Citation Nr: 20023041 Decision Date: 04/02/20 Archive Date: 04/02/20 DOCKET NO. 18-36 995 DATE: April 2, 2020 ORDER New and material evidence has been presented to reopen claims of entitlement to service connection for a skin disorder, chronic fatigue syndrome, a pulmonary disorder, and joint pain and fibromyalgia. Entitlement to service connection for irritable bowel syndrome, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, is granted. Entitlement to service connection for gastroesophageal reflux disease (GERD) is granted as secondary to service-connected irritable bowel syndrome. Entitlement to service connection for chronic fatigue syndrome, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, is denied. REMANDED Entitlement to service connection for a pulmonary and/or respiratory disorder, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, is remanded. Entitlement to service connection for fibromyalgia and joint pain, to include joint arthritis, and to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, is remanded. Entitlement to service connection for a skin disorder, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, is remanded. FINDINGS OF FACT 1. A final May 1997 Agency of Original Jurisdiction (AOJ) rating decision denied service connection for a pulmonary disorder on the basis that the evidence did not show a current disability. 2. A final April 2015 AOJ rating decision denied entitlement to service connection for a skin disorder on the basis evidence did not show that it began in service or is causally related to service, and denied entitlement to service connection for fatigue and joint pain on the basis that the evidence of record did not reflect a separate disability for either of these claims. 3. The evidence received since the prior denials relates to unestablished facts and raises a reasonable possibility of substantiating the claims for entitlement to service connection for a skin disorder, chronic fatigue syndrome, a pulmonary disorder, and joint pain and fibromyalgia. 4. The Veteran has irritable bowel syndrome of an unknown etiology. 5. The Veteran’s GERD is attributable to his service-connected irritable bowel syndrome. 6. The Veteran’s fatigue symptomology is related to other diagnosed disorders, including obstructive sleep apnea and service-connected posttraumatic stress disorder (PTSD). CONCLUSIONS OF LAW 1. Following the prior final denials of May 1997 and April 2015, new and material evidence has been presented to reopen the claim of entitlement to service connection for a skin disorder, chronic fatigue syndrome, a pulmonary disorder, and joint pain and fibromyalgia. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. The criteria for entitlement to service connection for irritable bowel syndrome, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, have been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.317. 3. The Veteran’s GERD is proximately due to, or the result of, his service-connected irritable bowel syndrome. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310. 4. The criteria for entitlement to service connection for chronic fatigue syndrome, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1987 to February 1993. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an April 2017 rating decision. The Board also notes that a prior, unappealed April 2015 rating decision denied entitlement to service connection for diarrhea. The Veteran later filed a service connection claim for irritable bowel syndrome in May 2016. The AOJ interpreted this claim as a request to reopen the Veteran's previously denied claim for diarrhea. See April 2017 rating decision. However, the Board notes that claims that are based upon distinctly diagnosed diseases or injuries must be considered separate and distinct claims for new and material evidence purposes. Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008); Ephraim v. Brown, 82 F.3d 399, 402 (Fed. Cir. 1996) (noting that a newly diagnosed psychiatric disorder (e.g., PTSD, even if medically related to a previously diagnosed disorder (such as depressive neurosis), is not the same for jurisdictional purposes when it has not previously been considered). Therefore, the Board has determined that a de novo service connection analysis is proper for the irritable bowel syndrome issue on appeal. Here, irritable bowel syndrome was not previously adjudicated in any way by the RO; thus, it constitutes a new and distinct claim. The Board has consequently characterized the issue as noted above. Although the Veteran’s claim regarding joint pain was initially limited to the question of entitlement to service connection for chronic joint pain and/or fibromyalgia in the context of an undiagnosed illness or medically unexplained chronic multisymptom illness, the medical evidence reflects in-service treatment for joint pain and some current diagnoses of joint arthritis. Therefore, the Board has broadened the appeal to include service connection for fibromyalgia and joint pain, to include joint arthritis. See Clemons v. Shinseki, 23 Vet. App. 1, 9 (2009). 1. New and material evidence has been presented to reopen claims of entitlement to service connection for a skin disorder, chronic fatigue syndrome, a pulmonary disorder, and fibromyalgia and joint pain If a claim of entitlement to service connection is denied by an AOJ decision and no notice of disagreement or additional evidence is filed within one year, that decision becomes final and generally cannot be reopened or allowed. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. Once that decision becomes 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). Evidence is new and material if it: (1) has not been previously submitted to agency decision-makers; (2) by itself or in connection with evidence previously included in the record, relates to an unestablished fact necessary to substantiate the claim; (3) is neither cumulative nor redundant of evidence already of record at the time the last prior final denial of the claim sought to be opened; and (4) raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a); Shade v. Shinseki, 24 Vet. App. 110 (2010). Further, the threshold for raising a reasonable possibility of substantiating the claim is low. Shade, 24 Vet. App. at 117. Evidence may be considered new and material if it contributes “to a more complete picture of the circumstances surrounding the origin of a Veteran’s injury or disability, even where it will not eventually convince the Board to alter its rating decision.” Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998). For the purposes of determining whether new and material evidence has been received to reopen a finally adjudicated claim, the evidence submitted since the last final AOJ or Board decision will be presumed credible. Justus v. Principi, 3 Vet. App. 510, 513 (1992). A veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. See Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (2009). In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. See Fagan, 573 F.3d at 1287 (quoting 38 U.S.C. § 5107(b)). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). However, the benefit of the doubt doctrine does not apply to a new and material analysis. Annoni v. Brown, 5 Vet. App. 463, 467 (1993). In general, service connection is established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during periods of active service. 38 U.S.C. § 1110. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In May 1997, the AOJ denied entitlement to service connection for a pulmonary disorder on the basis evidence did not show a current disability. The evidence of record at that time included service treatment records and a July 1993 VA examination. By letter dated May 1997, the Veteran was notified of this decision. However, the Veteran did not appeal or submit new and material evidence within the one-year appeal period after notice of the decision was provided. Hence, that decision is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. In April 2015, the AOJ denied entitlement to service connection for a skin disorder on the basis evidence did not show that it began in service or is causally related to service, and denied entitlement to service connection for fatigue and joint pain on the basis that the evidence of record did not reflect a separate disability for either of these claims. The evidence of record at that time included service treatment records, VA treatment records, and April 2015 VA examinations. The claims file appears to indicate that a notification letter dated April 2015 was returned as undeliverable. However, the Veteran submitted a September 2015 notice of disagreement for a different issue contained in the April 2015 rating decision and notification letter. Therefore, the Board considers the Veteran to have received notice of the April 2015 rating decision. However, the Veteran did not appeal or submit new and material evidence within the one-year appeal period after notice of the decision was provided. Hence, that decision is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. The Bord acknowledges that the evidence received since the May 1997 and April 2015 decisions includes military personnel records. See Military personnel records received in May 2014 and April 2016. However, these records primarily consist of administrative data and duplicate service treatment records that were already considered. To the extent that these records provide information regarding the Veteran’s active service in Southwest Asia, the AOJ had already acknowledged such service by the time of the May 1997 rating decision. Thus, these records are cumulative of evidence previously considered. In this regard, the Board notes that 38 C.F.R. § 3.156(c) provides that at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim, notwithstanding the finality rules of 38 C.F.R. § 3.156(a) noted above. Relevant means noncumulative and pertinent to the matter at issue in the case. Kisor v. Shulkin, 869 F.3d 1360, 1368-69 (Fed. Cir. 2017), vacated sub nom. on other grounds, Kisor v. Wilkie, 139 S. Ct. 2400 (2019) (accepting VA's interpretation of the relevancy requirement of 38 C.F.R. § 3.156(c), i.e., that as used in § 3.156(c)(1), "relevant" means noncumulative and pertinent to the matter at issue in the case). Given that the STRs and information regarding the Veteran’s Southwest Asia service were of record at the time of the prior decisions, they are cumulative and therefore not relevant. The newly received evidence also includes additional VA examinations and unconsidered Veteran statements. See, e.g., July 2018 Substantive Appeal; April 2017 Notice of Disagreement. This evidence relates to unestablished facts needed to establish service connection for these claims (i.e., nexus to service, current disability). Therefore, the Board finds that new and material evidence has been received and the criteria to reopen the Veteran’s claims of service connection for a skin disorder, chronic fatigue syndrome, a pulmonary disorder