Citation Nr: 1802282 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 16-60 393 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for chronic fatigue. 3. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a sciatic disorder. 4. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a miscarriage disorder. 5. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a disorder manifested by tumors. 6. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for residuals of a tumor removed from the abdomen. 7. Entitlement to service connection for adjustment disorder, with mixed anxiety and depressed mood. 8. Entitlement to service connection for insomnia. 9. Entitlement to service connection for degenerative arthritis of the cervical spine. 10. Entitlement to service connection for a pain disorder, to include fibromyalgia and chronic pain syndrome. 11. Entitlement to service connection for a skin disorder, to include idiopathic guttate hypomelanosis. 12. Entitlement to service connection for a gastrointestinal disorder, to include irritable bowel syndrome. 13. Entitlement to service connection for a menstrual disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Behlen, Associate Counsel INTRODUCTION The appellant served in the Army Reserve, with periods of active duty from June 18, 1985, to August 22, 1985; November 17, 1990, to May 29, 1991; and January 17, 2003, to February 9, 2003, including service in the Southwest Asia theater of operations during the Gulf War. This matter comes before the Board of Veterans' Appeals (Board) from a February 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The appellant filed a timely Notice of Disagreement (NOD), received in February 2014. A Statement of the Case (SOC) was issued in October 2016. A timely substantive appeal was received in December 2016. The appellant was afforded a Central Office hearing before the undersigned in October 2017. A transcript is of record. During the hearing, the appellant appeared to raise the issue of entitlement to service connection for a gallbladder disorder, to include gallstones. The appellant and her representative are advised that, effective March 24, 2015, VA amended its regulations to require that all claims governed by VA's adjudication regulations be filed on a standard form. See 79 Fed. Reg. 57,660 (Sept. 25, 2014), codified as amended at 38 C.F.R. §§ 3.151, 3.155. Should the appellant wish to file a claim of entitlement to service connection for such disability, she and her representative should file the claim with the RO on the proper form. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issues of entitlement to service connection for chronic fatigue, PTSD, insomnia, adjustment disorder with mixed anxiety and depressed mood, a skin disorder, to include idiopathic guttate hypomelanosis, and a pain disorder, to include fibromyalgia and chronic pain syndrome, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. A March 2003 rating decision denied service connection for chronic fatigue. The appellant was duly notified of the RO's determination and her appellate rights but she did not appeal within the applicable time period, nor was new and material evidence received in the year following notification of the decision. 2. Evidence received since the final March 2003 rating decision denying service connection for chronic fatigue relates to an unestablished fact necessary to substantiate the claim and, presuming its credibility, raises a reasonable possibility of substantiating the claim. 3. An April 2011 rating decision denied service connection for PTSD, miscarriage, sciatic pain, residuals of tumor removal from neck with recurring tumors, residuals of tumor removal from abdomen, recurring tumor of stomach, and recurring tumor of left buttock. The appellant was duly notified of the RO's determination and her appellate rights but she did not appeal within the applicable time period, nor was new and material evidence received in the year following notification of the decision. 4. Evidence received since the final April 2011 rating decision denying service connection for PTSD relates to an unestablished fact necessary to substantiate the claim and, presuming its credibility, raises a reasonable possibility of substantiating the service connection claim for PTSD. 5. Evidence received since the final April 2011 rating decision denying service connection for a sciatic disorder is cumulative, does not relate to an unestablished fact necessary to substantiate the claim, and does not raise a reasonable possibility of substantiating the claim. 6. Evidence received since the final April 2011 rating decision denying service connection for a miscarriage disorder is cumulative, does not relate to an unestablished fact necessary to substantiate the claim, and does not raise a reasonable possibility of substantiating the claim. 7. Evidence received since the final April 2011 rating decision denying service connection for residuals of tumor removal from neck with recurring tumors, residuals of tumor removal from abdomen, recurring tumor of stomach, and recurring tumor of left buttock relates to an unestablished fact necessary to substantiate the claim and, presuming its credibility, raises a reasonable possibility of substantiating the service connection claims for a disorder manifested by tumors and residuals of a tumor removed from the abdomen. 8. The appellant does not have a disorder manifested by tumors which was caused by or incurred during active service, to include service in the Persian Gulf. 9. The appellant does not have residuals of a tumor removed from the abdomen which were caused by or incurred during active service, to include service in the Persian Gulf. 10. A cervical spine disability, to include degenerative arthritis, was not incurred in active service and cervical spine degenerative arthritis may not be presumed to have been incurred in active service. 11. The appellant does not have a gastrointestinal disorder, to include irritable bowel syndrome, which was caused by or incurred during active service, to include service in the Persian Gulf. 13. The appellant does not have a menstrual disorder which was caused by or incurred during active service, to include service in the Persian Gulf. CONCLUSIONS OF LAW 1. The March 2003 rating decision denying service connection for chronic fatigue is final. 38 U.S.C. § 7105(c) (2000); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2002). 2. New and material evidence has been received to warrant reopening of the claim of service connection for chronic fatigue. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The April 2011 rating decision denying service connection for PTSD, miscarriage, sciatic pain, residuals of tumor removal from neck with recurring tumors, residuals of tumor removal from abdomen, recurring tumor of stomach, and recurring tumor of left buttock is final. 38 U.S.C. § 7105(c) (2006); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2010). 4. New and material evidence has been received to warrant reopening of the claim of service connection for PTSD. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156 (2017). 5. New and material evidence has not been received to warrant reopening of the claim of service connection for a sciatic disorder. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156 (2017). 6. New and material evidence has not been received to warrant reopening of the claim of service connection for a miscarriage disorder. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156 (2017). 7. New and material evidence has been received to warrant reopening of the claim of service connection for a disorder manifested by tumors. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156 (2017). 8. New and material evidence has been received to warrant reopening of the claim of service connection for residuals of a tumor removed from the abdomen. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156 (2017). 9. The criteria for entitlement to service connection for a disorder manifested by tumors have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.317 (2017). 10. The criteria for entitlement to service connection for residuals of a tumor removed from the abdomen have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2017). 11. The criteria for entitlement to service connection for a cervical spine disability, to include degenerative arthritis, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.317 (2017). 12. The criteria for entitlement to service connection for a gastrointestinal disorder, to include irritable bowel syndrome, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2017). 13. The criteria for entitlement to service connection for a menstrual disorder have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) During the October 2017 hearing, the appellant's representative indicated that it appeared that the appellant's VA medical records associated with the claims file were incomplete. However, since the hearing, the appellant and her representative have submitted copies of additional VA medical records. Based upon the dates provided by the appellant during the hearing regarding when she was seen at VA medical facilities in Tennessee, New York, and Virginia, such appear to now be complete. The appellant and her representative have not contended otherwise. Also during the hearing, it was noted that the appellant had applied for, but did not participate in, vocational rehabilitation or the Veterans Retraining Assistance Program (VRAP). There is no indication that such records would be relevant to the claims before the Board. Thus, a remand to obtain any such records would only serve to delay this matter with no benefit to the appellant. 38 U.S.C § 5103A(c); 38 C.F.R. § 3.159(c); McGee v. Peake, 511 F.3d 1352, 1357 (Fed. Cir. 2008) (noting that Congress has explicitly defined VA's duty to assist in terms of relevance). Neither the appellant nor her 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 a duty to assist argument). II. Applicable Law A. Standard of Proof The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). "It is in recognition of our debt to our veterans that society has [determined that,] [b]y tradition and by statute, the benefit of the doubt belongs to the veteran." See Gilbert, 1 Vet. App. at 54. B. New and Material Evidence In general, decisions of the RO and the Board that are not appealed in the prescribed time period are final. See 38 U.S.C. 7104, 7105; 38 C.F.R. §§ 3.104, 20.1100, 20.1103. Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. For claims such as this one, filed on or after August 29, 2001, new evidence means existing evidence not previously submitted to agency decision makers. 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. To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, the credibility of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary's duty to assist. Id. at 118; but see Villalobos v. Principi, 3 Vet. App. 450 (1992) (evidence that is unfavorable to a claimant is not new and material). C. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. § 1110. "To establish a right to compensation for a present disability, 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." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including arthritis, an organic disease of the nervous system, peptic ulcers, and malignant tumors, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). i. Gulf War Disabilities VA will pay compensation to a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that manifest "during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War" or to a degree of 10 percent or more before December 31, 2021. 38 U.S.C. § 1117; see 38 C.F.R. § 3.317(a); 81 Fed. Reg. 71,382-84 (Oct. 17, 2016) (extending the presumptive period for compensation for Gulf War veterans from December 31, 2016 to December 31, 2021). A qualifying chronic disability is as a chronic disability that results from an undiagnosed illness or a medically unexplained chronic multisymptom illness such as chronic fatigue syndrome, fibromyalgia, or a functional gastrointestinal disorder (excluding structural gastrointestinal diseases). 38 C.F.R. § 3.317(a)(2)(i). A "medically unexplained chronic multisymptom illness" has been defined as 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." 38 C.F.R. § 3.317(a)(2)(ii). "Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained." Id. Along with the three examples of a medically unexplained chronic multisymptom illness provided by section 1117(a)(2)(B), Congress has provided a list of signs or symptoms that may be a manifestation of a medically unexplained chronic multisymptom illness that includes: skin symptoms, headaches, muscle pain, joint pain, neurologic symptoms, neuropsychological symptoms, respiratory system symptoms, sleep disturbances, gastrointestinal symptoms, cardiovascular symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C. § 1117(g); 38 C.F.R. § 3.317(b). III. Analysis A. New and Material Evidence In a March 2003 rating decision, the RO denied service connection for chronic fatigue because there was no evidence of a diagnosis of, or treatment for, chronic fatigue or any other chronic illness that could be related to service in Southwest Asia. The appellant was duly informed of this decision in a March 2003 letter, but she did not perfect an appeal within the applicable time period, nor was new and material evidence received within one year of the letter. Thus, the determination is final. In an April 2011 rating decision, the RO denied service connection for (1) PTSD because there was no current diagnosis; (2) miscarriages because there was no evidence of the claimed disability and because the condition in and of itself was not compensable unless caused by a disease or disability; (3) sciatic pain because there was no evidence of a current disability and pain alone is not a diagnosed disability subject to service connection; (4) residuals of tumor removal from neck with recurring tumors because there was no link to service; (5) residuals of tumor removal from abdomen because there was no link to service; (6) recurring tumor of stomach because there was no link to service; and (7) recurring tumor of left buttock because there was no evidence of a current disability. The appellant was duly informed of these decisions in a May 2011 letter, but she did not perfect an appeal within the applicable time period, nor was new and material evidence received within one year of the letter. Thus, the determination is final. The appellant now seeks to reopen these previously denied claims. Despite the finality of a prior adverse decision, a claim will be reopened and the former disposition reviewed if new and material evidence is presented or secured with respect to the claim which has been disallowed. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. i. Chronic fatigue In order to determine whether new and material evidence has been received, the Board has reviewed the entire record, with particular attention to the additional evidence received since the last final rating decision in March 2003. That evidence includes the appellant's March 2013 statement that she experiences chronic fatigue and her October 2017 testimony regarding experiencing chronic fatigue which she attributed to insomnia. This evidence is new, as the evidence before the RO at the time of its March 2003 rating decision did not include a current diagnosis. Further, presuming its credibility, it is material, as it relates to an unestablished fact necessary to substantiate the claim. Service connection was denied, in part, because there was no current disability manifested by chronic fatigue. The Board finds that this additional evidence, when presumed credible, relates to unestablished facts necessary to substantiate the claim and triggers VA's duty to provide a medical examination. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006) (discussing the four elements to consider in determining whether a VA medical examination should be provided). Under these circumstances, the Board finds that new and material evidence has been presented. Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010). Accordingly, the Board finds that the appellant's previously denied claim for service connection for chronic fatigue is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Although the record is sufficient to warrant reopening of the claim, it is not sufficient to allow the grant of the benefits sought. Once a claim is reopened, the statutory duty to assist is triggered. See 38 U.S.C. § 5103. For reasons explained below, additional development is necessary before the Board may proceed with a decision on the merits. ii. PTSD In order to determine whether new and material evidence has been received, the Board has reviewed the entire record, with particular attention to the additional evidence received since the last final rating decision in April 2011. That evidence includes a private October 2013 PTSD diagnosis. This evidence is new, as the evidence before the RO at the time of its April 2011 rating decision did not include a current diagnosis of PTSD. Further, presuming its credibility, it is material, as it relates to an unestablished fact necessary to substantiate the claim. Service connection was denied, in part, because there was no current diagnosis of PTSD. The Board finds that this additional evidence, when presumed credible, relates to unestablished facts necessary to substantiate the claim and triggers VA's duty to provide a medical examination. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006) (discussing the four elements to consider in determining whether a VA medical examination should be provided). Under these circumstances, the Board finds that new and material evidence has been presented. Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010). Accordingly, the Board finds that the appellant's previously denied claim for service connection for PTSD is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Although the record is sufficient to warrant reopening of the claim, it is not sufficient to allow the grant of the benefits sought. Once a claim is reopened, the statutory duty to assist is triggered. See 38 U.S.C. § 5103. For reasons explained below, additional development is necessary before the Board may proceed with a decision on the merits. iii. Sciatic disorder In order to determine whether new and material evidence has been received, the Board has reviewed the entire record, with particular attention to the additional evidence received since the last final decision in April 2011. After reviewing the record, the Board finds that the additional evidence received is not new and material within the meaning of 38 C.F.R. § 3.156. The additional evidence received since the final April 2011 rating decision includes the appellant's statements and testimony, the report of a February 2013 VA examination, and additional VA medical records. The Board finds that such evidence is cumulative of the evidence of record at the time of the prior final denial of the claim. Thus, the Board concludes that this evidence is not new and material. 38 C.F.R. § 3.156. The evidence of record at the time of the April 2011 rating decision included the appellant's statements that she experienced sciatic-type pain. Nonetheless, the RO denied service connection for a sciatic disorder because there was no evidence of a current disability. Pain alone, without a showing that the pain derives from an in-service disease or injury, is not a disability for which service connection can be granted. Sanchez-Benitez v. Principi, 259 F.3d 1356, 1362 (Fed. Cir. 2001). Like the appellant's statements that she experiences sciatic-type pain, the clinical evidence received since the prior final denial of the claim is cumulative of that previously considered by the RO. The additional clinical evidence received notes complaints of pain in the buttocks, primarily on the right side, which sometimes shoots down the thigh. Again, these reported symptoms were previously considered by the RO. The additional clinical evidence, however, continues to lack any indication of a sciatic disorder or other disability producing the appellant's reported pain. In that regard, the Board notes that the appellant was afforded a February 2013 VA examination at which the examiner found that there were no objective findings or pathology which would support a diagnosis of low back disorder, sciatic disorder, lumbar radiculopathy, or other disability. Although this examination report is new, and contains information material to the claim, it cannot serve to reopen it as it is unfavorable to the appellant. See Villalobos v. Principi, 3 Vet. App. 450 (1992) (evidence that is unfavorable to a claimant is not new and material). In summary, the record continues to lack any indication of a current disability manifested by sciatic pain that is causally related to service or any incident therein. The additional lay and clinical evidence does not relate to an unestablished fact necessary to substantiate the claim, nor would it trigger VA's duty to assist. 38 C.F.R. § 3.156. For these reasons, the Board finds that the additional evidence received since the final April 2011 rating decision is not new and material under the meaning of 38 C.F.R. § 3.156(a). Consequently, the Board finds that new and material has not been received and the claim of service connection for sciatic disorder is not reopened. In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). iv. Miscarriage disorder In order to determine whether new and material evidence has been received, the Board has reviewed the entire record, with particular attention to the additional evidence received since the last final decision in April 2011. After reviewing the record, the Board finds that the additional evidence received is not new and material within the meaning of 38 C.F.R. § 3.156. The additional evidence received since the final April 2011 rating decision includes the appellant's statements, the report of a February 2013 VA examination and additional VA medical records. The Board finds that such are cumulative and redundant of the evidence of record at the time of the prior final denial of the claim or do not otherwise provide a basis upon which to reopen the claim. Thus, the Board concludes that this evidence is not new and material. 38 C.F.R. § 3.156. The evidence of record at the time of the April 2011 rating decision included the appellant's statements of a history of miscarriage. The RO denied the claim on the basis that the record lacked evidence of a current disability. The RO explained that service connection for a miscarriage, in and of itself, could not be granted. Rather, there must be evidence that the miscarriage was caused by a disease or disability. In this case, the additional evidence and the appellant's statements that she has a history of miscarriage were previously considered by the RO. With respect to the February 2013 examination report, the examiner explained that, although the appellant had a history of spontaneous abortion (miscarriage) in the 1990s, such was an acute event which resolved with no ongoing symptoms. The examiner concluded that there was no history of recurrent miscarriages which would indicate an underlying disorder. Although this examination report is new, and contains information material to the claim, it cannot serve to reopen it as it is unfavorable to the appellant. See Villalobos v. Principi, 3 Vet. App. 450 (1992) (evidence that is unfavorable to a claimant is not new and material). In summary, the record continues to lack any indication of a current disability manifested by miscarriages that is causally related to service or any incident therein. The additional lay and clinical evidence does not relate to an unestablished fact necessary to substantiate the claim, nor would it trigger VA's duty to assist. 38 C.F.R. § 3.156. For these reasons, the Board finds that the additional evidence received since the final April 2011 rating decision is not new and material under the meaning of 38 C.F.R. § 3.156(a). Consequently, the Board finds that new and material has not been received and the claim of service connection for miscarriage disorder is not reopened. In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). v. A disorder manifested by tumors and vi. residuals of a tumor removed from the abdomen In the final April 2011 rating decision referenced above, the RO denied service connection for (1) residuals of tumor removal from neck with recurring tumors because there was no link to anything in service; (2) residuals of tumor removal from abdomen because there was no link to anything in service; (3) recurring tumor of stomach because there was no link to anything in service; and (4) recurring tumor of left buttock because there was no evidence of a current disability. The appellant now seeks to reopen her claims, currently characterized as entitlement to service connection for (1) a disorder manifested by tumors, and (2) residuals of a tumor removed from the abdomen. In order to determine whether new and material evidence has been received, the Board has reviewed the entire record, with particular attention to the additional evidence received since the last final rating decision in April 2011. That evidence includes a February 2013 lipoma diagnosis. This evidence is new, as it was not before the RO at the time of its April 2011. Further, presuming its credibility, it is material, as it relates to an unestablished fact necessary to substantiate the claim. Service connection was denied, in part, because there was no evidence of a current disability. The Board finds that this additional evidence, when presumed credible, relates to unestablished facts necessary to substantiate the claim and triggers VA's duty to provide a medical examination. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006) (discussing the four elements to consider in determining whether a VA medical examination should be provided). Under these circumstances, the Board finds that new and material evidence has been presented. Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010). Accordingly, the Board finds that the appellant's previously denied claims for service connection for a disorder manifested by tumors and residuals of a tumor removed from the abdomen are reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. In this particular case, the Board finds that the evidence already of record, including the report from the February 2013 medical examination, is sufficient to decide the claim. Thus, although VA's duty to provide a medical examination has been triggered, another examination is not needed to decide these issues because the RO treated such claims as reopened, afforded the appellant an appropriate examination, and decided the claims on the merits. Thus, the duty to assist has been met and the appellant is not prejudiced by the Board's consideration of the claim on the merits. See Bernard v. Brown, 4 Vet. App. 384 (1993). B. Service Connection a. A disorder manifested by tumors and b. residuals of a tumor removed from the abdomen Service treatment records are negative for active duty complaints, treatment, observations, or diagnoses regarding tumors. Surgical excision of the abdominal lipoma did not occur while on active duty and the appellant has not contended otherwise. The appellant was afforded a VA examination in February 2013. The examiner reviewed the appellant's claims file in connection with the examination. The appellant reported a history of a tumor removed from her left abdominal wall, which left a scar. She stated that it was adipose tissue (lipoma). She reported a fatty mass on the left buttock which is "a little tender or dull pain." She also reported that lymph nodes had been removed from the back of her head in the past. Examination revealed a 2 cm. lipoma palpable in the subcutaneous tissues of the left buttock. It was nontender and stable. There was a well-healed 4 cm. by 0.4 cm. surgical scar of the left anterior abdomen status post lipoma removal. Such was nontender and stable. There were no palpable lymph nodes upon examination. The examiner diagnosed the appellant as having lipoma, personal history of lipoma removal with residual scar, and personal history of reactive lymph node with no current objective findings upon examination. With respect to the claim for tumors of the whole body, the appellant had a current diagnosis of lipoma, which is a disease with a clear and specific etiology. After examining the appellant, reviewing her claims file, and considering her medical history, the examiner concluded that it was less likely than not that the appellant's lipoma disorder was related to service, including a specific exposure event experienced during active service in Southwest Asia because lipomas are collections of fatty or adipose tissue which develop in susceptible individuals. There is no known correlation between lipomas and environmental exposures. Some individuals may be genetically susceptible to developing lipomas and can have multiple lipomas during their lifetime. Upon weighing the evidence the Board finds that the preponderance of the evidence is against the appellant's lipoma or reactive lymph node being caused by or incurred during her active service, to include service in the Persian Gulf. The record shows, and the appellant does not dispute, that her lipomas did not have their inception during a period of active duty. Moreover, the most probative evidence establishes that her lipomas are not otherwise causally related to her active service or any incident therein. The February 2013 examiner explained that lipomas have a clear and specific etiology and explained that there was no correlation between lipomas and environmental exposures. Rather, some individuals may be genetically susceptible to their development. There is no competent evidence of an in-service event, injury, or disease, aside from service in Southwest Asia, to which the appellant's lipoma may be related. The Board finds the examiner's opinion highly probative because it was based on a clinical examination of the appellant, a review of the claims file, consideration of the relevant medical history, and the opinion was accompanied by a detailed rationale. The Board also finds that the preponderance of the evidence is also against the appellant having a current disability characterized by residuals of a tumor removed from the abdomen. The examiner observed that there were no current objective findings upon examination with respect to such. As the appellant's abdominal lipoma was not caused by or incurred in service, its residuals cannot be caused by or incurred in service either. There is no competent medical evidence to the contrary. Thus, such is not a chronic disability that results from an undiagnosed illness or a medically unexplained chronic multisymptom illness. See 38 C.F.R. § 3.317. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). c. Degenerative arthritis of the cervical spine Service treatment records are negative for complaints, treatment, observations, or abnormalities regarding the cervical spine. In January 2003, and again in March 2004, the appellant completed Reports of Medical History on which she specifically denied having or ever having had arthritis or other joint deformity. There were no complaints or abnormalities regarding the cervical spine. The post-active duty clinical records include an April 2010 imaging study of the cervical spine which showed degenerative changes. Alignment was unremarkable. There were no fractures. There was no prevertebral soft tissue swelling. The appellant was afforded a VA examination in February 2013. The claims file was reviewed. She was diagnosed with mild degenerative arthritis of the cervical spine. She reported stiffness, trouble moving her neck, and dull sensations in her left arm and right side. The examiner explained that such had a clear and specific etiology and diagnosis. The examiner opined that the appellant's cervical spine disability was less likely than not related to a specific exposure event in Southwest Asia because degenerative changes of the cervical spine, especially those of a mild nature, are not uncommon in persons of the appellant's age and are due to routine biomechanical stresses and day-to-day wear and tear related to aging. There was no known relationship between cervical spine degenerative arthritis and environmental exposures. Further, arthralgias are also known to be related to HIV/AIDS; and the appellant is known to have had HIV since 2002 with AIDS diagnosis. Thus, such is not a chronic disability that results from an undiagnosed illness or a medically unexplained chronic multisymptom illness. See 38 C.F.R. § 3.317. Upon weighing the evidence, the Board finds that the preponderance of the evidence is against the appellant having a cervical spine disorder which was caused by or incurred in service. As noted above, service treatment records show that the appellant's cervical spine disability did not have its inception during active duty. Further, there is no indication, nor is it contended, that arthritis developed within one year of separation from active duty. Thus, presumptive service connection is not for application. Although a cervical spine disability was not present in service or manifest to a compensable degree within one year of separation from active duty, service connection may nonetheless be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. In this case, however, the record preponderates against finding that the appellant's current cervical spine arthritis is causally related to his active service. As discussed above, a VA examiner has concluded, after examining the appellant, reviewing her claims folder, and considering her medical history, that her current cervical spine disability is less likely than not related to her active service. The Board has considered the appellant's contentions to the effect that her cervical spine disability was incurred in service, possibly due to exposure to environmental hazards or the rigors of her military duties. Although the record reflects that the appellant has dental training, the Board affords greater probative weight to the February 2013 VA examiner's opinion because it is based on a clinical examination of the appellant, a review of the claims file and medical history, and includes an explanation for the conclusions reached. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). d. A gastrointestinal disorder, to include irritable bowel syndrome The appellant also seeks service connection for a gastrointestinal disorder, to include irritable bowel syndrome, which she contends developed as a result of her service in the Persian Gulf theater of operations. In connection with her claim, the appellant was afforded a VA examination in February 2013. The examiner reviewed the appellant's claims file in connection with the examination. In reviewing the appellant's history and current complaints, the examiner noted that the appellant reported that if she thinks about something and tries to come up with a solution at home, it seems to cause her to have to use the restroom, which results in a loose stool. She described such as different than regular diarrhea. The appellant wondered if such was stress-related because certain mindsets seem to stimulate the gastrointestinal tract. She stated that this only occurs when she is thinking about important or stress-inducing things. Continuous medication was not required for control; and no surgical treatment had occurred. The only sign or symptom attributable to any non-surgical, non-infectious intestinal condition was diarrhea, described as intermittent, loose stools which appear to be related to stress. There were no other pertinent physical findings, complications, conditions, signs, or symptoms. After examining the appellant, reviewing her claims file, and considering her medical history, the examiner concluded that there were no objective findings or pathology upon examination which would support a diagnosis of irritable bowel syndrome or other functional gastrointestinal disorder. The examiner explained that the appellant's history was inconsistent with a diagnosis of irritable bowel syndrome. Moreover, the examiner noted that the appellant had not, nor had she ever been, diagnosed with an intestinal disorder. Upon weighing the evidence, the Board finds that the preponderance of the evidence is against the claim. As a preliminary matter, the Board finds that the record on appeal is negative for probative evidence of a current diagnosed gastrointestinal disability. Indeed, the appellant appears to concede that a current gastrointestinal disability has not been diagnosed. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Gilpin v. West, 155 F.3d 1353, 1356 (Fed. Cir. 1998). As a result, the Board has considered the appellant's entitlement to service connection for a gastrointestinal disability under 38 C.F.R. § 3.317. Under that provision, service connection for chronic, undiagnosed illness (or a medically unexplained chronic multisymptom illness such as fibromyalgia) arising from service in Southwest Asia during the Gulf War may be awarded to a Persian Gulf veteran. In this case, however, the Board concludes that the preponderance of the evidence is against an award of service connection under that provision. In this case, the February 2013 VA examiner expressly concluded that the appellant did not exhibit irritable bowel syndrome or other functional gastrointestinal disorder. In addition, although she reported occasional diarrhea, it was noted to be a manifestation of stress and was not the result of an gastrointestinal disability. Indeed, the examiner expressly indicated that the appellant exhibited no other pertinent physical findings, complications, conditions, signs, or symptoms of a chronic gastrointestinal disability. The Board finds that the examiner's opinion is highly probative, as it was based on an examination of the appellant, a review of her claims folder, detailed consideration of her medical history and reported symptoms, and included a rationale for the conclusions reached. There is no other clinical evidence of record which contradicts the examiner's conclusions or otherwise directly addresses the question at issue in this case. In summary, absent probative evidence of an undiagnosed illness established by objective indications of chronic disability, a medically unexplained chronic multisymptom illness, or a functional gastrointestinal disorder, service connection for a gastrointestinal disability under 3.317 is not warranted. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). e. A menstrual disorder The appellant also seeks service connection for a menstrual disorder, which she contends developed as a result of her service in the Persian Gulf theater of operations. In connection with her claim, the appellant was afforded a VA examination in February 2013. The examiner reviewed her claims file in connection with the examination and included a detailed medical history. In that regard, the appellant reported that she had not experienced a period for the past few months. The examiner noted that it was unclear if the appellant was truly menopausal as of yet. The appellant reported fluctuating periods in the past, including light and heavy periods. She was currently experiencing hot flashes. The examiner determined that the appellant did not exhibit any signs or symptoms related to a gynecological condition, including any disease, injuries, or adhesions of the female reproductive organs. With respect to the appellant's menstrual disorder claim, the examiner stated that the appellant was currently experiencing symptoms of perimenopausal state (approaching menopause). The examiner explained that such was not a disease or disorder, but was rather a normal and routine part of aging. The examiner observed that the appellant had a diagnosis of cervical dysplasia. It was explained that such was a disease with a clear and specific etiology. The examiner opined that it was less likely than not that such cervical dysplasia was related to service, including any particular environmental exposure during service in Southwest Asia. Rather, the most likely cause of cervical dysplasia is the appellant's sexually-transmitted HPV. Upon weighing the evidence, the Board finds that the preponderance of the evidence is against the appellant having a menstrual disorder which was caused by or incurred during active service. As a preliminary matter, the Board notes that the February 2013 examiner concluded that the appellant did not exhibit any signs or symptoms related to an undiagnosed gynecological condition. Rather, she was diagnosed as having cervical dysplasia and perimenopause, diagnoses which have clear and specific etiologies. Under these circumstances, service connection for a menstrual disorder under 38 C.F.R. § 3.317(b) is not available. Thus, the Board has considered whether direct service connection may be established. After considering the record in its entirety, the Board concludes that the preponderance of the evidence is against the claim. In that regard, the Board first finds that perimenopause is not a disability for which service connection may be established. As explained by the examiner, perimenopause is not a disease or disability. Rather, it is a normal and routine part of aging. With respect to the appellant's cervical dysplasia, the Board notes that the service treatment records are negative for any indication that the appellant's cervical dysplasia had its inception during a period of active duty. She has not contended otherwise. Rather, the appellant contends that her menstrual disorder is causally related to stress from her service in the Gulf War. In that regard, however, the February 2013 VA examiner explained that it is more likely that the appellant's cervical dysplasia is due to the HPV virus, which the record does not show, nor does the appellant contend, was contracted during her active service. There is no other clinical evidence of record which suggests otherwise. Although the appellant contends otherwise, and the record reflects that she has dental training, the Board affords greater probative weight to the February 2013 VA examiner's opinion because it is based on a clinical examination of the appellant, a review of the claims file, and consideration of her medical history. Moreover, the examiner provided a rationale for the conclusion reached. There is no other probative evidence of record which contradicts the conclusions of the examiner. For these reasons, the Board concludes that the evidence preponderates against the claim; thus, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER New and material evidence having been received, the claim of entitlement to service connection for chronic fatigue is reopened. New and material evidence having been received, the claim of entitlement to service connection for PTSD is reopened. New and material evidence having not been received, the application to reopen the previously denied claim of entitlement to service connection for sciatic disorder is denied. New and material evidence having not been received, the application to reopen the previously denied claim of entitlement to service connection for miscarriage disorder is denied. New and material evidence having been received, the claim of entitlement to service connection for a disorder manifested by tumors is reopened. New and material evidence having been received, the claim of entitlement to service connection for residuals of a tumor removed from the abdomen is reopened. Entitlement to service connection for a disorder manifested by tumors is denied. Entitlement to service connection for residuals of a tumor removed from the abdomen is denied. Entitlement to service connection for degenerative arthritis of the cervical spine is denied. Entitlement to service connection for a gastrointestinal disorder, to include irritable bowel syndrome, is denied. Entitlement to service connection for a menstrual disorder is denied. REMAND Although the appellant denied symptoms of fatigue during the February 2013 VA examination, in a statement received in March 2013, and in her October 2017 testimony, she reported experiencing fatigue. Given her documented service in the Persian Gulf Theater of Operations, the appellant should be afforded an appropriate examination to determine the nature and etiology of any fatigue-related disorder present. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Although the February 2013 VA examiner determined that the appellant did not meet the criteria for a PTSD diagnosis under DSM-IV and opined that her claimed stressor was not sufficient to support a PTSD diagnosis, a private clinician diagnosed the appellant as having PTSD in October 2013. In addition, since the February 2013 examination was conducted, VA amended 38 C.F.R. § 4.125(a) to indicate that a diagnosis of a mental disorder, to include PTSD, must conform to the standards set in the DSM-5. The amendments are applicable to the appellant's claim. See 38 C.F.R. § 4.125; 79 Fed. Reg. 45,093, 45,094-096 (Aug. 4, 2014); 80 Fed. Reg. 14,308 (Mar. 19, 2015) (final) (providing that for claims that were initially certified for appeal to the Board, the Court of Appeals for Veterans Claims (CAVC), or the U.S. Court of Appeals for the Federal Circuit prior to August 4, 2014, DSM-IV will apply. For all applications for benefits received by VA or pending before the AOJ on or after August 4, 2014, DSM-5 will apply). As the appellant's claim was first certified for appeal in December 2016, DSM-5 applies to her claim. Thus, the appellant was afforded a VA examination in October 2016. The examiner determined that the appellant did not meet the criteria for a diagnosis of PTSD under DSM-5 criteria, although prior diagnoses of PTSD were noted in the record. Rather, only HIV-related cognitive impairment was diagnosed. The examiner, however, did not discuss the appellant's previous diagnoses of adjustment disorder with mixed anxiety and depressed mood, depression, and dementia. Thus, a remand is required to provide the appellant with a VA psychiatric examination that uses DSM-5, in accordance with current VA regulations, and discusses all psychiatric disorders diagnosed during the period on appeal. In that regard, the record shows that a private clinician diagnosed PTSD, depression, and dementia in October 2013. The October 2016 examiner diagnosed HIV-related cognitive impairment. An October 2012 clinical note states that the appellant had diagnoses of PTSD and depression. The February 2013 VA examiner diagnosed adjustment disorder with mixed anxiety and depressed mood. In February 2013, the appellant reported a stressor incurred while serving in Saudi Arabia in 1990 or 1991, when a man jumped in front of her with his arms outstretched, in an effort to stop her. He indicated that he would like to sleep with her. Although she does not remember exactly what was said, she described the man's manner as mild-mannered. In October 2016, the appellant explained that the incident shook her up and that she told the chaplain; however nothing happened. It appears that the appellant's service personnel records have not been associated with the claims file, although such may be relevant as to whether a stressor, sufficient to support a diagnosis of PTSD, occurred. This has not escaped the attention of the appellant's representative, who, during the Board hearing, inquired as to whether service personnel records would include further information about a potential stressor which caused the appellant to have to be driven home by a First Sergeant when she was unexpectedly relieved from active duty in 2003. In addition, the Board notes that it is unclear as to whether insomnia and fatigue are symptoms of a psychiatric disorder or separate disabilities. In March 2013, the appellant reported that she is often fatigued due to a lack of sleep, chronic pain, and anxiety. In February 2013, the appellant was diagnosed with idiopathic guttate hypomelanosis and the examiner explained that such was a disease with a clear and specific etiology and diagnosis. The examiner opined that it was less likely than not that idiopathic guttate hypomelanosis is related to a specific exposure event experienced by the appellant during service in Southwest Asia because such tends to occur in middle age and appears to be related to sun exposure. There is no known correlation between the disorder and other particular environmental exposures. However, although sun exposure was noted as a possible cause of such disorder, the examiner did not discuss whether the appellant's exposure to the sun while on active duty may have been the cause of the development of such skin disorder. Thus, remand is required for an adequate etiological opinion. See Barr v. Nicholson, 21 Vet. App. 312 (2007) (holding that once VA undertakes the effort to provide a veteran with a medical examination, it must ensure that such examination is adequate). Although the February 2013 VA examiner did not diagnose the appellant with fibromyalgia because there were no objective findings or pathology upon current examination which would support a diagnosis of fibromyalgia, a September 2016 clinical note states that the appellant has a diagnosis of chronic pain. Such diagnosis has not escaped the attention of the appellant's representative. Thus, remand is required for an adequate examination. See Barr, 21 Vet. App. at 312. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Associate any and all outstanding VA medical records with the claims file. 2. Undertake the necessary steps to obtain and associate with the claims file the appellant's service personnel records. All attempts must be documented in the claims file. 3. The appellant should be afforded an examination to determine the nature and etiology of any and all fatigue and pain disorders present, to include chronic fatigue syndrome, chronic pain syndrome, and fibromyalgia. After reviewing the record, the examiner should state whether the appellant currently exhibits an undiagnosed illness manifested by chronic pain or chronic fatigue, or a medically unexplained chronic multisymptom illness such as chronic fatigue syndrome or fibromyalgia. If so, the examiner should provide an opinion as to whether any such disorder identified on examination was caused by a supervening condition or event that occurred between the appellant's departure from active duty in the Southwest theater of operations and the onset of that disability. A complete explanation must be provided for any opinion offered. 4. The appellant should be afforded an examination to determine the nature and etiology of any and all current psychiatric disorders. Access to the appellant's electronic VA claims file should be made available to the examiner for review in connection with the examination. After reviewing the record and examining the appellant, the examiner should delineate all current mental disorders exhibited by the appellant, if any. Diagnoses should be rendered in accordance with DSM-5. The examiner is asked to provide opinions on the following: A) If PTSD is diagnosed, is it at least as likely as not (50% or greater probability) that any of the claimed stressors caused the appellant's PTSD? B) For any other mental disorder that is diagnosed, is it at least as likely as not that such disorder is causally related to the appellant's active service or any incident therein? The examiner must provide a rationale for the requested opinions. In doing so, the examiner is asked to specifically address the relevant evidence of record, including clinical evidence showing diagnoses of PTSD, depression, dementia, and adjustment disorder with mixed anxiety and depressed mood. If such are not currently diagnosed, the examiner should still opine as to the above for each, as such disorders have been diagnosed during the period on appeal. 5. Provide the appellant's claims folder to a clinician for the purpose of obtaining an addendum opinion addressing the etiology of the appellant's idiopathic guttate hypomelanosis. After reviewing the record, the clinician should provide an opinion as to whether is it at least as likely as not (i.e., at least a 50 percent probability) that the appellant's idiopathic guttate hypomelanosis is causally related to her periods of active duty or any incident therein, to include sun exposure. A complete explanation must be provided for any opinion offered. An examination of the appellant may be scheduled if the clinician deems such examination necessary. 6. After completing the above actions, and any other development deemed necessary, readjudicate the claims. If any claim remains denied, a Supplemental Statement of the Case must be provided to the appellant and her representative. After the appellant and her representative have had the appropriate opportunity to respond, the appeal must be returned to the Board for appellate review. 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). ______________________________________________ K. Conner Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs