Citation Nr: 1752041 Decision Date: 11/14/17 Archive Date: 11/22/17 DOCKET NO. 10-07 207 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Service connection for muscle and joint aches, to include as a result of an undiagnosed illness. 2. Service connection for headaches, to include as a result of an undiagnosed illness. 3. Service connection for nosebleeds, to include as a result of an undiagnosed illness. 4. Service connection for pre-malignant keratosis on face, arms, and lips, to include as a result of an undiagnosed illness or medically unexplained chronic multisymptom illness. 5. Service connection for chronic fatigue syndrome (CFS), as due to medically unexplained chronic multisymptom illness. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD W. R. Stephens, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1981 to June 1996. He also was a member of the South Carolina Army National Guard. This matter comes before the Board of Veterans' Appeals (Board) from November 2008 and January 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In a decision dated in September 2015, the Board denied the Veteran's appeal of the headaches and nosebleed claims, and he appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In January 2016, the Veteran, through his attorney, and the Secretary of Veterans Affairs, submitted a Joint Motion For Partial Remand (JMPR). In an Order also dated in January 2016, the Court granted the Motion, vacated the September 2015 Board decision in part, and remanded the case to the Board for further appellate review consistent with the JMPR. The September 2015 Board decision remanded Issues 1, 4, and 5 for additional development. In a May 2017 Remand, the Board ordered additional development for each issue now on appeal. FINDINGS OF FACT 1. Muscle and joint pain has been attributed to a known etiology as it is related to the Veteran's service-connected fibromyalgia and is not a symptom of a separate undiagnosed or medically unexplained chronic multisymptom illness. 2. The Veteran's headaches have been attributed to a known etiology as they are the result of tension headaches, and are not a symptom of an undiagnosed or medically unexplained chronic multisymptom illness. 3. Tension headaches were not manifest in service and are not attributable to service. 4. The Veteran's nosebleeds have been attributed to a known etiology as they are the result of allergic rhinitis, and are not a symptom of an undiagnosed or medically unexplained chronic multisymptom illness. 5. Allergic rhinitis was not manifest in service and is not attributable to service. 6. The Veteran's skin disorder has been attributed to a known etiology as it is the result of actinic keratosis, and is not a symptom of an undiagnosed or medically unexplained chronic multisymptom illness. 7. Actinic keratosis was not manifest in service and is not attributable to service. 8. The more probative evidence of record indicates that the Veteran does not have a "qualifying chronic disability" manifested by chronic fatigue syndrome, nor is there any indication that the Veteran has a relevant disability for which service connection can be awarded. CONCLUSIONS OF LAW 1. The criteria for service connection for muscle and joint pain, to include as due to an undiagnosed illness, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2017). 2. The criteria for service connection for a headache disorder, to include as due to an undiagnosed illness, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2017). 3. The criteria for service connection for nosebleeds, to include as due to an undiagnosed illness, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2017). 4. The criteria for service connection for premalignant keratosis, to include as due to an undiagnosed illness, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2017). 5. The criteria for service connection for chronic fatigue syndrome, to include as due to an undiagnosed illness, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duty to Notify and Assist The Veteran's representative suggests in an October 2017 Written Brief Presentation that the most recent VA treatment records included in the claims file date back to February 2014. However, a review of the record indicates that treatment records as recent as 2017 are associated with the file. As such, the Board finds that in this specific regard, the duty to assist has been met. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 (c). Neither the Veteran nor his representative has raised any other issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). II. Service Connection Veterans are entitled to compensation if they develop a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. § 1110 (wartime service), 1131 (peacetime service). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service -the so-called 'nexus' requirement." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). With respect to the issues on appeal, the Veteran has not been diagnosed with a disability identified as a "chronic" disease under 38 U.S.C.A §1101 and 38 C.F.R. § 3.309(a). As a result, the provisions of 38 CFR 3.303 (b) are not applicable. For veterans who served in the Southwest Asia theater of operations during the Persian Gulf War, service connection may also be established for chronic disability that cannot be attributed to a known clinical diagnosis (undiagnosed illness) or for a medically unexplained multisymptom illness (e.g., chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome). See 38 C.F.R. § 3.317. A claimant's signs or symptoms need not be shown by medical evidence; however, some objective indications of disability are required. 