Citation Nr: 21070614 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 17-13 919A DATE: November 24, 2021 ORDER Entitlement to service connection for a low back disorder, diagnosed as degenerative disc disease other than intervertebral disc syndrome, is granted. REMANDED Entitlement to service connection for a disorder manifested by fatigue, to include chronic fatigue syndrome, and as due to an undiagnosed illness, a medically unexplained chronic multisymptom illness, and/or exposure to Gulf War environmental hazards; and as secondary to service-connected generalized anxiety disorder with social phobia, is remanded. Entitlement to service connection for sleep apnea, to include as due to an undiagnosed illness, a medically unexplained chronic multisymptom illness, exposure to Gulf War environmental hazards, and/or in-service immunizations; and as secondary to service-connected generalized anxiety disorder with social phobia, is remanded. Entitlement to service connection for an esophageal disorder, to include esophageal fungal infection and gastroesophageal reflux disease (GERD), to include as due to an undiagnosed illness, a medically unexplained chronic multisymptom illness, exposure to Gulf War environmental hazards, and/or in-service immunizations; and as secondary to service-connected generalized anxiety disorder with social phobia, is remanded. FINDING OF FACT The Veteran's low back disorder, diagnosed as degenerative disc disease other than intervertebral disc syndrome, is at least as likely as not related to an injury he sustained during a period of active duty for training. CONCLUSION OF LAW The requirements to establish entitlement to service connection for a low back disorder, diagnosed as degenerative disc disease other than intervertebral disc syndrome, have been met. 38 U.S.C. §§ 1101, 1154, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had service in the United States Army and Army Reserve. He had a period of active duty for training (ACDUTRA) from April 1983 to July 1983, October 24, 1986 to October 26, 1986, and a period of active duty from December 1990 to March 1991. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision. The Board previously denied the Veteran's claims in a September 2019 decision. The Veteran appealed that determination to the United States Court of Appeals for Veterans Claims (Court). In an October 2020 Order, the Court vacated the Board's decision and remanded the matter to the Board for development consistent with the parties' Joint Motion for Remand (Joint Motion). In a subsequent April 2021 decision, the Board remanded the case to the agency of original jurisdiction (AOJ) for additional development and adjudication. The case has since been returned to the Board for appellate review. In addition to the issues listed above, the Board remanded the Veteran's service connection claim for an acquired psychiatric disorder. The AOJ later issued an August 2021 Decision Review Officer (DRO) decision that granted entitlement to service connection for generalized anxiety disorder with social phobia. The grant of service connection for this disability constitutes a full award of the benefits sought on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Thus, that issue is no longer before the Board. The Board notes that the April 2021 decision remanded the issue of entitlement to service connection for an esophageal fungal infection. In addition to this claimed disorder, the record reflects that the Veteran has been diagnosed with GERD during the appeal period. See June 2021 VA examination. The Board has consequently recharacterized this issue as noted above to include all current esophageal disorders. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). 1. Entitlement to service connection for a low back disorder, to include as due to an undiagnosed illness, a medically unexplained chronic multisymptom illness, and/or exposure to Gulf War environmental hazards. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (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-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Service connection may also be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a threshold matter, veteran status must be established as a condition of eligibility for service connection benefits. See Bowers v. Shinseki, 26 Vet. App. 201, 206 (2013). A veteran is a person who served in the active military, naval, or air service and who was discharged or released under conditions other than dishonorable. 38 C.F.R. § 3.1(d). The term "active military, naval, or air service" includes active duty, any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty for training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C. § 101(24); 38 C.F.R. §§ 3.6 (a)-(d). The fact that a claimant has established veteran status for other periods of service does not obviate the need to establish veteran status for the period of ACDUTRA or INACDUTRA on which the claim is based. Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998). The advantage of certain evidentiary presumptions, provided by law, that assist veterans in establishing service connection for a disability do not extend to those who claim service connection based on a period of ACDUTRA or INACDUTRA. Paulson v. Brown, 7 Vet. App. 466, 470-71 (1995) (noting that the Board did not err in not applying presumptions of sound condition and aggravation to veteran's claim where he served only on ACDUTRA and had not established any service-connected disabilities from that period); McManaway v. West, 13 Vet. App. 60, 67 (1999), vacated on other grounds sub nom; McManaway v. Principi, 14 Vet. App. 275 (2001) (citing Paulson, 7 Vet. App. at 469-70, for the proposition that if a claim "relates to period of [ACDUTRA], disability must have manifested itself during that period; otherwise, period does not qualify as active military service and claimant does not achieve veteran status for purposes of that claim."); see also Biggins v. Derwinski, 1 Vet. App. 474, 479 (1991) (Steinberg, J., concurring). Thus, the evidentiary burden is on the claimant to show that he or she became disabled from an injury or disease incurred in line of duty during ACDUTRA or from an injury incurred in line of duty during INACDUTRA. In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of a chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For veterans with service in the Southwest Asia theater of operations during the Persian Gulf War, service connection may be established under 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Under this law and regulation, service connection may be warranted for a Persian Gulf veteran who exhibits objective indications of "a qualifying chronic disability" that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317, qualifying chronic disabilities include, among other things, an undiagnosed illness and a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317(a)(2). A MUCMI is 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. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 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. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. 38 C.F.R. § 3.317. Signs or symptoms which may be manifestations of undiagnosed illness or MUCMI include, but are not limited to, fatigue, signs or symptoms involving skin, headaches, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 C.F.R. § 3.317(b). Although entitlement to service connection on any of the presumptive bases noted above may not be established, a veteran is not precluded from establishing service connection on a direct basis. See 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis). An illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive and the determination of whether an illness is "medically unexplained" is particular to the claimant in each case. Stewart v. Wilkie, 30 Vet. App. 383, 389 (2018). The Veteran has asserted that he has a low back disorder that is related to his active service. The record has also raised the theory that he has an undiagnosed illness or MUCMI as a result of his active service in the Southwest Asia theater of operations during the Persian Gulf War. As the Veteran's DD 214 for his period of active duty from December 1990 to March 1991 documents that he had service in Southwest Asia from January 1991 to March 1991, the Veteran is considered a Persian Gulf veteran under 38 C.F.R. § 3.317(e). The Board also notes that the record reflects that the Veteran has a current diagnosis of degenerative disc disease other than intervertebral disc syndrome. See June 2021 VA examination. Regarding the relationship between the Veteran's current lumbar spine disorder and service, the Veteran has contended that there is direct association with the job duties of being a first line leader working on, and with, the "Medical-Unit-Self contained-Transportable (MUST)" equipment and an in-service back injury that led to continued low back problems. See August 2015 Notice of Disagreement. The Veteran reported that as part of the EVAC hospital, there was a continual set up and tear down of equipment, the training was intense, and there was a lot of heavy work. The Veteran stated that during one incident in October 1987 that involved the setting up and tearing down of the MUST equipment at the local VA hospitals as part of a community service demonstration to the public, the Veteran experienced a sudden onset of low back pain while lifting the equipment. The Veteran has also reported that this injury occurred at the VA in Fargo, North Dakota. See June 2021 VA examination. The Veteran indicated in the August 2015 notice of disagreement that although he did not report this event as part of his service medical record, he did seek treatment from his civilian physician. The Veteran also reported that an attempt to retrieve these private treatment records had been unsuccessful as the facility had been closed. Since that time, he had experienced several flare ups and received numerous injections. The Veteran also reported that as the back pain continued, a colleague ordered a CT scan of his lumbar spine that was completed in approximately 1987 or 1988 at St. Ansgar Hospital in Fargo that revealed bulging discs in his lumbar spine. See June 2021 VA examination. Consistent with his earlier statement, the Veteran reported during the June 2021 VA examination that he had been unable to obtain these records as that facility closed years ago. The Veteran also denied having any back pain or injuries prior to his military service, and he denied having any back injuries since his military separation. The Board notes that the Veteran's service treatment records (STRs) are silent for a complaint, treatment, or diagnosis of a low back disorder. Although the Veteran's military personnel records do not document a specific period of ACDUTRA or INACDUTRA in October 1987, they do note that the Veteran had a period of ACDUTRA from October 24, 1986 to October 26, 1986. In addition, an Enlisted Evaluation Report for the period from October 1986 through September 1987 noted that the Veteran's principal duty title was as a practical nurse, and his military unit was noted to be assigned to the 311th Evac Hospital in Fargo, North Dakota. The record further stated that he assisted with the setting up and tearing down of MUST Equipment, its operation and functions. In addition, J.M., PA-C, submitted a December 2015 letter on the Veteran's behalf. J.M. noted that he had been deployed with the Veteran during the first Gulf War. However, the statement suggests that J.M. also had earlier service with the Veteran as he noted that he had worked with the Veteran to set up MUST equipment for the relevant VA demonstration when the Veteran injured his back. Indeed, the Veteran reported during the June 2021 VA examination that the injury at the Fargo VA was observed by his military roommate who wrote a letter in support of his claim. J.M. recalled in the letter that the Veteran had been laid up for 2 weeks after the injury. In addition, J.M. stated that the Veteran had been "on orders" at the time of the injury, and J.M. confirmed that the Veteran had experienced recurrent problems with his back since the injury occurred. In light of this evidence, and affording the Veteran the benefit of the doubt, the Board finds that the Veteran's report indicating that he sustained an in-service back injury during a period of ACDUTRA in October 1986 is consistent with the circumstances of his service. See 38 U.S.C. § 1154(a). The Board has also considered the Veteran's report that he has continued to experience low back problems since he sustained the above injury, and that he was found to have bulging discs of the lumbar spine based on the results from a CT scan obtained shortly after the injury occurred. The Board notes that the Veteran is competent to relay what a medical provider has told him and to report his history of observable events and symptoms such as pain. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board also finds the Veteran's reported history to be credible as his reports have been largely consistent throughout the appeal period, and his reported history was supported by the December 2015 buddy statement from J.M.. The Veteran also provided an explanation for the lack of evidence of in-service treatment for a low back complaint as he reported in his August 2015 notice of disagreement that the nature of his job duties in a military hospital were not conducive to sick call each time there was a medical issue. In addition, the Veteran also highlighted the fact that he was a registered nurse as a civilian and worked with medical doctors on a daily basis. The Veteran stated that although this was not the proper way to deal with things, setting an example was the most important thing at the time. In addition, the Veteran reported that the private treatment records related to the 1986 injury and subsequent CT scan were no longer available. The record shows that a VA examination related to the Veteran's lumbar spine was initially conducted in September 2014, and the examiner provided a negative nexus opinion. The examiner noted under the remarks section of the examination report as well as in a separate rationale for the negative opinion that the Veteran's back condition was not related to Gulf War Syndrome, and the examiner noted that there was no evidence in the STRs of the Veteran's claimed back condition. However, the Board finds that this rationale is inadequate as the examiner did not address the Veteran's reported medical history of continuous symptoms or the question of whether his current lumbar spine disorder was otherwise related to service pursuant to 38 C.F.R. § 3.303(d). During the subsequent June 2021 VA examination, the examiner also provided a negative nexus opinion. The examiner noted in the rationale that the Veteran's STRs were silent for any lumbar spine symptoms, conditions, or concerns. The examiner added that she had reviewed the Veteran's statements before observing that the Veteran was a credible historian; and the examiner indicated that she had also considered the buddy statements with a history of back pain that was plausible during military service. However, due to the STRs being silent for a lumbar spine condition, imaging, and related consultation, the examiner noted that she was unable to say with a 50 percent or greater certainty that the Veteran's current lumbar condition and symptoms were caused or related to active military service. Although the Board has considered this opinion, the Board finds that it provides minimal probative value. The examiner appeared to focus on the lack of relevant findings in the STRs without giving appropriate consideration to the competent and credible reports from J.M. and the Veteran regarding his chronic history of low back complaints following the in-service injury. In this regard, the Board notes that the lack of contemporaneous medical evidence does not warrant a conclusion of a lack of nexus. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). With respect to the claimed low back disorder, the Board has considered the Veteran's competent and credible reports of in-service low back pain following his 1986 injury. Moreover, and as noted in the Joint Motion, the Veteran has also reported that he has professional medical training, including as a licensed practical nurse; demonstrating that his reported history of symptoms should be afforded even greater weight than would be provided to a layperson's statements. J.M.'s December 2015 letter provides further support for the Veteran's reported history as J.M. stated that the Veteran had ongoing back issues from working with the MUST equipment. Similar to the Veteran, J.M's professional credentials as a PA-C are reflective of medical training and expertise beyond that of a layperson. The Board also finds it significant that the June 2021 VA examiner appeared to acknowledge that the Veteran's reported medical history was plausible. Based on this evidence, the Board finds that the most probative evidence establishes a nexus between the Veteran's current low back disorder and the in-service injury he sustained during the period of ACDUTRA in October 1986. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, service connection is granted for a low back disorder, diagnosed as degenerative disc disease other than intervertebral disc syndrome. See 38 C.F.R. § 3.303(a) (service connection must be considered on the basis of the places, types, and circumstances of his service as shown by his service records, the official history of each organization in which he served, his medical records, and all pertinent medical and lay evidence); see also Buchanan, 451 F.3d at 1335 (Fed. Cir. 2006) ("[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself"). As the Board is granting entitlement to service connection on this basis, it is unnecessary to address any other theory of entitlement that has been advanced. REASONS FOR REMAND 1. Entitlement to service connection for a disorder manifested by fatigue, to include chronic fatigue syndrome, and as due to an undiagnosed illness, a medically unexplained chronic multisymptom illness, and/or exposure to Gulf War environmental hazards; and as secondary to service-connected generalized anxiety disorder with social phobia, is remanded. 2. Entitlement to service connection for sleep apnea, to include as due to an undiagnosed illness, a medically unexplained chronic multisymptom illness, exposure to Gulf War environmental hazards, and/or in-service immunizations; and as secondary to service-connected generalized anxiety disorder with social phobia, is remanded. 3. Entitlement to service connection for an esophageal disorder, to include esophageal fungal infection and GERD, to include as due to an undiagnosed illness, a medically unexplained chronic multisymptom illness, exposure to Gulf War environmental hazards, and/or in-service immunizations; and as secondary to service-connected generalized anxiety disorder with social phobia, is remanded. As the Veteran's DD 214 for his period of active duty from December 1990 to March 1991 documents that he had service in Southwest Asia from January 1991 to March 1991, the Veteran is considered a Persian Gulf veteran under 38 C.F.R. § 3.317(e). For the service connection claims on appeal, the record has raised the theories that the claimed disorders are associated with an undiagnosed illness, a medically unexplained chronic multisymptom illness, or otherwise related to the Veteran's exposure to environmental hazards during his active service in Southwest Asia. See, e.g., Arguments submitted by Veteran in October 2020. The April 2021 Board remand directed the AOJ to obtain additional VA examinations and medical opinions in connection with the service connection claims on appeal. Relevant VA examinations and medical opinions were provided in June 2021. Regarding the service connection claim sleep apnea, the June 2021 examiner stated that the Veteran's sleep apnea was a disease with a clear and specific etiology and diagnosis that was not due to Gulf War environmental exposure. However, 38 C.F.R. § 3.317(a)(2)(ii) provides that a medically unexplained chronic multisymptom illness contemplates a diagnosed illness without conclusive pathophysiology or etiology, and the provided opinions related to sleep apnea did not address whether the pathophysiology of this diagnosed disorder was also unknown. As such, an additional medical opinion should be obtained on remand to address this theory. Regarding the Veteran's service connection claim for an esophageal disorder, the June 2021 examiner completed a Disability Benefits Questionnaire (DBQ) for esophageal conditions and noted that the Veteran had a diagnosis for GERD. The examiner also noted a diagnosis of history of esophageal fungal infection and gastritis with the date of diagnosis reported to be in August 2010. However, the examiner opined that the Veteran's current symptoms were attributable to his intermittent GERD, and there were no current symptoms related to an esophageal fungal infection and gastritis. The examiner also stated that the disorder was a diagnosable chronic multisymptom illness with a partially explained etiology that was not due to Gulf War environmental exposure. The Board notes that the diagnosis of GERD reflects that the esophageal symptoms have been attributed to a known clinical diagnosis and therefore cannot be considered to be due to undiagnosed illness. 38 C.F.R. § 3.317(a)(1)(i), (ii). Moreover, "[g]iven the clarity of the Secretary's exclusion based on the regulatory history concerning this section, GERD cannot qualify as a [medically unexplained chronic multisymptom illness]." Atencio v. O'Rourke, 30 Vet. App. 74, 85 (2018). This does not, however, preclude the Veteran from establishing service connection on a direct basis, to include as due to environmental exposures during the Gulf War. See 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis). In this regard, the Board finds that the examiner's rationale for the negative nexus opinion did not clearly explain why the Veteran's GERD was unrelated to Gulf War environmental exposures. An additional medical opinion regarding this question should therefore be obtained on remand. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board also finds that the record has raised the theory that the Veteran's obesity was an intermediate step between his now service-connected generalized anxiety disorder with social phobia and his claimed sleep apnea and esophageal disorder. See Walsh v. Wilkie, 32 Vet. App. 300 (2020) (holding that obesity as an "intermediate step" in a causal chain for service connection can be established on either a causal or aggravation basis). In the March 2017 VA Form 9, the Veteran indicated that the use of medications for his psychiatric symptoms had a direct effect on his diet and exercise. A January 2019 VA MOVE assessment also stated that the Veteran's nutrition-related diagnosis was obesity related to excessive energy intake and/or physical inactivity as evidenced by a BMI greater than 30. The record further noted that relevant medications/supplements included sertraline. A November 2019 mental disorders DBQ completed by Dr. T., MD, also indicated that the Veteran was taking sertraline to treat his psychiatric symptoms. The June 2021 VA examiner additionally opined that the Veteran's obstructive sleep apnea was likely due to his obesity. In support of the negative opinion for an esophageal disorder, the examiner also highlighted the fact that the Veteran's May 2021 body mass index (BMI) of 41.44 was obese and stated that the most likely risk factors for developing an esophageal fungal infection with gastritis and GERD included tobacco use and obesity. The Board finds that the foregoing evidence meets the low threshold as set forth in McLendon to secure a VA medical opinion that addresses the theory of entitlement discussed above. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Thus, a remand is warranted to obtain a medical opinion to address this theory. Regarding the Veteran's service connection claim for chronic fatigue syndrome, the June 2021 VA examiner stated that the Veteran did not have chronic fatigue syndrome; therefore, a Gulf War environmental exposure medical opinion was not applicable. The examiner stated that the Veteran had subjective symptoms of unknown etiology without a medical workup completed. Although the examiner indicated that the Veteran only had subjective symptoms of fatigue, the Veteran reported during the examination that these symptoms caused work limitations that included reduced concentration and taking a daily nap at noon for 30 to 45 minutes. It is therefore unclear whether any fatigue symptoms associated with this claimed disorder cause functional impairment of earning capacity such that they could constitute a current disability. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Based on the foregoing, an additional medical opinion should be obtained that clarifies whether the Veteran has fatigue related to the claimed chronic fatigue syndrome that causes a functional impairment of earning capacity or if these symptoms are related to his diagnosed sleep apnea. In addition, the Veteran has raised the theory that his fatigue is secondary to his service-connected generalized anxiety disorder with social phobia. In an August 2015 notice of disagreement, the Veteran reported that his anxiety and depressive symptoms had led to other ongoing symptoms such as chronic fatigue; indicating that the symptoms occurred in conjunction. In the March 2017 VA Form 9, the Veteran additionally indicated that his psychiatric symptoms contributed to his fatigue symptoms and affected his recovery attempts as a result of his medications for psychiatric symptoms. The Veteran is competent to report his observable fatigue symptoms with the use of medication, and this report suggests that his fatigue may be secondary to his service-connected generalized anxiety disorder with social phobia. See Layno v. Brown, 6 Vet. App. 465, 46769 (1994). Consequently, the opinion obtained on remand should also address this theory. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any health care providers who have provided treatment for a disorder manifested by fatigue, sleep apnea, and esophageal disorder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA medical records, to include records dated since August 2021. 2. After completing the preceding development in paragraph 1, obtain a VA medical opinion from a qualified examiner that addresses the Veteran's service connection claim for a disorder manifested by fatigue, to include chronic fatigue syndrome. The claims file must be made available to the examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. A clear explanation for all opinions based on specific facts for the case as well as relevant medical principles is needed. If an examination is deemed necessary, one must be provided. The Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should provide an opinion as to the following questions: (a) The examiner should state whether the Veteran has a current diagnosis of chronic fatigue syndrome. (b) If any current fatigue symptom is not a manifestation of an identifiable disability, such as sleep apnea, the clinician must opine whether the symptom at least as likely as not (a 50 percent or greater probability) represents an objective indication of chronic disability resulting from an undiagnosed illness. If so, the examiner should also describe the extent to which the illness has manifested. (c) If any current fatigue symptom is not a manifestation of an identifiable disability, such as sleep apnea, the examiner should state whether the Veteran's fatigue causes functional impairment of earning capacity. (d) If fatigue causing functional impairment in earning capacity is identified, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the disorder manifested during, or is otherwise related to, the Veteran's active service, including environmental exposures during service in Southwest Asia during the Persian Gulf War. (e) If fatigue causing functional impairment in earning capacity is identified, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the disorder was caused or aggravated by the Veteran's service-connected generalized anxiety disorder with social phobia, to include medication used to treat the disability. 3. After completing the preceding development in paragraph 1, obtain a VA medical opinion from a qualified examiner that addresses the etiology of the Veteran's sleep apnea. The claims file must be made available to the examiner. The examiner is requested to review all pertinent records associated with the claims file. A clear explanation for all opinions based on specific facts for the case as well as relevant medical principles is needed. If an examination is deemed necessary, one must be provided. The Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. For the Veteran's diagnosed obstructive sleep apnea, the examiner should provide an opinion as to the following questions: (a) Is the Veteran's disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology or pathophysiology, (2) a diagnosable chronic multisymptom illness with a partially explained etiology and pathophysiology, or (3) a disease with a clear and specific etiology and diagnosis. The examiner should note that a "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 out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. (b) If it is determined that the Veteran's disability pattern is either a diagnosable chronic multi-symptom illness with a partially explained etiology and pathophysiology or a disease with a clear and specific etiology and diagnosis, then the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the disorder manifested during, or is otherwise related to, a period of ACDUTRA and/or active duty service, including environmental exposures during service in Southwest Asia during the Persian Gulf War and/or in-service immunizations. In providing an opinion, the examiner should also address the Veteran's contention from his August 2015 notice of disagreement that he developed sleep apnea due to poor sleeping conditions during his service at Fort McCoy in Wisconsin, including exposure to soot. (c) Whether it is at least as likely as not (a 50 percent or greater probability) that the disorder was caused or aggravated by the Veteran's service-connected generalized anxiety disorder with social phobia, to include medication used to treat the disability. In providing an opinion, the examiner should address whether the Veteran's obesity was an intermediate step between his current sleep apnea his service-connected generalized anxiety disorder with social phobia. In so doing, the examiner should state whether it is at least as likely as not (a 50 percent or greater probability) that the service-connected generalized anxiety disorder with social phobia, to include medication used to treat the disability, caused the Veteran to become obese or gain weight; or aggravated his obesity. If so, the examiner should provide an opinion as to whether the obesity, or the aggravation of obesity, as a result of the service-connected disability was a substantial factor in causing the Veteran's obstructive sleep apnea. He or she should also provide an opinion as to whether the Veteran's obstructive sleep apnea would not have occurred but for the obesity caused or aggravated by his service-connected disability. 4. After completing the preceding development in paragraph 1, obtain a VA medical opinion from a qualified examiner that addresses the etiology of any current esophageal disorder. The claims file must be made available to the examiner. The examiner is requested to review all pertinent records associated with the claims file. A clear explanation for all opinions based on specific facts for the case as well as relevant medical principles is needed. If an examination is deemed necessary, one must be provided. The Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify all current esophageal disorders. The examiner should also provide an opinion as to the following questions: (a) For any identified disorder other than GERD, the examiner should state whether the disability pattern is consistent with: (1) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology or pathophysiology, (2) a diagnosable chronic multisymptom illness with a partially explained etiology and pathophysiology, or (3) a disease with a clear and specific etiology and diagnosis. The examiner should note that a "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 out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. (b) For any identified GERD and/or any other esophageal disorder that is determined to have a disability pattern that is either a diagnosable chronic multi-symptom illness with a partially explained etiology and pathophysiology or a disease with a clear and specific etiology and diagnosis, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the disorder manifested during, or is otherwise related to, a period of ACDUTRA and/or active duty service, including environmental exposures during service in Southwest Asia during the Persian Gulf War and/or in-service immunizations. (c) Whether it is at least as likely as not (a 50 percent or greater probability) that the disorder was caused or aggravated by the Veteran's service-connected generalized anxiety disorder with social phobia, to include medication used to treat the disability. In providing an opinion, the examiner should address whether the Veteran's obesity was an intermediate step between his current esophageal disorder and his service-connected generalized anxiety disorder with social phobia. In so doing, the examiner should state whether it is at least as likely as not (a 50 percent or greater probability) that the service-connected generalized anxiety disorder with social phobia, to include medication used to treat the disability, caused the Veteran to become obese or gain weight; or aggravated his obesity. If so, the examiner should provide an opinion as to whether the obesity, or the aggravation of obesity, as a result of the service-connected disability was a substantial factor in causing the Veteran's esophageal disorder. He or she should also provide an opinion as to whether the Veteran's esophageal disorder would not have occurred but for the obesity caused or aggravated by his service-connected disability. 5. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.C. Spragins, 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.