Citation Nr: 21076291 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 19-07 484 DATE: December 23, 2021 ORDER An effective date of July 12, 2017, but no earlier, for the assignment of an initial 50 percent rating for PTSD is granted. Service connection for sinusitis, claimed as breathing problems, is granted. Service connection for chronic fatigue syndrome is granted. Service connection for granulomatous lung disease, claimed as lung condition, is granted. Service connection for gastroesophageal reflux disease (GERD), claimed as gastrointestinal problems, is denied. Service connection for a testosterone disorder is denied. Service connection for skin conditions is denied. REMANDED Entitlement to service connection for a neck condition is remanded. Entitlement to service connection for a traumatic brain injury (TBI) is remanded. Entitlement to service connection for a neurological disorder is remanded. Entitlement to service connection for allergies is remanded. Entitlement to an increased disability rating for posttraumatic stress disorder (PTSD) is remanded. Entitlement to an increased disability rating for fibromyalgia is remanded. Entitlement to an increased disability rating for headaches is remanded. FINDINGS OF FACT 1. The Veteran's PTSD resulted in manifestations that more nearly approximated occupational and social impairment with reduced reliability and productivity as of July 12, 2017; it is not factually ascertainable that such manifestations were present prior to that date. 2. The Veteran served in Southwest Asia during the Persian Gulf War. 3. The Veteran is presumed exposed to fine, particulate matter during service in Southwest Asia during the Persian Gulf War. 4. The Veteran's sinusitis became manifest to a degree within 10 years from his date of separation from military service in Southwest Asia. 5. The Veteran has been diagnosed with chronic fatigue syndrome that is compensably disabling. 6. The evidence of record is in relative equipoise as to whether the Veteran's granulomatous lung disease is due to service, to include exposure to environmental hazards in Southwest Asia. 7. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of GERD. 8. Hypogonadism, claimed as a testosterone disorder, is not shown to be causally or etiologically related to any disease, injury, or incident in service. 9. The Veteran's skin conditions are not shown to be causally or etiologically related to any disease, injury, or incident in service. CONCLUSIONS OF LAW 1. The criteria for an effective date of July 12, 2017, but no earlier, for the assignment of a 50 percent rating for PTSD, have been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.321, 3.400, Part 4, including §§ 4.7, 4.130, Diagnostic Code 9411. 2. The criteria for service connection for sinusitis have been met on a presumptive basis as due to exposure to particulate matter. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.2 (i), 3.102, 3.303, 3.317(e)(2); 86 Fed. Reg. 42724 (August 5, 2021), to be codified at 38 C.F.R. § 3.320. 3. The criteria for service connection for chronic fatigue syndrome have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.317. 4. The criteria for service connection for granulomatous lung disease have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.317. 5. The criteria for service connection for GERD are not met. 38 U.S.C. §§ 1131, 1137, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310, 4.14. 6. The criteria for service connection for a testosterone disorder have not been met. 38 U.S.C. §§ 1131, 1137, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 7. The criteria for service connection for skin conditions have not been met. 38 U.S.C. §§ 1131, 1137, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in September 2017, March 2018 and February 2019 by a Department of Veterans Affairs (VA) Regional Office. The Veteran testified at a hearing before the undersigned, held in August 2021. A transcript of that hearing has been associated with the record. At the outset, the Board notes that the Veteran's claims of entitlement to service connection for chronic fatigue, granulomatous lung disease and sinusitis were initially denied in the September 2017 rating decision on appeal. In March 2018, the Veteran filed a new claim for the conditions and submitted medical evidence in support. In an August 2018 rating decision the RO determined that new and material evidence would be needed to reopen the claims; it then reopened and denied each of them. However, the Board finds that the Veteran's March 2018 filling acted as a request for reconsideration and, thus, the September 2017 rating decision did not become final. Therefore, new and material evidence is not necessary to decide the claims. In addition, the Board notes that the point is moot, as it is granting service connection for each of these conditions, infra, and thus any such procedural error is harmless. Referred Claim The Board notes that, in his initial November 2016 claim for benefits, the Veteran sought service connection for a disorder manifested as "sleep problems." However, this claim was not addressed or adjudicated in the subsequent August 2017 rating decision, or since its filing. As such, proper development and initial adjudication is required regarding the claim, and it is referred to the RO for appropriate action. See 38 C.F.R. § 19.9(b). Effective Date PTSD The Veteran is seeking an effective date prior to November 27, 2017 for the assignment of an initial 50 percent rating for PTSD. The assignment of effective dates of awards is generally governed by 38 U.S.C. § 5110 and 38 C.F.R. § 3.400. Unless specifically provided otherwise, the effective date of an award based on a claim for service connection or for an increase of compensation "shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefore." 