38 C.F.R. § 3.317 (a). Objective indications of chronic disability include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317 (b). The Veteran's personnel records indicate that he had active service in the Southwest Asia Theater of Operations during the Persian Gulf War. 38 C.F.R. § 3.317. As a result, the law and regulations pertaining to undiagnosed illness incurred due to Persian Gulf service are applicable in this case. He served as a missile system repair technician and was awarded the Bronze Star Medal for this service. In his June 2008 compensation claim, the Veteran reported exposure to environmental hazards during his service in the Persian Gulf War. Specifically, the Veteran reported exposure to oil fires, munitions fires, and sarin. Muscle and Joint Aches In the Veteran's original July 2008 compensation claim, he sought compensation for muscle aches. In a September 2009 statement, he referenced service connection for fibromyalgia. In a February 2010 statement, the Veteran states that he had never been diagnosed with fibromyalgia and that the problems with his joints and muscles began after he returned home from Iraq. Active duty and National Guard physical examinations in April 1993 and June 1998 are silent for any joint and muscle symptoms. The Board notes that the Veteran was granted service connection for fibromyalgia in an August 2017 rating decision. In order to determine whether the reported muscle and bone pain were symptoms of an undiagnosed illness, the Veteran was afforded a June 2017 VA examination. The examiner explained that the Veteran does not have a muscle injury and that his "muscle aches and joint aches are likely related to [service-connected fibromyalgia]...therefore he does not have a muscle injury and it is less likely related to or incurred in service or related to any exposure event from SW Asia service." There is no evidence that the June 2017 examiner was not competent or credible, and as the opinion is based on the medical evidence of record, the Board finds that it is entitled to significant probative weight concerning the etiology of the claimed muscle and bone pain. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-05 (2008). Furthermore, a review of additional medical evidence of record is not inconsistent with the June 2017 examiner's findings. VA and private treatment records are silent for any notations attributing muscle or bone pain to an undiagnosed illness, other than service-connected fibromyalgia. No additional, separate muscle or bone disability has been diagnosed other than the fibromyalgia. The Board notes the Veteran's assertion that muscle and bone pain began after service in the Gulf War, however, the medical evidence attributing such symptoms to actual pathology and the diagnosed fibromyalgia is far more reliable and credible than statements from a lay informant. Based on the competent and credible evidence of record, the Board finds that the claimed muscle and bone pain have been competently and credibly associated with a known etiology and diagnosis, namely the Veteran's service-connected fibromyalgia, and therefore service connection based on the law and regulations pertaining to undiagnosed illness incurred due to Persian Gulf service is not warranted. 38 C.F.R. § 3.317. The rule against pyramiding states that separate additional ratings are not to be assigned if the symptomatology of one condition is duplicative of the symptomatology of another. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In this case, as the claimed muscle and bone impairment have all been found to be symptoms of the already service-connected fibromyalgia, and therefore to grant service connection and assign ratings for these claimed issues would violate the rule against pyramiding. As such, the Board finds that these issues are fully considered by the currently assigned rating for the fibromyalgia and service connection for them as separate disabilities is not warranted on a direct or presumptive basis. 38 C.F.R. §§ 3.303, 3.307, 3.309. The preponderance of the evidence weighs against a finding that the Veteran's muscle and bone pain are symptoms or manifestations of a medically unexplained or undiagnosed chronic multisymptom illness, and instead shows that the issues are symptoms of an already service-connected fibromyalgia. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. Headaches The Veteran contends that his current headache disorder is the result of his active service, to include his service in the Persian Gulf. At a July 2008 Persian Gulf examination, the Veteran reported that he had experienced headaches for the previous 10 years. Service treatment records do not document any relevant complaints, treatment, diagnosis, or other notation. At an April 1993 in-service examination the Veteran specifically denied frequent or severe headaches in a report of medical history. The Veteran similarly denied frequent or severe headaches at a June 1998 report of medical history while in the National Guard. The head was normal upon physical examination. At a June 2017 VA examination, the examiner noted that the Veteran had a long history of headaches, but that they were not noted in service treatment records. The examiner elaborated that: symptoms seem to be consistent with a chronic tension type headaches as he meets all the criteria except that it is typically unilateral....It is less than likely that his [headaches] are related to or incurred in during service based on the facts that he did not complain of them at the time of exit exam and it was not reported as an issue until 19978 at the earliest....[Tension type headaches] can be seen in increased frequency in patients with [fibromyalgia] but they are not the result of [fibromyalgia]. The heightened sensitivity may be associated with worse symptoms but there is no clear evidence to suggest causal effect. He doe meet the criteria for chronic tension type headaches. It is my opinion that there is not enough evidence to suggest that his [headaches] are part of a medically unexplained multisymptom illness related to service in SW Asia. Therefore it is less than likely that his [headaches] are part of a medically unexplained multisymptom illness related to service in SW Asia. There is no evidence that this examiner was not competent or credible, and as the opinion is based on the medical evidence of record, the Board finds that it is entitled to significant probative weight concerning the etiology of the claimed headaches. Nieves-Rodriguez, supra. Furthermore, a review of additional medical evidence of record is not inconsistent with the June 2017 examiner's findings. A review of the record does not indicate that the Veteran experienced headaches while in active service, as service treatment records document the Veteran specifically denying the presence of headaches and the Veteran himself has stated that his headaches did not begin until at least 1998. There is no evidence suggesting that service connection is warranted for the diagnosed tension type headaches on a direct basis. 38 U.S.C.A. § 1110, 1131. The June 2017 VA examination makes clear that the Veteran's reported headaches are not associated with an undiagnosed illness, and are instead due to diagnosed tension headaches. Additional VA and private treatment records do not contradict this finding. The medical evidence attributing such symptoms to actual pathology and the diagnosed tension headaches is far more reliable and credible than the Veteran's lay statements. Based on the competent and credible evidence of record, the Board finds that the claimed headaches have been competently and credibly associated with a known etiology and diagnosis, namely the diagnosed tension headaches, and therefore service connection based on the law and regulations pertaining to undiagnosed illness incurred due to Persian Gulf service is not warranted. 38 C.F.R. § 3.317. The preponderance of the evidence weighs against a finding that the Veteran's headaches are symptoms or manifestations of a medically unexplained or undiagnosed chronic multisymptom illness, and instead shows that the issues are symptoms of diagnosed tensions headaches, which the evidence does not show to be related to service. 38 U.S.C. § 1110, 1131. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107 (b); Ortiz, supra; Gilbert, supra; 38 C.F.R. § 3.102. For these reasons, the claim is denied. Nosebleeds The Veteran contends that he has experienced frequent nose bleeds in the aftermath of service. He has provided no assertion with respect to their relationship to service. At the July 2008 Persian Gulf examination, the Veteran reported that he had experienced frequent nosebleeds for the past two years, approximately twice per month. Service treatment records do not document any relevant complaints, treatment, diagnosis, or other notation. At an April 1993 in-service examination the Veteran specifically denied any nose trouble in a report medical history. The Veteran similarly denied any nose trouble at a June 1998 report of medical history while in the National Guard. Physical examination at both examinations revealed a normal nose. At a June 2017 VA examination, the examiner noted that the Veteran had a self-reported history of nose bleeds, but that they were not noted in service treatment records. The examiner notes that the Veteran has been diagnosed with allergic rhinitis. The examiner opined that: [The Veteran] may have some intermittent epistaxis that could be related to allergies. There [were no significant] abnormalities on exam today...with no evidence on exam and no other etiologies to explain this condition, it is likely that his epistaxis is related to his [allergic rhinitis]. His symptoms started sometime around 2006....given the state of the symptoms 10 years after [Gulf War] service and likely relation to [allergic rhinitis], it is less than likely that his epistaxis is related to or incurred in service. It is less than likely that his epistaxis is related to any exposure events in [Gulf War] service." There is no evidence that this examiner was not competent or credible, and as the opinion is based on the medical evidence of record, the Board finds that it is entitled to significant probative weight concerning the etiology of