Citation Nr: 21064374 Decision Date: 10/20/21 Archive Date: 10/20/21 DOCKET NO. 16-63 045 DATE: October 20, 2021 REMANDED Entitlement to service connection for chronic fatigue syndrome is remanded. Entitlement to service connection for narcolepsy is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1976 to June 1979 and from January 1991 to June 1991, to include service in the Southwest Asia theater of operations during the Gulf War Era. These matters were last before the Board in July 2021, whereupon they were remanded to the Agency of Original Jurisdiction (AOJ) for further development of the record. Following the issuance of a September 2021 supplemental statement of the case continuing the denial of both claims, the case was returned to the Board for its adjudication. The Board in its prior July 2021 remand instructed the AOJ to secure new examinations to determine whether the Veteran had diagnosable chronic fatigue syndrome and narcolepsy as well as procure opinions as to the likely etiology of both claimed conditions. In setting forth these instructions, the Board highlighted deficiencies in prior examinations regarding these same matters. Specifically, the Board noted that the Veteran had prior diagnoses of both chronic fatigue syndrome and narcolepsy and that the chosen examiner was to reconcile conflicting evidence as to whether the Veteran had either condition for VA compensation purposes. In separate examinations dated in August 2021, the same VA examiner, a nurse practitioner, declined to endorse a diagnosis of either chronic fatigue syndrome or narcolepsy. As a rationale in support of dismissing both diagnoses, the examiner stated only that the Veteran's complaints were highly subjective, and that there was no objective evidence to support a diagnosis of either condition. To further muddle this determination, however, on a corresponding Gulf War Syndrome examination also dated in August 2021 the same examiner inexplicably listed chronic fatigue syndrome and narcolepsy as diagnosed conditions in the Veteran's medical history. The Board cannot rely on the August 2021 examinations and opinions as the examiner ignored the Board's July 2021 remand instructions. Specifically, the Board highlighted evidence which suggested that the Veteran had diagnosable narcolepsy and/or chronic fatigue syndrome that accounted for symptomatology to include daytime fatigue and somnolence which was not encompassed within his separately diagnosed obstructive sleep apnea. The Board explicitly requested that the chosen examiner reconcile this evidence with the April 2021 VA examiner's dismissal of diagnoses for narcolepsy and chronic fatigue syndrome. The August 2021 examiner's perfunctory rationale for electing to not endorse diagnoses of either narcolepsy and/or chronic fatigue syndrome is not sufficient as it did not take into consideration any of the positive diagnostic evidence highlighted by the Board. Furthermore, the corresponding notation on the August 2021 Gulf War Syndrome examination that the Veteran did have diagnosed narcolepsy and chronic fatigue syndrome contradicts the August 2021 examiner's own determination. As such, remand is necessary in order to secure an addendum examination and opinion addressing all of the queries outlined in the prior remand instructions, which are copied in large part below. Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following action: Schedule the Veteran for a VA medical examination to evaluate the nature and likely etiology of his claimed narcolepsy and chronic fatigue syndrome conditions. The electronic claims file and any other information deemed pertinent must be provided to and reviewed by the examiner, who must address the following matters: A) First, please determine whether there is a diagnosable disability and/or disabilities to account for the Veteran's reported daytime somnolence and chronic fatigue symptomatology. The examiner is specifically asked to identify whether the Veteran has diagnosable narcolepsy. Furthermore, regardless of whether narcolepsy is deemed to be diagnosable, the examiner must also identify whether the Veteran has chronic fatigue syndrome that is a distinct disease pattern or whether the Veteran's documented daytime fatigue is a symptom of other diagnosed disabilities (namely, obstructive sleep apnea and/or narcolepsy). If a diagnosis of narcolepsy and/or chronic fatigue syndrome is deemed inappropriate, the examiner must provide a thorough rationale to support such a conclusion with an explicit discussion of the medical evidence in support of both diagnoses, that is, the long-standing history of diagnosis and treatment for narcolepsy as well as the November 2017 disability benefits questionnaire which included a diagnosis of chronic fatigue syndrome. B) If a diagnosable condition (known clinical diagnosis) is identified that accounts for some or all of this symptomatology, the examiner must provide an opinion as to whether it is at least as likely as not (an approximate balance of positive and negative evidence) that any such diagnosed condition or conditions (to specifically include narcolepsy and/or chronic fatigue syndrome) is/are: 1) etiologically related to the Veteran's service, to include as due to exposure to hazardous materials while serving in the Southwest Asia theater of operations; or 2) caused or aggravated by PTSD, or weight gain therefrom. C) If a diagnosable condition is not appropriate to account for any or all of the daytime somnolence or chronic fatigue symptoms detailed by the Veteran, please note whether the Veteran has a medically unexplained chronic multisymptom illness corresponding to those symptoms detailed by the Veteran for which there is no diagnosable condition that accounts for that symptomatology. D) Furthermore, if the answer to (C) is negative for any or all of these symptoms, please describe whether any of the symptoms were chronic in nature since service and thus would constitute a qualifying chronic disability under 38 C.F.R. § 3.317(a)(2)(i)(B). If this question is answered in the negative, an explanation for this determination is needed. If this question is answered in the positive, please address the possible etiologies of such chronic disability. If a chronic disability is found to be attributable to a supervening condition or event that occurred between the Veteran's departure from active duty in the Southwest Asia theater of operations and the onset of the illness, the examiner should so state. The examiner must provide any and all opinions as to etiology in the form of a probability and must provide a complete rationale for any opinion expressed. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christopher M. Collins, 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.