Citation Nr: 1802097 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 13-29 135 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for memory loss. 2. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for fatigue. 3. Entitlement to service connection for memory loss. 4. Entitlement to service connection for fatigue. 5. Entitlement to service connection for a tension headache condition, to include as due to an undiagnosed illness. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD J. R. Higgins, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from December 30, 1987 to June 8, 1988 and December 1988 to November 1991. This matter is before the Board of Veterans' Appeal (Board) on appeal from rating decisions issued in March 2011 and August 2013 by the Department of Veteran Affairs (VA) Regional Office (RO) in Nashville, Tennessee. This appeal was processed using the Virtual VA/VBMS paperless claim processing system. Accordingly, any future consideration of this Veteran's case should take into account the existence of this electronic record. The issues of entitlement to service connection for memory loss and fatigue are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In a January 1997 rating decision, the RO denied service connection for memory loss and fatigue. The Veteran did not appeal that decision and it became final. 2. Evidence added to the record since the January 1997 rating decision is not cumulative or redundant of the evidence of record at the time of the decision, and raises a reasonable possibility of substantiating the claims of service connection for memory loss and fatigue. 3. A tension headache condition is not shown to be casually or etiological related to an in-service event, injury or disease, or an undiagnosed multisymptom illness. CONCLUSIONS OF LAW 1. The January 1997 rating decision, which denied a claim of entitlement to service connection for memory loss is final. 38 U.S.C. § 7105 (c) (1991); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (1996). 2. New and material evidence has been received since the January 1997 rating decision denying for entitlement to service connection for memory loss. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (a) (2017). 3. The January 1997 rating decision, which denied a claim of entitlement to service connection for fatigue loss is final. 38 U.S.C. § 7105 (c) (1991); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (1996). 4. New and material evidence has been received since the January 1997 rating decision denying for entitlement to service connection for fatigue. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (a) (2017). 5. A tension headache condition was not incurred in or aggravated by service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1137, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. Veterans Claims Assistance Act of 2000 (VCAA) Neither the Veteran nor his representative has raised any 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 a duty to assist argument). 2. New and Material Evidence Pertinent procedural regulations provide that "[n]othing in [38 U.S.C.A. § 5103A] shall be construed to require [VA] to reopen a claim that has been disallowed except when new and material evidence is presented or secured, as described in [38 U.S.C.A. § 5108 ]." 38 U.S.C.A. § 5103A(f). Reopening a claim for service connection which has been previously and finally disallowed requires that new and material evidence be presented or secured since the last final disallowance of the claim. 38 U.S.C.A. § 5108; Evans v. Brown, 9 Vet. App. 273, 285 (1996); see also Graves v. Brown, 8 Vet. App. 522, 524 (1996). New evidence means existing evidence not previously submitted to VA. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). In Elkins v. West, 12 Vet. App. 209 (1999), the Court of Appeals for Veterans Claims (the Court) held the Board must first determine whether the appellant has presented new and material evidence under 38 C.F.R. § 3.156(a) in order to have a finally denied claim reopened under 38 U.S.C.A. § 5108. Then, if new and material evidence has been submitted, the Board may proceed to evaluate the merits of the claim, but only after ensuring that VA's duty to assist has been fulfilled. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). The law should be interpreted to enable reopening of a claim, rather than to preclude it. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Even if no appeal is filed, a rating decision is not final if new and material evidence is submitted within the appeal period and has not yet been considered by VA. 38 C.F.R. § 3.156(b); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011). A. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for memory loss. The Veteran contends that she has presented new and material evidence to reopen her claim of service connection memory loss. Here, the claim of entitlement to service connection for a cognitive disorder (claimed as memory loss) was originally denied in a June 1996 rating decision. The claim was subsequently denied in a January 1997 rating decision. The claim was denied because there was no competent evidence that the Veteran's condition occurred in or was caused by service, nor did it manifest in service or within two years of Persian Gulf service. The Veteran did not appeal that decision and it became final. 38 U.S.C. § 7105 (c) (1991); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (1996). Pursuant to the Veteran's claim to reopen service connection, a March 2011 rating decision, the RO granted the Veteran's application to reopen her claim of service connection for a cognitive disorder (claimed as memory loss) but denied the underlying service connection claim. Although the RO reopened the claim, RO decisions are not binding on the Board and consequently, the Board must decide whether new and material evidence has been received to reopen the Veteran's claim. Jackson v. Principe, 265 F.3d 1366 (Fed. Cir. 2001) (holding that Board reopening is unlawful when new and material evidence has not been submitted). As the January 1997 rating decision is the last final disallowance regarding the claim, the Board must review all of the evidence submitted since that time to determine whether the Veteran's claim should be reopened and readjudicated on a de novo basis. The credibility of the new evidence is presumed for the purpose of determining whether the new evidence is material. Justus, 3 Vet. App. at 512-13. The new evidence includes January 2012 statements from the Veteran's father and husband, and the August 2013 VA examination report. This evidence qualifies as new as it was not of record at the time of the January 1997 rating decision. The Board must now determine whether this evidence also qualifies as material, such that it relates to an unestablished fact necessary to substantiate the Veteran's claim. In undertaking this analysis, the Board notes that the evidence of record prior to the January 1997 rating decision did not establish a nexus between the Veteran's cognitive disorder and military service. As such the Board will analyze the new information of record for evidence to substantiate whether there is a nexus between the Veteran's cognitive disorder and military service. In doing so, the Board finds that the new evidence also qualifies as material, as it raises a reasonable possibility of substantiating the Veteran's claim. 38 C.F.R. § 3.156(a) (2017). The Board notes that the Veteran submitted statements from her father and husband in January 2012. The Veteran's husband provided that since the Veteran returned home from the Gulf War, he has observed issues with the Veteran's memory. He provided that the Veteran was forgetful, and would often forget to turn-off the stove. Moreover, he provided that the Veteran had difficulty communicating with others, maintaining attention and concentration, and following instructions. The Veteran's father also asserted that the Veteran returned home from service in the Gulf War with memory loss complications. Specifically, the Veteran's father provided that the Veteran often lost track of her thoughts during conversations, and easily forgot names of friends and the days of the week. The Board also finds the August 2013 VA examination report as new and material evidence. The examiner provided the Veteran with a diagnosis of early onset dementia. Moreover, the examiner found that the Veteran's cognitive condition was at least as likely as not incurred in or caused by Veteran's military service. The Board finds that aforementioned evidence raises a reasonable possibility of substantiating the Veteran's claim because it establishes a connection between the Veteran's cognitive disorder and her military service. As the above reports are presumed credible for the limited purpose of reopening the claim, the Board finds that it qualifies as material. See Justus, 3 Vet. App. at 512-1. Therefore, the Board finds that new and material evidence is of record since the prior final denial of this claim in January 1997. Shade, 24 Vet. App. at 117. The claim of entitlement to service connection for a cognitive disorder is thus reopened. B. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for fatigue The Veteran contends that she has presented new and material evidence to reopen her claim regarding entitlement to service connection for fatigue. The question for the Board is whether the Veteran has presented new and material to reopen her claim of service connection for fatigue. Here, the claim of entitlement to service connection for fatigue was originally denied in a June 1996 rating decision. The Veteran appealed that decision, and the claim was denied again in January 1997. The claim was denied because there was no competent evidence that the Veteran's condition occurred in or was caused by service despite the one time treatment for fatigue in service. The Veteran did not appeal that decision and it became final. The Veteran did not appeal that decision and it became final. 38 U.S.C. § 7105 (c) (1991); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (1996). Pursuant to the Veteran's claim to reopen service connection, a March 2011 rating decision, the RO granted the Veteran's application to reopen her claim of service connection for fatigue but denied the underlying service connection claim. Although the RO reopened the claim, RO decisions are not binding on the Board and consequently, the Board must decide whether new and material evidence has been received to reopen the Veteran's claim. Jackson v. Principe, 265 F.3d 1366 (Fed. Cir. 2001) (holding that Board reopening is unlawful when new and material evidence has not been submitted). As the January 1997 rating decision is the last final disallowance regarding the claim, the Board must review all of the evidence submitted since that time to determine whether the Veteran's claim should be reopened and readjudicated on a de novo basis. The credibility of the new evidence is presumed for the purpose of determining whether the new evidence is material. Justus, 3 Vet. App. at 512-13. The new evidence includes the January 2012 statements from the Veteran's father and husband. This evidence qualifies as new as it was not of record at the time of the January 1997 rating decision. The Board must now determine whether this evidence also qualifies as material, such that it relates to an unestablished fact necessary to substantiate the Veteran's claim. In undertaking this analysis, the Board notes that the evidence of record prior to the January 1997 rating decision did not establish a nexus between the Veteran's fatigue condition and military service. As such the Board will analyze the new information of record for evidence to substantiate whether there is a nexus between the Veteran's fatigue condition and military service. In doing so, the Board finds that the new evidence also qualifies as material, as it raises a reasonable possibility of substantiating the Veteran's claim. 