and joint pain and fibromyalgia are met. Service Connection Service connection will be granted if the Veteran has a disability resulting from personal injury or disease incurred in the line of duty, or for aggravation of a preexisting injury or disease incurred in the line of duty during active service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. To establish service connection, the evidence must show competent evidence of (1) a present disability, (2) an in-service incurrence or aggravation of a disease or injury, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A valid service connection claim requires competent evidence of a current disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). However, the presence of a disability at any time during the claim process – or relatively close thereto – can justify a grant of service connection, even where such disability has become asymptomatic. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Service connection may also be granted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 48 (1995) (en banc). In addition, the law provides for compensation for Persian Gulf veterans suffering from a chronic disability resulting from an undiagnosed illness or medically unexplained chronic multisymptom illness that became manifest during active duty in the Southwest Asia theater of operations or became manifest to a compensable degree within the prescribed presumptive period and 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. That is, if an undiagnosed chronic symptom or illness is not manifest in service, the claimed chronic disability must have been manifest to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317(a)(1). A “Persian Gulf Veteran” is one who served in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e). The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e)(2). In this case, the Veteran’s service records reflect he served in the Southwest Asia Theater during the Persian Gulf War from December 1990 to April 1991. See, e.g., Service Records, Combat History and Expeditions. Accordingly, the Veteran is a Persian Gulf Veteran and the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 may apply if the Veteran is found to have a qualifying chronic disability. The term “qualifying chronic disability” means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) functional gastrointestinal disorders (excluding structural gastrointestinal disorders). 38 C.F.R. § 3.317 (a)(2)(i). With claims for service connection for a qualifying chronic disability under 38 C.F.R. § 3.317, the Veteran is not required to provide competent evidence linking a current disability to an event during service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). For purposes of § 3.317, 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. 38 C.F.R. § 3.317 (a)(2)(ii). 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). In a notice in the Federal Register, the Secretary provided an explanation with regard to 38 C.F.R. § 3.317 (a)(2)(i)(B) as follows: If a veteran has an illness other than chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome, it is solely a medical determination whether that illness qualifies under revised § 3.317(a)(2)(i)(B) as a “medically unexplained chronic multisymptom illness.” In adjudicating claims under § 3.317(a)(2)(i)(B), VA will continue to apply the term “medically unexplained chronic multisymptom illness” as currently defined in § 3.317(a)(2)(ii): “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.” Finally, § 3.317(a)(2)(ii) exempts “[c]hronic multisymptom illnesses of partially understood etiology and pathophysiology” from being considered medically unexplained chronic multisymptom illnesses. To further clarify this exclusion, we have added the specific examples “diabetes” and “multiple sclerosis.” This clarification does not alter any existing rights under the current regulation, but merely provides examples to better illustrate the current regulation. The two listed examples, diabetes and multiple sclerosis, were cited by Congress in the legislative history of the authorizing legislation as examples of conditions that would not be within the scope of the statutory term “medically unexplained chronic multisymptom illnesses.” See Joint Explanatory Statement, 147 Cong. Rec. at S13, 238. When VA issued the rule currently in § 3.317(a)(2)(ii), we similarly explained that diabetes and multiple sclerosis were examples of conditions that would not meet the statutory and regulatory definition of “medically unexplained chronic multisymptom illnesses.” 68 FR 34539, 34540 (June 10, 2003). 75 Fed. Reg. 61,995-01, 61,995-96 (Oct. 7, 2010). The Joint Explanatory Statement included the following language: Section 202 of the compromise agreement authorizes the Secretary effective March 1, 2002, to pay compensation to any eligible Gulf War veteran chronically disabled by an “undiagnosed illness,” a “medically unexplainable chronic multisymptom illness defined by a cluster of signs or symptoms,” or “any diagnosed illness that the Secretary determines in regulations prescribed under subsection (d) warrants a presumption of service-connection” (or any combination of these). The term “undiagnosed illnesses” has been interpreted by VA to preclude from eligibility for benefits under sections 1117 or 1118 of title 38, United States Code, any veteran who has received a diagnosis, even if that diagnosis is merely a descriptive label for a collection of unexplained symptoms. This provision’s addition of “medically unexplained chronic multisymptom illness defined by a cluster of signs or symptoms” to the list of compensable conditions fully implements the intent of Public Law 103-446. Public Law 103-446 authorized the Secretary to compensate certain Gulf War veterans disabled by symptoms that could not be connected conclusively to specific wartime exposures otherwise not compensable under other existing statutory bases. In selecting this language, it is the intent of the Committees to ensure eligibility for chronically disabled Gulf War veterans not withstanding a diagnostic label by a clinician in the absence of conclusive pathophysiology or etiology. The compromise agreement’s definition encompasses a variety of unexplained clinical conditions, characterized by overlapping symptoms and signs, that share features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Aaron and Buchwald, A Review of the Evidence for Overlap Among Unexplained Clinical Conditions, 134(9) Annals of Internal Med:868-880 (2001). Although chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome are the most common diagnoses under this definition, other conditions that may be characterized similarly include other chronic musculoskeletal pain disorders and chronic headache disorders. By listing the first three diagnoses as examples, it is the Committees’ intent to give guidance to the Secretary rather than to limit eligibility for compensation based upon other similarly described conditions that may be defined or redefined in the future. The Committees do not intend this definition to assert that the cited syndromes can be clinically or scientifically linked to Gulf War service based on current evidence, nor do they intend to include chronic multisymptom illnesses of partially understood etiology and pathophysiology such as diabetes or multiple sclerosis. For purposes of § 3.317, “objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). For purposes of § 3.317(a)(1), signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: fatigue; signs or symptoms involving skin, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 C.F.R. § 3.317(b). Presumptive service connection is available for Persian Gulf veterans for certain enumerated infectious diseases. 38 C.F.R. § 3.317(c). The Veteran has never alleged that he had any of the enumerated diseases. Whenever there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the veteran. 38 U.S.C. § 5107(b). 2. Entitlement to service connection for irritable bowel syndrome, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness 3. Entitlement to service connection for GERD, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness Service treatment records do not reflect that the Veteran sought treatment for any gastrointestinal issues. VA treatment records reflect that the Veteran has sought treatment for nausea, abdominal pain, bloody stools, and heartburn. See, e.g., November 2016 and September 2014 VA Treatment Records. During an April 2015 VA examination, the examiner determined that the Veteran’s complaint of diarrhea was not consistent with a diagnosis of irritable bowel syndrome or related to his Persian Gulf Service, opining instead that it was likely related to the Veteran’s cholecystectomy, dietary habits, and mental status. The examiner did note that the Veteran had reported symptomology “for over 20 years,” but did not address the statement further in providing an opinion. By contrast, a November 2016 VA examiner diagnosed the Veteran with irritable bowel syndrome, noted signs of diarrhea and exacerbations of intestinal conditions, and determined it was “a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology.” Additionally, the examiner diagnosed the Veteran with GERD and noted signs of pyrosis, regurgitation, and esophageal stricture, spasm, and diverticula. The examiner determined that the Veteran’s GERD is related to his irritable bowel syndrome, noting both are functional gastrointestinal disorders, and further noting that the Veteran’s history of onset supports the bowel and GERD symptoms as part of “the overall constellation of symptoms” of irritable bowel syndrome. Therefore, the examiner opined that GERD should be categorized under irritable bowel syndrome as “a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology.” The Veteran has stated that his gastrointestinal symptoms, including acid reflux and diarrhea, began after he was exposed to environmental hazards, including heavy smoke from oil fires, during service. See, e.g., July 2018 Substantive Appeal; March 1993 Claim. The Veteran is competent to attest to matters of which he has first-hand knowledge, including experiencing these symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board finds the Veteran’s statements to be consistent with the circumstances of his service, and to be credible and probative of the issues. While the April 2015 and November 2016 examiners are in conflict regarding whether the Veteran’s symptoms warrant a diagnosis of irritable bowel syndrome, the Veteran’s testimony and VA treatment records reflect several gastrointestinal symptoms. As the evidence regarding the Veteran’s diagnoses is in relative equipoise and resolving reasonable doubt in the Veteran’s favor, the Board finds that it is at least as likely as not that the Veteran has irritable bowel syndrome and GERD related to his irritable bowel syndrome. As noted above, the November 2016 VA examiner found that the Veteran’s irritable bowel syndrome is a medically unexplained chronic multi-symptom illness of unknown etiology. As there is no conclusive pathophysiology or etiology shown for the Veteran’s irritable bowel syndrome, and consistent with the stated intent of the Persian Gulf War legislation discussed above, the Board resolves reasonable doubt in favor of the Veteran and awards service connection for irritable bowel syndrome on a presumptive basis under 38 C.F.R. § 3.317. Despite the November 2016 VA examiner's opinion that the Veteran's GERD was the type of functional gastrointestinal disorder contemplated by 38 C.F.R. § 3.317(a)(2)(i)(B)(3), the Court later clarified that GERD is not a medically unexplained chronic multisymptom illness. See Atencio v. O'Rourke, 30 Vet. App. 74 (2018). Nevertheless, the Board finds that the examiner’s rationale that the Veteran's GERD is part of the symptoms of his IBS provides evidence to support finding that the GERD is proximately due to, or the result of, the Veteran’s irritable bowel syndrome. After considering the opinion as a whole and in the context of the record, the Board finds that the examiner's conclusion provides probative value as it addresses the medical issues in this case and was based on an analysis of the evidence and current medical understanding. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (providing that an examination is not rendered inadequate where the rationale provided by an examiner did not explicitly lay out the examiner's journey from facts to a conclusion); see also Acevedo v. Shinseki, 25 Vet. App. 289, 294 (2012) (stating that medical reports must be read as a whole and in the context of the evidence of record). There is also no negative opinion to weigh against the examiner's conclusion. As discussed above, the Board is granting entitlement to service connection for irritable bowel syndrome herein. Based on the evidence of record, the Board concludes that the Veteran's GERD was caused by his service-connected irritable bowel syndrome. Entitlement to service connection for GERD is therefore granted. 38 C.F.R. § 3.310. As the record supports a grant of secondary service connection, the Board need not address any other theory of entitlement advanced. 4. Entitlement to service connection for chronic fatigue syndrome, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness The Veteran is currently service-connected for PTSD. See April 2015 Rating Decision. Additionally, he has a diagnosis of obstructive sleep apnea. See September 2016 VA Treatment Records. During an April 2015 VA examination for PTSD, the examiner indicated that chronic sleep impairment is part of the Veteran’s PTSD symptomology. A different April 2015 VA examiner evaluated the Veteran for chronic fatigue syndrome, but also determined that Veteran’s report of fatigue is more likely than not related to his mental health condition. May 2016 VA treatment records also reflect that the Veteran’s treating physician determined that fatigue is “likely multifactorial,” including related to PTSD and possibly related to obstructive sleep apnea. A November 2016 VA examiner determined that the Veteran did not have chronic fatigue syndrome, and that his fatigue is related to his sleep disturbance symptom of PTSD. Finally, a different December 2016 VA examiner determined the Veteran’s fatigue was likely related to sleep apnea. The Veteran has stated that his fatigue is related to his environmental exposures in the Persian Gulf. See, e.g., July 2018 Substantive Appeal. While he is competent to describe feeling fatigue, he is not competent to provide the complex medical opinion necessary in this case to determine the etiology of his symptom. See Charles v. Principi, 16 Vet. App. 370, 374- 75 (2002). He does not have the medical expertise to make such a finding. Given the Veteran’s lack of demonstrated medical expertise, the Board finds that the several VA examiners’ opinions to be the most probative evidence of record as to the relationship between the Veteran’s fatigue and service, and these opinions ultimately outweigh the Veteran’s contentions as to etiology. See Jandreau, 492 F.3d at 1376-77. Additionally, for VA purposes, a diagnosis of chronic fatigue syndrome requires: (1) new onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least six months; and (2) the exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms; and (3) six or more of the following: (i) acute onset of the condition, (ii) low grade fever, (iii) nonexudative pharyngitis, (iv) palpable or tender cervical or axillary lymph nodes, (v) generalized muscle aches or weakness, (vi) fatigue lasting 24 hours or longer after exercise, (vii) headaches (of a type, severity, or pattern that is different from headaches in the pre-morbid state), (viii) migratory joint pains, (ix) neuropsychologic symptoms, (x) sleep disturbance. 38 C.F.R. § 4.88a. The evidence of record does not reflect that the Veteran’s fatigue meets VA’s standard for a diagnosis of chronic fatigue syndrome. April 2015 and November 2016 VA examiners specifically found that the Veteran did not have chronic fatigue syndrome. Entitlement to service connection for chronic fatigue syndrome, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for a pulmonary and/or respiratory disorder, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a pulmonary and/or respiratory disorder because no VA examiner has opined as to whether the Veteran has a diagnosis of a pulmonary or respiratory disorder, including bronchitis and obstructive sleep apnea, that is directly related to service. Additionally, while VA examiners have determined the Veteran does not have a diagnosed pulmonary disorder, VA treatment records reflect treatment for bronchitis and obstructive sleep apnea. See, e.g., November 2016 VA Examination; November and September 2016 VA Treatment Records. A remand is needed to obtain a VA examination to determine the nature and etiology of any diagnosed pulmonary disorder. 2. Entitlement to service connection fibromyalgia and joint pain, to include joint arthritis, and to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for fibromyalgia and joint pain, to include joint arthritis, because no VA examiner has addressed relevant service treatment records indicating treatment for joint pain and current diagnoses of joint arthritis. See, e.g., November 2016 VA Examination; 1992 Service Treatment Records. A remand is needed to obtain a VA examination to determine the nature and etiology of any diagnosed fibromyalgia and/or joint pain and joint arthritis. 3. Entitlement to service connection for a skin disorder, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a skin disorder, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, because no VA examiner has adequately addressed service treatment records reflecting treatment for rash, or whether the diagnosis of recurrent dermatitis of unclear etiology is a symptom of a medically unexplained chronic multisymptom illness related to his Persian Gulf service. See, e.g., November 2016 VA Examination; June 1992 Service Treatment Records. A remand is needed to obtain a VA examination to determine the nature and etiology of any diagnosed skin disorder. The matters are REMANDED for the following action: 1. Obtain VA treatment records since December 2016 and associate them with the claims file. 2. Schedule the Veteran for an examination to determine the nature and etiology of any diagnosed pulmonary or respiratory disorders, including bronchitis and obstructive sleep apnea. The examiner should determine whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any such diagnosed disorders are etiologically related to active duty, to include exposure to environmental hazards like burning petrol. The examiner should address the following: • November 2016 VA examination reflecting no diagnosis for a respiratory condition, including normal chest imaging and pulmonary function testing, and noting the Veteran had smoked since he was ten years old; • VA treatment records reflecting bronchitis and diagnosed obstructive sleep apnea (see, e.g., November and September 2016 VA Treatment Records); and • the Veteran’s July 2018 substantive appeal indicating he was exposed to oil fires, depleted uranium dust, and Anthrax medication (see also March 1993 claim of exposure to petrochemicals). A complete rationale must be provided for any opinions offered. 3. Schedule the Veteran for an examination to determine the nature and etiology of any joint pain or diagnosed joint disorders. The examiner should determine whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any joint pain or diagnosed joint disorders are etiologically related to active duty. The examiner should address the following: • November 1992 service treatment records indicating treatment for foot, leg and hip issues including pain; • VA treatment records reflecting treatment for joint pain (see, e.g., September 2014 VA Treatment Records); • December 2016 VA examinations reflecting lumbar, hip, and knee arthritis, and reflecting shoulder pain and joint pain related to cervical spine narrowing; and • the Veteran’s July 2018 substantive appeal indicating he was exposed to oil fires, depleted uranium dust, and Anthrax medication. A complete rationale must be provided for any opinions offered. 4. Schedule the Veteran for an examination to determine the nature and etiology of any diagnosed skin disorder. The examiner should answer the following questions: (a) Is it at least as likely as not (i.e., probability of 50 percent or greater) that any diagnosed skin disorder is etiologically related to active duty? (b) Is it at least as likely as not (i.e., probability of 50 percent or greater) that any skin rash or other symptoms constitute an undiagnosed illness or medically unexplained chronic multi-symptom illness? The examiner should address the following: • March 1990 service treatment records reflecting that the Veteran sought treatment for a red bump on his nose that had lasted for at least four months; • June 1992 service treatment records, subsequent to his deployment in the Persian Gulf, reflecting treatment for a rash on his foot, and ruling out Lyme disease and tinea pedis; • July 1993 VA examination diagnosing the Veteran with athlete’s foot on the left foot, but failing to provide an opinion regarding its nexus to service, or addressing any other skin disorders; • VA treatment records reflecting that the Veteran has sought treatment for dermatology issues that include rash and chronic pruritic intermittent dermatitis (see, e.g., November 2016 and December 2014 VA Treatment Records); • November 2016 VA examination diagnosing the Veteran with recurrent dermatitis of “unclear etiology;” and • the Veteran’s July 2018 substantive appeal indicating he was exposed to oil fires, depleted uranium dust, and Anthrax medication. A complete rationale must be provided for any opinions offered. K.C. Spragins Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Howell, 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.