Citation Nr: 21071958 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 16-47 490 DATE: December 1, 2021 REMANDED Service connection for a spinal disability is remanded. Service connection for a medically unexplained chronic multi-symptom illness (MUCMI) or undiagnosed illness (including chronic fatigue syndrome or fibromyalgia) manifested by joint, muscle, and nerve pain, muscle cramping, memory loss, dizziness, balance issues, indigestion, constipation, skin rashes, Graves' disease, hypothyroidism, and a history of kidney stones and seizures is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from September 1987 to September 1991 with confirmed service in Southwest Asia. These matters are before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision. In August 2019, the Board remanded these claims along with service connection for a psychiatric disability. The AOJ then granted service connection for PTSD in August 2020, so that issue is no longer before the Board. The Veteran originally claimed service connection for chronic fatigue syndrome and fibromyalgia separately from "gulf war syndrome" or "chronic multi-symptom illness," and the rating decision on appeal and prior Board remand followed this framing (i.e., service connection for chronic fatigue syndrome, back disability also claimed as fibromyalgia, and chronic multi-symptom illness). However, as chronic fatigue syndrome and fibromyalgia are chronic multi-symptom illnesses, and the Veteran has claimed service connection for separate spinal diagnoses (i.e., cervical and lumbar spine degenerative arthritis) in statements he submitted supporting his "back" disability claim, the Board is recharacterizing the issues remaining on appeal for clarity and to afford the Veteran the most sympathetic review. 1. Service connection for a low back disability is remanded. The prior remand directed that a VA examiner clarify the nature and likely cause of all back disabilities and specifically noted evidence of both lumbar and cervical pathology in the remand instructions. The remand also directed that the examiner specifically consider the Veteran's lay reports of a back injury in service. The April 2020 VA examination report and medical opinion obtained on remand does not adequately comply with the prior remand. Specifically, it appears to only consider the Veteran's lumbar spine disability without substantively addressing his cervical spine (other than to use cervical spine disability as a means of discounting his claims of undiagnosed illnesses or MUCMI without further explanation) and, in finding that his current low back arthritis with radiculopathy is "not specifically related to any documented injury," the examiner does not properly consider the Veteran's lay reports of record. Notably, the examiner appears to summarily dismiss the possibility of a low back injury based solely on the lack of documentation confirming one, despite the fact the Veteran has a history of combat experience and his reported back injury is consistent with the circumstances of his service. Similarly, there is no attempt to consider whether, even absent any specific injury, his current back condition could be related to the aggregate effect of repeated strain in service, particularly given he indicated he "had to carry...heavy equipment weighing approximately 160 [pounds]" and the examiner acknowledged that arthritis is often related to "wear-and-tear." Consequently, a new examination and medical opinion is needed. 2. Service connection for an MUCMI or undiagnosed illness (including chronic fatigue syndrome or fibromyalgia) is remanded. The prior remand directed that VA examiners assess the Veteran for a potential undiagnosed or MUCMI manifested by a constellation of reported symptoms and medical history, but it does not appear that the April 2020 VA examinations scheduled on remand did so adequately. The only specific symptoms those examinations substantively discussed were back pathology and a history of seizures. Moreover, the ultimate opinion found the Veteran has no chronic multi-symptom illnesses and vaguely concluded that his "neurological and physical issues" are attributable to hypothyroidism, Graves' disease, degenerative arthritis of the lumbar and cervical spine, lumbar radiculopathy, depressive disorder, hearing loss, and tinnitus, without explaining why. In addition, neither the April 2020 examination report nor any other VA examination of record adequately explains the repeated findings that the Veteran does not have fibromyalgia or chronic fatigue syndrome or reconciles them with his several reported symptoms, some of which do appear facially consistent with those conditions. Consequently, additional clarification is needed. The matters are REMANDED for the following action: 1. Obtain all updated records (i.e., those not already of record) of VA and adequately identified private treatment the Veteran has received for the disabilities remaining on appeal. 2. Schedule the Veteran for an in-person or telehealth (whichever is appropriate) examination by an appropriate physician (or multiple physicians) to determine the nature and cause of any spinal disability. Based on a review of the record, examination of the Veteran (INCLUDING A COMPLETE SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF HIS SYMPTOMS), and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Please diagnose all cervical and lumbar spine disability entities found. All diagnostic findings (or lack thereof) must be reconciled with conflicting evidence in the record. If any previously documented diagnoses are no longer or otherwise not felt to apply, the examiner must explain why, citing to the pertinent diagnostic criteria. (b.) For each disability diagnosed, please opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such disability is related to the Veteran's military service, to include his COMPETENT REPORTS of a back injury while packing a traversing unit for a missile system OR the aggregate effect of repeated strain, including as a result of frequently carrying heavy equipment. All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. 3. Schedule the Veteran for an in-person or telehealth (whichever is appropriate) examination by an appropriate physician (or multiple physicians) to determine the nature and cause of his alleged multi-symptom illness. Based on a review of the record, examination of the Veteran (INCLUDING A COMPLETE SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF HIS SYMPTOMS), and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Does the Veteran meet the diagnostic criteria for chronic fatigue syndrome or fibromyalgia? The examiner MUST EXPLAIN their finding, specifically citing to the diagnostic criteria and the Veteran's reported or documented symptoms as appropriate (including, but not limited to, muscle pain, joint pain, nerve pain, muscle cramping, memory loss, constipation, indigestion, fatigue, dizziness, balance issues, skin rashes, Graves' disease, hypothyroidism, and a history of seizures and kidney stones). (b.) Is any of the Veteran's claimed symptomatology (including, but not limited to, muscle pain, joint pain, nerve pain, muscle cramping, memory loss, constipation, indigestion, fatigue, dizziness, balance issues, skin rashes, Graves' disease, hypothyroidism, and a history of seizures and kidney stones) consistent with any known clinical diagnoses when considered either independently or together in any combination? (c.) If so, please identify all such diagnoses and their associated symptoms and indicate whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) related to the Veteran's military service, to include any environmental exposures (like particulate matter from burn pits) he may have encountered in Southwest Asia. (d.) Is any of the Veteran's claimed symptomatology (including, but not limited to, muscle pain, joint pain, nerve pain, muscle cramping, memory loss, constipation, indigestion, fatigue, dizziness, balance issues, skin rashes, Graves' disease, hypothyroidism, and a history of seizures and kidney stones) consistent with a medically unexplained chronic multi-symptom illness? The examiner should keep in mind that "medically unexplained chronic multi-symptom illness" is defined as "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? All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. David Gratz Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Yuan, 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.