38 C.F.R. § 3.156(a) (2017). The Board notes that Veteran submitted statements from her father and husband in January 2012. The Veteran's husband provided that since the Veteran returned home from service, she has complained of excessive fatigue. The Veteran's husband stated that, "there are many days that she (the Veteran) cannot get out of bed at all. Her fatigue is intense." Moreover, he provided that the Veteran's quality life has declined due to her chronic fatigue. The Veteran's father also provided that the Veteran has been constantly tired since returning home from service. He stated that the Veteran was full of energy prior to military service. The Board finds that aforementioned evidence raises a reasonable possibility of substantiating the Veteran's claim because it establishes a connection between the Veteran's fatigue and her military service. As the above reports are presumed credible for the limited purpose of reopening the claim, the Board finds that it qualifies as material. See Justus, 3 Vet. App. at 512-1. Therefore, the Board finds that new and material evidence is of record since the prior final denial of this claim in January 1997. Shade, 24 Vet. App. at 117. The claim of entitlement to service connection for fatigue is thus reopened. 3. Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may be awarded on a presumptive basis to a Persian Gulf veteran who (1) exhibits objective indications; (2) of a chronic disability such as those listed in 38 C.F.R. § 3.317(b) (including fatigue and headaches); (3) which became manifest either during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10% or more not later than December 31, 2016; and (4) such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. Gutierrez v. Principi, 19 Vet. App. 1, 7 (2004); 38 U.S.C. § 1117; 38 C.F.R. § 3.317; 76 Fed. Reg. 81834-81836 (Dec. 29, 2011). A "Persian Gulf veteran" is one who served in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e)(1). The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e)(2). The United States Congress has defined the Persian Gulf War as beginning on August 2, 1990, the date that Iraq invaded the country of Kuwait, through a date to be prescribed by Presidential proclamation of law. 38 C.F.R. § 3.2(i). The Veteran's records show that she had service in Southwest Asia from January 1991 to May 1991. Therefore, the Veteran had active service in the Southwest Asia Theater of operations during the Persian Gulf War. The term "qualifying chronic disability" means a chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, or functional gastrointestinal disorders (excluding structural gastrointestinal disease). 38 C.F.R. § 3.317(a)(2)(i). The Veteran contends that her tension headache condition is related to her military service. In the present case, the Board first finds competent evidence of a current disability. The Veteran was diagnosed with tension headaches in 2012. See February 2012 VA Examination. Accordingly, the Board finds that the first element of service connection has been met. The Board also finds that competent and credible evidence of in-service incurrence or aggravation of an injury of disease. The Veteran served in the Gulf War from about 1990 to 1991. The Veteran stated that she was exposed to thick black smoke from burning oil wells, which contained harmful chemicals that the Veteran contends is related to her current disability. It follows that her lay statements are sufficient to show the occurrence of hazardous environmental hazards during service as they are consistent with the circumstances of her service. See 38 U.S.C.A. § 1154 (b); 38 C.F.R. § 3.304 (d). Turning to the question of whether there is a nexus, or link, between the current shown disability and service, the Board finds that the preponderance of the evidence is against finding that the Veteran's tension headache condition was caused or aggravated by her military service. The Veteran's STRs are absence of any complaints, treatment, diagnosis, or injury in service related to tension headaches. The Veteran's VA medical treatment records noted complaints of tension headaches beginning in 2010. The Veteran underwent a VA examination related to her tension headache condition in February 2012. The examiner confirmed the Veteran's 2010 diagnosis of tension headaches upon examination. The examiner noted that the Veteran reported that headaches began a year before and denied any head injury or trauma. The Veteran described the headaches as pulsating of throbbing pain on both sides of her head. Nausea was associated with the Veteran's condition. The examiner concluded that the Veteran's tension headache condition was less likely than not incurred in or caused by the Veteran's military service. The examiner provided that Veteran headaches started in 2010, which was 19 years after active duty service. Moreover, the examiner