the claimed epistaxis, or nosebleeds. Nieves-Rodriguez, supra. Furthermore, a review of additional medical evidence of record is not inconsistent with the June 2017 examiner's findings. A review of the record does not indicate that the Veteran experienced nosebleeds while in active service, as service treatment records document the Veteran specifically denying the presence of nose trouble and the Veteran himself has stated that his nosebleeds did not begin until approximately 2006, pursuant to the 2008 Gulf War examination. Furthermore, service treatment records do not document any complaints, treatment, or diagnosis relevant to the Veteran's diagnosed allergic rhinitis. The Veteran specifically denied any relevant symptoms in the aforementioned in-service examinations. There is no evidence suggesting that service connection is warranted for nose bleeds or the related allergic rhinitis on a direct basis. 38 U.S.C. § 1110, 1131. The June 2017 VA examination makes clear that the Veteran's reported nosebleeds are not associated with an undiagnosed illness, and are instead due to diagnosed to non-service connected allergic rhinitis. Additional VA and private treatment records do not contradict this finding. The medical evidence attributing such symptoms to actual pathology and the diagnosed allergic rhinitis is far more reliable and credible than the Veteran's lay statements. Based on the competent and credible evidence of record, the Board finds that the claimed nosebleeds have been competently and credibly associated with a known etiology and diagnosis, namely the diagnosed and non-service connected allergic rhinitis, and therefore service connection based on the law and regulations pertaining to undiagnosed illness incurred due to Persian Gulf service is not warranted. 38 C.F.R. § 3.317. In making this determination, the Board again notes that the record does not contain any evidence suggesting a link between the Veteran's diagnosed allergic rhinitis and his military service. 38 U.S.C.A. § 1110, 1131. The preponderance of the evidence weighs against a finding that the Veteran's nosebleeds are symptoms or manifestations of a medically unexplained or undiagnosed chronic multisymptom illness, and instead shows that the issues are symptoms of diagnosed non-service connected allergic rhinitis, which the evidence does not show to be related to service. 38 U.S.C.A. § 1110, 1131. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107 (b); Ortiz, supra; Gilbert, supra; 38 C.F.R. § 3.102. For these reasons, the claim is denied. Pre-malignant keratosis The Veteran contends that his claimed skin disorder is related to his active service, to include his service in the Persian Gulf. A June 2008 private treatment record notes that areas of skin from his right cheek, left ear, left forearm, right forearm, and upper lip were removed after they were shown to be premalignant keratoses, or precancerous areas. At the Veteran's most recent June 2017 VA examination, he was diagnosed with actinic keratosis. Service treatment records do not document any relevant complaints, treatment, diagnosis, or other notation. An April 1993 in-service examination reveals normal skin and the Veteran specifically denied any skin disease or relevant symptoms in a report medical history. Skin examination was again normal and the Veteran similarly denied any skin disease or relevant symptoms at a June 1998 examination while in the National Guard. At a June 2017 VA examination, the examiner noted that the Veteran's skin disorder was the "result of sun exposure and it is not possible to know how much sun exposure he has post service....It is less than likely that his actinic keratosis was incurred in or related to active duty service as there is no objective evidence to suggest that it was present then. It is less than likely that his actinic keratosis is related to any exposure events during SW Asia service given the time delay to onset of symptoms and the major risk factor being sun exposure." There is no evidence that this examiner was not competent or credible, and as the opinion is based on the medical evidence of record, the Board finds that it is entitled to significant probative weight concerning the etiology of the claimed skin disorder, diagnosed as actinic keratosis. Nieves-Rodriguez, supra. Furthermore, a review of additional medical evidence of record is not inconsistent with the June 2017 examiner's findings. A review of the record does not indicate that a skin disorder manifested while in active service, as service treatment records document normal skin upon examination and the Veteran specifically denied any skin disease. Skin was clear upon examination at the Veteran's July 2008 Persian Gulf examination. Furthermore, service treatment records do not document any complaints, treatment, or diagnosis relevant to the Veteran's claimed skin disorder or diagnosed actinic keratosis. The Veteran specifically denied any relevant symptoms in the aforementioned in-service examinations. There is no evidence suggesting that service connection is warranted for a skin disorder or the diagnosed actinic keratosis on a direct basis. 38 U.S.C § 1110, 1131. Rather, the evidence suggests that the diagnosed actinic keratosis is the result of post-service sun exposure. The June 2017 VA examination makes clear that the Veteran's reported skin disorder is not associated with an undiagnosed illness, and is instead due to the diagnosed actinic keratosis. Additional VA and private treatment records do not contradict this finding. The medical evidence attributing such symptoms to actual pathology and the diagnosed actinic keratosis is far more reliable and credible than the Veteran's lay statements. Based on the competent and credible evidence of record, the Board finds that the claimed skin disorder has been competently and credibly associated with a known etiology and diagnosis, namely the diagnosed actinic keratosis which is the result of post-service sun exposure, and therefore service connection based on the law and regulations pertaining to undiagnosed illness incurred due to Persian Gulf service is not warranted. 38 C.F.R. § 3.317. In making this determination, the Board again notes that the record does not contain any evidence suggesting a link between the Veteran's diagnosed actinic keratosis and his military service. 38 U.S.C.A. § 1110, 1131. Skin was normal upon examination throughout service and most recently at the Veteran's July 2008 Persian Gulf examination. The preponderance of the evidence weighs against a finding that the Veteran's skin disorder involves symptoms or manifestations of a medically unexplained or undiagnosed chronic multisymptom illness, and instead shows that the issues are symptoms of diagnosed actinic keratosis, which the evidence does not show to be related to service. 38 U.S.C.A. § 1110, 1131. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107 (b); Ortiz, supra; Gilbert, supra; 38 C.F.R. § 3.102. For these reasons, the claim is denied. Chronic Fatigue Syndrome To warrant entitlement to service connection for chronic fatigue syndrome under 38 C.F.R. § 3.317, the evidence must show a condition characterized by chronic or recurrent symptoms. In this case, the most probative medical evidence of record, specifically a June 2017 VA examination, indicates that there have been no objective findings of chronic or recurrent symptoms suggestive of chronic fatigue syndrome. Further, there is no evidence at this time that chronic fatigue syndrome has manifested to a compensable degree. Specifically, the June 2017 VA examiner noted that the Veteran reported a November 2015 diagnosis of chronic fatigue syndrome. The Veteran reported that he easily falls asleep, sleeps about six to seven hours per night, is able to exercise for 30 minutes five days per week without fatigue that lasts more than 24 hours. There were no reported fevers, no disturbance to sleep, and denied pharyngitis or palpable/tender cervical or axillary lymph nodes. There was no medication required. Upon interview and examination, the examiner determined that the Veteran had no findings, signs, or symptoms attributable to chronic fatigue syndrome. The examiner elaborated: "based on my exam/interview, Veteran does not meet the criteria for [chronic fatigue syndrome]. He does not have post-exertional malaise lasting [more than] 24 hours (works after working out), does not have orthostatic intolerance. Therefore, it is less than likely that he has [chronic fatigue syndrome] related to or incurred in service or related to any exposure event during SW Asia service." The Board acknowledges that a VA examiner in December 2009 found no clinical or objective evidence of chronic fatigue syndrome and a November 2015 VA examiner did diagnose chronic fatigue syndrome. However, finds the June 2017 VA examination and determination that the Veteran does not have a diagnosis of chronic fatigue syndrome to be more probative. The November 2015 VA examiner did not review the Veteran's claims file, and instead referred only to VA treatment records. Conversely, the June 2017 VA examiner reviewed the entire claims file. In essence, the Veteran does not exhibit chronic fatigue syndrome that had its clinical onset in service or that is otherwise related to active service. In the absence of proof of a present disability or any complaint related to chronic or recurrent symptoms, there can be no valid claim, including under the provisions allowing service connection based on an undiagnosed illness. 38 C.F.R. § 3.317; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the absence of any competent evidence of chronic fatigue syndrome or documentation of complaints of chronic or recurrent symptoms related to such a disorder, the Board concludes that the Veteran does not currently suffer from such a disability, undiagnosed or otherwise. For these reasons, service connection is not warranted. ORDER Service connection for muscle and joint aches, to include as a result of an undiagnosed illness is denied. Service connection for headaches, to include as a result of an undiagnosed illness is denied. Service connection for nosebleeds, to include as a result of an undiagnosed illness is denied. Service connection for pre-malignant keratosis on face, arms, and lips, to include as a result of an undiagnosed illness or medically unexplained chronic multisymptom illness is denied. Service connection for chronic fatigue syndrome (CFS), as due to medically unexplained chronic multisymptom illness is denied. ____________________________________________ J. W. FRANCIS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs