Citation Nr: 20009934 Decision Date: 02/06/20 Archive Date: 02/05/20 DOCKET NO. 19-13 423 DATE: February 6, 2020 REMANDED Entitlement to service connection for posttraumatic stress disorder is remanded. Entitlement to service connection for unspecified depressive disorder, to include as secondary to posttraumatic stress disorder, is remanded. Entitlement to service connection for undiagnosed illness due to exposure to Gulf War environmental hazards is remanded. Entitlement to service connection for headaches, to include as due to exposure to Gulf War environmental hazards, is remanded. Entitlement to service connection for sleep disturbance, to include sleep apnea and insomnia, to include as due to exposure to Gulf War environmental hazards, is remanded. Entitlement to service connection for athlete’s foot of the bilateral feet, to include as due to exposure to Gulf War environmental hazards, is remanded. Entitlement to service connection for fibromyalgia with bilateral leg pain, to include as due to exposure to Gulf War environmental hazards, is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for right knee disability, to include as due to exposure to herbicide agents and/or exposure to Gulf War environmental hazards, is remanded. Entitlement to service connection for left knee disability, to include as due to exposure to herbicide agents and/or exposure to Gulf War environmental hazards, is remanded. Entitlement to service connection for lumbar spine disability, to include as due to exposure to herbicide agents and/or exposure to Gulf War environmental hazards, is remanded. Entitlement to service connection for skin rash on face and head, to include as due to exposure to Gulf War environmental hazards, is remanded. Entitlement to service connection for gastroesophageal reflux disease, to include as due to exposure to Gulf War environmental hazards, is remanded. Entitlement to service connection for a cholesterol condition is remanded. Entitlement to service connection for diabetes mellitus is remanded. Entitlement to a total disability based on individual unemployability is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Army from October 1998 to March 1999 as well as two periods of deployment from November 2001 to August 2003. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office. 1. Entitlement to service connection for posttraumatic stress disorder (PTSD), skin rash on face and head, undiagnosed illness, gastroesophageal reflux disease (GERD), and cholesterol condition is remanded. The Veteran indicated in a May 2017 VA Form 21-8940 (Veteran’s Application for Increased Compensation Based on Unemployability) that he received treatment from the Atlanta VA medical center (VAMC) from 2006 to “present” (i.e., May 2017). The earliest VAMC record associated with the claims file is dated June 26, 2017. Thus, remand is required to obtain any VAMC records prior to June 26, 2017. 2. Entitlement to service connection for unspecified depressive disorder, to include as secondary to PTSD, is remanded. An additional VA examination is required to address discrepancies in prior VA examinations. An April 2017 VA examination diagnosed unspecified depressive disorder and found it at least as likely as not that it was incurred in service, however it lacked rationale beyond citing the lack of a diagnosed mental health condition in the June 1998 entrance examination. In addition, the same VA examiner then determined in an April 2017 VA medical opinion that it would be “mere speculation” to determine whether the Veteran’s depression was incurred in or caused by service. Finally, a June 2017 VA examination found no evidence of any mental disability diagnosis. Clarification is accordingly required in an additional VA examination. 3. Entitlement to service connection for headaches, to include as due to exposure to Gulf War environmental hazards, is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for headaches because no VA examiner has opined whether the reported headaches are due to exposure to Gulf War environmental hazards — as reported in a July 2003 Post-Deployment Health Assessment — specifically, being “often” exposed to sand/dust and smoke from oil fire. 4. Entitlement to service connection for sleep disturbance, to include sleep apnea and insomnia, to include as due to exposure to Gulf War environmental hazards, is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for sleep disturbance (to include sleep apnea and insomnia) because no VA examiner has established whether the Veteran has sleep apnea. Moreover, no VA examiner has determined whether the Veteran’s sleep apnea and insomnia are due to exposure to Gulf War environmental hazards — as reported in the July 2003 Post-Deployment Health Assessment — specifically, being “often” exposed to sand/dust and smoke from oil fire. 5. Entitlement to service connection for athlete’s foot of the bilateral feet, to include as due to exposure to Gulf War environmental hazards, is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for athlete’s foot of the bilateral feet because no VA examiner has determined whether the Veteran’s athlete’s foot is due to exposure to Gulf War environmental hazards — as reported in the July 2003 Post-Deployment Health Assessment — specifically, being “often” exposed to sand/dust and smoke from oil fire. 6. Entitlement to service connection for fibromyalgia with bilateral leg pain, to include as due to exposure to Gulf War environmental hazards, is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for fibromyalgia with bilateral leg pain because no VA examiner has established whether the Veteran has fibromyalgia. 7. Entitlement to service connection for hypertension is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for hypertension because no VA examiner has determined whether the Veteran’s hypertension is due to exposure to Gulf War environmental hazards — as reported in the July 2003 Post-Deployment Health Assessment — specifically, being “often” exposed to sand/dust and smoke from oil fire. 8. Entitlement to service connection for right and left knee disability, to include as due to exposure to herbicide agents and/or exposure to Gulf War environmental hazards, is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for bilateral knee disability because no VA examiner has opined whether the reported disabilities are due to in-service injury and/or exposure to Gulf War environmental hazards — as reported in the July 2003 Post-Deployment Health Assessment — specifically, being “often” exposed to sand/dust and smoke from oil fire. 9. Entitlement to service connection for lumbar spine disability, to include as due to exposure to herbicide agents and/or exposure to Gulf War environmental hazards, is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for lumbar spine disability because no VA examiner has opined whether the reported disabilities are due to in-service injury and/or exposure to Gulf War environmental hazards — as reported in the July 2003 Post-Deployment Health Assessment — specifically, being “often” exposed to sand/dust and smoke from oil fire. 10. Entitlement to service connection for diabetes mellitus is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for diabetes mellitus because no VA examiner has determined whether the Veteran’s diabetes mellitus is due to exposure to Gulf War environmental hazards — as reported in the July 2003 Post-Deployment Health Assessment — specifically, being “often” exposed to sand/dust and smoke from oil fire. 11. Entitlement to a total disability based on individual unemployability (TDIU) is remanded. Because a decision on the remanded issues could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. A remand of the claim for a TDIU is required. The matters are REMANDED for the following action: 1. Obtain the Veteran’s treatment records from the Atlanta VAMC for the period from 2006 to June 26, 2017. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any mental disability, to include unspecified depressive disorder. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, to include being “often” exposed to sand/dust and smoke from oil fire (see July 2003 Post-Deployment Health Assessment). 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his claimed headaches. The examiner should address the following: (a.) Specify whether the Veteran’s headaches are indicative of undiagnosed illness or chronic multi-symptom illness of the type contemplated by 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. To this end, specifically indicate whether these symptoms, instead, are attributable to known clinical diagnoses. (b.) If no diagnosis is made accounting for the Veteran’s headaches, the examiner must reconcile this conclusion with the evidence of record detailing the Veteran’s complaints. (c.) If the Veteran’s headaches cannot be ascribed to any known clinical diagnosis, specify whether he has objective indications of a chronic disability resulting from an undiagnosed 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. (d.) If the Veteran’s headaches can be ascribed to a known clinical diagnosis, the examiner is asked to address whether it is at least as likely as not (a 50 percent probability or greater) that the diagnosed disability was incurred in service or is otherwise etiologically related to service, to include being “often” exposed to sand/dust and smoke from oil fire (see July 2003 Post-Deployment Health Assessment). 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his claimed sleep disturbances, including sleep apnea and insomnia. The examiner should address the following: (a.) Specify whether the Veteran’s sleep disturbances symptoms are indicative of undiagnosed illness or chronic multi-symptom illness of the type contemplated by 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. To this end, specifically indicate whether these symptoms, instead, are attributable to known clinical diagnoses. (b.) If no diagnosis is made accounting for the Veteran’s sleep disturbance symptoms, the examiner must reconcile this conclusion with the evidence of record detailing the Veteran’s complaints. (c.) If the Veteran’s sleep disturbance symptoms cannot be ascribed to any known clinical diagnosis, specify whether he has objective indications of a chronic disability resulting from an undiagnosed 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. (d.) If the Veteran’s sleep disturbance symptoms can be ascribed to a known clinical diagnosis, the examiner is asked to address whether it is at least as likely as not (a 50 percent probability or greater) that each diagnosed disability was incurred in service or is otherwise etiologically related to service, to include being “often” exposed to sand/dust and smoke from oil fire (see July 2003 Post-Deployment Health Assessment). 5. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his claimed athlete’s foot. The examiner should address the following: (a.) Specify whether the Veteran’s athlete’s foot is indicative of undiagnosed illness or chronic multi-symptom illness of the type contemplated by 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. To this end, specifically indicate whether these symptoms, instead, are attributable to known clinical diagnoses. (b.) If no diagnosis is made accounting for the Veteran’s athlete’s foot, the examiner must reconcile this conclusion with the evidence of record detailing the Veteran’s complaints. (c.) If the Veteran’s athlete’s foot cannot be ascribed to any known clinical diagnosis, specify whether he has objective indications of a chronic disability resulting from an undiagnosed 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. (d.) If the Veteran’s athlete’s foot can be ascribed to a known clinical diagnosis, the examiner is asked to address whether it is at least as likely as not (a 50 percent probability or greater) that the diagnosed disability was incurred in service or is otherwise etiologically related to service, to include being “often” exposed to sand/dust and smoke from oil fire (see July 2003 Post-Deployment Health Assessment). 6. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his claimed fibromyalgia with bilateral leg pain. The examiner should address the following: (a.) Specify whether the Veteran experiences fibromyalgia. To this end, specifically indicate whether the Veteran’s reported symptoms are attributable instead to known clinical diagnoses. (b.) If no diagnosis is made accounting for the Veteran’s reported fibromyalgia, the examiner must reconcile this conclusion with the evidence of record detailing the Veteran’s complaints. (c.) If the Veteran’s fibromyalgia cannot be ascribed to any known clinical diagnosis, specify whether he has objective indications of a chronic disability resulting from an undiagnosed 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. (d.) If the Veteran’s reported fibromyalgia can be ascribed to a known clinical diagnosis, the examiner is asked to address whether it is at least as likely as not (a 50 percent probability or greater) that the diagnosed disability was incurred in service or is otherwise etiologically related to service, to include being “often” exposed to sand/dust and smoke from oil fire (see July 2003 Post-Deployment Health Assessment). 7. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his claimed hypertension. The examiner should address the following: (a.) Specify whether the Veteran’s hypertension is indicative of undiagnosed illness or chronic multi-symptom illness of the type contemplated by 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. To this end, specifically indicate whether these symptoms, instead, are attributable to known clinical diagnoses. (b.) If no diagnosis is made accounting for the Veteran’s hypertension, the examiner must reconcile this conclusion with the evidence of record detailing the Veteran’s complaints. (c.) If the Veteran’s hypertension cannot be ascribed to any known clinical diagnosis, specify whether he has objective indications of a chronic disability resulting from an undiagnosed 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. (d.) If the Veteran’s hypertension can be ascribed to a known clinical diagnosis, the examiner is asked to address whether it is at least as likely as not (a 50 percent probability or greater) that the diagnosed disability was incurred in service or is otherwise etiologically related to service, to include being “often” exposed to sand/dust and smoke from oil fire (see July 2003 Post-Deployment Health Assessment). 8. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his claimed bilateral knee disabilities. The examiner should address the following: (a.) Specify whether the Veteran’s bilateral knee symptoms are indicative of undiagnosed illness or chronic multi-symptom illness of the type contemplated by 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. To this end, specifically indicate whether these symptoms, instead, are attributable to known clinical diagnoses. (b.) If no diagnosis is made accounting for the bilateral knee symptoms, the examiner must reconcile this conclusion with the evidence of record detailing the Veteran’s complaints. (c.) If the Veteran’s bilateral knee symptoms cannot be ascribed to any known clinical diagnosis, specify whether he has objective indications of a chronic disability resulting from an undiagnosed 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. (d.) If the Veteran’s bilateral knee symptoms can be ascribed to a known clinical diagnosis, the examiner is asked to address whether it is at least as likely as not (a 50 percent probability or greater) that the diagnosed disabilities were incurred in service or are otherwise etiologically related to service, to include the reported knee injury during basic training (see June 2017 VA examination) and/or being “often” exposed to sand/dust and smoke from oil fire (see July 2003 Post-Deployment Health Assessment). 9. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his claimed lumbar spine disabilities. The examiner should address the following: (a.) Specify whether the Veteran’s lumbar spine symptoms are indicative of undiagnosed illness or chronic multi-symptom illness of the type contemplated by 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. To this end, specifically indicate whether these symptoms, instead, are attributable to known clinical diagnoses. (b.) If no diagnosis is made accounting for the lumbar spine symptoms, the examiner must reconcile this conclusion with the evidence of record detailing the Veteran’s complaints. (c.) If the Veteran’s lumbar spine symptoms cannot be ascribed to any known clinical diagnosis, specify whether he has objective indications of a chronic disability resulting from an undiagnosed 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. (d.) If the Veteran’s lumbar spine symptoms can be ascribed to a known clinical diagnosis, the examiner is asked to address whether it is at least as likely as not (a 50 percent probability or greater) that the diagnosed disability was incurred in service or is otherwise etiologically related to service, to include the reported back injury during advanced individual training (see June 2017 VA examination) and/or being “often” exposed to sand/dust and smoke from oil fire (see July 2003 Post-Deployment Health Assessment). 10. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any diabetes mellitus. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including being “often” exposed to sand/dust and smoke from oil fire (see July 2003 Post-Deployment Health Assessment). M. H. HAWLEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board W. Ripplinger, 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.