asserted that the Veteran's STRs "contained no clinical documentation to support a diagnosis, complaint, or treatment for a headache condition during her military service." In August 2013 the Veteran was afforded a VA examination to ascertain whether her tension headache condition was related to service or Gulf War Syndrome. The examiner opined that the Veteran's tension headache condition was less likely than not incurred in or caused by her military service. The examiner cited the length of time between the complaints of headaches and her discharge of service, which was nineteen (19) years as justification for the medical opinion. Moreover, the examiner asserted that the Veteran's STRs "contained no clinical documentation to support a diagnosis, complaint, or treatment for a headache condition during her military service." With regards to whether the Veteran's condition is related to her Southwest Asia service, the examiner opined that since the Veteran's tension headache condition "is a disease with a clear and specific etiology and diagnosis not related to any specific exposure event experience by the Veteran during service in Southwest Asia," therefore the Veteran's tension headache condition is not related to any undiagnosed illness. When assessing the probative value of a medical opinion, the access to the claims file and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean, 13 Vet. App. at 448-9. Claims file review, as it pertains to obtaining an overview of a claimant's medical history, is not a requirement for medical opinions. A medical opinion that contains only data and conclusions has reduced probative weight. Further, a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez, 22 Vet. App. at 304. In this case, as to the issue of whether the Veteran's tension headache condition is related to her military service, the Board finds that the August 2013 VA examination report is the most probative evidence of record as it was definitive, based upon a complete review of the Veteran's entire claims file, in consideration of the Veteran's reported history, and contemporaneous physical evaluation of the Veteran. Furthermore, the examiner provided a complete and thorough rationale in support of his opinion. The examiner based his opinion on review and evaluation of the record; and he provided rationale for his findings. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board has considered the Veteran's contention that her tension headache condition is due to her military service. In this regard, the Veteran is competent to report the symptoms that she experienced and her history of treatment. See Charles v. Principi, 16 Vet. App. 370, 374- 75 (2002). However, the Veteran, as a lay person, has not been shown to be capable of making medical conclusions, especially as to a complex medical diagnosis and/or opinion regarding the etiology of a tension headache disability and whether her headaches are related to an unexplained chronic multisymptom illness. Given the Veteran's lack of demonstrated medical expertise, the Board finds that the opinion of the August 2013 VA examiner, a medical professional, to be the most probative evidence of record as to the current nature and etiology of her tension headache condition and its relationship to her military service. This opinion ultimately outweighs the Veteran's lay contentions. See Jandreau, 492 F.3d at 1372. (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions); see also Layno v. Brown, 6 Vet. App. 465 (1994) (cautioning that lay testimony that the Veteran suffered a particular illness (bronchial asthma) was not competent evidence because matter required medical expertise). Moreover, the presumption for the Gulf War veterans is not warranted in this case because as mentioned above by the August 2013 VA examiner, the Veteran's tension headache condition "is a disease with a clear and specific etiology and diagnosis not related to any specific exposure event experience by the Veteran during service in Southwest Asia." 38 C.F.R. § 3.317. Therefore, the Veteran diagnosed tension headache condition is not related to any unexplained chronic multisymptom illness. ORDER New and material evidence having been received, the Veteran's claim for entitlement to service connection for memory loss is reopened, and to that extent only, the appeal is granted. New and material evidence having been received, the Veteran's claim for entitlement to service connection for fatigue is reopened, and to that extent only, the appeal is granted. Entitlement to service connection for a tension headache condition is denied. REMAND Although the Board has reopened the claims for entitlement to service connection for memory loss and fatigue, further development is necessary before a decision can be made on the merits. With regards to the Veteran's claim of service connection for memory loss, the Board finds the most recent VA examination reports are inadequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The August 2013 VA examination report provided that the Veteran's dementia was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. Subsequently, the September 2013 examiner noted that Veteran received a diagnosis of early onset dementia. However, the examiner opined that "it is (was) less likely than not that her complaints (of memory loss) in 1994 were an initial manifestation of ones that were recently diagnosed as dementia NOS, early onset." The examiner provided that the Veteran had a recent onset of memory complaints in December 2010. The Board finds that the current evidence is inadequate because the examiner does not take into account the lay evidence of record; the Veteran has consistently reported complaints regarding memory loss since discharge from service with an onset of August 1991. Also, the May 1994 VA examination documented the Veteran's complaints of memory loss. Moreover, the Veteran has submitted statements from her father and husband that support her assertion that memory loss has been a constant problem for her since discharge from service. Therefore, the Board finds that an addendum medical opinion is necessary to address the aforementioned concerns regarding the Veteran's claim for service connection for memory loss. Turning to the Veteran's claim for service connection for fatigue, the Board notes that the Veteran was afforded a VA examination in April 1994 that acknowledged the Veteran's persistent fatigue. However, the examiner did not provide a diagnosis, or an etiological opinion for her fatigue condition. The Board finds the April 1994 VA examination report is inadequate due to the failure to provide a medical opinion. Since then, the Veteran has continued to report issues with chronic fatigue. See September 2012 VA Medical Records. The Veteran's father and husband have submitted statements describing the Veteran's issues with chronic fatigue since discharge from service. Thus, the Board finds that a new examination is warranted. Barr, 21 Vet. App. at 303. On remand, the RO should contact the Veteran to determine whether there are any outstanding VA and private treatment related to her claims. Accordingly, the case is REMANDED for the following actions: 1. Contact the Veteran and ascertain if she has received any VA, private, or other medical treatment, pertinent to the claims on appeal, that is not evidenced by the current record, to specifically include, but not limited to, any VA medical records related to treatment for any cognitive disorder, to include dementia, or her chronic fatigue condition. The Veteran must be provided with the necessary authorizations for the release of any private treatment records not currently on file. The AOJ must then obtain these records, as well as any other pertinent records, and associate them with the claims folder. If the AOJ is unsuccessful in obtaining any medical records identified by the Veteran, it must inform him and provide him an opportunity to submit copies of the outstanding medical records. 2. After the foregoing development, obtain an addendum opinion from the examiner who conducted the September 2013 examination or other similarly qualified examiner. If an evaluation is deemed necessary by the examiner, one shall be provided. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. An explanation for all opinions expressed must be provided. Is it at least as likely as not (i.e., a 50 percent probability) that the Veteran's memory loss had its onset during service, or is otherwise related to service, to include exposure to environmental hazards consistent with her service in Southwest Asia? For any complaints of memory loss not attributable to a clinical diagnosis, are there objective indications of a chronic disability that are at least as likely as not ( 50 percent probability or greater) resulting from an undiagnosed illness or medically unexplained multisymptom illness? The examiner should note that the record reflects an onset of memory loss complaints predating 2010. Specifically, the examiner should consider the lay statements that contend that the Veteran has suffered from memory complaints since discharge and the May 1994 VA examination that documented the Veteran's complaints of memory loss. A detailed rationale supporting the examiner's opinion must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. Provide the Veteran with a VA examination to determine the etiology of fatigue. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and lay statements. The examiner must elicit a full medical history from the Veteran. The examiner must address the following inquiries: Provide the diagnosis for any conditions related to fatigue during the appeal period. Is it at least as likely as not (i.e., a 50 percent probability) that the Veteran's fatigue had its onset during service, or is otherwise related to service, to include exposure to environmental hazards consistent with his service in Southwest Asia? In offering such opinion, the examiner should consider the Veteran's statement that she has suffered from fatigue since service. For fatigue not attributable to a clinical diagnosis, are there objective indications of a chronic disability that are at least as likely as not ( 50 percent probability or greater) resulting from an undiagnosed illness or medically unexplained multisymptom illness? The examiner should consider the lay testimony of record. Specifically, the examiner should consider the statements by the Veteran, her husband, and her father concerning an onset of chronic fatigue since discharge from service. A detailed rationale supporting the examiner's opinion must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 4. After completing the above, readjudicate the issues on appeal. If the benefits sought on appeal remain denied, provide an additional supplemental statement of the case to the Veteran and her representative, and return the appeal to the Board for appellate review, after the Veteran and her representative have had an adequate opportunity to respond. The Veteran has the right to submit additional evidence and argument on the 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). ______________________________________________ LANA K. JENG Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs