Citation Nr: 18160178 Decision Date: 12/27/18 Archive Date: 12/26/18 DOCKET NO. 17-05 703 DATE: December 27, 2018 REMANDED Entitlement to service connection for a disorder manifested by fatigue, to include chronic fatigue syndrome (CFS), to include as secondary to service-connected asthma, or as due to an undiagnosed illness under 38 C.F.R §3 317, is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from April 1981 to November 1988 and from November 1990 to May 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a Department of Veterans Affairs (VA) Regional Office (RO) rating decision in May 2015. The Veteran perfected an appeal. See June 2015 Notice of Disagreement (NOD); December 2016 Statement of the Case (SOC); January 2017 VA Form-9. Although the Board regrets the additional delay, a remand is necessary to ensure that due process is provided and that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2017). 1. Entitlement to service connection for a disorder manifested by fatigue, to include chronic fatigue syndrome (CFS), to include as secondary to service-connected asthma, or as due to an undiagnosed illness under 38 C.F.R §3 317. The Veteran contends that she suffers from fatigue, to include CFS, as a result of exposure to chemical and environmental hazards during the Persian Gulf War; specifically, exposure to burn pits. Alternatively, she contends that her condition is secondary to her service-connected asthma. Service connection may be granted on a presumptive basis for a Persian Gulf War veteran who exhibits objective indications of qualifying chronic disability, including resulting from undiagnosed illness, that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 21, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1). A qualifying chronic disability for VA purposes is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multisymptom illness (such as CFS, fibromyalgia, or functional gastrointestinal disorders) that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that VA determines in regulation prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service connection. 38 U.S.C. § 1117 (a)(2); 38 C.F.R. § 3.317 (a)(2)(i)(B). As an initial matter, the Board notes that military personnel records document that the Veteran served in Southwest Asia from January 14, 1991 to May 7, 1991; thus, exposure to environmental hazards/burn pits is verified. Additionally, the Veteran is service connected for asthma, evaluated as 10 percent disabling, from May 8, 2014. The Veteran maintains that she was exposed to numerous toxic chemicals, as well as burn pits during the Gulf War. She noted that she had to maintain a MOPP-4 level chemical protective posture on several occasions during her Gulf service. She reported that it was because of her exposure to burn pits and other chemicals that she suffered from asthma as well as chronic fatigue. The Veteran indicated that she did not suffer from fatigue prior to, or during, the Gulf War. Rather, these symptoms manifested upon her return from the Gulf. Private treatment records mention fatigue in March 2010 but provide no etiology for the symptom. A VA examination from December 2016 shows that the Veteran reported close proximity to burn pits for brief periods, with proximity of burn pits being a matter of several blocks away for four weeks. The Veteran also indicated daily exposure to sand storms, several times a day for durations of 30 minutes to one hour. The Veteran reported not sleeping well and waking up two to three times per night. She tried Trazadone without success and reported using Benadryl to assist sleep. The Veteran denied diagnoses for chronic fatigue syndrome or fibromyalgia. See December 2016 VA Examination. The VA examiner identified no diagnosed illnesses for which no etiology exists and noted a normal physical examination except as noted on additional questionnaires included as part of the examination report. It was further noted that the Veteran was without a chronic disability pattern, with history for remote or current diagnosis for chronic fatigue syndrome or fibromyalgia. The examiner concluded that the Veteran was without a chronic disability attributable to her service in Southwest Asia. Id. The Board finds the December 2016 VA examination inadequate. The implication of the medical opinion is that the Veteran does not have a current disability manifested by fatigue, to include CFS. However, deficiencies in the provided rationale leave the Board unable to make such a determination. In this regard, although the VA examiner found no diagnosed illnesses for which no etiology exists, she provided no discussion of why the Veteran’s fatigue symptoms do not satisfy the criteria for CFS. The Board considered that it could presume that the examiner competently assessed the Veteran’s symptoms in not rendering a diagnosis of CFS, and thus rely on her medical expertise to find that there is no current diagnosis of CFS. However, the examiner made no indication as to whether the Veteran’s symptoms of fatigue were attributable to any other known clinical diagnosis. Further, she failed to provide more than a conclusory rationale for her determination that the Veteran was without a chronic disability pattern with respect to her reported fatigue. Instead, the examiner’s opinion relied primarily upon the Veteran’s report that she had never been diagnosed for CFS or fibromyalgia, as well as an absence of such diagnoses in the record. Despite the absence of a diagnosis of CFS or fibromyalgia, the Veteran has reported symptoms of fatigue throughout the appeal period and has asserted that such symptoms began following her return from the Gulf War. The Veteran is competent to report such symptoms, as they are capable of lay observation. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Layno v. Brown, 6 Vet. App. 465, 469 (1994). VA may not simply disregard lay evidence because it is unaccompanied by medical evidence. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Thus, the December 2016 VA opinion essentially finds that the Veteran has no current disability manifested by fatigue, without ever specifically discussing the basis for this conclusion. In the absence of a medical opinion and rationale which adequately address the Veteran’s competent and credible reports of chronic fatigue, the Board finds that an addendum medical opinion is required to provide further guidance. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (the probative value of a medical opinion is determined by whether the examiner was informed of sufficient facts upon which to base an opinion and whether the report contains data, conclusions, and a complete rationale in support thereof); 38 C.F.R. § 4.2 (noting that if the examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes). Lastly, the examiner offered no opinion as to what, if any, relationship exists between the Veteran’s fatigue and her service-connected asthma. The Board acknowledges that, in the absence of a current disability manifested by fatigue, the issue of secondary service connection would be moot. However, given that further medical guidance is needed as to the nature of the Veteran’s claimed fatigue, the Board finds that the relationship, if any, between the Veteran’s asthma and fatigue should also be addressed on remand. Based on the foregoing, the Board finds that an addendum opinion is required in order to establish whether or not the Veteran has a diagnosis for her symptoms of fatigue; or in the alternative whether such symptoms constitute an undiagnosed illness or chronic disability; and whether or not her symptoms noted above are attributable to any other diagnosis, to include her service connected asthma. Accordingly, the matter is REMANDED for the following action: 1. Obtain and associate with the claims file all updated treatment records. 2. Obtain an addendum opinion which addresses the nature and etiology of any conditions related to the Veteran's symptoms of fatigue. If deemed necessary by the examiner, afford the Veteran a VA examination. The electronic claims file, including a complete copy of this remand, must be made available to and reviewed by the examiner, and this fact should be noted in the accompanying medical report. All testing deemed necessary by the examiner should be performed and the results reported in detail. a) The examiner should specifically state whether the Veteran's symptoms of fatigue are attributed to a known clinical diagnosis. If so, please specify each such diagnosis. (Continued on the next page)   The examiner is specifically asked to comment on whether the Veteran’s symptoms of fatigue can be attributed to her service-connected asthma, and to address what, if any, relationship exists between the Veteran’s fatigue and asthma. (b) If any symptoms of fatigue have not been determined to be associated with a known clinical diagnosis, the examiner should indicate whether the Veteran has objective indications of a chronic disability resulting from a medically unexplained chronic multisymptom illness, as established by history, physical examination, and laboratory tests, that has either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. (c) For each diagnosed fatigue disorder, please opine whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that the diagnosed disorder manifested during service or is causally or etiologically due to service. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved is required. Please explain in detail the underlying reasoning for the opinion provided. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Lewis