearing preceded certain changes to the regulations standardizing the process for filing claims through the use of prescribed forms. See 38 C.F.R. § 3.155 (as amended, effective from March 24, 2015); 79 Fed. Reg. 57660 (Sept. 25, 2014) (final rule). The issue of entitlement to service connection for a disability of the right hip has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b). Additionally, discussion on the record during the June 2014 Board hearing reflects that the Veteran and his representative believe that the Veteran has been rated incorrectly with regard to his already service-connected undiagnosed illness manifestations. The Veteran and his representative assert that the Veteran has a diagnosable orthopedic disability of the left knee that may be separate and distinct from his service-connected undiagnosed illness manifested by joint pain (currently rated under Diagnostic Code 8850-5002 as analogous to rheumatoid arthritis). The representative asked for consideration of whether the alleged orthopedic left knee disability should be recognized as separately service-connected as a distinct disability. Similar contentions appear to have been suggested with regard to the Veteran's testimony concerning digestive disorder involving reportedly medically observed ulcers, polyps, and various stomach problems that may be beyond the scope of the service-connected undiagnosed illness manifested by diarrhea (currently rated under Diagnostic Code 8873-7319 as analogous to irritable colon syndrome). The matter of providing the Veteran with clarification of the scope of the currently established service-connection for the currently recognized undiagnosed illnesses manifested by joint pain and by diarrhea is hereby referred to the AOJ for appropriate action (i.e. clarifying and informing the Veteran whether his claimed orthopedic left knee disability and his claimed stomach problems are contemplated as part of his current awards of service connection, and if they are not, obtaining clarification from the Veteran or his representative as to whether the Veteran is raising a claim of entitlement to service connection for the claimed orthopedic left knee disability and/or the claimed stomach problems). Also, during the June 2014 Board hearing, the Veteran's representative argued that the Veteran's original award of service connection (in October 1997) for joint pain as a manifestation of undiagnosed illness may have improperly rated the Veteran's disability. The Veteran's representative argued that the Veteran has an orthopedic left knee disability that had onset during service due to in-service injury. To reiterate what was discussed with the Veteran and his representative during the hearing, the Board here notes that the scope of the current appeal does not include any consideration of revising the October 1997 RO rating decision, which is final. To the extent that the Veteran may wish to pursue revision of the final October 1997 RO rating decision, he must file a claim alleging clear and unmistakable error (CUE) in that decision; he may file such a claim at any time. The Board observes that a November 2016 SOC addresses an issue of entitlement to an earlier effective date for the award of service connection for PTSD. However, the Veteran did not perfect an appeal of this issue to the Board with a timely filed Substantive Appeal following the issuance of the SOC, and the matter is not in appellate status before the Board at this time. Governing regulations provide that an appeal consists of a timely filed notice of disagreement in writing and, after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200. Finally, the Board notes that the Veteran filed a notice of disagreement in April 2017 initiating an appeal on issues addressed in a March 2017 RO rating decision. That appeal awaits the issuance of a statement of the case (SOC) by the RO. The Board is aware of the holding in Manlincon v. West, 12 Vet. App. 238, 240 (1999), which requires the Board to remand issues to instruct the RO that the issues remain pending in appellate status (see 38 C.F.R. § 3.160(c)) and require further action. See 38 U.S.C. § 7105; 38 C.F.R. § 19.26. However, in this case, it is clear that the RO is aware of and is currently processing the appeal initiated by the April 2017 notice of disagreement; this is documented in the Veterans Appeals Control and Locator System (VACOLS). The Board notes that the Veteran filed a properly executed VA Form 21-22a in July 2017, newly appointing his attorney as his representative in this case. The new representative is accordingly listed on the title page of this decision. The issues of (1) entitlement to service connection for a disorder manifested by fatigue, to include as due to undiagnosed illness, and (2) entitlement to an increased disability rating for service-connected undiagnosed illness manifested by joint pain, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran is not shown to have had any left hip disability during the pendency of his instant claim seeking service connection for such disability. 2. For the period prior to February 20, 2013, resolving reasonable doubt in the Veteran's favor, the evidence supports finding that the Veteran's service-connected disability manifested by diarrhea was productive of alternating diarrhea and constipation with more or less constant abdominal distress. 3. For the period from February 20, 2013, onward, the Veteran's service-connected disability manifested by diarrhea has been no more than moderate in severity, without manifesting in more or less constant abdominal distress. CONCLUSIONS OF LAW 1. Service connection for a left hip disability is not warranted. 38 U.S.C. § 1110, 1116, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). 2. For the period prior to February 20, 2013, the criteria for a 30 percent rating (the maximum schedular rating for disability analogous to irritable colon syndrome) have been met for the Veteran's service-connected disability manifested by diarrhea. 38 U.S.C. §§ 1155, 5103, 5103A and 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, and 4.114, Diagnostic Code 8873-7319 (2017). 3. For the period from February 20, 2013, onward, the criteria for a disability rating in excess of 10 percent for service-connected disability manifested by diarrhea are not met. 38 U.S.C. §§ 1155, 5103, 5103A and 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, and 4.114, Diagnostic Code 8873-7319 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Analysis Initially, the Board notes that it has reviewed all of the evidence in the appellant's record with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Service Connection for Left Hip Disability Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish service connection for a claimed disorder, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Certain chronic diseases, such as arthritis, may be presumed to have been incurred during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection is also warranted for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Under 38 C.F.R. § 3.310, secondary service connection is permitted based on aggravation; compensation is payable for the degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between a service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection may be established for a chronic disability resulting from an undiagnosed illness that became manifested either during active 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, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1)(i). Service connection may also be established for a Persian Gulf Veteran who exhibits objective indications of "qualifying chronic disability," a chronic disability resulting from an undiagnosed illness, 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, or any diagnosed illness that the Secretary determines warrants a presumption of service connection. 38 U.S.C. § 1117. An "undiagnosed illness" is one that by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) irritable bowel syndrome; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a)(2)(i). For purposes of this section, the term medically unexplained chronic multisymptom 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 multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). For purposes of this section, "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). Service connection is limited to those cases where disease or injury has resulted in a disability. In the absence of proof of a current disability for which service connection is sought, there is no valid claim of service connection. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement of having a current disability is met "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Veteran filed the claim for service connection for a left hip disability in October 2009. The Veteran has already established service connection for an undiagnosed illness manifested by generalized joint pain, which is current rated under Diagnostic Code 8850-5002 as analogous to rheumatoid arthritis, a systemic disability broadly affecting various joints. Thus, to any extent that the Veteran may experience any unexplained left hip pain that is not associated with a known medical diagnosis, such symptomatology is within the scope of the established service-connected joint pain and, thus, not a matter in controversy before the Board at this time. In any event, as discussed below, the Veteran's testimony and other evidence of record reflects that the Veteran has had neither any diagnosis nor any symptomatology of the left hip during the pendency of this claim on appeal. The scope of the left hip service connection claim on appeal is limited to the question of whether any other manner of left hip disability (in particular, a distinct diagnosed disability of the left hip) may be established as a service-connected disability in this case. Significantly, the Veteran's contentions with regard to the left hip disability in this case have been revised such that the Veteran appears to no longer contend that he has had any impairment of the left hip at any time during the pendency of this claim. During the June 2014 Board hearing, the Veteran referred to a VA examination in which the examiner informed the Veteran of a hip problem. The Veteran expressed some confusion as to which of his VA examinations brought a hip problem to his attention, but the Board notes that the Veteran's initial suggestion that a hip problem was first brought to his attention in connection with a 2013 VA examination was clearly mistaken, as the Veteran himself later confirmed and as is apparent in light of the fact that the Veteran filed the claim for service connection for a left hip disability in October 2009. The Veteran's hearing testimony later expressly confirmed that the examination in question was one with "a diagnosis of hip strain," with the Veteran noting: "That's the one. That's the actual appointment." Left hip strain was diagnosed in a June 2009 VA examination report. The Veteran also testified at the Board hearing that the appointment in question involved diagnostic X-ray imaging of his hips; the June 2009 VA examination featured X-ray diagnostic imaging of the Veteran's hips, with no later such X-ray diagnostic imaging having been completed during any subsequent VA examination (the record reflects that the Veteran did not report for X-ray imaging for the hips in connection with the February 2013 VA examination report.) The June 2009 VA examination report (from prior to the pendency of the left hip claim on appeal) shows normal findings for both hips, including on X-ray study and clinical testing, with the exception of "pain" on movement of the left hip. The June 2009 VA examiner included "left hip strain" on the list of diagnoses at that time. Notably, however, this diagnosis of left hip strain pre-dates the pendency of this claim; the claim of entitlement to service connection for a left hip disability was raised by the Veteran in this case in October 2009. Additionally, the Board observes that the notation of left hip strain appears in the June 2009 VA examination report in the context of assessing complaints associated with a service-connected undiagnosed illness manifesting in joint pain, and no objective abnormalities of the left hip were found on diagnostic imaging or clinical testing aside from the Veteran's report of pain. It is significant that during the pendency of this claim, from October 2009 to the present, there is no evidence of a medically diagnosed left hip disability, and the Veteran has denied experiencing any left hip symptomatology. The February 2013 VA examination report clearly and specifically documents that the Veteran's "only joint symptoms are specifically in the left knee and right hip." The February 2013 VA examination report shows a diagnosis of trochanteric bursitis of the right side, with no diagnosis of any left hip disability. There were no symptoms or clinical findings suggesting any impairment of the left hip noted during the February 2013 VA examination. The Veteran's testimony at the June 2014 Board hearing described, consistent with the information in the February 2013 VA examination report, that he understood that "the left hip was fine." Although not entirely clear, it appears that the Veteran otherwise describes that he understands his hip problem to be a right hip impairment due to the pressure placed on his right hip by his keeping weight off of his painful left knee; the Veteran appears to have tried to correct his representative during the presentation in identifying that "the right side" was the hip of concern, when the Veteran noted "the left hip was fine." Notably, this is consistent with the information in the February 2013 VA examination report showing that the Veteran had no left hip complaints at all, but rather had a right hip pain associated with a diagnosed disability of the right hip. The Veteran has not formally withdrawn the claim of entitlement to service connection for a left hip disability, and the Board has considered the claim on the basis of the evidence of record. The Board must conclude that the Veteran's own statements and the medical evidence of record indicate that the Veteran has not had a diagnosed left hip disability during the pendency of this claim on appeal. Accordingly, the claim of entitlement to service connection for a left hip disability must be denied. As it appears that the Veteran's contentions now seek to establish that he has a right hip disability (resulting from a left knee disability which he also believes to be service connected), the Veteran is hereby again notified that there is no claim currently in appellate status before the Board concerning these contentions. If the Veteran wishes to establish entitlement to service connection for a right hip disability and/or for a left knee disability (to the extent distinct from service-connected generalized joint pain due to undiagnosed illness), the Veteran may wish to file a new claim for those benefits. As the Veteran is not shown to have, or at any time during the pendency of this claim to have had, a disability of the left hip, he has not presented a valid claim of service connection for such disability. See Brammer, 3 Vet. App. at 225. Accordingly, the appeal in this matter must be denied. Gilbert, 1 Vet. App. at 56. Increased Rating for Service-Connected Undiagnosed Illness Manifested by Diarrhea Disability ratings are assigned in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from a disability. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher rating will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. With a claim for an increased initial rating, separate "staged" ratings may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In a claim for increase in a previously established rating (as in this case), the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran filed the claim on appeal, seeking an increased disability rating for undiagnosed illness manifested by diarrhea in July 2008. The issue of entitlement to an increased rating requires consideration of a period beginning 1 year prior to the July 2008 claim; thus, the period for consideration begins in July 2007. (The effective date of an award of increased disability compensation shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if the claim is received within one year from such date, otherwise, date of receipt of claim. 38 C.F.R. § 3.400(o)(2).) The Veteran's service-connected undiagnosed illness manifested by diarrhea is currently evaluated as 10 percent disabling under Diagnostic Code 8873-7319 as analogous to irritable colon syndrome. Hyphenated diagnostic codes are used when a rating for a particular disability under one diagnostic code is based upon rating of the residuals of that disability under another diagnostic code. 38 C.F.R. § 4.27. The first four numbers reflect the diagnosed disability. The second four numbers after the hyphen identifies the criteria used to evaluate that disability. Diagnostic Code 8873 is used for tracking purposes when rating an undiagnosed illness for a Persian Gulf War veteran by analogy to one of the gastrointestinal diseases found in VA's Rating Schedule. The provisions of 38 C.F.R. § 4.114, Diagnostic Code 7319, pertain to irritable colon syndrome. A 10 percent rating is assigned for moderate irritable colon syndrome with frequent episodes of bowel disturbance with abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319. A maximum 30 percent rating is assigned for severe irritable colon syndrome with diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. Id. After considering the evidence, the Board finds that resolution of reasonable doubt in the Veteran's favor permits an award of a 30 percent rating for the portion of the period on appeal prior to February 20, 2013, but the evidence preponderates against finding that the criteria for an increased rating have been met during the period from February 20, 2013, onward. A June 2009 VA examination report shows that the Veteran reported that "he has diarrhea and alternating diarrhea and constipation." Furthermore, the Veteran reported that he experiences "abdominal pain located mid abdomen. It occurs more than 2/3[rds] of the year. The abdominal pain has the characteristic of distress and cramps. The symptoms described occur constantly." The Veteran reported that "[o]ver the past 10 years [he] has lost 52 lbs." A February 2013 VA examination report presents the VA examiner's discussion of observations, informed by review of the claims-file, that the Veteran "has given quite variable GI histories over the years." The February 2013 VA examination report notes: "At times he has claimed diarrhea alternating with constipation and cramping pain although he specifically denies those symptoms now." The February 2013 report also presents the Veteran's description of "epigastric pain" that "lasts all night but does not consist of reflux into his throat or substernal burning but is a hunger sensation across the epigastrum and to the right and left," and that the pain "occurs every day and is not relieved by mylanta ...." The report is clear in stating that the "epigastric pain ... occurs at night." The report also indicates that the Veteran "has no constipation." The February 2013 VA examiner discusses that the Veteran's account of significant weight loss over the years since his separation from service is contradicted by the documentation of the Veteran's weight in his contemporaneous medical records, noting that the Veteran was at the time of the examination "far heavier than the 145 pounds he was shortly after he left the service," and further discussing the Veteran's documented increased weight during his post-service years in conflict with the Veteran's statements indicating weight loss and inability to keep on weight. The VA examiner also explained that the Veteran's described "epigastric burning symptom at night is not consistent with any actual GI pathology but may be due to anxiety. Such a symptom is not a feature of irritable bowel syndrome." Additionally, the VA examiner noted that the "loose stool occurs only once a day and is not associated with cramping. It does not sound suspicious for any GI disorder. It is very likely due to his daily intake of mylanta...." The Veteran's June 2014 hearing testimony included his description of symptoms of diarrhea that he described as occurring "maybe biweekly." The Veteran also described that he believed that he has "stomach burning" that he believed to be associated with "ulcer problems." The Veteran testified that he had never been treated by a GI specialist. Reading the pertinent findings of the June 2009 VA examination report together, the Board interprets the June 2009 report as indicating that the Veteran was experiencing alternating diarrhea and constipation with more or less constant abdominal distress for "more than 2/3[rds] of the year," noting that when the symptoms manifested the abdominal pain was experienced "constantly." The report suggests that there is some portion of the year (some unspecified period less than one-third of the year) that the Veteran was not experiencing abdominal distress, and the report indicates that abdominal tenderness was not noted upon direct examination at that time. The Board observes that subsequent evidence of record raises some confusion regarding the details of the Veteran's own report of his symptom history associated with his disability manifested by diarrhea. However, resolving reasonable doubt in the Veteran's favor and noting that the June 2009 VA examination report presents no clear indication that the Veteran's pertinent symptom complaints were inconsistent with the examiner's findings, the Board finds that the June 2009 VA examination report indicates that the Veteran's pattern of symptoms met the criteria for a 30 percent rating most of the time. For the period prior to February 20, 2013, the Board is unable to find sufficiently detailed indications of the timing of the periods during which the Veteran's symptoms did not feature the otherwise "constant" abdominal distress described in the June 2009 VA examination report. Thus, the Board is unable to make an informed determination distinguishing stages with symptoms warranting an increased rating from stages without such symptomatology. Although the evidence is not entirely clear, the Board finds that it can resolve reasonable doubt in the Veteran's favor: the Board finds that a 30 percent rating is warranted for the period prior to February 20, 2013 based upon the indications that the Veteran's symptoms featured alternating diarrhea and constipation with more or less constant abdominal distress during the period prior to February 20, 2013. For the period beginning on February 20, 2013, the date of the February 2013 VA examination report, the pertinent evidence significantly indicates that the Veteran's diarrhea no longer features symptoms meeting the criteria for a rating in excess of 10 percent. The February 2013 VA examination report describes abdominal pain that "occurs at night," and does not otherwise indicate the presence of 'more or less constant' abdominal distress contemplated by the criteria for a rating in excess of 10 percent. The symptoms described at the time of the February 2013 VA examination report of "loose stool occurs only once a day ... not associated with cramping" do not reflect the severe level of symptoms contemplated by the criteria for a rating in excess of 10 percent. The Veteran's testimony at his June 2014 Board hearing also does not describe symptomatology that meets the criteria for a rating in excess of 10 percent. The Veteran's description of "bi-weekly" episodes of diarrhea with "stomach burning" presents no indication of a greater level of severity than the symptoms the Veteran reported during the February 2013 VA examination. That level of severity, featuring abdominal pain at night but not on a 'more or less constant' basis, does not meet the criteria for a rating in excess of 10 percent. In summary, the Board finds that the evidence of record, with resolution of reasonable doubt in the Veteran's favor, permits a finding that the criteria for a 30 percent rating for the Veteran's undiagnosed illness manifested by diarrhea is warranted for the period prior to February 20, 2013. The Board finds that the preponderance of the evidence is against finding that the criteria for a rating in excess of 10 percent is warranted for the period from February 20, 2013 onward. The Board notes that the medical evidence in this case raises some question as to whether the Veteran's diarrhea and abdominal distress during the period on appeal is due to his service-connected disability. However, for the purposes of this analysis, the Board has considered all such symptomatology to be part of the Veteran's service-connected undiagnosed illness manifested by diarrhea. The Court has held that when it is not possible to separate the effects of a service-connected condition and a nonservice-connected condition, the provisions of 38 C.F.R. § 3.102 mandate that reasonable doubt on any issue is to be resolved in the Veteran's favor, and that all signs and symptoms be attributed to the service-connected condition. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER Service connection for a left hip disability is denied. For the period prior to February 20, 2013, a 30 percent rating is granted for the Veteran's service-connected disability manifested by diarrhea, subject to the regulations governing payment of monetary awards. From February 20, 2013, a rating in excess of 10 percent is denied for the Veteran's service-connected disability manifested by diarrhea. REMAND Service Connection for a Disorder Manifested by Fatigue During the pendency of the appeal for service connection for a disorder manifested by fatigue (to include as due to undiagnosed illness), the RO processed a new claim from the Veteran for service connection for sleep apnea, to include as secondary to service-connected PTSD. The RO characterized the sleep apnea issue as a distinct claim from that of entitlement to service connection for a disability manifested by fatigue. A prior October 2010 RO rating decision denied service connection for sleep apnea on the basis that "[t]here is no evidence to show that you have sleep apnea." During the pendency of the appeal for service connection for a disorder manifested by fatigue (to include as due to undiagnosed illness), the RO has recently processed the Veteran's attempts to reopen the prior denial of service connection for sleep apnea as a matter distinct from the undiagnosed illness / fatigue issue on appeal; the RO issued rating decisions denying service connection for sleep apnea in August 2016, November 2016, and March 2017. Significantly, the Veteran submitted a notice of disagreement to initiate a new appeal of this separately adjudicated sleep apnea issue in April 2017. VA's Veterans Appeals Control and Locator System (VACOLS) shows that the RO is currently processing the notice of disagreement and taking steps to readjudicate the issue in connection with the need to issue a statement of the case; these actions remain in progress at this time. Notably, the development of evidence for the sleep apnea claim during the RO adjudication (during the pendency of the appeal before the Board) has produced new evidence indicating that the Veteran has a medical diagnosis of sleep apnea associated with symptoms including fatigue; this new evidence includes VA examination reports and medical opinions developed by the RO in August 2016 and January 2017. The evidence indicating a medical diagnosis of sleep apnea manifesting in fatigue was received and added to the record after the last RO adjudication of the undiagnosed illness / fatigue issue on appeal in March 2016 (the most recent supplemental statement of the case). Evidence regarding a known medical diagnosis responsible for the Veteran's symptoms of fatigue is significantly pertinent to the issue on appeal of entitlement to service connection for fatigue as due to an undiagnosed illness. The sleep apnea issue pending before the RO and the undiagnosed illness / fatigue issue before the Board are inextricably intertwined. Final appellate review of the fatigue service connection issue must be deferred until the appropriate actions concerning the intertwined sleep apnea service connection issue are completed and the matter is either resolved or prepared for appellate review. See Harris v. Derwinski, 1 Vet. App. 180. 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together). The Board has considered that the sleep apnea issue may arguably be currently before the Board as encompassed within the scope of the undiagnosed illness / fatigue issue on appeal, but the Board finds that the most reasonable action at this time is to defer adjudication of the undiagnosed illness / fatigue issue rather than to engage in an unexpected (to the Veteran and to the RO) final appellate review of the sleep apnea issue as part of this appeal. The RO has repeatedly informed the Veteran that the sleep apnea issue is being considered separately, and the RO is currently processing a new adjudication of the sleep apnea issue in preparation for the issuance of a statement of the case. The pending development in the RO's ongoing adjudication of the sleep apnea service connection issue is pertinent to consideration of the undiagnosed illness / fatigue issue on appeal (as is the new medical evidence concerning the Veteran's fatigue added to the claims-file since the most recent supplemental statement of the case in March 2016). For these reasons, the Board shall defer adjudication of the undiagnosed illness / fatigue issue on appeal and remand the issue to the AOJ so that it may be considered together with the inextricably intertwined claim of entitlement to service connection for sleep apnea that is currently pending before the RO. The Board also notes that a January 2017 VA "Chronic Fatigue Syndrome" examination report includes a medical diagnostic finding that the Veteran has suffered from "chronic fatigue syndrome," which is later listed as "Chronic fatigue secondary to sleep apnea, resolved." This is also evidence developed by the RO pertinent to the claim of entitlement to service connection for disability manifested by fatigue, and the RO shall have the opportunity to consider this evidence in an adjudication of the undiagnosed illness / fatigue issue for the first time during the processing of this remand. The Board additionally observes that it further appears that the undiagnosed illness / fatigue issue on appeal also may be intertwined with a claim of entitlement to an increased rating for posttraumatic stress disorder (PTSD) that is also pending at the RO. The PTSD issue was also denied in the March 2017 RO rating decision and was also addressed by the Veteran's April 2017 notice of disagreement. The Veteran's April 2017 notice of disagreement includes an assertion that he suffers from fatigue "related to: PTSD." A January 2017 VA psychiatric examination report lists sleep apnea, and by implication its associated manifestations of fatigue, as "relevant to the understanding or management of the Mental Health Disorder" while attributing concentration and memory problems to the psychiatric impairment. Increased Rating for Undiagnosed Illness Manifested by Joint Pain The Veteran's service-connected undiagnosed illness manifested by joint pain is currently rated under Diagnostic Code 8850-5002 as analogous to rheumatoid arthritis. Significantly, the February 2013 VA examination report specifies, consistent with other indications of record, that "his only joint symptoms are specifically in the left knee and right hip.... He denies diffuse joint pains." The February 2013 VA examiner diagnosed trochanteric bursitis of the right hip, but did not diagnose any specific disability of the left knee. In the pertinent section of the questionnaire, the February 2013 VA examiner answered "No," indicating that the Veteran does not "now have [n]or has [he] ever had a knee and/or lower leg condition." The Board observes that some difficulty in providing a diagnosis resulted from the Veteran failing to report for an indicated diagnostic X-ray study and possibly also by the noted "inconsistent" history provided by the Veteran to the examiner. The VA examiner found: "The knee problem is not consistent with any Gulf War syndrome etiology. It is either degenerative arthritis or it could be an internal derangement of the knee. It is not an 'undiagnosed joint disease' problem in the Gulf War sense." The VA examiner explained that "although the veteran was contacted twice about having the X-rays and he stated he'd had them done, there was no record of his having appeared in the radiology department to have them done and after two calls requesting that he come in to have them done, he did not do so." The examiner noted that "this report is released without that significant piece of information." Additionally, the VA examiner explained that "[t]he veteran was asked to bring in or fax [] outside reports about his knee treatment in the private sector and failed to do so." The February 2013 VA examiner's opinion is essentially to the effect that the Veteran does not have, or no longer has, an undiagnosed illness manifesting in any joint pain. However, the prior June 2009 VA examination report during the period on appeal does not clearly draw the same conclusion, and notably the June 2009 VA examination report had the benefit of review of contemporaneous diagnostic X-ray imaging. The June 2009 VA examination report's diagnostic imaging showed no abnormalities, and the clinical testing of the Veteran's left knee revealed no abnormalities. The June 2009 VA examiner diagnosed "left knee strain" on the basis of the Veteran's complaint of left knee pain without any noted detectable abnormalities. The Court has held that when it is not possible to separate the effects of a service-connected condition and a nonservice-connected condition, the provisions of 38 C.F.R. § 3.102 mandate that reasonable doubt on any issue is to be resolved in the Veteran's favor, and that all signs and symptoms be attributed to the service-connected condition. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Although the June 2009 VA examination findings were cited in the February 2013 VA examiner's expressions of doubt as to the whether the Veteran actually has an undiagnosed illness manifested by joint pain, the Board does not find that the June 2009 VA examination report itself demonstrates that the Veteran's service-connected joint pain due to undiagnosed illness had ceased to exist by the time of the June 2009 examination. The Board must be careful to ensure that the Veteran is not unduly deprived of the benefit of having already established entitlement to service-connection for joint pain due to an undiagnosed illness. The June 2009 VA examination report essentially finds that the Veteran had complaints of left knee pain without any clinical findings to clearly explain the pain. While the June 2009 VA examiner diagnosed a "strain," it did not present any explanation sufficient to persuade the Board that the Veteran's left knee complaints were distinctly attributable to a clear medically diagnosed pathology rather than the Veteran's already-established service-connected undiagnosed illness manifesting in joint pain. Likewise, the Veteran's left hip pain noted in the same June 2009 VA examination report was also diagnosed as "strain" at that time with a reasonably similar lack of persuasive demonstration of any pathology distinct from the joint pain attributable to the service-connected undiagnosed illness (clinical findings and diagnostic imaging were essentially normal for the left hip aside from complaint of pain). If the Board is unable to find that the Veteran's complaints of left knee and left hip pain have been clearly medically distinguished from his service-connected joint pain due to undiagnosed illness throughout the entire period on appeal (based upon the Veteran's filing of the claim for increase in July 2008), then the Board must consider the impairment of the painful joints to complete final appellate review of the Veteran's claim of entitlement to an increased disability rating. The Board finds that, at least for the period prior to the February 2013 VA examination report, the joint pain complaints documented in the June 2009 VA examination report have not been clearly distinguished from the service-connected undiagnosed illness in the evidence of record. Thus, for at least a portion of the period on appeal, informed appellate review requires adequate range of motion information to appropriately assess the extent of joint impairment and apply the applicable rating criteria in this case. Therefore, the Board must consider this case in light of the recent Court decision in Correia v. McDonald, 28 Vet. App. 158 (2016). In Correia, the Court held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include certain range of motion testing whenever possible in cases of joint disabilities. The last sentence of 38 C.F.R. § 4.59 provides that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. The Court further indicated that whether a joint is weight-bearing is a medical question that has to be answered by the examiner, not the adjudicator. The Board concludes that the existing June 2009 and February 2013 VA examination reports' findings do not meet the specifications of Correia. Furthermore, to the extent that the Veteran has reported left knee pain throughout the period on appeal, the differing diagnostic conclusions of the June 2009 and February 2013 VA examiners concerning the left knee reflect either (1) a change in the left knee during the appeal period, or (2) conflicting medical impressions concerning the nature of the Veteran's left knee pain. Even allowing for the fact that the Veteran did not fully cooperate with the February 2013 VA examination, resolution of the uncertainty on this matter appears to be essential to rendering final appellate review. If the left knee disability has changed during the appeal period such that the arthritis or derangement of the knee discussed by the February 2013 VA examiner is a recent development (emerging after the June 2009 VA examination), the emergence of a new left knee disability would not necessarily demonstrate that the previous joint pain due to undiagnosed illness was no longer present; a clarifying medical opinion addressing this matter would be of great assistance to determine whether any extent of current left knee impairment is clearly distinguishable from the service-connected pathology. On the other hand, if the left knee disability has not changed in nature during the appeal period, then a new medical opinion is warranted to reconcile the February 2013 VA examiner's conclusion (that the Veteran's left knee disability is attributable to non-service-connected internal derangement or arthritis) with the June 2009 VA examiner's contrary findings (finding no internal derangement, arthritis, or any other clinical or diagnostic findings aside from 'strain' apparently based upon the Veteran's otherwise unexplained report of pain). For the reasons discussed above, the Board finds that a remand is warranted for a new VA examination with a medical opinion providing the necessary findings and opinion to comply with the Court's holding in Correia and to further clarify / reconcile the key evidence of record pertaining to the joint pain rating issue on appeal. The Court also recently issued a significant opinion addressing whether a VA examiner is permitted to decline to offer an estimate as to additional functional loss during flare-ups if the veteran is not undergoing a flare-up at the time of the examination. In Sharp v. Shulkin, No. 16-1385 (September 6, 2017), the Court recently held that the Board may accept a VA examiner's assertion that he or she cannot offer such an opinion without resort to speculation only after it determines that the examiner's conclusion is not based on the absence of procurable information or on a particular examiner's shortcomings or general aversion to offering an opinion on issues not directly observed. It must be clear that such an opinion is not procurable based on a lack of knowledge among the "medical community at large" and not merely on a lack of expertise, insufficient information, or unprocured testing on the part of the specific examiner. Accordingly, in directing the needed new VA examination in this case, the Board shall also present instructions to ensure compliance with the recent holding in Sharp. Completion of Development Directed by the September 2014 Board Remand The September 2014 Board remand directed that the AOJ should take appropriate steps to attempt to obtain records of the Veteran's reported hospitalization at the Army Medical Hospital associated with Fort Bliss, Texas (possibly described by the Veteran as "Briggs Army Hospital," but the search should proceed for records at the appropriate Army Hospital at Fort Bliss of any name). The reported hospitalization took place in approximately April 1991 and involved treatment of the Veteran's left knee. The September 2014 Board remand also directed that the AOJ should take appropriate steps to attempt to obtain records of the Veteran's reported medical treatment at Walter Reed Army Medical Hospital. The treatment reportedly began in approximately July 1992 and involved treatment and rehabilitation of the Veteran's left knee. Furthermore, the September 2014 Board remand directed that the AOJ should arrange for exhaustive development to secure for the record the complete STRs from the Veteran's Reserve and ACDUTRA service (and specifically reports of all enlistment/periodic examinations for Reserve duty). This should include any necessary steps to verify the Veteran's dates of pertinent Reserve and ACDUTRA service, as well as contacting the Veteran's Reserve unit(s) and all records storage facilities for retired Reserve members of the service. With regard to these records searches, the Board's September 2014 remand directed that if such records are not located, this should be so certified, and the scope of each search must be noted in the record. The claims-file reflects that the AOJ did undertake significant efforts to search for each of the three sets of records discussed above, but resolution of these efforts is not clearly documented in the claims-file (including whether or not the attempts were considered completed with a determination that all reasonable avenues of obtaining the records had been exhausted). Where the remand orders of the Board are not complied with, the Board, as a matter of law, errs when it fails to ensure compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The AOJ shall have the opportunity to ensure compliance with the prior Board remand directives during the processing of this remand. Accordingly, the case is REMANDED for the following action: 1. The AOJ should associate with the claims file any outstanding pertinent treatment records, including additional VA treatment records (such as those that may have been created since the last such update of the claims-file). 2. The AOJ should take appropriate steps to complete the development directed by directives 3, 4, and 5 of the Board's September 2014 remand regarding attempts to obtain: records of treatment at the Army Medical Hospital associated with Fort Bliss, Texas; treatment at Walter Reed Army Medical Hospital; and the complete STRs from the Veteran's Reserve and ACDUTRA service. The final resolution of each of these efforts must be documented in the claims-file (including, if unsuccessful, whether or not the attempts are considered to have been completed with a determination that all reasonable avenues of obtaining the records has been exhausted). 3. After the record is determined to be complete, the AOJ should schedule the Veteran for a new VA examination to determine the severity of his service-connected undiagnosed illness manifested by joint pain. The Veteran should be interviewed and all indicated tests and studies should be accomplished. All findings should be reported in detail. The Veteran's claims folder must be reviewed by the examiner in conjunction with the examination. The examiner is asked to offer responses to the following: a) The examiner should identify and completely describe all current symptomatology associated with the Veteran's service-connected undiagnosed illness manifested by joint pain. The examiner should specifically state range of motion findings for each joint for which the Veteran has joint pain that is not clearly distinguishable from his service-connected undiagnosed illness manifested by joint pain. The examination should record the results of range of motion (1) on BOTH active and passive motion AND (2) in weight-bearing and non-weight-bearing. If the examiner is unable to conduct the required testing he or she should clearly explain why that is so. b) If the examiner determines that any joint pain reported by the Veteran or any associated impairment is attributable to a clearly identifiable known medical diagnosis, entirely distinct from the service-connected undiagnosed illness manifested by joint pain, the examiner is asked to please state this finding and explain the basis for reaching that conclusion. In this regard, please specifically discuss as necessary (1) the February 2013 VA examiner's determination that none of the Veteran's joint pain at that time was associated with the service-connected undiagnosed illness, and (2) prior evidence of record indicating that the Veteran had complaints of joint pain that were not clearly attributable to an known medical diagnosis demonstrated by medical findings (such as, to some extent, the June 2009 VA examination report), and reconcile any conflicting indications to form an opinion regarding the extent to which the Veteran's joint pain complaints are or are not medically distinct from his service-connected undiagnosed illness. The examiner is hereby advised that, for the purposes of this matter, if it is not possible to separate the effects of the service-connected joint pain due to undiagnosed illness from any diagnosed nonservice-connected joint disability, the impairment is to be attributed to the service-connected undiagnosed illness. c) The examiner should also express an opinion concerning whether there would be additional functional impairment of the affected joints on repeated use or during flare-ups (if the Veteran describes experiencing flare-ups). The examiner should assess or estimate the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss. If the Veteran is not having a flare-up when examined, the examiner should determine whether he or she can estimate, given the Veteran's description of symptoms, what his range of motion would be on flare-up. If it is not feasible to offer such an opinion to any degree of medical certainty without resort to speculation, the examiner must provide a specific explanation for why this is so. If such an opinion is not procurable based on a lack of knowledge, then the inability to offer such an opinion must be based on a lack of knowledge among the "medical community at large," and not merely a lack of expertise, insufficient information, or unprocured testing on the part of the examiner. d) The examiner should review the prior VA examination reports of record concerning the Veteran's disability manifested by joint pain (in particular, the June 2009 and February 2013 VA examination reports with testing of the hips and knees). The examiner should attempt to render, if possible to do so without resorting to mere speculation, a retrospective opinion that identifies the ranges of motion of the Veteran's affected joints in active motion, passive motion, weight-bearing, and nonweight-bearing at each time the affected joints were previously examined with range of motion testing for rating purposes. The examiner should also attempt to render, if possible to do so without resorting to mere speculation, a retrospective opinion that identifies the additional functional impairment on repeated use or during flare-ups (in terms of the degree of additional range of motion loss) at each time an affected joint was previously examined with range of motion testing for rating purposes. If it is not possible to provide such opinions / estimations without resorting to mere speculation, the examiner should please so state and provide an explanation as to why such opinions / estimations cannot be given. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. If an opinion cannot be provided without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 4. The AOJ should then review the record and readjudicate the claims remaining on appeal, with attention to the issues currently before the AOJ (including entitlement to service connection for sleep apnea) that are intertwined with the issue of entitlement to service connection for an undiagnosed illness manifested by fatigue being remanded by the Board. If any issue on appeal remains denied to any extent, the AOJ should issue an appropriate supplemental statement of the case, afford the Veteran and his representative an opportunity to respond, and return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ M. C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs