Citation Nr: 1803825 Decision Date: 01/22/18 Archive Date: 01/31/18 DOCKET NO. 12-09 700 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for laryngitis, to include as due to an undiagnosed illness. 2. Entitlement to service connection for chronic fatigue syndrome (CFS), to include as due to an undiagnosed illness. 3. Entitlement to service connection for headaches, to include as due to an undiagnosed illness. 4. Entitlement to service connection for narcolepsy, to include as due to an undiagnosed illness. 5. Entitlement to service connection for and acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and bipolar disorder. 6. Entitlement to a rating in excess of 10 percent for sinusitis. 7. Entitlement to a compensable rating for rhinitis. 8. Entitlement to a compensable rating for dyshidrosis of the hands and feet. 9. Entitlement to an initial compensable rating for right elbow disability. 10. Entitlement to school child benefits for dependent, R.P.W., from July 21, 2009 to May 31, 2010, while attending Great Onyx Job Corps. REPRESENTATION Veteran represented by: J. Michael Woods, Attorney ATTORNEY FOR THE BOARD J. Cheng, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1988 to May 1996, June 2002 to August 2005, and October 2005 to November 2007, to include service in the National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March 1999, April 2008, January 2010, and March 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran, through her attorney, requested a 90-day extension of time to submit evidence regarding the claims addressed in this decision in a letter received June 12, 2017. The 90-day extension of time has expired, and appellate review may proceed. The scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of the record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Thus, the Board has recharacterized the issue of mood disorder/bipolar disorder to a non-PTSD acquired psychiatric disorder to allow for consideration of any diagnosed psychiatric disability. The Board notes that the RO has adjudicated the issues of service connection for laryngitis, CFS and headaches as requests to reopen previously denied claims. However, during the course of the current action, additional service records were associated with the claim file that are relevant to the issues. Therefore, as there are relevant official service department records that existed and had not been associated with the claim file when VA first decided the issues, the Veteran's claims for service connection for laryngitis, headaches, and CFS are reconsidered de novo under the provisions of 38 C.F.R. § 3.156 (c)(1). The Board has recharacterized the issues as such on the tile page of the decision. The issues of entitlement to service connection for narcolepsy, an acquired psychiatric disorder and laryngitis, as well as increased rating claims for sinusitis, rhinitis, dyshidrosis of the hands and feet, and a right elbow disability are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The evidence of record demonstrates that the Veteran has a current diagnosis of sleep apnea and narcolepsy, manifesting in chronic fatigue symptoms, and as such, the Veteran's chronic fatigue is not a manifestation of an undiagnosed illness or a medically unexplained chronic multisymptom illness. 2. There is no competent evidence of a diagnosis of CFS at any point during the appeal period. 3. Resolving reasonable doubt in the Veteran's favor, headaches are etiologically related to her military service. 4. There is no basis in the law for the Veteran to be awarded retroactive child school benefits for dependent, R.P.W., from July 21, 2009 to May 31, 2010, for attending Great Onyx Job Corps. CONCLUSIONS OF LAW 1. The criteria for service connection for chronic fatigue syndrome have not been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.317 (2017). 2. The criteria for service connection for headaches have been met. 38 U.S.C. §§ 1110, 1131, 1137, 5107 (2012); 38 C.F.R. § 3.303 (2017). 3. The criteria for entitlement to school child benefits for dependent, R.P.W., from July 21, 2009 to May 31, 2010, while attending Great Onyx Job Corps, have not been met. 38 U.S.C. §§ 101(4)(A), 1115 (2012); 38 C.F.R. §§ 3.57(a), 3.667(f)(2) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duty to Notify and Assist With respect to the Veteran's issues being decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. The record also shows that VA has fulfilled its obligation to assist the Veteran in developing the claim, including with respect to VA examination of the Veteran. Neither the Veteran nor her representative has identified any deficiency in VA's notice or assistance duties. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). II. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be established for a Persian Gulf veteran who exhibits objective indications of a chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal complaints (excluding structural gastrointestinal disorders)) that is defined by a cluster of signs or symptoms, or any diagnosed illness that the Secretary determines, in regulations, warrants the presumption of service connection resulting from an illness or from any combination of illnesses manifested by one or more signs or symptoms such as those listed below. The symptoms must be manifest to a degree of 10 percent or more during the presumptive periods prescribed by the Secretary or by December 31, 2016. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from the VA Schedule for Rating Disabilities for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. A disability referred to in this section shall be considered service-connected for the purposes of all laws of the United States. 38 C.F.R. § 3.317(a)(3-5). Signs or symptoms which may be manifestations of an undiagnosed illness or a chronic multisymptom illness include, but are not limited to: fatigue, signs or symptoms involving the skin, headache, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317(b). If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98. The Veteran's DD-214 indicates active military service in the Southwest Asia Theater of operations during the Persian Gulf War. As such, the aforementioned Persian Gulf statutory and regulatory provisions are applicable in this case. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board notes that it has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting its decision, there is no requirement that the Board discuss every piece of evidence in the record. The Board will summarize the relevant evidence, as deemed appropriate, and the Board's analysis will focus on what the evidence shows, or fails to show, as to the claims. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). A. Chronic Fatigue Syndrome The Veteran is seeking service connection for CFS. Service treatment records (STR) from the Veteran's first period of active service do not show any diagnosis or treatment for CFS. However, there were reports of fatigue noted after the first period of service. Specifically, a July 1998 VA Neurology Clinic medical record notes the Veteran's prior medical history of chronic fatigue and multiple motor vehicle accidents where the Veteran fell asleep at the wheel three times. At the time, the Veteran was diagnosed excessive daytime somnolence. The Veteran was afforded a VA examination in July 1998. The examiner noted the Veteran had three accidents in the last two years due to her falling asleep at the wheel. The Veteran reported she felt that her chronic fatigue could have been the result of her six months in Kuwait and indicated that her chronic fatigue and headaches became more pronounced after her discharge in 1996. The examiner diagnosed chronic fatigue and depression with headaches. The examiner did not provide an etiological opinion. The Veteran underwent a sleep study in April 1999 that showed the Veteran had excessive daytime somnolence and the study indicated that the presence of REM sleep in naps may denote sleep deprivation and narcolepsy. Another sleep study in June 2000 revealed the Veteran had abnormally short sleep latency, meaning excessive daytime sleepiness and indicated that the presence of REM sleep in all four trials made for a diagnosis of narcolepsy. During the second period of active service, an April 2005 medical treatment record from Capital Family Physicians noted the Veteran was positive for chills and fatigue. The record noted an assessment of sinusitis and bronchitis. A May 2005 medical treatment record from Capital Family Physicians noted the Veteran was positive for chills, fatigue, fever, and headaches. The record noted an assessment of bronchitis. During the last period of service, a July 2006 medical treatment record from Capital Family Physicians noted the Veteran's complaints of daytime sleepiness. The Veteran reported she had this problem for years and that during her 30 mile commute, she found herself falling asleep at the wheel, fighting to stay awake. The provider noted an assessment of uncontrolled malaise/fatigue with prior possible diagnosis of narcolepsy. A sleep study was ordered. The requested sleep study was conducted in August 2006 by the Central Kentucky Sleep Center at Frankfort Regional Medical Center that noted an overall impression of narcolepsy and mild obstructive sleep apnea (OSA). The Veteran had complained of chronic fatigue, tiredness, exhaustion, irritability, and depression with sleep attacks during the day. Another sleep study was conducted at the same location in January 2007. The study noted the Veteran's sleep history of snoring, excessive daytime sleepiness, fatigue, and witnessed apneas. The study noted an interpretation of results as OSA. An August 2007 medical treatment record from Capital Family Physicians noted the Veteran's fatigue, nasal congestion, post-nasal drip, and rhinitis and noted an assessment of acute sinusitis. The Veteran was provided another VA examination in February 2008. The examiner noted the Veteran fell asleep during the interview portion of the examination. The Veteran reported noticing increased fatigue after returning from Desert Storm. Se reported she was seen and evaluated at Fort Knox and eventually was told she had chronic fatigue syndrome in 1999. After an examination, the examiner found that the Veteran did not meet the criteria of six or more of the ten criteria for CFS. Instead, the examiner diagnosed sleep apnea and narcolepsy and indicated that chronic fatigue was a problem associated with these diagnoses. Additional service treatment records do not show a diagnosis of CFS albeit noting the Veteran's continued fatigue. VA treatment records noted the Veteran's diagnoses of narcolepsy and OSA. The Veteran's father, O.S., submitted a statement in support of the Veteran's claim wherein he stated that the Veteran was reassigned in January 1996 to Fort Stewart and was informed that there was no housing available at the base. He indicated that the Veteran could not afford to rent another place since she was still paying rent for her home at her last assignment in Hawaii. As a result, the Veteran stayed with her parents and she had a three and a half hour drive to Fort Stewart every day, needing to leave at 2:30am to make it to the base on time. He stated that the Veteran had an accident in March 1996 when she fell asleep behind the wheel. In a September 2016 VA medical opinion, after review of the claim file, the examiner opined that the Veteran's claimed CFS was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale was that the Veteran did not have chronic fatigue syndrome nor was she diagnosed with chronic fatigue syndrome in service. The examiner noted the Veteran had complained of fatigue, that the examiner indicated was a symptom, and was diagnosed with OSA. Upon review of the evidence above, the Board finds that service connection for CFS is not warranted. The Veteran's treatment records during active service and after service do not show a diagnosis for chronic fatigue syndrome. The record does not show that chronic fatigue syndrome has ever been diagnosed. As noted above, there are complaints of the fatigue during active service and after active service. Nevertheless, the February 2008 and September 2016 VA examiners found that the Veteran's fatigue was a symptom of her diagnosed sleep disorders, to include narcolepsy and OSA. In the absence of proof of a current separate disability, there can be no valid claim for service connection. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Giplin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (indicating service connection presupposes a current diagnosis of the condition claimed). The requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim...even though the disability resolves prior to the Secretary's adjudication of the claim." McClain v. Nicholson, 21 Vet. App. 319 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Here, there is no disputing the Veteran has complained of fatigue both during service and even since discharge. The Veteran is competent to report experiencing fatigue and sleepiness and is credible in this regard. However, the February 2008 and September 2016 VA examiners specifically determined there is no diagnosis of chronic fatigue syndrome and that the Veteran's fatigue is a symptom of her sleep disorders. The Board attaches significant probative value to these opinions and the most probative value in this case, as they are well reasoned, detailed, consistent with other evidence of record to the extent there has not been a diagnosis of chronic fatigue syndrome, and included consideration of the Veteran's relevant medical history, including her symptoms and responsibilities in service. See also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (indicating most of the probative value of an opinion comes from its underlying reasoning, not just from mere review of the record, although that, too, has its importance if evidence in the file may affect the underlying basis of the opinion such as by revealing relevant facts). The Board finds that the VA examiners' opinion is more probative than the Veteran's personal assertions to the contrary because the examiners have medical expertise that the Veteran does not possess. The Veteran is certainly competent to report experiencing fatigue and sleepiness, but she is not competent to ascribe this symptoms to a particular diagnosis or, in turn, relate it to her military service, especially when, as here, there is countervailing medical comment and there are other confounding sources for her fatigue, sleep apnea and narcolepsy, which, as the objective evidence of record shows, results in poor sleep patterns and increased daytime sleepiness. Distinguishing between fatigue due to sleep and an actual chronic fatigue disorder is not within the realm of lay expertise. Thus, the most probative evidence establishes there is no present disability of chronic fatigue syndrome. Absent a current diagnosis for the underlying symptom of fatigue not yet addressed in this decision, service connection is not warranted. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). The Board notes that to the extent the Veteran experiences symptoms of fatigue from her service-connected sleep apnea, those symptoms are properly encompassed in the current rating of the service-connected sleep apnea and in the continued appeal of narcolepsy. With respect to the Veteran's chronic fatigue as related to an undiagnosed illness, the Board reiterates that such has been medically determined to be a symptom of other disorders or conditions, and not a disability in and of itself. As discussed in detail above, the Veteran's chronic fatigue, although clearly present, has been characterized not as a stand-alone disability, but as a symptom of her OSA and narcolepsy. Thus, based the competent and credible evidence of record, the Board finds that the claimed chronic fatigue has been competently and credibly associated with a known etiology and diagnosis, namely the Veteran's OSA and narcolepsy, and therefore service connection based on the law and regulations pertaining to undiagnosed illness incurred due to Persian Gulf service is not warranted. 38 C.F.R. § 3.317. Accordingly, the criteria for service connection have not been met, and the Veteran's claim for entitlement to service connection for chronic fatigue syndrome is denied. B. Headaches The Veteran is seeking service connection for chronic headaches. At the outset, the board notes that as there are objective indications that she has a history a known clinical diagnosis for her headaches, a claim that this disorder is due to an undiagnosed illness incurred during Persian Gulf service, pursuant to 38 C.F.R. § 3.317, is precluded. See also VAOPGCPREC 8-98. This issue will therefore be considered on a direct service connection basis. A review of the Veteran's medical treatment records during active service shows the Veteran's repeated complaints of headaches. Indeed, a July 1994 STR noted an assessment of possible migraine. A February 1996 VA Health Questionnaire for Dental Treatment noted the Veteran's reports of frequent headaches. During her March 1996 separation report of medical history from her first period of service, the Veteran had indicated she experienced, or had experienced frequent or severe headaches. The Veteran reported that she usually experienced headaches once a month and treated it with sleep. After her first period of service, in an April 1998 neurology consultation report, the provider noted the Veteran experienced headaches since Desert Storm and provided a provisional diagnosis of headaches. The provider requested a Persian Gulf examination of the Veteran. The Veteran was subsequently provided a Persian Gulf Registry Examination in April 1998. During examination, the Veteran reported she had been experiencing bad headaches since the Persian Gulf War. She stated that recently, the frequency of the headaches had been daily and that the duration of the headaches had usually been all day. She rated the severity of the headaches as a five out of ten. She stated she rarely vomited with the headaches, but experienced dizziness. The examiner noted the Veteran's headaches' onset date as September 1992 and diagnosed "migraines/headaches." A July 1998 VA Neurology Clinic medical record noted the Veteran's reports that her headaches began prior to the Gulf War but were only one to two times per year. However, the Veteran reported that after the Persian Gulf War, her headaches increased to two times a week and has continued to worsen. The Veteran reported the headaches were throbbing in nature and was relieved with sleep. The provider diagnosed intermittent migraine headaches without aura. During the Veteran's second period of active service, the Veteran also reported intermittent headaches. In a November 2004 medical treatment record from Capital Medical Group, the provider noted the Veteran's complaints of frontal headache, sinus drainage, voice loss, minimal cough, and yellow nasal discharge. The record noted an assessment of acute sinusitis. In a March 2005 medical treatment record from Capital Medical Group, the provider noted the Veteran was positive for headaches, ear pain, nasal congestion, facial pain, and sore throat. The record noted an assessment of acute sinusitis. In a May 2005 medical treatment record from Capital Medical Group, the provider noted the Veteran was positive for headaches, discharge, nasal congestion, nasal obstruction, rhinorrhea, and facial pain. The record noted an assessment of acute bronchitis. During the last period of service, in a November 2005 medical treatment record from Capital Medical Group, the provider noted the Veteran's complaints of headaches, sore throat, and body aches. The record noted an assessment of acute strep sore throat. In a December 2005 medical treatment record from Capital Medical Group, the provider noted the Veteran was positive for headaches, nasal congestion, facial pain, sore throat, PND, and hoarseness. The record noted an assessment of acute sinusitis. In a February 2006 medical treatment record from Capital Medical Group, the provider noted the Veteran's complaints of headache, nausea, and diarrhea. The record noted an assessment of gastroenteritis. In an April 2006 STR, the provider noted the Veteran complained of neck pain as well as a current headache a week following a motor vehicle accident. In a January 2007 medical treatment record from Capital Medical Group, the provider noted the Veteran's complaints of her head hurting and neck pain. The record noted an assessment of acute spasm of muscle. The Veteran was provided VA examinations on February 25, 2008 and February 29, 2008. During the examinations, the Veteran reported that she developed headaches when she was first stationed in Germany with an estimated onset date in 1989. The Veteran reported that since then, she had treated her headaches with ibuprofen and rest. She reported her headaches occurred six to seven times a month that she described as tight squeezing temporal/frontal headaches with specks of light vision, with some nausea but no vomiting. She reported the headaches usually lasted a couple of hours with occasional headaches that lasted for the day. The examiners diagnosed migraine headaches. Subsequent VA treatment records from 2009 to 2015 note the Veteran's continued complaints of headaches and migraine headaches. In a September 2016 VA examination opinion, the examiner opined that the Veteran's disability was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner's rationale was that the Veteran did not have a chronic headache disability while on active duty. The examiner noted the Veteran had headache pain with two acute illnesses which resolved in service and were associated with acute illnesses. Upon review of the evidence above, the Board finds that the September 2016 VA examiner's opinion is inadequate as the examiner failed to address the Veteran's repeated reports of frequent headaches during the her first period of active service. The September 2016 VA examiner also failed to address the April 1998 Persian Gulf Registry Examination and February 2008 VA examiners' diagnoses of headaches and migraine headaches. Additionally, the September 2016 VA examiner's rationale was based on inaccurate facts. The examiner indicated that the Veteran had headache pain with two acute illnesses which resolved in service. However, a review of the treatment records notes the Veteran's consistent complaints of headaches, albeit some that were associated with several acute illnesses, not limited to two instances. Nevertheless, due to the above mentioned inadequacies, the Board affords the September 2016 VA examiner's opinion little to no probative value. Headaches were first reported by the Veteran in active service in February 1996 with a possible diagnosis of migraine in July 1994. The Veteran's report of a continuity of headache symptoms in active service and after active service separation is competent evidence of a continuity of symptomatology. Such symptoms are "observable" symptoms. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Her lay statements are found to be credible as they have been consistent and are supported by the evidence of record. As noted, the treatment records during service and post-service document continued complaints and reports of headaches. Subsequent lay statements by the Veteran and medical evidence of record document that headaches have continued to the present. Furthermore, the April 1998 Persian Gulf Registry Examination and February 2008 VA examiners diagnosed headaches and migraine headaches, all examinations noting the Veteran's continued reports of headaches. Providing the Veteran benefit of the doubt, the Board finds that service connection for a headache disability is warranted. The disability was first noted in active service. The Veteran has consistently and continually reported symptoms of headaches since that time. There are no adequate contrary opinions of record. Service connection on a direct basis is warranted based on continuity of symptomatology, as headaches are a listed chronic disease. 38 C.F.R. §§ 3.303(b), 3.309(a); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). For those reasons, the appeal is granted. III. School Child Benefits The Veteran seeks additional monetary benefits for a dependent child, R.P.W., for the period following his 18th birthday based on school attendance from July 21, 2009 to May 31, 2010, while attending the Great Onyx Job Corps. A veteran who is in receipt of disability compensation of 30 percent or more is entitled to an additional allowance for each dependent. 38 U.S.C. §§ 1115, 1134, 1135. Specific rates are provided for a veteran's spouse and children. A child is defined as an unmarried person who is (i) under the age of 18 years; (ii) before the age of 18 years became permanently incapable of self support; or (iii) after attaining the age of 18 years and until completion of education or training (but not after attaining the age of 23 years) is pursuing a course of instruction at an approved educational institution. 38 U.S.C. § 101(4)(A); 38 C.F.R. § 3.57(a). The allowance is generally discontinued when a dependent child turns 18, or when the child turns 23 if he or she is enrolled in school. 38 C.F.R. §§ 3.503, 3.667. Pension or compensation may be paid from a child's 18th birthday based on school attendance if the child was at that time pursuing a course of instruction at an approved educational institution and a claim for such benefits is filed within 1 year from the child's 18th birthday. 38 C.F.R. § 3.667(a)(1). Pension or compensation based upon a course of instruction at an approved educational institution which was begun after a child's 18th birthday may be paid from the commencement of the course if a claim is filed within 1 year from that date. 38 C.F.R. § 3.667(a)(2). A "claim" is defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). However, to establish a claim, the Veteran must assert the claim expressly or impliedly. Brannon v. West, 12 Vet. App. 32, 35 (1998). See also Talbert v. Brown, 7 Vet. App. 352, 356-57 (1995) (holding that, while the Board must interpret a veteran's submissions broadly, the Board is not required to conjure up issues that were not raised by the veteran). Indeed, VA's duty to adjudicate all claims reasonably raised does not require VA to anticipate a claim for a particular benefit where no intention to raise it was expressed. See Brannon, supra. According to 38 C.F.R. § 3.151, a specific claim in the form prescribed by the VA Secretary must be filed in order for benefits to be paid to any individual under the laws administered by VA. See 38 U.S.C. § 5101(a). Individuals to whom benefits are being paid are required to certify, when requested, that any or all of the eligibility factors which established entitlement to the benefit being paid continue to exist. 38 C.F.R. § 3.652(a). When the required certification is received, benefits will be adjusted, if necessary, in accordance with the facts found. 38 C.F.R. § 3.652(b). Historically, service connection is in effect for OSA, sinusitis, right elbow lateral epicondylitis, degenerative disc disease of the cervical spine, allergic rhinitis, and dyshidrosis of hands and feet. A 60 percent combined rating due to service-connected disabilities has been in effect since December 1, 2007. The Board notes that the issue of entitlement to service connection for headaches has also been granted in this decision. Nevertheless, since the Veteran's combined rating is already at 60 percent prior to consideration of possible additional rating for headaches, there is a sufficient combined rating to consider entitlement to an additional allowance for a dependent. The Veteran submitted a Declaration of Status of Dependents form that listed several dependent children; one of whom was R.P.W., unmarried and born in April 1988. VA received VA-Form 21-674, Request for Approval of School Attendance for R.P.W., which was dated October 14, 2009, signed by the Veteran. The form noted R.P.W. began attending Black Onyx Job Corps on July 22, 2009 with an "unknown" expected date of graduation. As such, the Board notes that the Veteran submitted a timely application considering the application was filed within one year from the date of commencement of the course. The form also noted the Veteran's affirmation that the tuition and/or allowance for the student's education or training was being paid by VA Dependents Educational Assistance (DEA), the Federal Employee's Compensation Act or any other agency or program of the United States Government and that such payments were began July 30, 2009. In a December 2009 Report of Contact form, the form noted the Veteran was contacted via telephone and was explained to that the Job Corps was not a school and that R.P.W. could not be added on her award. The Veteran had indicated that R.P.W. was being paid $100 every two weeks. In December 2009, VA received a separation notice form regarding the Great Onyx Job Corps Civilian Conservation Center. The form indicated that R.P.W. was expected to graduate on April 23, 2010. The form also noted that an amount of $552 for transition pay was dispersed. In a January 2010 decision notification letter, the Veteran was informed that VA was unable to add R.P.W. to her award because she had indicated "unknown" in the "Expected Date of Graduation" block of the VA-Form 21-674, received October 27, 2009. The notification letter also noted that if the Veteran disagreed with the decision, she may call VA with the information or submit another VA Form 21-674. Subsequently in January 2010, the Veteran submitted a notice of disagreement, stating that her dependent, R.P.W., was expected to complete his course in 120 days from the July 22, 2009 date of enrollment. The Veteran submitted in January 2010, a student profile form from the Great Onyx Job Corps Center Information System that noted R.P.W. was enrolled beginning July 21, 2009, with a residential status as a resident student in a dorm, with 186 paid tenure days. A trade instructor, B.T.B., at the Great Onyx Job Corps submitted a letter indicating that R.P.W. had recently had a trade change from Computer Technology to Office Administration and that the dependent had entered B.T.B.'s trade on January 11, 2010. B.T.B. explained that all students were required to at least stay in trade for 120 days (4 months) and that R.P.W. was currently 33 percent complete and was progressing steadily. VA received another VA-Form 21-674, Request for Approval of School Attendance for R.P.W. that was dated January 22, 2010, signed by the Veteran. The form noted R.P.W. began attending Great Onyx Job Corps on July 21, 2009 with an expected date of May 31, 2010 for graduation. The form also noted the Veteran's affirmation that the tuition and/or allowance for the student's education or training was being paid by VA Dependents Educational Assistance (DEA), the Federal Employee's Compensation Act or any other agency or program of the United States Government. A June 30, 2010 VA Administrative Decision found that the Great Onyx Job Corps was not an accredited school for VA purposes and that school child dependency benefits for the Veteran's son, R.P.W., was denied under M21-1MR III.iii.6.A.2.a, M21-1MR III.iii.6.A.2.e, and M21-1MR III.iii.6.A.2.h. The decision's reasons and bases were that after review of the manual rewrite, the Great Onyx Job Corps was not found to meet the Department of Veteran Affairs standards. Great Onyx Job Corps was not on the accreditation list of Kentucky schools and universities, nor is it accredited by the Department of Education. The decision noted that research was further confirmed from the Education Center in St. Louis, Missouri, that the Great Onyx Job Corps was not accredited for VA purposes. On May 10, 2011, VA sent the Veteran a decision notification letter informing the Veteran that her request to have R.P.W. added onto her award as a school child dependent from July 21, 2009 to May 31, 2010, was denied because he was attending Great Onyx Job Corps, which is a federally supported facility. The Board notes that the Great Onyx Job Corps is not recognized as an accredited institution by the U.S. Department of Education's Database of Accredited Postsecondary Institutions and Programs. However, the Board notes that regardless to whether Great Onyx Job Corps is an approved educational institution recognized by the VA, the institution is a federally supported facility. The Veteran has specifically indicated on both VA Forms 21-674 dated October 14, 2009 and January 22, 2010, that the tuition and/or allowance for the student's education or training was being paid by VA Dependents Educational Assistance (DEA), the Federal Employee's Compensation Act or any other agency or program of the United States Government. Furthermore, review of the Great Onyx Job Corps website specifically indicated that Job Corps is a no-cost education and career technical training program administered by the United States Department of Labor. See https://greatonyx.jobcorps.gov/about-us. Further review of the evidence notes the R.P.W. received payment for his enrollment. See December 2009 Report of Contact form, January 2010 Great Onyx Job Corps Civilian Conservation Center separation notice form, and January 2010 Great Onyx Job Corps Center Information System student profile form. 38 C.F.R. § 3.667(f)(2) states that pension, compensation or dependency and indemnity compensation may not be authorized based on an educational program in a school where the child is wholly supported at the expense of the Federal Government, such as a service academy. Here, there is no dispute that from the facts and evidence of record, that Great Onyx Job Corps is an education program that is wholly support at the expense of the Federal Government, namely the U.S. Department of Labor. The Veteran has not submitted any evidence disputing these facts. As such, the Board finds that pursuant to 38 C.F.R. § 3.667(f)(2), entitlement to school child benefits for dependent, R.P.W., from July 21, 2009 to May 31, 2010, while attending Great Onyx Job Corps, is denied. ORDER Service connection for chronic fatigue syndrome is denied. Service connection for headaches is granted. Entitlement to school child benefits for R.P.W., from July 21, 2009 to May 31, 2010, while attending Great Onyx Job Corps, is denied. REMAND The Veteran contends that she currently has chronic laryngitis that had its onset during service, or was otherwise related to service. Upon review of the record, the Board finds additional development is needed prior to deciding this issue. Laryngitis was noted once during service. Medical treatment records during the Veteran's last period of service noted the Veteran's continued complaints related to sore throat and hoarse voice but the complaints were not assessed as due to laryngitis. Instead, the Veteran's symptoms were associated with other diagnoses, to include sinusitis, strep throat, rhinitis, bronchitis, and pharyngitis. Post-service, the Veteran was afforded a VA examination on February 25, 2008. During examination, the Veteran reported that she developed laryngitis when she was stationed at Fort Knox in a motor pool where most people smoked. She stated that she suffered laryngitis about twice a year and each episode lasted two weeks. The Veteran indicated that during an acute episode, she was treated with antibiotics. The date of onset was noted as 2000. Based on the history provided by the Veteran, the examiner diagnosed recurrent laryngitis. The examiner did not provide an etiological opinion. An October 2008 VA treatment record noted an impression of allergic laryngitis and noted the Veteran's reports that she experienced attacks of laryngitis two times a year. November 2008 VA treatment record noted the Veteran had two bouts of laryngitis per year. An August 2010 VA treatment record noted the Veteran's laryngitis was better. December 2010 VA treatment records noted the Veteran had a diagnosis of laryngitis and upper respiratory infection. An October 2011 VA treatment record noted the Veteran's reports that she had laryngitis twice a year for six years. A January 2012 VA treatment record noted the Veteran's complaints of intermittent hoarseness for several years. In a September 2016 VA medical opinion, after review of the claims file, the examiner opined that the Veteran's claimed disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale was that the Veteran did not have a diagnosis of chronic laryngitis during active duty. The examiner noted the Veteran was seen for acute sinus infections, acute pharyngitis, and acute bronchitis which resolved in service. The examiner also noted the Veteran was seen for allergic rhinitis but was not diagnosed with chronic laryngitis. The Board finds this opinion to be inadequate as the basis for the rationale is the lack of a diagnosis in service. This rationale is inadequate as the absence of a diagnosis in service does not preclude service connection. See Hensley v. Brown, 5 Vet. App. 15, 159 (1993). As such a new opinion is needed prior to deciding the issue. Additional development is also needed regarding the issue of entitlement to an initial increased rating for a right elbow disability. Although VA examinations were conducted, recent case law renders those examinations inadequate. See Correia v. McDonald, 28 Vet. App. 158 (2016). In particular, the Board notes that findings from those examinations appear insufficient to assess the Veteran's motion in passive motion, and (where relevant) weight-bearing and nonweight-bearing settings. Accordingly, the Veteran should be afforded another VA examination to assess the current nature and severity of the right elbow disability. Regarding the service-connected issues of rhinitis and sinusitis, the Board notes that the Veteran was last afforded VA examinations for these service-connected disabilities in April 2011. At that time, the examiner noted that for treatment, the Veteran was receiving allergenic extracts injection shots under the skin to treat both rhinitis and sinusitis. The examiner also noted the Veteran had taken antibiotic three times in the last 12 months for sinusitis infection and that the Veteran took antibiotics twice in the last 12 months for rhinitis infection. VA treatment records also noted that in April 2011, the Veteran's medication list included prescribed oral medications of Fexofenadine (antihistamine) and Guaifenesin (expectorant). However, since the April 2011 VA examination, the Veteran has continued to experience sinusitis and rhinitis infections and also has been prescribed additional medications for treatment of these disabilities. Specifically, in a July 2015 VA treatment record, the Veteran's medication list included two types of nasal spray for nasal allergy, and an oral medication of Loratadine, in addition to the previously prescribed Guaifenesin. The Board notes that at most, the Veteran was prescribed one nasal allergy spray prior to the April 2011 VA examination. VA treatment records also show worsening symptoms of both disabilities. The Veteran was seen and treated for her sinusitis every few months, to include in June 2012, August 2012, December 2012, and February 2013. A January 2014 VA treatment record noted the Veteran had experienced nose drainage for the past four months and that the Veteran also reported that she continued to have post nasal drip in which her medications had not helped her symptoms. The Veteran also had reported doing sinus rinses. A May 2014 VA treatment record also noted the Veteran had increased rhinorrhea. As there is evidence of worsening sinusitis and rhinitis symptoms since the April 2011 VA examination, another VA examination is warranted to determine the current severity of the Veteran's service-connected sinusitis and rhinitis. Regarding the service-connected issue of dyshidrosis of hands and feet, the Veteran was last provided a VA examination in April 2011. Since the April 2011 VA examination, VA treatment records have indicated worsening symptoms. A July 2012 VA treatment record noted a bilateral hand rash that included small, five to six papules, 1 millimeter round, scattered on bilateral posterior wrists and on lateral side of palmar surface. The Veteran was treated with topical corticosteroid ointment. In an August 2012 VA treatment record, the Veteran reported the rash had spread to her whole arm up to her shoulder. A September 2012 VA treatment record also noted the Veteran had a rash on her ankles and leg. Subsequent VA treatment records noted continued treatment for skin rashes on her arms, ankles, and leg. A January 2015 VA treatment record noted the Veteran complaints of chronic rash. Medication lists in October 2012, December 2012, February 2013, March 2013, April 2013, May 2013, June 2013, July 2013, September 2013, October 2013, December 2014, January 2015, and May 2015 noted the Veteran had been prescribed corticosteroid ointments for treatment of rashes. As there is indication that the Veteran's skin disability has worsened since the April 2011 VA examination, another VA examination is warranted to determine the current severity of the Veteran's service-connected skin disability. Regarding the issue of narcolepsy, the Board notes, preliminarily, that as there are objective indications that the Veteran has a history a known clinical diagnosis for narcolepsy, a claim that this disorder is due to an undiagnosed illness incurred during Persian Gulf service, pursuant to 38 C.F.R. § 3.317, is precluded. See also VAOPGCPREC 8-98. This issue will therefore be considered on a direct and secondary service connection basis. The Veteran was provided VA examinations in February 25, 2008, February 29, 2008, and April 2011. The February 2008 VA examiners noted the Veteran's reports that she was diagnosed with narcolepsy at the Louisville VA medical center in 1997 to 1998. However, she reported that she was not treated at the time. The Veteran reported that in 2005, she was again evaluated and was found to have sleep apnea and narcolepsy. The Veteran reported that she had problems falling asleep while driving. The February 25, 2008 VA examiner noted the Veteran fell asleep during the subjective portion of examination. The February 2008 VA examiners did not provide opinions as to the etiology of the disability. However, the April 2011 VA examination provided a negative opinion regarding nexus. The April 2011 VA examiner opined after examination that the Veteran's diagnosis of narcolepsy without cataplexy was not caused by or a result of military service or any other service connected condition such as OSA. The examiner noted that although patients with sleep apnea may have daytime sleepiness if not well treated, those that are well treated do not have hypersomnolence. The examiner further noted that narcolepsy was more than hypersomnolence or sleepiness and that narcolepsy is a neurologic disorder due to genetics, chemical loss of orexine signaling or rare brain lesion, none of which are caused by sleep apnea or related to military service. The examiner as such has indicated the Veteran's narcolepsy could be a genetic disorder. While congenital or developmental defects are not diseases or injuries subject to VA compensation, they can be subject to superimposed disease or injury and, if the superimposed disease or injury occurs during service, service connection may be warranted. 38 C.F.R. § 3.303(c); VAOPGCPREC 82-90 (1990), 55 Fed. Reg. 45711 (1990). Given the April 2011 examiner's acknowledgment that the Veteran's narcolepsy had its onset in service in 2006 and sleep studies in April 1999 and June 2000 show impressions of narcolepsy, the AOJ should obtain an opinion and clarification on whether the Veteran's narcolepsy preexisted any periods of active service, and whether the disorder is a genetic disorder and if so, if the congenital or developmental defect of narcolepsy was subjected to superimposed disease or injury during service. To ensure a complete medical opinion, the AOJ should afford the Veteran a new examination to allow the examiner to obtain any needed information. Regarding the issues of an acquired psychiatric disorder, to include PTSD and bipolar disorder, the Veteran was most recently afforded a VA examination for these disabilities in April 2011. The April 2011 VA examiner found that the Veteran did not have PTSD, mood disorder, or bipolar disorder. Instead, the examiner diagnosed personality disorder and alcohol abuse. The examiner disregarded the VA treatment providers' continued diagnoses of PTSD, mood disorder, and bipolar disorder by explaining that these diagnoses were based on questionnaires. However, the Board finds that the examiner failed to adequately address the STRs, VA treatment notes, and prior VA examinations. The Board notes that a review of the claim file shows that the diagnoses of PTSD and bipolar disorder were not just based on questionnaires but also were based on clinical interviews performed during an eight week residential treatment program. See February 2011 VA Residential PTSD Program Discharge Summary. The April 2011 VA examiner also failed to address the Veteran's STRs that noted psychiatric related complaints. During her March 1996 separation report of medical history from her first period of service, the Veteran had indicated she experienced, or had experienced, depression or excessive worry and nervous trouble. The Veteran reported that she experienced stress and depression but that she had not received treatment. In an April 1998 VA Persian Gulf Registry Examination, the Veteran reported that since the Persian Gulf War, she had been having swings of deep depression and anxiety. The Veteran was given a provisional diagnosis of depression and anxiety and that the date of onset was August 1995 and was currently present. In a July 1998 VA Mental Disorders Examination, the examiner diagnosed chronic fatigue and depression with headaches. The April 2011 VA examiner also failed to address the Veteran's diagnosis of Major Depressive Disorder. See January 2011 VA Mental Health Note. VA treatment records subsequent to the April 2011 VA examination continue to find the Veteran positive for depression, and continue to diagnose the Veteran with PTSD, anxiety disorder, and mood disorder, based on continued therapy sessions and evaluations. The Veteran was also prescribed Risperidone, an atypical antipsychotic, for mood, and Lamotrigine, both treatments for bipolar disorder. See Dorland's Illustrated Medical Dictionary, 1003, 1650 (32nd ed. 2012); May 2015 VA Active Outpatient Medications. The Board further notes that the April 2011 VA examiner failed to adequately address the Veteran's sexual harassment during her last period of service. The April 2011 VA examiner noted the Veteran had filed a complaint against a superior officer and that she was stalked by a co-worker following the incident. The April 2011 VA examiner instead noted the claimed stressor was due to an incident post-service in 2010 despite the Veteran's numerous submissions that the stressor stemmed from her superior officer's sexual harassment and subsequent harassment when she refused to have sex with the officer. Thus, given the inadequacy of the April 2011 VA Initial PTSD examination, a remand for another VA examination is warranted. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the current severity of service-connected right elbow disability, skin disability, rhinitis, and sinusitis. The entire claims file should be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must utilize the appropriate Disability Benefits Questionnaire. Additionally, for the service-connected right elbow disability, the examiner must test the range of motion in active motion, passive motion, and (where appropriate) weight-bearing and nonweight-bearing settings. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. For the service-connected skin disability, the examiner must detail what symptoms are related specifically to the service-connected skin disability, to include if the dyshidrosis of hands and feet has spread to other parts of the Veteran's body. The examiner should then specifically identify the percentage of exposed areas of the Veteran's body affected by the service-connected skin disability, as well as the percentage of the entire body affected by the disability. The examiner should also indicate whether or not the disorder requires treatment with systemic therapy (such as oral corticosteroids or other immunosuppressive drugs). 2. Schedule the Veteran for a VA psychiatric examination to determine the nature and etiology of any diagnosed acquired psychiatric disability, to include PTSD, mood disorder, bipolar disorder, and depressive disorder. The entire claims file should be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner should address the following: a. Identify each psychiatric disorder experienced by the Veteran; either diagnose or rule out PTSD, mood disorder, bipolar disorder, and/or depression. b. For each psychiatric disability present, the examiner should indicate whether it is at least as likely as not (50 percent or greater probability) that it had its clinical onset in service or is otherwise related to the Veteran's military service, including the claimed personal assault and/or MST. c. If the Veteran is diagnosed with PTSD, the examiner must identify the stressor that serves as the basis for the diagnosis. If PTSD based on personal assault/MST is diagnosed, the examiner should review the claims folder and render an opinion as to whether there is evidence of changed behavior after the Veteran's alleged assault, or any other evidence of record/MST markers, which would be consistent with the alleged trauma. 3. Schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of her narcolepsy and laryngitis. The entire claims file should be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner should address the following: (a) Does the Veteran have a diagnosis of narcolepsy or laryngitis which clearly and unmistakably (undebatably) existed prior to entrance to any of the two periods of active service? If so, is it clear and unmistakable (undebatable) that the preexisting narcolepsy was not aggravated during active service? If the disability underwent any increase in disability, was that increase in disability due to the natural progress of the disability? (b) If any of the disabilities are not found to clearly and unmistakably exist prior to active service, is it at least as likely as not (50 percent or greater probability) that the disability had its onset during active service or within one year thereafter, or is causally related to active service? (c) Is the Veteran's narcolepsy during service a congenital or developmental defect? If so, was the disorder subjected to any superimposed disease or injury during service? 4. Then, readjudicate the claims remaining on appeal. If any benefit sought on appeal remains denied, the Veteran and representative should be provided a supplemental statement of the case. An appropriate period of time should be allowed for response before the case is returned to the Board. 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 Appeal must be afforded expeditious treatment. The law requires that all issues 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. ______________________________________________ E.I. VELEZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs