Citation Nr: 18142619 Decision Date: 10/17/18 Archive Date: 10/16/18 DOCKET NO. 14-05 861 DATE: October 17, 2018 ORDER Whether new and material evidence has been received to reopen a previously denied claim for service connection for a disability manifested by fatigue, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness is reopened; to this limited extent only, the appeal is granted. Entitlement to service connection for a disability manifested by joint pain, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness is granted. REMANDED Entitlement to service connection for a disability manifested by fatigue, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness is remanded. Entitlement to service connection for a gastrointestinal disorder, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness is remanded. Entitlement to service connection for headaches, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness is remanded. Entitlement to service connection for a sleep disability, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness is remanded. Entitlement to an initial disability rating in excess of 60 percent for a bilateral hearing loss disability. FINDINGS OF FACT 1. Service connection for a disability manifested by fatigue was initially denied in a September 1998 rating decision as not-well-grounded. The Veteran did not appeal this decision, and it became final. 2. Evidence submitted since the September 1998 rating decision was not previously considered by agency decision makers; is not cumulative and redundant of evidence already of record; relates to an unestablished fact; and raises a reasonable possibility of substantiating his claim for service connection for a disability manifested by fatigue. 3. The Veteran has a disability manifested by joint pain, which has not been attributed to any diagnosed illness. CONCLUSIONS OF LAW 1. The September 1998 rating decision, wherein the RO denied the claim for service connection for a disability manifested by fatigue, is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2017). 2. The criteria for reopening the claim of entitlement to service connection for service connection for a disability manifested by fatigue have been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3.The criteria are met for service connection for a disability manifested by joint pain, as due to undiagnosed illness. 38 U.S.C. §§ 1101, 1110, 1117, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2017); REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from April 1969 to January 1972 and from September 1976 to March 1992. His awards and decorations include the Combat Infantryman’s Badge (CIB). These matters come before the Board of Veterans’ Appeals (Board) on appeal from an April 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. By that rating action, the RO confirmed and continued its previous denial of a claim for service connection for a disability manifested by fatigue, joint and muscle pain, sleep disturbance and denied service connection for a headache disability, to include as due to an undiagnosed illness. The Veteran appealed the April 2012 rating action and the RO’s determinations therein to the Board. This appeal also stems from a December 2014 rating action. By that rating action, the RO continued a 60 percent disability rating assigned to the service-connected bilateral hearing loss. The Veteran appealed the December 2014 rating action and the RO’s determination therein to the Board. In May 2018, the Veteran and his fiancé, A. G., testified before the undersigned at a video conference hearing conducted at the above RO. A copy of the hearing transcript has been uploaded to the Board’s Veteran’s Appeals Co-Locator System (VACOLS). During the hearing, the Veteran submitted a May 2018 VA audiological examination report without a signed waiver of initial Agency of Original Jurisdiction (AOJ) review. See 38 C.F.R. § 20.1304 (2018). However, as the VA audiological examination report was submitted at the hearing by the Veteran, and he perfected an appeal and the claim was certified to the Board after February 2, 2013, explicit waiver of initial AOJ consideration is not required. See Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012, Public Law No. 112-154, 126 Stat. 1165. Hence, this evidence has been added to the record on appeal. I. New and Material Evidence Claim-Disability Manifested by Fatigue The Veteran seeks to reopen a previously denied claim for service connection for a disability manifested by fatigue. After a brief discussion of the laws and regulations governing new and material claims, the Board will analyze the merits of the claim. A decision of the RO becomes final and is not subject to revision on the same factual basis unless a notice of disagreement is filed within one year of the notice of the decision, or new and material evidence is received during the appeal period after the decision. 38 U.S.C. 7105; 38 C.F.R. 3.156, 20.302, 20.1103. If a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. 5108; see Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). VA must review all of the evidence submitted since the last final rating decision in order to determine whether the claim may be reopened. See Hickson v. West, 12 Vet. App. 247, 251 (1999). The threshold is low and does not require new and material evidence regarding each element of the claim that had not been proved in the prior final decision. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). For purposes of determining whether new and material evidence has been received to reopen a finally adjudicated claim, the recently submitted evidence will be presumed credible. Justus v. Principi, 3 Vet. App. 510, 513 (1992). New evidence is defined as 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 (a). By a September 1998 rating action, the RO, in part, denied service connection for a disability manifested by fatigue, finding that the claim was not-well-grounded. The RO based its conclusion on a finding that the Veteran’s in-service complaints of fatigue had been attributed to a diagnosis of an adjustment disorder. The RO also found that there was no objective evidence of fatigue since the Veteran’s separation from active service. (See September 1998 rating action). Notice of the September 1998 rating decision was provided to the Veteran that same month (i.e., September 14, 1998). The Veteran did not appeal the September 1998 rating decision, and no new and material evidence pertinent to the issue was physically or constructively associated with the claims folder within one year of the rating decision. 38 C.F.R. § 3.156 (b). Thus, the September 1998 rating decision became final based on the evidence then of record. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. The Board notes that the Veterans Claims Assistance Act of 2000 (VCAA) provided for a re-adjudication of claims that became final between July 14, 1999 and November 9, 2000, and that were denied as not-well-grounded, as if the denial had not been made. This was so, as long as a claimant requested a re-adjudication or VA moved for a re-adjudication by November 9, 2002-two years after the enactment of the VCAA. Here, the Veteran’s claim in question was denied as not-well-grounded and the decision became final within the requisite time period (i.e., September 14, 1999). Significantly, the Veteran did not request re-adjudication prior to November 9, 2002 for the instant claim. In addition, VA did not re-adjudicate the claim for service connection for a disability manifested by fatigue on its motion by November 9, 2002. Thus, the provisions of the VCAA that pertain to the re-adjudication of claims that were denied as not-well-grounded are not applicable to the present case. See VAOPGCPREC 03-2001 (Jan. 22, 2001). Therefore, the denial of the claim for service connection for a disability manifested by fatigue remains finally decided. The Board finds that new and material evidence has been received to reopen a previously denied claim for service connection for a disability manifested by fatigue. Since the September 1998 rating decision, evidence added to the record includes, but is not limited to, the Veteran’s and A. G’s May 2018 testimony before the undersigned regarding the nature of the Veteran’s fatigue and the chronicity thereof since his discharge from service. The Veteran’s and A.G.’s hearing testimony is new because it was not of record at the time of the RO’s September 1998 denial. It is also material. It is material because it relates to the Veteran having had complaints of fatigue since military service. This evidence was not previously considered by agency decision makers; it is not cumulative and redundant of evidence already of record; it relates to an unestablished fact; and it raises a reasonable possibility of substantiating the claim for service connection. Thus, reopening the Veteran’s claim for service connection for a disability manifested by fatigue, to include as due to an undiagnosed illness or medically unexplained multisymptom illness is warranted based on the receipt of new and material evidence. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). The reopened claim is further addressed in the remand section following the decision below. B. Service Connection Claim-Joint Pain as due to an undiagnosed illness The Veteran seeks service connection for a disability manifested by joint pain, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness. He contends that he has had joint pain ever since his service in the Persian Gulf and that it is so severe that he is unable to perform his occupation as mechanic. (Transcript (T.) at pages (pgs.) 6-8)). After a recitation of the laws governing service connection, to include those based on a theory of undiagnosed illness, the Board will analyze the merits of the claim. Service connection means that a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Service connection may be granted for any disease diagnosed after discharge when the evidence shows that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Entitlement to service connection is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or “medical nexus” between the current disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see 38 C.F.R. § 3.303 (a). Additionally, for the chronic diseases listed in 38 C.F.R. § 3.309 (a), if the chronic disease manifested in service, then service connection will be established for subsequent manifestations of the same chronic disease at any date after service, no matter how remote, without having to show a causal relationship or medical nexus, unless the later manifestations are clearly due to causes unrelated to service (“intercurrent causes”). 38 C.F.R. § 3.303 (b); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012) (holding that § 3.303(b) only applies to the chronic diseases listed in 38 U.S.C. § 1101 § 3.309(a)). When the condition noted during service is not shown to be chronic, or its chronicity may be legitimately questioned, then a continuity of symptoms after service must be shown to establish service connection under this provision. Id; Walker, 708 F.3d at 1338-39 (observing that a continuity of symptoms after service is a relaxed evidentiary showing that itself “establishes the link, or nexus” to service and also “confirm[s] the existence of the chronic disease while in service or [during a] presumptive period”). In addition, where a Veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, there is a presumption of service connection for VA-defined chronic diseases if the disease manifested to a degree of 10 percent or more within one year from the date of separation from service, even if there is no evidence of the disease during the service period itself. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). This presumption may be rebutted by affirmative evidence to the contrary. 38 C.F.R. § 3.307 (d). Initially, the Board observes the Veteran qualifies as a “Persian Gulf veteran.” The Veteran’s DD Form 214 notes that he received the Southwest Asia service medal. See 38 C.F.R. § 3.317 (e)(2). Service connection may be established for a Persian Gulf veteran who has a qualifying chronic disability that became manifest during service or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317; 81 Fed. Reg. 71382 (Oct. 7, 2016). A “qualifying chronic disability” includes: (A) an undiagnosed illness, or (B) a medically unexplained chronic multisymptom illness, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal disease). 38 U.S.C. § 1117 (a)(2); 38 C.F.R. § 3.317 (a)(2)(i). The term “medically unexplained chronic multisymptom illness” means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii). 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. 38 C.F.R. § 3.317 (a)(4). A qualifying chronic disability shall be considered service connected. 38 C.F.R. § 3.317 (a)(6). Compensation shall not be paid for a qualifying chronic disability if there is affirmative evidence that the disability was caused by a supervening condition or event that occurred between the Veteran’s most recent Southwest Asia duty and the onset of the disability. 38 C.F.R. § 3.317 (a)(7)(ii). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: (1) fatigue, (2) signs or symptoms involving skin, (3) headache, (4) muscle pain, (5) joint pain, (6) neurological signs or symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the upper or lower respiratory system, (9) sleep disturbances, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, (12) abnormal weight loss, or (13) menstrual disorders. 38 C.F.R. § 3.317 (b). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. See id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Board finds that service connection is warranted for joint pain, as due to undiagnosed illness. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. In this regard, joint and muscle pain are among the signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness in Persian Gulf veterans. See 38 C.F.R. § 3.317 (b). The Veteran’s service treatment records pertinently reflect that he complained of neck and joint pain that was attributed to a viral infection in September 1970. A February 1992 retirement examination report reflects that the Veteran’s upper and lower extremities were evaluated as “normal.” On an accompanying Report of Medical History, the Veteran reported that he had had swollen/painful joints; cramps in his legs; painful or “trick” shoulder, elbow; and, “trick” or locked knee. Post-service VA treatment records reflect that the Veteran complained of left thumb and hand pain in February 2001. The examining clinicians entered an assessments of left thumb pain, etiology uncertain and left-hand pain with erythema, etiology uncertain. In April and May 2004, assessments of left shoulder pain were recorded. In November 2005, the Veteran complained of having. intermittent joint pain. A December 2011 VA treatment report contains an assessment of muscle pain of the right arm and right side of the neck that was considered to have been fibromyalgia and related to the Veteran’s Persian Gulf Syndrome. (See VA treatment records, dated from May 1992 to December 2011, labeled as “CAPRI” and received into the Veteran’s Legacy Content Manager Document (LCMD) electronic record on January 17, 2012). A March 2012 VA Fibromyalgia examination report reflects that the Veteran described having non-specific-pain in his knees and shoulders. The examiner concluded that the Veteran did not meet the criteria for fibromyalgia. (See March 2012 VA Fibromyalgia Disability Benefits Questionnaire (DBQ)). Finally, when seen at a VA clinic in February 2014, the Veteran denied having any joint pain, but complained of having had intermittent myalgias. An assessment of intermittent arthralgia was entered. (See VA treatment reports, dated from September to December 2014, labeled as “CAPRI” and received into the Veteran’s Veterans Benefits Management System (VBMS) electronic record on December 12, 2014)). Here, Moreover, despite repeated evaluations, the VA clinicians who have treated and examined the Veteran have not assigned clear diagnoses to his joint pains. Rather, the March 2012 VA examiner specifically determined that the Veteran did not have fibromyalgia. (See March 2012 Fibromyalgia DBQ). Further, although the December 2014 VA clinician determined that the Veteran’s complaints of intermittent myalgias were attributable to a known diagnostic identity, namely intermittent arthralgia, the Board notes that a diagnosis of arthralgia is merely a diagnosis of pain. See DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 150 (32d ed. 2012) (defining “arthralgia” as simply “pain in a joint). Arthralgia is therefore not a “known clinical diagnosis” sufficient to preclude service connection under 38 C.F.R. § 3.317. Accordingly, the Board finds that the Veteran’s symptoms of joint pain have not been attributed to any diagnosed disorder. Further, the Veteran’s joint pain, notably in his knees and shoulders, represents the manifestation of undiagnosed disability to at least a compensable (10 percent) degree. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317; and 81 Fed. Reg. 71382 (Oct. 7, 2016) (reflecting that service connection may be established for a Persian Gulf veteran who has a qualifying chronic disability that became manifest to a degree of 10 percent or more not later than December 31, 2021). In this regard, the Board notes that the rating schedule provides that joints that are actually painful should be entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that section 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Thus, in view of the foregoing, and resolving reasonable doubt in the Veteran’s favor, the Board finds that the criteria are met for service connection for joint pain, pursuant to the undiagnosed illness provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND Having reopened the Veteran’s claim for service connection for a disability manifested by fatigue, the Board must now determine whether service connection is warranted. Additional substantive development is required for all remaining claims on appeal, notably, to obtain outstanding VA treatment records and to schedule the Veteran for VA examinations. The Board will discuss each reason for remand below. i) Outstanding VA treatment Reports-All Claims The Board notes that the most recent VA outpatient treatment records are dated through 2014. A December 2014 VA treatment report reflects that an additional follow-up was expected in three (3) months. (See VA treatment reports, dated from September to December 2014, labeled as “CAPRI” and received into the Veteran’s VBMS electronic record on December 12, 2014). As the outstanding VA treatment records might disclose the presence and etiology of the Veteran’s claimed disabilities manifested by fatigue, sleep, headaches and gastrointestinal problems, as well as the current severity of his service-connected bilateral hearing loss, they should be sought on remand. Bell v. Derwinski, 2 Vet. App. 611 (1992). ii) VA examinations-Headaches, Fatigue, Sleep and Gastrointestinal Disabilities First, regarding the claim for service connection headaches, to include as due to an undiagnosed illness or medically unexplained multisymptom illness, a VA examiner concluded that the Veteran did not have a diagnosis consistent with Gulf War Syndrome. (See March 2012 VA Gulf War General Medical examination report). The Veteran was diagnosed as having non-specific headaches during a March 2012 examination. (See March 2012 VA headache examination report). A review of that examination report does not reflect that the examiner provided an opinion as to whether the Veteran’s diagnosed non-specific headaches are etiologically related to his period of military service, notably in-service complaints of headaches in September 1970 and April 1971 and were associated with a viral syndrome (September 1970). Although the March 2012 VA examiner provided an opinion regarding a qualifying chronic disability manifested by headaches and the Gulf War presumption of service connection under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, the examiner did not provide an opinion regarding direct service connection for the diagnosis of non-specific headaches. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994) (holding that a veteran is not precluded from establishing service connection with proof of actual direct causation). Accordingly, a remand is necessary to have the Veteran scheduled for a VA examination and to have the examining clinician provide an opinion as to the relationship between his diagnosed non-specific headaches and their relationship to his period of military service. With regards to the claims for service connection for a disability manifested by fatigue and sleep disability, the Board finds that another examination is necessary to clarify whether the Veteran has a diagnosis of chronic fatigue syndrome (CFS), or any other disability manifested by fatigue, other than CFS. In this regard, a December 2011 VA treatment report reflects that one of the Veteran’s “Problems” was listed as “Chronic fatigue, Persian Gulf syndrome.” (See VA treatment reports, dated from May 1992 to December 2011, labeled as “CAPRI” and received into the LCMD electronic record on January 17, 2012). Conversely, when examined by VA in March 2012, the examiner concluded that the Veteran did not have a diagnosis consistent with Gulf War Syndrome, and that his complaints of fatigue did not rise to the level of a diagnosis of CFS. (See March 2012 VA Chronic Fatigue Syndrome DBQ). Accordingly, the Board finds that an examination is necessary to clarify whether the Veteran has a confirmed diagnosis of CFS or any other disability manifested by fatigue, and sleep disability other than CFS. The Board also finds that another VA examination is warranted to clarify whether the Veteran has a functional gastrointestinal disorder, namely irritable bowel syndrome (IBS) or any other gastrointestinal disability, other than IBS, that is related to his period of military service. Here, a December 2011 VA treatment report reflects that one of the Veteran’s “Problems” was listed as “Diarrhea and constipation which is part of the Persian Gulf syndrome--irritable bowel.” (See VA treatment reports, dated from May 1992 to December 2011, labeled as “CAPRI” and received into the LCMD electronic record on January 17, 2012). Conversely, when examined by VA in March 2012, the VA examiner concluded that the Veteran did not have a diagnosis consistent with Gulf War Syndrome, despite noting that the Veteran had occasional episodes of bowel disturbance with abdominal distress. (See March 2012 VA Gulf War General Medical and Infectious Intestinal Disorders Disability Benefits Questionnaires (DBQs)). Accordingly, the Board finds that an examination is necessary to clarify whether the Veteran has a confirmed diagnosis of IBS or any other gastrointestinal disability that is related to, or had its onset during, his period of military service. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment, dated from December 2014 to the present. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his headache disability, currently diagnosed as non-specific headaches. The entire claims file must 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 provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s headache disability, currently diagnosed as non-specific headaches, had their onset during, or are otherwise etiologically related to service, including his service in Southwest Asia. The examiner must specifically consider the Veteran’s assertions of an in-service headaches and continuity of symptomatology since service separation. The examiner must also consider the findings of headaches contained in the Veteran’s STRs, notably in September 1970 and Apri 1971. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of any disability manifested by fatigue and sleeping problems. The entire claims file must 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. a. The examiner is requested to clarify whether the Veteran’s claimed fatigue and sleep-related problems are disabilities in and of themselves, or are manifestations of another underlying disability or disabilities, such as CFS. In answering this question, the examiner is requested to reconcile the conflicting evidence of record, notably a December 2011 VA treatment record reflecting that one of the Veteran’s “Problems” was “Chronic fatigue, Persian Gulf syndrome” with a March 2012 CFS DBQ containing the examiner’s opinion that his complaints of fatigue did not rise to the level of a diagnosis of CFS. b. For any fatigue disability or disability manifested by fatigue and/or sleep disability identified in (a) above, other than CFS, the examiner must opine as to whether it is at least as likely as not (50 percent probability or greater) that that the condition had its onset during, or is otherwise etiologically related to the Veteran’s military service, to include his service in Southwest Asia. 4 After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of any gastrointestinal disability. The entire claims file must 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. a The examiner is requested to clarify whether the Veteran has a gastrointestinal disability in and of itself, or a manifestation of another underlying disability or disabilities, such as IBS. In answering this question, the examiner is requested to reconcile the conflicting evidence of record, notably a December 2011 VA treatment report reflecting that one of the Veteran’s Problems was listed as “Diarrhea and constipation which is part of the Persian Gulf syndrome--irritable bowel” and March 2012 VA examiner’s opinion that the Veteran did not have a diagnosis consistent with Gulf War Syndrome b. For any gastrointestinal disability or disability manifested by gastrointestinal problems identified in (a) above, other than IBS, the examiner must opine as to whether it is at least as likely as not (50 percent probability or greater) that that the disability had its onset during, or is otherwise etiologically related to service, to include his Southwest Asia service, and his lay statements of in-service onset. (Continued on the next page)   5. Ensure compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). THOMAS H. O'SHAY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Carole Kammel, Counsel