Citation Nr: 21001829 Decision Date: 01/11/21 Archive Date: 01/11/21 DOCKET NO. 14-31 876 DATE: January 11, 2021 ORDER Entitlement to service connection for irritable bowel syndrome (IBS), to include as secondary to service-connected Crohn's disease is granted. Entitlement to a rating higher than 30 percent for Crohn’s disease is denied. REMANDED Entitlement to service connection for osteoarthritis, other than of the lumbar spine, to include as secondary to service-connected Crohn's disease is remanded. Entitlement to service connection for a sleep disability, to include as secondary to service-connected Crohn's disease is remanded. Entitlement to service connection for fibromyalgia, to include as secondary to service-connected Crohn's disease is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Resolving all reasonable doubt in favor of the Veteran, the evidence supports a finding that the Veteran has IBS that is related to service-connected Crohn’s disease. 2. Throughout the period of appeal, the Veteran’s service-connected Crohn’s disease has been productive of painful symptoms with numerous attacks a year of diarrhea and abdominal distress but not by malnutrition with health only fair during remissions. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for irritable bowel syndrome (IBS), to include as secondary to service-connected Crohn's disease, have been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 2. Throughout the period of appeal, the criteria for a rating higher than 30 percent for the Veteran’s service-connected Crohn’s disease were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.20, 4.21, 4.27, 4.110, 4.112, 4.113, 4.114, Diagnostic Code 7399-7323. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1991 to June 1993. The Veteran appeared at a June 2018 videoconference hearing before the undersigned Veterans Law Judge. The hearing transcript is of record. This case was previously remanded for further development. In light of the treatment records that have been obtained and associated with the record, the obtaining of the requested medical opinions, and the further adjudicatory actions taken by the Agency of Original Jurisdiction, the Board finds that there has been substantial compliance with the prior remand directives concerning the issues of entitlement to service connection for IBS and entitlement to a higher rating for Crohn’s disease. Stegall v. West, 11 Vet. App. 268 (1998); D’Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141 (1999). 1. Entitlement to service connection for irritable bowel syndrome (IBS), to include as secondary to service-connected Crohn's disease Service connection may be established for disability caused by disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection for a claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in service incurrence or aggravation of a disease or injury; and (3) evidence, generally medical, of a causal relationship between the claimed in service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). Service connection may also be established for any disease initially diagnosed after service, when the evidence establishes that the disease was incurred in service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503 (1992). The disease entity for which service connection is sought must be chronic rather than acute and transitory in nature. For the showing of chronic disease in service, a combination of manifestations must exist sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Service incurrence will be presumed for certain chronic diseases if manifest to a compensable degree within one year after active service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. A disability that is proximately due to or the result of a service connected disease or injury shall be service connected. When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In that instance, the Veteran is compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). In reviewing the evidence of record, the Board notes that there is conflicting evidence regarding the presence, or lack thereof, of a diagnosis of IBS. On VA examination in June 2019, the examiner opined that the Veteran did not have irritable bowel syndrome at that time. The examiner attributed the Veteran’s symptoms to service-connected Crohn’s disease. However, an August 2014 VA treatment record contains the treatment provider’s observation that in the past, the Veteran had inactive Crohn’s disease, yet he presently was having significant gastrointestinal issues with diarrhea and abdominal pain, which suggested a component of IBS. Additionally, a June 2018 private treatment record contains a diagnosis of irritable bowel syndrome with diarrhea. Overall, the Board finds that the evidence of record shows that the Veteran has had a diagnosis of IBS during the pendency of this claim. The remaining question is whether that diagnosed disability was caused or aggravated by the Veteran’s service-connected Crohn’s disease, as the Veteran claims. In an August 2018 letter, J.R.F., M.D., opined that the Veteran’s Crohn’s disease had caused irritable bowel syndrome. In an August 2018 letter, J.R.F., M.D., opined that the Veteran’s Crohn’s disease had caused irritable bowel syndrome. No other medical opinion contradicting the August 2018 letter from Dr. F. is of record. Taken as a whole, the Veteran’s diagnosed IBS cannot be disassociated from the Veteran’s service-connected Crohn’s disease. The Board finds that the evidence is in relative equipoise as to whether the Veteran has IBS related to his service-connected Crohn’s disease. Therefore, the Board will resolve doubt in favor of the Veteran and grant the claim. The Board finds that the evidence shows that it is at least as likely as not that the Veteran has IBS due to his service-connected Crohn’s disease. Accordingly, resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for IBS, due to Crohn’s disease, is warranted. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to a rating higher than 30 percent for Crohn’s disease Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which rating to apply to a Veteran’s disability, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and coordination of rating with impairment of function. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Staged ratings are appropriate when the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a Veteran’s lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010). The Veteran’s service-connected Crohn’s disease is rated by analogy under Diagnostic Code 7399-7323 (ulcerative colitis). 38 C.F.R. § 4.114. When an unlisted condition is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. According to the policy in the Rating Schedule, when a disability is not specifically listed, the Diagnostic Code will be “built up,” meaning that the first two digits will be selected from that part of the schedule most closely identifying the part of the body involved, and the last two digits will be “99.” 38 C.F.R. § 4.27. For example, Diagnostic Code 7399 is used to identify unlisted digestive system disabilities. Specific provisions apply to rating disabilities of the digestive system. For purposes of rating conditions in § 4.114, the term “substantial weight loss” means a loss of greater than 20 percent of the individual’s baseline weight, sustained for three months or longer; and the term “minor weight loss” means a weight loss of 10 to 20 percent of the individual’s baseline weight, sustained for three months or longer. The term “inability to gain weight” means that there has been substantial weight loss with inability to regain it despite appropriate therapy. “Baseline weight” means the average weight for the two-year-period preceding onset of the disease. 38 C.F.R. § 4.112. There are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia, and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title “Diseases of the Digestive System,” do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14. 38 C.F.R. § 4.113. The rating of the same disability or the same manifestations of disability under multiple diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. For certain diseases of the digestive system, ratings under Diagnostic Codes 7301 to 7329, 7331, 7342, and 7345 to 7348 will not be combined with each other. A single rating is assigned under the diagnostic code that indicates the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability so warrants. 38 C.F.R. § 4.114. Under Diagnostic Code 7323 for ulcerative colitis, a 10 percent rating is warranted for moderate symptoms with infrequent exacerbations. A 30 percent rating is warranted for moderately severe symptoms with frequent exacerbations. A 60 percent rating is warranted for severe symptoms with numerous attacks a year and malnutrition, with health only fair during remissions. A 100 percent rating is warranted for pronounced symptoms resulting in marked malnutrition, anemia, and general debility, or with serious complications, such as liver abscess. 38 C.F.R. § 4.114. The words slight, moderate, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. It should also be noted that use of terminology such as severe by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. After review of the evidence, lay and medical, the Board finds that, throughout the period of appeal, the Veteran’s predominant symptomatology is abdominal pain, bowel disturbances with abdominal distress, and frequent exacerbations or attacks of the intestinal condition. Therefore, the Board finds that based on the predominant disability, the Veteran’s Crohn’s disease symptoms more closely approximate with symptoms of a 30 percent rating under Diagnostic Code 7323. 38 C.F.R. § 4.114, Diagnostic Code 7323. VA medical records from throughout the period of appeal show that the Veteran has had continuing treatment for symptoms associated with Crohn’s disease, to include abdominal pain and diarrhea. On VA examination in October 2012, the examiner noted that the Veteran was currently prescribed Mesalamine. The Veteran described experiencing pain in the abdomen and stated that he had diarrhea four to five times a day. The Veteran stated that he had experienced weight loss, but the examiner found that weight loss was not demonstrated through the weight measurements taken at the VA Medical Center through the years. The examiner stated that continuous medication was required for control of the Veteran’s condition. Additionally, the Veteran had episodes of nausea when he had abdominal pain. The examiner indicated that the Veteran experienced frequent episodes of bowel disturbance with abdominal distress, and the Veteran experienced seven or more exacerbations or attacks in the prior 12 months. It was specified that the Veteran did not have weight loss attributable to Crohn’s disease. The examiner opined that the Veteran had serious complications such as osteoporosis and vitamin D deficiency. At his June 2018 Board hearing, the Veteran stated that he had diarrhea several times a day. He took medication daily. In an August 2018 statement, the Veteran stated that he experienced diarrhea and abdominal pain several times per day and night. On VA examination in June 2019, the Veteran reported that he experienced three bowel movements a day. He stated that his bowel movements were not mixed with blood or mucus. He stated that he sometimes experienced cramping and pain. He had been prescribed Mesalamine and Hydrocortisone. The examiner noted that continuous medication was required for control of the condition. The Veteran had not required surgical treatment. The examiner indicated that the Veteran did not have episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition. The examiner stated that the Veteran did not have weight loss, malnutrition, serious complications, or other general health effects attributable to the intestinal condition. The examiner did not find any other pertinent physical findings, complications, conditions, signs, or symptoms related to Crohn’s disease. Based on the foregoing evidence, the Board finds that a higher rating of 60 percent under Diagnostic Code 7323 for Crohn’s disease is not warranted because the lay and medical evidence does not show malnutrition with health only fair during remissions. Malnutrition is one of the required criteria to assign a higher rating under Diagnostic Code 7323. The Board has considered whether any other diagnostic codes would allow for a higher or separate rating. The Board finds that no other higher or separate ratings are warranted under any of the other diagnostic codes pertaining to the digestive system. Initially, disability ratings assigned under Diagnostic Codes 7301 to 7329 (inclusive), 7331, 7342, and 7345 to 7348 (inclusive) will not be combined with each other. 38 C.F.R. § 4.114; Esteban v. Brown, 6 Vet. App. 259 (1994) (the critical element is that none of the symptomatology for any condition is duplicative of or overlapping with the symptomatology of the other condition). The Veteran has not, at any time, been found to have peritoneal partial obstruction, colic distension, a perforated ulcer, operative/traumatic/infectious process, or disturbance of motility; therefore a rating under Diagnostic Code 7301 is not appropriate. Although the Veteran has lost weight, the evidence does not show malnutrition at any time during the period on appeal, and the Veteran was not noted by the October 2012 or June 2019 VA examiners as having any malnutrition or other general health effects. Therefore, a rating higher than 30 percent based on a findings of malnutrition or general health effects cannot be assigned under Diagnostic Code 7323. 38 C.F.R. § 4.114. Accordingly, the preponderance of the evidence weighs against finding that the Veteran’s Crohn’s disease symptoms warrant a rating higher than 30 percent. As the preponderance of evidence weighs against claim, there is no reasonable doubt to be resolved, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to service connection for osteoarthritis, other than of the lumbar spine, to include as secondary to service-connected Crohn's disease, is remanded. At a June 2018 Board hearing, the Veteran testified that he had pain in the joints, including the shoulders, elbows, knees, fingers, hands, and ankles. The Veteran contended that he had osteoarthritis, and he felt that osteoarthritis was related to the service-connected disabilities. In support of that contention, he submitted an August 2018 letter from a private doctor, in which the doctor opined that treatment with longterm steroids caused the Veteran’s osteoporosis, which in turn caused osteoarthritis. Service connection has previously been established for osteoporosis. In November 2018, the Board remanded this claim to schedule the Veteran for a VA examination to determine if any diagnosed joint disability, other than osteoarthritis of the spine, was related to the service-connected disabilities, and specifically osteoporosis. The examiner was requested to opine whether it was at least as likely as not that any joint disability identified was due to or the result of a service-connected disability, to include Crohn’s disease, osteoporosis, or any medication taken for a service-connected disability. The requested examination was performed in August 2019. The examiner stated that the Veteran had bilateral knee strain and subjective bilateral hip pain that were not due to the service-connected Crohn’s disease, as they were separate conditions from one another, and that type of strain and pain condition as not a known residual of Crohn’s disease. The examiner specified that the Veteran did not have osteoarthritis of the bilateral hips or knees. The examiner also opined that the Veteran’s subjective bilateral hip pain and bilateral knee strain was less likely than not aggravated by Crohn’s disease, as Crohn’s disease is related to a separate organ system and not related. The Board observes that while the Veteran has claimed that he has osteoarthritis of the joints, including the shoulders, elbows, knees, fingers, hands, and ankles, the VA examiner apparently only examined the knees and hips. The examiner did not discuss the August 2018 letter from the private doctor. Additionally, while the VA examiner opined that the Veteran’s hip and knee disabilities were less likely than not caused or aggravated by Crohn’s disease, the examiner offered no opinion regarding any possible connection between the Veteran’s claimed joint disabilities and service-connected osteoporosis, or any medication taken for a service-connected disability. When VA obtains an examination or opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Remand is required to obtain a VA medical opinion which complies with the November 2018 Board remand instructions. 2. Entitlement to service connection for a sleep disability, to include as secondary to service-connected Crohn's disease, is remanded. At a June 2018 Board hearing, the Veteran testified that he first experienced symptoms of sleep disturbance in 1992, when he first developed problems with Crohn’s disease while on active duty. The Veteran testified that he continued to experience symptoms of sleep disturbance to the present. In support of the contention, he submitted an August 2018 private medical letter, in which the Veteran’s doctor opined that the Veteran’s sleep disturbances were due to diarrhea and abdominal pain associated with Crohn’s disease. In November 2018, the Board remanded the claim to schedule the Veteran for a VA examination to determine if any diagnosed sleep disability was related either to service or to the service-connected disabilities, to include as secondary to medication taken for any service-connected disability. The requested VA examination was performed in June 2019. The examiner noted the Veteran’s report that he was unable to have a good night’s sleep due to having to wake up several times at night to urinate. The examiner stated that was likely due to a urinary condition. The examiner opined that the Veteran’s sleep apnea was less likely than not incurred in or caused by service. The examiner noted that the medical records were silent for a diagnosis of sleep apnea or symptoms related to sleep apnea. The examiner acknowledged that there was a lay statement from the Veteran regarding symptoms of a sleep disturbance experienced in 1992, but that was not evidence of a sleep apnea diagnosis. The examiner further opined that the Veteran’s obstructive sleep apnea was less likely than not due to or aggravated by service-connected Crohn’s disease, as the diagnoses pertained to two separate disease etiologies and organ systems. The Board observes that the examiner did not discuss the August 2018 letter from the private doctor which supports the claim. Additionally, the examiner relied on the absence of evidence in the service medical records to provide a negative opinion regarding whether sleep apnea was directly related to service. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Therefore, additional VA examination is required. Barr v. Nicholson, 21 Vet. App. 303 (2007) (when VA provided an examination, even if not required to do so, an adequate one must be provided). 3. Entitlement to service connection for fibromyalgia, to include as secondary to service-connected Crohn's disease, is remanded. The Veteran has asserted that he has fibromyalgia related to service-connected Crohn’s disease, and specifically, due to long-term use of steroids for treatment of Crohn’s disease. The Veteran was provided a VA examination in April 2015 for fibromyalgia. The examiner opined that diagnosed fibromyalgia was not related to service-connected Crohn’s disease as Crohn’s disease was a separate and distinct condition of unclear etiology. The examiner did not specifically address any possible effect of long-term steroid use or other medication use on the development or aggravation of fibromyalgia. The examiner also noted that adrenal insufficiency can cause symptoms similar to fibromyalgia. Subsequent to the April 2015 examination, the Veteran established service connection for adrenal insufficiency associated with Crohn’s disease. Additionally, the Veteran’s VA medical records indicated a diagnosis of fibromyalgia. Therefore, in November 2018, the Board remanded the claim obtain an opinion to clarify whether diagnosed fibromyalgia was related to steroid medication taken for Crohn’s disease, or was related to now service-connected adrenal insufficiency. The requested VA examination was performed in June 2019. The examiner opined that the Veteran did not currently have and had never been previously diagnosed with fibromyalgia. The examiner noted that in 2015, the Veteran was noted to have “probable fibromyalgia,” and that notation had been carried over on his medical chart since that time. The examiner noted that “probable fibromyalgia” is a loose term, and no neurologist or rheumatologist had confirmed a diagnosis of fibromyalgia. The Board notes that, contrary to the June 2019 VA examiner’s statement, a VA doctor appears to have diagnosed fibromyalgia in October 2014 after the Veteran was positive for 12 out of 18 tender points, and after the Veteran reported having diffuse muscle soreness for the past two to three years that was worse with movement. Further, while the June 2019 VA examiner stated that no neurologist or rheumatologist had confirmed a diagnosis of fibromyalgia, the June 2019 VA examiner was also not a neurologist or rheumatologist. According to the examination report, the June 2019 VA examiner’s specialty was internal medicine. According to the June 2019 VA examiner, a neurologist or rheumatologist is needed to confirm a diagnosis of fibromyalgia. Therefore, remand is required to schedule the Veteran for a VA examination from a neurologist or rheumatologist. When VA provides an examination or obtains an opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. The Board finds that the claims for service connection and entitlement to TDIU are inextricably intertwined, and the claim for TDIU must also be remanded pending resolution of the claims for service connection. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. After obtaining appropriate authorization, obtain any VA and private treatment records identified by the Veteran that are not already of record. 2. Schedule the Veteran for a VA joints examination with a medical doctor examiner who has not previously examined the Veteran. The examiner must review the claims file and should note that review in the report. The rationale for all opinions should be provided. The examiner should explicitly provide the following opinions: (a.) Identify any joint disabilities, including any disabilities of the shoulders, elbows, knees, fingers, hands, and ankles. For each joint disability found, including of the shoulders, elbows, knees, fingers, hands, and ankles, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that each joint disability was incurred during service, or is due to any event, disease, or injury during service. The examiner should note that the absence of evidence of symptoms in service is not always fatal to a service connection claim and should consider the Veteran’s reports and lay statements. (b.) For each joint disability found, including of the shoulders, elbows, knees, fingers, hands, and ankles, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that each joint disability is due to or the result of a service-connected disability, to specifically include Crohn's disease or osteoporosis, or any medication taken for a service-connected disability. The examiner should discuss the August 2018 letter from a private doctor, in which the doctor opined that treatment with longterm steroids caused the Veteran’s osteoporosis, which in turn caused osteoarthritis. (c.) For each joint disability found, including of the shoulders, elbows, knees, fingers, hands, and ankles, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that each joint disability has been aggravated (permanently increased in severity beyond the natural progression of the disability) by a service-connected disability, to include Crohn's disease or osteoporosis or any medication taken for a service-connected disability. The examiner should discuss the August 2018 letter from a private doctor, in which the doctor opined that treatment with longterm steroids caused the Veteran’s osteoporosis, which in turn caused osteoarthritis. 3. Schedule the Veteran for a VA fibromyalgia examination with a neurologist or a rheumatologist. The examiner must review the claims file and should note that review in the report. The rationale for all opinions should be provided. The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that a diagnosis of fibromyalgia is warranted. The examiner should discuss the criteria for a diagnosis of fibromyalgia and whether those criteria are met. The examiner is requested to reconcile the opinion with the other evidence of record, to specifically include the diagnosis of fibromyalgia by a VA treatment provider in October 2014. If a diagnosis of fibromyalgia is warranted, the examiner should opine whether it is at least as likely as not (50 percent probability or greater) that any fibromyalgia disability had its onset in service, was aggravated by service, or is otherwise related to any incident of service. The examiner should also provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) (1) that any fibromyalgia disability was caused by service-connected disabilities, to specifically include Crohn’s disease and osteoporosis, to include as a result of medication or steroids prescribed for service-connected disabilities, or (2) that any fibromyalgia has been aggravated (increased in severity beyond the natural progress of the disorder) by service-connected disabilities, to specifically include Crohn’s disease and osteoporosis, to include as a result of medication or steroids prescribed for service-connected disabilities. The examiner should note that the absence of in-service evidence of symptoms is not always fatal to a service connection claim and should consider the Veteran’s reports and lay statements. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of any sleep disability. The examiner must review the claims file and should note that review in the report. All tests and studies deemed necessary by the examiner must be performed. A complete rationale must be given for all opinions and conclusions. Based on a review of the claims file and the clinical findings of the examination, the examiner is requested to provide the following opinions: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran has a sleep disability that began in service or is related to any event, disease, or injury during service? The examiner should note that the absence of in-service evidence of symptoms is not always fatal to a service connection claim and should consider the Veteran’s reports and lay statements of symptoms during and since service. (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran has a sleep disability that is due to or the result of the service-connected disabilities, to specifically include Crohn's disease, or any other service-connected disability or medication taken for a service-connected disability? The examiner is requested to discuss the August 2018 private medical letter, in which a doctor opined that the Veteran’s sleep disturbances were due to diarrhea and abdominal pain associated with Crohn’s disease. (c.) Is it at least as likely as not (50 percent or greater probability) that the Veteran has a sleep disability that has been aggravated (permanently increased in severity beyond the natural progression of the disability) by the service-connected disabilities, to specifically include Crohn's disease disability or any other service-connected disability, or medication taken for a service-connected disability? The examiner is requested to discuss the August 2018 private medical letter, in which the Veteran’s doctor opined that the Veteran’s sleep disturbances were due to diarrhea and abdominal pain associated with Crohn’s disease. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Layton, 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.