Citation Nr: 19192727 Decision Date: 12/10/19 Archive Date: 12/10/19 DOCKET NO. 17-19 994 DATE: December 10, 2019 ORDER New and material evidence having been received, the petition to reopen the claim for entitlement to service connection for a nervous condition with depression and low tolerance to stress is granted. New and material evidence having not been received, the petition to reopen the claim for entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. New and material evidence having not been received, the petition to reopen the claim for entitlement to service connection for tinnitus is denied. New and material evidence having not been received, the petition to reopen the claim for entitlement to service connection for a head injury is denied. Entitlement to service connection for major depressive disorder is granted. Entitlement to service connection for bipolar disorder is denied. Entitlement to service connection for obstructive sleep apnea is denied. Entitlement to service connection for hepatitis C is denied. REMANDED Entitlement to service connection for neurological or cognitive symptoms, to include as due to Gulf War Illness, or in the alternative, as secondary to the now service-connected major depressive disorder, is remanded. Entitlement to service connection for memory issues, to include as due to Gulf War Illness, or as secondary to the now service-connected major depressive disorder, is remanded. Entitlement to service connection for chronic fatigue syndrome, to include as due to Gulf War Illness, or as secondary to the now service-connected major depressive disorder, is remanded. Entitlement to service connection for insomnia, to include as due to Gulf War Illness, or as secondary to the now service-connected major depressive disorder, is remanded. Entitlement to service connection for headaches, to include as due to Gulf War Illness, or as secondary to the now service-connected major depressive disorder, is remanded. Entitlement to service connection for joint pains, to include as due to Gulf War Illness, is remanded. FINDINGS OF FACT 1. Final March 1995 and September 1995 rating decisions denied entitlement to service connection for depression with low tolerance to stress and a nervous condition, as the evidence at the time did not reflect a current acquired psychiatric disorder related to service. Evidence received since these decisions includes a November 2018 private psychiatric opinion, which provided the Veteran with a diagnosis of major depressive disorder, and provided a positive nexus opinion. 2. A final May 2008 rating decision denied entitlement to service connection for PTSD, as there was insufficient information to confirm the Veteran’s alleged stressors. Evidence received since the May 2008 rating decision includes medical treatment records, which do not contain any information related to the Veteran’s alleged stressors, and lay statements from the Veteran, which are repetitive of statements made at the time of the May 2008 denial. 3. A final March 1995 rating decision denied entitlement to service connection for tinnitus, as the evidence of record did not reflect an in-service incurrence. Evidence received since the March 1995 rating decision includes VA treatment records confirming an already established tinnitus diagnosis, and service treatment records that were already of record at the time of the March 1995 denial. 4. Final rating decisions in March 1995 and May 2008 denied entitlement to service connection for a head injury, as the evidence of record did not reflect an in-service incurrence. Subsequently added medical records do not reflect an in-service incurrence. 5. Resolving reasonable doubt in favor of the Veteran, his currently diagnosed major depressive disorder first manifested in service. 6. The preponderance of the evidence of record does not reflect that the Veteran has a current diagnosis of bipolar disorder. 7. The preponderance of the evidence of record does not reflect that the Veteran’s currently diagnosed obstructive sleep apnea is related to service. 8. The preponderance of the evidence of record does not reflect that the Veteran’s currently diagnosed hepatitis C is related to service. CONCLUSIONS OF LAW 1. New and material evidence sufficient to reopen the claim of entitlement to service connection for a nervous condition with depression and low tolerance to stress has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. New and material evidence sufficient to reopen the claim of entitlement to service connection for PTSD has not been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. New and material evidence sufficient to reopen the claim of entitlement to service connection for tinnitus has not been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 4. New and material evidence sufficient to reopen the claim of entitlement to service connection for a head injury has not been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. The criteria for entitlement to service connection for major depressive disorder have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for entitlement to service connection for bipolar disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for entitlement to service connection for obstructive sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for entitlement to service connection for hepatitis C have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1990 to December 1991. These matters come before the Board of Veterans’ Appeals (Board) on appeal from March 2015 and July 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Board notes that the Veteran has elected to have his claims for entitlement to nonservice-connected disability pension benefits, entitlement to a total disability rating based on service-connected disabilities, and entitlement to a 10 percent evaluation based on multiple, noncompensable, service-connected disabilities, be reviewed under the modernized appeals system. As such, these issues will be addressed in a separate decision. New and Material Evidence In general, decisions of the RO and the Board that are not appealed in the prescribed time period are final. 38 U.S.C. §§ 7104, 7105, 7266; 38 C.F.R. §§ 3.104, 20.1100, 20.1103. A finally disallowed claim, however, may be reopened when new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary’s duty to assist or consideration of a new theory of entitlement. Id. at 117-18. Nervous Condition with Depression The Veteran maintains that he has submitted sufficient new and material evidence to reopen his claim for entitlement to service connection for a nervous condition with depression and low tolerance to stress. The Veteran’s claim for entitlement to service connection for depression with low tolerance to stress was first denied in a March 1995 rating decision, as the service treatment records were negative for clinical findings of a chronic nature. His claim for a nervous condition was later denied in a September 1995 rating decision, as the Veteran did not have a diagnosed nervous condition at the time. As the Veteran did not challenge either of these rating decisions, or submit new and material evidence within one year of these decisions, they both have become final. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Evidence added since the March 1995 and September 1995 rating decisions include VA treatment records and VA and private medical opinions. Specifically, a November 2018 private psychiatric evaluation provided a diagnosis of major depressive disorder and provided a positive nexus opinion between this disability and service. This evidence is material because it relates to unestablished facts necessary to establish the Veteran’s claim—specifically, a current disability and a nexus to service. Additionally, the evidence is neither cumulative nor redundant, as this evidence was not of record at the time of the prior denial. Accordingly, for all of the above reasons, the Veteran’s claim for entitlement to service connection for an acquired psychiatric disorder, claimed as a nervous condition with depression and low tolerance to stress, is reopened. PTSD The Veteran maintains that he has submitted sufficient new and material evidence to reopen his claim for entitlement to service connection for PTSD. The Veteran’s claim for entitlement to service connection for PTSD was initially denied in a May 2008 rating decision as there was insufficient evidence of record to confirm his claimed stressors. As the Veteran did not challenge the May 2008 rating decision, or submit new and material evidence within one year of this decision, it has become final. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Evidence of record at the time of the May 2008 rating decision includes a July 2007 Statement in Support of Claim for Service Connection for PTSD. Therein, the Veteran claimed stressors of breaking his wrist after getting into a fight with another soldier, and his roommate falling and sustaining multiple injuries. Subsequent statements reflect the Veteran feeling ostracized from his unit after feeling he was at fault for his roommate falling and injuring himself. Evidence received since the May 2008 rating decision includes VA and private treatment records, and statements from the Veteran, his mother, and his aunt. While the medical treatments records are new in that they were not previously of record, the Board finds that they are not material to the Veteran’s claims, as they do not raise a reasonable possibility of substantiating the Veteran’s claim. Specifically, here is no indication in these records of confirmation of the Veteran’s alleged PTSD stressors. Further, statements submitted by the Veteran since the May 2008 final rating decision related to the claimed PTSD stressors were redundant of the evidence of record at the time of the last prior final denial of the claim. These statements do not contain any new allegations or claims regarding the Veteran’s alleged PTSD stressors. Further, while newly submitted statements from the Veteran’s mother and aunt describe the Veteran’s mental health symptomology after separation from service, these statements do not contain any information regarding the claimed stressors. Accordingly, as this newly added evidence is not material to the Veteran’s claim, the Board finds that the petition to reopen the claim for entitlement to service connection for PTSD is denied. Tinnitus The Veteran maintains that sufficient new and material evidence has been submitted to reopen his claim for tinnitus. The Board notes that the Veteran has also previously claimed entitlement to service connection for bilateral hearing loss, a perforated left eardrum, and otitis media (claimed as an ear infection), which were all denied in prior rating decisions and are not currently on appeal. The Veteran’s claim for entitlement to service connection for tinnitus was initially denied in a March 1995 rating decision, as there was no evidence of an in-service incurrence. As the Veteran did not challenge the March 1995 rating decision, or submit new and material evidence within one year of this decision, it has become final. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Evidence of record at the time of the March 1995 rating decision includes the Veteran’s service treatment records, which did contain reports of, and treatment for, an ear infection and a “clogged” ear, but did not contain any indications of reports of tinnitus. Also of record was a September 1994 VA examination where the VA examiner opined that “[c]hronic intermittent tinnitus [was] probably secondary to noise exposure the patient experienced in the service.” Nevertheless, the Veteran’s claim was denied, as the RO found this evidence insufficient to establish that the Veteran’s tinnitus was related to service. Evidence submitted subsequent to the March 1995 rating decision regarding tinnitus includes VA treatment records, lay statements from the Veteran, as well as service treatment records submitted by the Veteran. While the VA treatment records reflect the Veteran being treated for tinnitus, there is no indication in these records of an in-service incurrence, or nexus opinion connecting this disability to service. Further, the Veteran has also submitted statements regarding his ear infection and perforated eardrum in service, however, these issues are not currently before the Board. Similarly, VA ear examinations conducted in March 2018 did not address the Veteran’s tinnitus. Finally, the service treatment records submitted by the Veteran were duplicative of records previously associated with the claims file at the time of the March 1995 final denial. Accordingly, while the VA medical records were newly added, they are not material to the Veteran’s claim, as they do not raise a reasonable possibility of substantiating the Veteran’s claim. Specifically, these records confirm an already established element of the Veteran’s claim—a currently disability. Further the service treatment records submitted by the Veteran, while material, are not new, as they were already of record at the time of the prior March 1995 denial. Thus, the petition to reopen the claim for entitlement to service connection for tinnitus is denied. Head Injury The Veteran maintains that sufficient new and material evidence has been submitted to reopen his claim for entitlement to service connection for a head injury. The Veteran’s claim for a head injury was initially denied in a March 1995 rating decision, as there was insufficient evidence of an in-service incurrence. The RO noted that there was evidence in the Veteran’s service treatment records that he underwent an excision of a pyogenic granuloma in August 1990, however, the Veteran was already service-connected for the residuals of this disability. As the Veteran did not challenge the March 1995 rating decision, or submit new and material evidence within one year of this decision, it has become final. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. The Veteran’s claim for service connection for a head injury was last denied in a May 2008 rating decision, again because there was insufficient evidence of an in-service incurrence. As the Veteran did not challenge the May 2008 rating decision, or submit new and material evidence within one year of this decision, it has become final. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Evidence of record at the time of the prior final denials includes VA treatment records, which do not contain any indication of a head injury other than the pyogenic granuloma for which the Veteran is already service connected. Also of record at the time was a July 2007 statement from the Veteran indicating that he sustained a head injury during training. Evidence added subsequent to the final May 2008 rating decision includes VA treatment records. The VA treatment records reflect notations indicating that the Veteran sustained multiple head injuries after service, to include multiple car accidents, and the Veteran having a garage door fall on his head. However, there are no indications of an in-service incurrence. Accordingly, while the VA medical records were newly added, they are not material to the Veteran’s claim, as they do not raise a reasonable possibility of substantiating the claim. Specifically, there is no indication of an in-service incurrence, or a nexus connecting any current head disability to service. Thus, the petition to reopen the claim for entitlement to service connection for a head injury is denied. Service Connection Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In general, service connection requires the following: (1) evidence of a current disability; (2) evidence of an in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Acquired Psychiatric Disorders The Veteran maintains that entitlement to service connection is warranted for an acquired psychiatric disorder, to include depression with low tolerance to stress, a nervous condition, and bipolar disorder. A review of the medical evidence of record reflects a current diagnosis of major depressive disorder; thus, the current disability element for this claim has been established. As will be discussed below, the preponderance of the evidence of record does not reflect a current diagnosis of bipolar disorder. A review of the Veteran’s service treatment records reflect that he was not found to have any psychiatric disabilities in his March 1992 separation examination. However, the Board notes that there were numerous behavioral issues noted in his military personnel records. Further, a July 1991 report from the Veteran’s superior officer indicates that, during service, the Veteran requested to see an Army psychiatrist for a mental evaluation. His superior officer indicated that other than an interest in no longer being in the Army, he had no reason to believe the Veteran had any psychiatric disability warranting discharge. A July 1991 Report of Mental Status Evaluation found the Veteran’s behavior to be normal, that he was fully alert, fully oriented, his thinking process was clear, his thought content was normal, and his memory was good. However, he was noted as having an anxious mood or affect. The Veteran reported extreme difficulty conforming to the standards of being a soldier in the U.S. Army. The examiner indicated that the Veteran was also experiencing numerous personal problems that were also impacting job performance. He indicated that the Veteran seemed to be unwilling or unable to adjust to the social structure of the military. Reports from the Veteran’s commanding officers dated August 1991 reflect the Veteran struggling to cope with “family” and “internal” problems, as well as “serious personal problems.” There is also an indication in his military personnel records that he received nonjudicial punishment for the wrongful use of marijuana. The Board notes that the Veteran was discharged from service for unsatisfactory performance, however, in September 2001, the U.S. Army Discharge Review Board upgraded the Veteran’s characterization of discharge to “honorable.” Also of record regarding the Veteran’s claim for an acquired psychiatric disorder are lay statements from the Veteran, his mother, and his aunt. In a July 2007 statement, the Veteran expressed distress in service over feeling like he was being criticized by fellow soldiers in service after being medically sent back to Germany from Saudi Arabia. He claims he received bad remarks, dirty looks, and was often provoked into fights. He also detailed an incident where he was assisting a roommate balance from a window and his roommate fell and was seriously injury. The Veteran felt as if he was blamed by others for the incident. He reported that due to this treatment, he could no longer handle the stress of service, and his behavior and attitude began to change. He claims he attempted to receive assistance from his superior officers, but was denied. He admitted to failing a drug screening. The Board notes that the Veteran has submitted subsequent statements that largely recount these same in-service incidents and stressors. A July 2007 statement from the Veteran’s mother indicates that the Veteran was not the same when he came back from service. He indicated to her that his head was killing him and that he felt like he was losing his mind. A subsequent July 2014 statement from the Veteran’s mother indicated that he had limited social interactions and expressed serious suicidal ideations. A June 2015 statement from the Veteran’s aunt indicated that the Veteran lived with her on and off since separation from service. She indicated that he was very depressed after separation, and that he was never able to sleep. She also indicated that he apparently overdosed on sleeping pills. The Veteran was provided a VA mental disorder examination in January 2015, where he was provided diagnoses of alcohol use disorder, severe, in full remission (per Veteran’s reports), and adjustment disorder with mixed anxiety and depressed mood. The examiner indicated that the Veteran had possible cognitive effects related to multiple, post-service, motor vehicle accidents, and that he had a history of treatment for hepatitis C. The examiner indicated that due to the Veteran’s extensive history of alcohol and other psychoactive substance abuse, combined with mood symptoms likely related to the consequences of that use, it was not possible for the examiner to differentiate what portion of each symptom was attributable to each of the Veteran’s mental health diagnoses even taking into consideration that he reported current abstinence from such substances. Regarding service stressors, the Veteran reported that he felt as if he was not being treated fairly in service. He also reported the incident where his roommate was injured, and getting into numerous fights with other soldiers in service. The Veteran further reported difficulty concentrating due to insomnia and headaches. He also reported having a history of hallucinations when he had not slept for prolonged periods of time. However, the VA examiner specifically noted that upon review of the Veteran’s extensive medical records, there was no indication of psychotic symptoms when he was not also using perceptual- and mind-altering substances. He also reported significant alcohol and substance abuse post-service. The examiner opined that the Veteran’s current diagnosis of adjustment disorder, with mixed anxiety and depressed mood, was not caused by, a result of, or permanently aggravated by service. She reasoned that the culmination of the evidence of record supports the conclusion that the Veteran began using alcohol and other substances heavily in service, and that this use, combined with financial stressors, likely led to the depression and anxiety in service. The examiner also specifically noted that the Veteran had a difficulty providing a clear narrative regarding his substance abuse after service, and did not mention numerous substances which were documented in his VA records. Finally, regarding a diagnosis of bipolar disorder, the VA examiner indicated that the Veteran denied symptoms consistent with hypomania or mania “such that previous diagnoses of bipolar disorder by his VA psychiatrist cannot be confirmed.” The examiner acknowledged that the Veteran was being treated by VA for bipolar disorder, however, she reiterated that she did not find any evidence supporting such a diagnosis. She indicated that heavy substance abuse is commonly misdiagnosed as bipolar disorder due to overlapping symptoms such as mood swings, irritability, sleep disturbances, and reckless behavior. Also of record is a November 2018 private psychological evaluation. The Board notes that the name used in the first sentence of this report is not the Veteran’s; however, since the Veteran’s name is correctly used throughout the rest of the opinion, and all of the evidence cited in the evaluation clearly relate to the Veteran, the Board will presume this is a typographical error. After a clinical interview with the Veteran, and a review of the record, the private examiner provided a current diagnosis of chronic major depressive disorder. He indicated that the Veteran had previous diagnoses of alcohol and substance use disorders that are currently in full sustained remission. There was no indication in the report that the Veteran had a current diagnosis of bipolar disorder. The private examiner opined that it was more likely than not that the Veteran’s major depressive disorder manifested during service. The private examiner indicated that there was no evidence of a psychiatric disability prior to service. He noted that the Veteran’s service records contained evidence of depression symptoms and a behavioral shift. Specifically, these records reflect that his mood was anxious, and that he requested psychiatric evaluations and treatment from professionals. The private examiner also cited to the fact that the Veteran’s period of service was cut short due to his behavior, which the examiner attributed to the Veteran’s depression symptoms. Further, the private examiner noted that it was specifically indicated in the Veteran’s records that his military service was causing him to experience personal problems. The Veteran also reported depression and excessive worry on his separation examination. The examiner indicated that the Veteran’s behavioral shift was also confirmed by his mother and aunt. Regarding the Veteran’s significant history of alcohol and substance abuse, the private examiner indicated that these actions should be interpreted as the Veteran self-medicating his depressive symptoms. Specifically, the Veteran reported that he self-medicated in order to help sleep and cope with his symptoms. The Veteran indicated that his substance use went from alcohol and marijuana to methamphetamine use while in service. The examiner opined that the Veteran’s post-service stressors were “actually a result of his psychiatric condition rather than a cause of it.” In light of the foregoing, due to the conflicting medical opinions of record, the Board finds that the evidence of record is at least in equipoise as to whether the Veteran’s currently diagnosed major depressive disorder began in service. The Board acknowledges that while the Veteran’s service treatment records do not contain a specific diagnosis of an acquired psychiatric disorder, his military personnel records do reflect numerous indications of a behavioral shift during service. The expert medical opinions of record differ as to whether the Veteran’s in-service substance abuse and post-service stressors caused his major depressive disorder, or whether, as the November 2018 private opinion maintains, these stressors were the result of the Veteran’s major depressive disorder that first manifested during service. Thus, resolving reasonable doubt in favor of the Veteran, the Board finds that entitlement to service connection for major depressive disorder is warranted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). However, regarding the Veteran’s claim for bipolar disorder, the Board finds that service connection is not warranted, as the preponderance of the evidence of record does not reflect a current diagnosis for this disability. The Board acknowledges that the Veteran’s VA treatment records reflect a current diagnosis and treatment for bipolar disorder. However, the Board finds persuasive the detailed report by the January 2015 VA examiner finding no evidence to support a current bipolar diagnosis and her reasoning of commonly overlapping symptoms. Further, the Board notes that the Veteran’s November 2018 private psychological examination did not reflect a current bipolar diagnosis. Accordingly, as the preponderance of the evidence of record does not reflect a current diagnosis, the Board finds that entitlement to service connection for bipolar disorder is not warranted. In summary, the Board finds that entitlement to service connection for major depressive disorder is granted, as the evidence is in equipoise as to whether the major depressive disorder began in service. Further, as the preponderance of the evidence of record does not reflect a current diagnosis, entitlement to service connection for bipolar disorder is denied. Finally, the Board notes that evidence of record does not reflect a current diagnosis of alcohol or substance abuse during the period on appeal, thus, any consideration for service connection of this disability, to include as secondary to the now service-connected major depressive disorder, is not warranted at this time. Obstructive Sleep Apnea The Veteran claims that entitlement to service connection for obstructive sleep apnea is warranted. The Board notes that the Veteran has also claimed entitlement to service connection for insomnia; however, this issue will be discussed in the REMAND section below. A review of the medical evidence of record reflects a current diagnosis of obstructive sleep apnea that was first diagnosed in June 2008, however, there were indications of suspected obstructive sleep apnea in December 2007. Accordingly, the current disability element for this claim has been established. However, the Board finds that entitlement to service connection for obstructive sleep apnea is not warranted, as the evidence of record does not reflect an in-service incurrence, or a nexus between the currently diagnosed obstructive sleep apnea and service. Initially, there is no indication of obstructive sleep apnea, or any related respiratory disability, in the Veteran’s service treatment records. Further, while the Veteran reported experiencing insomnia ever since separation from service in a February 2018 statement, he did not report experiencing any specific sleep apnea symptomology in service. Similarly, while a June 2015 statement from the Veteran’s aunt indicated that the Veteran was never able to sleep after separation from service, she did not report any sleep apnea symptoms. Finally, the Board notes that while the Veteran’s VA treatment record reflect a current diagnosis of, and treatment for, obstructive sleep apnea, there is no indication of a nexus between service and this disability, which was diagnosed many years after separation from service. Accordingly, as the preponderance of the evidence of record does not reflect an in-service incurrence or nexus between this current disability and service, the Board finds that entitlement to service connection for obstructive sleep apnea is not warranted. Thus, the Veteran’s claim is denied. Hepatitis C The Veteran claims entitlement to service connection for hepatitis C. A review of the medical evidence of record reflects a current diagnosis of hepatitis C; thus, the current disability element for this claim has been established. However, the Board finds that entitlement to service connection for hepatitis C is not warranted, as the evidence of record does not reflect that this disability is related to service. Specifically, there is no indication in the Veteran’s service treatment records of a diagnosis of hepatitis C. The earliest indication in the medical records associated with the claims file of a diagnosis of hepatitis C is in July 2007. There was no indication at the time of this initial diagnosis that this disability was related to service. The Board notes that the July 2007 statement from the Veteran’s mother indicated that the Veteran never had hepatitis C prior to service, but that he had it after separation. The Board notes that medical records from a few years after separation from service do not reflect a diagnosis of this disability. In a June 2015 statement from the Veteran regarding his hepatitis C claim, he admitted to using “hard drugs” for a short period of time, but claimed he had a “sterile technique.” There is otherwise no indication that the Veteran developed hepatitis C in service. Accordingly, as there is no evidence that the Veteran’s currently diagnosed hepatitis C developed in service, or was otherwise related to service, the Board finds that entitlement to service connection for this disability is not warranted. Thus, entitlement to service connection for hepatitis C is denied. REASONS FOR REMAND For the reasons discussed below, the Board finds that a remand is warranted for the remaining issues on appeal. The Veteran has generally claimed that his neurological or cognitive issues, memory issues, chronic fatigue syndrome, insomnia, headaches, and joint pain are due to Gulf War Illness. Initially, the Board notes that although the Veteran’s Form DD 214 reflects that the Veteran was awarded the Southwest Asia Service Medal, there is no indication on the form of which country, and from which dates, the Veteran served. The Veteran’s service personnel records only reflects overseas service in Germany from July 1990 to December 1991. The Veteran maintains that he served for two weeks in Saudi Arabia. He indicated that he injured his ankle and was subsequently returned to Germany. Service medical records appear to indicate that the Veteran was in Saudi Arabia, but the dates of service are not confirmed. Accordingly, the Board finds that a remand is warranted in order to confirm the country and dates of the Veteran’s Gulf War service. Regarding the Veteran’s claims for neurological or cognitive issues, memory issues, sleep difficulties (to include chronic fatigue syndrome and insomnia), and headaches, there is an indication in the Veteran’s medical treatment records that these disabilities might be associated with the Veteran’s now service-connected major depressive disorder. Specifically, the Veteran has attributed these symptoms to his psychiatric disability. Additionally, the record is unclear as to whether the Veteran has a diagnosis of chronic fatigue syndrome. A January 2015 VA examination diagnosed the Veteran with chronic fatigue syndrome and attributed the disability to the Veteran’s mood swings, anxiety, bipolar disorder, nightmares, sleep apnea and difficulty sleeping, and not to Gulf War Illness. However, the Board notes that no rationale was provided for this opinion. Further, a July 2015 Gulf War Illness examination indicated that the Veteran did not have a diagnosis of chronic fatigue syndrome. Due to these conflicting opinions regarding current diagnoses and etiology, the Board finds that a remand is warranted to obtain addendum medical opinions regarding the Veteran’s claims for entitlement to service connection for neurological or cognitive issues, memory issues, sleep difficulties (to include chronic fatigue syndrome and insomnia), and headaches. The Board further finds that a remand is warranted for the Veteran’s claim for entitlement to service connection for joint pains. The Veteran was provided a VA Gulf War examination in July 2015, with associated examinations for his claimed ankle, elbow and forearm, knee and lower leg, and shoulder and arm pain. The VA examiner indicated that the Veteran did not have an undiagnosed or medically unexplained chronic multisymptom illness because his symptomology could be explained based on standard medical definitions and practice. Specifically, the Veteran, in separate VA examinations, was provided diagnoses of a left ankle sprain, bilateral patellofemoral pain syndrome, and bilateral shoulder impingement syndrome. While the etiology of the Veteran’s left ankle was explained (a sprain in service) the etiology and pathophysiology of the other joint pain disabilities were not addressed. Accordingly, the Board finds that a remand for this issue is warranted to determine whether the Veteran’s reported symptomology is reflective of a medically unexplained chronic multisymptom illness. See 38 C.F.R. § 3.317; Stewart v. Wilkie, 30 Vet. App. 383, 390 (2018). Accordingly, these matters are REMANDED for the following action: 1. Conduct further development regarding the Veteran’s service in the Gulf War. Specifically, confirm whether the Veteran served in Saudi Arabia, and, if so, confirm the dates of such service. 2. Obtain and associate with the claims file any outstanding VA treatment records. 3. Thereafter, forward the Veteran’s electronic claims file to an appropriate examiner for addendum opinions regarding the Veteran’s neurological or cognitive issues, memory issues, chronic fatigue syndrome, insomnia, headaches, and joint pain. It is left to the examiner’s discretion whether to reexamine the Veteran. Regarding the Veteran’s alleged symptoms of neurological or cognitive issues, memory issues, chronic fatigue syndrome, insomnia, headaches, and joint pain, provide opinions, with complete rationales, to each of the following questions for each disability/symptom: (a.) Is the disability pattern consistent with (i) an undiagnosed illness; (ii) a diagnosable but medically unexplained chronic multisymptom illness; (iii) a diagnosable chronic multisymptom illness with a partially explained etiology and pathophysiology; or (iv) a disease with a clear and specific diagnosis, etiology, and pathophysiology. 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. Examples include, but are not limited to, the following: chronic fatigue syndrome; fibromyalgia; and functional gastrointestinal disorders. The response to this question should include a discussion of the pathophysiology and etiology of the Veteran’s claimed disability and/or reported symptomology. Pathophysiology is defined as the physiology of abnormal states; specifically, the functional changes that accompany a particular syndrome or disease. Consideration of pathophysiology and etiology is a veteran-specific inquiry, as opposed to an inquiry regarding the general knowledge of the medical community. (b.) If the Veteran’s disability pattern is consistent with either (iii) a diagnosable chronic multisymptom illness with a partially explained etiology and pathophysiology, or (iv) a disease with a clear and specific diagnosis, etiology, and pathophysiology, opine as to whether it is at least as likely as not (a 50 percent or greater probability) that said disability incurred in, or is otherwise related to service. (c.) Thereafter, opine as to whether it is at least as likely as not (a 50 percent or greater probability) that any of the above disabilities and/or symptomology was caused AND/OR aggravated (increased in severity) by the Veteran’s now service-connected major depressive disorder. 4. After undertaking any additional development deemed appropriate and giving the Veteran full opportunity to supplement the record, adjudicate the Veteran’s pending claims in light of any additional evidence added to the record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a Supplemental Statement of the Case and be afforded the applicable opportunity to respond before the record is returned to the Board for further review. M. Donohue Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. DeChiara, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.