38 U.S.C. § 5110(a). The implementing regulation clarifies this to mean that the effective date of an award of service connection or for increase compensation "will be the date of receipt of the claim or the date entitlement arose, whichever is later." 38 C.F.R. § 3.400. This claim is subject to the more specific criteria under 38 U.S.C. § 5110(b)(2) and 38 C.F.R. § 3.400(o)(2), which dictate that the effective date of an award for increased compensation "shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date." 38 U.S.C. § 5110(b)(2). The implementing regulation summarizes the criteria for an effective date of an award of increased compensation as the "[e]arliest date as of which it is factually ascertainable that an increase in disability had occurred if claim is received within 1 year from such date otherwise, date of receipt of claim." 38 C.F.R. § 3.400(o)(2). The United States Court of Appeals for Veterans Claims (Court) has indicated that it is axiomatic that the fact that must be found, in order for entitlement to an increase in disability compensation to arise, is that the service-connected disability must have increased in severity to a degree warranting an increase in compensation. See Hazan v. Gober, 10 Vet. App. 511, 519 (1992) (noting that, under section 5110(b)(2), which provides that the effective date of an award of increased compensation shall be the earliest date of which it is ascertainable that an increase in disability had occurred, "the only cognizable 'increase' for this purpose is one the next disability level" provided by law for the particular disability). Thus, determining whether an effective date assigned for an increased rating is correct or proper under the law requires (1) a determination of the date of the receipt of the claim for the increased rating as well as (2) a review of all the evidence of record to determine when an increase in disability was "ascertainable." Id. at 521. Here, the Veteran filed an intent to file his claim for service connection for PTSD on December 25, 2015. He subsequently filed the formal claim in November 2016. In an August 2017 rating decision, service connection for PTSD was granted and an initial 30 percent rating was assigned, effective December 25, 2015, the date of intent to file. In January 2018, within one year of the rating decision granting service connection, the Veteran filed a claim for an increased disability rating. Subsequently, in a March 2018 rating decision, the RO granted a 50 percent rating for PTSD, effective January 29, 2018, the date the claim for increase was filed. A subsequent rating decision, issued in February 2019, granted an effective date of November 28, 2017 for the 50 percent rating, finding that the Veteran met the criteria for the higher rating as of that date. Therefore, while the Veteran's claim was initially received on December 25, 2015, the RO determined that a factually ascertainable increase occurred on November 27, 2017, the date of a VA treatment note showing increased impairment in social and occupational functioning. Therefore, with regard to the Veteran's current effective date claim, the inquiry before the Board is whether there was a factually ascertainable increase in the severity of his PTSD prior to November 27, 2017, thus warranting a 50 percent rating. In this regard, disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation 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. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). As in the instant case, where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. at 126. PTSD is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. Pursuant to that General Rating Formula, a 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. As the United States Court of Appeals for the Federal Circuit explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation...requires an ultimate factual conclusion as to the Veteran's level of impairment in most areas." Vazquez-Claudio, supra; 38 C.F.R. § 4.130, Diagnostic Code 9411. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126(a). As noted supra the Veteran filed his claim in December 2015. He was provided with a VA examination in relation to the claim in August 2017. At that time, the Veteran reported experiencing anxiety, suspiciousness, chronic sleep impairment, mild memory loss and difficulty in establishing and maintaining effective work and social relationships. The VA psychologist determined that the Veteran was experiencing occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. As these findings met the criteria for a 30 percent rating, such was assigned for the disability. After the Veteran filed his claim for an increased rating in January 2018, he was provided with a VA examination in March. At that time, he reported experiencing a depressed mood, anxiety, weekly panic attacks, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective relationships. He reported abandoning former hobbies, such as hunting and fishing, and avoiding people. He missed work regularly, and was having issues with his boss and his work load. The VA examiner concluded that the Veteran's symptoms had increased, and he was experiencing social and occupational impairments with reduced reliability and productivity due to PTSD. He assessed a moderate level of severity. Based on this examination, the Veteran's disability rating was increased to 50 percent, effective as of the date of the increased rating claim. In November 2018, the Veteran filed a notice of disagreement, arguing that the effective date should be the date of his original claim, in December 2015. As noted above, in a February 2019 rating decision, an effective date of November 28, 2017 was assigned for the 50 percent rating. The RO found that a VA treatment note authored on that date showed that the Veteran's PTSD symptoms had worsened to the point that a 50 percent rating was warranted. Specifically, the Veteran reported during a VA mental health session that he had quit a second job due to an inability to be around people, and was experiencing decreased appetite, low energy, and low motivation. A January 2018 follow-up session showed increased stress at work, hypervigilance and the need to self-isolate. Thus, a 50 percent rating was warranted as of that date, but no earlier. Thus, to warrant an earlier effective date for the 50 percent rating, the evidence prior to November 28, 2017 must show that the Veteran experienced occupational and social impairment with reduced reliability and productivity due to his PTSD symptoms. Based on its review of the evidence of record, the Board finds that the Veteran arguably met the criteria for a 50 percent disability rating as of July 12, 2017, but no earlier. The Veteran was seen at VA for mental health treatment starting in October 2015, prior to his initial claim. At a January 2016 session, he reported increased stress and anxiety, irritability and insomnia. He was procrastinating more often, especially at work. On examination, he was found to be alert and oriented, pleasant and cooperative. His memory was intact and speech normal. The Veteran's thought process was linear, logical and goal-oriented. He denied suicidal or homicidal ideation, audio or visual hallucinations. His insight was found to be good and his judgment was fair. At a subsequent session that same month, he reported sleep problems, hypervigilance and isolation. His appetite was good, while energy and motivation were fair. He denied suicidal or homicidal ideation, audio or visual hallucinations. On exam, his thought processes were normal, and his mood euthymic. The Veteran's speech was clear and his memory intact. VA treatment notes for the remainder of 2016 show the Veteran consistently reported experiencing sleep issues, hypervigilance and isolation. His appetite was fair and energy and motivation were low. In each session for the rest of 2016, the Veteran was found to be alert and oriented on all planes, with intact cognition, normal grooming, normal thought processes, clear speech, good insight and judgment, and with memory intact. At no time did he endorse such symptoms as suicidal ideation, homicidal ideation, or audio or visual hallucinations. In February 2017, the Veteran was seen for counseling at VA and reported experiencing anxiety, insomnia, nightmares, and hypervigilance. He had recently moved. His energy and motivation remained low. On examination, his thought process was normal, his speech clear, judgment and insight good, and his memory fully intact. He denied suicidal or homicidal ideation, audio or visual hallucinations. In a March 2017 treatment note, the Veteran reported that he had recently married. He was experiencing insomnia, nightmares, and hypervigilance. He was isolating from other people, with low energy and motivation. He denied suicidal or homicidal ideation, and audio or visual hallucinations. On examination, his mood was euthymic with congruent affect, with normal thought process, clear speech, good judgment and insight, and intact memory. In June 2017, the Veteran reported that he had taken a second job to keep busy. He reported insomnia, nightmares, and hypervigilance. He reported feeling uncomfortable in social settings, with low energy and motivation. On exam, he found to have good grooming and hygiene, normal thought processes, and clear speech. His judgment and insight were good, and memory intact. By the time of his July 12, 2017, session, the Veteran was working both jobs, but finding himself behind at his full-time job, due to an inability to concentrate. He continued to have nightmares and feel hypervigilant. He had issues with his wife due to mood swings. His appetite had decreased. On examination, the Veteran had a depressed mood, but denied suicidal or homicidal ideation, or hallucinations. His thought process was normal, speech clear, judgment and insight good, and memory intact. In the November 2017 treatment note found to warrant a 50 percent rating, the Veteran reported a drop in concentration and getting in trouble at work due to an inability to finish his work in a timely manner. He had quit his second job due to an inability to be around the public. He was hypervigilant, could not sleep, and isolated himself. He explained that he spent all his free time in his garage, away from others, working on antique car. He had a decreased appetite, and his energy and motivation were low. His mood was found to be depressed, although his thought process was normal, speech clear, judgment and insight good, and his memory intact. The Board finds that it became factually ascertainable that the Veteran met the criteria for a 50 percent rating as of July 12, 2017. At that time, he was experiencing occupational difficulties due to impaired concentration. Although he had recently married, he was experiencing interpersonal conflict with his wife due to his mood swings. His appetite had decreased. He was depressed. The Board's finding that this symptomology warrants a 50 percent rating is supported by the fact that the November 2017 notation, which also documented employment difficulties and interpersonal conflict, was found by the RO to support such a rating. Therefore, an effective date of July 12, 2017 for a 50 percent disability rating for PTSD is warranted. However, prior to that date, the Board finds that the preponderance of the evidence is against a finding that it was factually ascertainable that the Veteran's PTSD resulted in manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity. Although, arguably, the Veteran had disturbances of mood and motivation, which is a symptom under the 50 percent criteria, he did not exhibit symptoms such as flattened affect, circumstantial, circumlocutory, or stereotyped speech; more than once a week panic attacks; difficulty in understanding complex commands; impairment of short and long-term memory; impaired judgment; or impaired abstract thinking. The record consistently shows that the Veteran's memory was intact and his speech was normal. He did not report panic attacks, and clearly understood complex commands, as he was able to obtain a second job during that period. Further, the Veteran moved houses and got married prior to July 12, 2017. Overall, the Veteran was consistently found to be alert, oriented, and cleanly dressed, with no delusional thinking. While the VA treatment records showed that he exhibited a depressed mood, sleep impairment, isolation, and withdrawal, these criteria are contemplated in the 30 percent criteria. The Board notes that the Court in Mauerhan, supra, stated that the symptoms listed in VA's general rating formula for mental disorders is noted intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. However, the Court further indicated that without those examples differentiating a 30 percent evaluation from a 50 percent evaluation would be extremely ambiguous. Id. at 442. In light of Mauerhan, the Board observes that the Veteran was able to marry during the appeal period, he exhibited his ability to maintain long-term social relationships. Prior to July 12, 2017 he was able to maintain his job, and even take a second job in order to "keep busy." The Veteran was able to perform his activities of daily living during this period. In other words, the overall PTSD symptomatology during this period did not cause occupational and social impairment with reduced reliability and productivity. Therefore, the Board must conclude that the Veteran's impairment prior to July 12, 2017 warranted no more than a 30 percent rating for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Board also finds it significant that the August 2017 VA examiner found that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, which again is the criteria for a 30 percent rating. The demonstrated PTSD symptomatology did not more nearly approximate the criteria for a higher rating. Thus, the clinical evidence simply does not show that a higher rating is warranted prior to July 12, 2017. The Board acknowledges that the Veteran, in advancing his appeal, believes that the disability on appeal has been more severe than the newly-assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). However, in the instant case, the Board finds that the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. In this regard, the symptoms shown by the record prior to July 12, 2017, including anxiety, hypervigilance, and chronic sleep impairment are all contemplated in the assigned 30 percent rating. In conclusion, the Board finds that an effective date of July 12, 2017, but no earlier, is warranted for the assignment of an initial 50 percent rating for PTSD. In making this determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the assignment of a higher 50 percent rating prior to that date and, thus, to that extent, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Service Connection Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge 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). Pertinent to all claims for service connection, such a determination requires a finding of current disability that is related to an injury or disease in service. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Sinusitis The Veteran seeks service connection for sinusitis, based on his service in Southwest Asia during the Persian Gulf War. Service connection may be awarded on a presumptive basis, meaning without competent evidence of a nexus between the claimed illness and service, to a Persian Gulf veteran who (1) exhibits objective indications; (2) of a chronic disability such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either 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; and (4) such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. Gutierrez v. Principi, 19 Vet. App. 1, 7 (2004); 38 U.S.C. § 1117; 38 C.F.R. § 3.317; 76 Fed. Reg. 81834 -81836 (Dec. 29, 2011). Effective August 5, 2021, VA issued an interim final rule amending its adjudication regulations and establishing presumptive service connection for three chronic respiratory health conditions, to include sinusitis and rhinitis, in association with presumed exposures to fine, particulate matter. These presumptions apply to veterans with a qualifying period of service, i.e., who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, as well as in Afghanistan, Syria, Djibouti, or Uzbekistan, on or after September 19, 2001, during the Gulf War. See Presumptive Service Connection for Respiratory Conditions Due to Exposure to Particulate Matter, 86 Fed. Reg. 42724 (August 5, 2021), to be codified at 38 C.F.R. § 3.320. Service connection shall be granted for a qualifying disease even though there is no evidence of such disease during the period of service if it becomes manifest to any degree (including non-compensable) within 10 years from the date of separation from military service. The Persian Gulf War began on August 2, 1990, and the Southwest Asia theater of operations encompasses 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, and the Red Sea. 38 C.F.R. §§ 3.2 (i), 3.317(e)(2). The Veteran's military personnel record reflects that he has a period of service that qualifies for the presumption. Therefore, the Veteran is presumed exposed to fine, particulate matter during such service, and there is no affirmative evidence to establish he was not exposed to fine, particulate matter during such service. A September 2017 VA examination shows the Veteran was diagnosed with sinusitis, with a 1991 onset. At the time, the Veteran reported congestion and a runny nose in service. Examination showed that the disability was manifested by headaches, pain and tenderness of the affected sinus, purulent discharge and crusting. Further, an October 2018 VA examination confirmed the 1991 diagnosis of chronic sinusitis. The Veteran's 1991 onset of sinusitis clearly indicates a manifestation within 10 years from the date of his qualifying period of service, as shown during the October 2018 VA examination. McGrath v. Gober, 14 Vet. App. 28, 35 (2000) (in determining the date entitlement arose, when an original claim for benefits is pending, the Board must determine when a claimant's disability manifested itself under all the "facts found" and "the date on which the evidence is submitted is irrelevant"); Traut v. Brown, 6 Vet. App. 495 (1994) (establishing service connection on a presumptive basis does not require that a chronic disease be diagnosed within the applicable time period; rather, symptoms that manifest within this time period may subsequently be determined to have been early manifestations of a chronic disease). A qualifying disease will not be presumed eligible for service connection if there is affirmative evidence that (1) the disease was not incurred during or aggravated by a qualifying period of service; or (2) the disease was caused by a supervening condition or event that occurred between the veteran's most recent departure from a qualifying period of service and the onset of the disease; or (3) the disease is the result of the veteran's own willful misconduct. Willful misconduct means an act involving conscious wrongdoing or known prohibited action. It involves deliberate or intentional wrongdoing with knowledge of, or wanton and reckless disregard of its probable consequences. 38 C.F.R. § 3.1 (n)(1). There is no affirmative evidence that the disease was not incurred in service. In so finding, the Board acknowledges the October 2018 examiner found no nexus to service, including due to environmental hazards in Southwest Asia, and a December 2018 VA examination report which found that the condition was less likely than not due to service, due to a lack of in-service reports of symptoms. However, these negative nexus opinions were made without knowledge of the presumption and the studies underlying it. The Board finds that they are not probative and cannot overcome the presumption. In addition, there is also no evidence that the disease was caused by a supervening condition or event or is the result of the Veteran's willful misconduct. The October 2018 examiner does not provide a rationale for his conclusion, and the rationale for the December 2018 opinion is based on lack of treatment records for the condition; thus, both opinions are lacking and their probative value is negated. Most importantly, both VA examiners diagnosed sinusitis. As the Veteran's sinus disability manifested to a degree within 10 years of his qualifying period of service in Southwest Asia, and he is presumed to have been exposed to particulate matter based on that service, entitlement to service connection for sinusitis is warranted on a presumptive basis. The claim is granted. Chronic Fatigue Syndrome As noted above, service connection is warranted on a presumptive basis to a Persian Gulf veteran who exhibits objective indications of certain chronic disabilities which became manifest either 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, when such symptomatology cannot be attributed to any known clinical diagnosis. Gutierrez, supra. Under 38 C.F.R. § 3.317, compensation may be warranted on a presumptive basis for disabilities due to undiagnosed illness as well as medically unexplained chronic multisymptom illnesses. See 38 C.F.R. § 3.317 (a). Thus, even if a Veteran's symptoms are attributed to a known clinical diagnosis, the presumptive provisions related to Gulf War service still apply. In particular, the term medically unexplained chronic multisymptom illness (MUCMI) means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, or disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(a)(2)(ii). Therefore, even if a multisymptom illness has a diagnosis, consideration should still be given as to whether the disability has no known etiology, or has a known, partially understood etiology. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. Id. As noted above, the Veteran is considered a Persian Gulf veteran and thus, the presumptions of 38 C.F.R. § 3.317 apply. To that end, while his service treatment records lack any treatment for, or reports of, fatigue, his post-service medical records show reports of fatigue on multiple occasions. Specifically, in an October 2018 VA Gulf War Examination, the Veteran's symptoms were acknowledged. At that time, the Veteran reported that he was diagnosed with chronic fatigue syndrome in 2010. He reported trouble sleeping and headaches as a result of the condition. The examiner, however, determined without explanation that the Veteran's disability pattern was not an undiagnosed condition, MUCMI, or a chronic multisymptom illness with a partially explained etiology. Rather, it had a clear and specific etiology and diagnosis, although the examiner failed to provide such. He concluded that it was less likely than not that the Veteran's fatigue had a correlation to his service in Southwest Asia. The Board rejects this opinion as inadequate on the question of nexus. A subsequent VA examination in December 2018 determined that the Veteran did not have a diagnosis of chronic fatigue syndrome at all. However, in an April 2016 private treatment note, a nurse practitioner acknowledged the Veteran's reported symptoms of fatigue and provided a diagnosis of chronic fatigue syndrome. Because this diagnosis was made just prior to the Veteran filing his claim in November 2016, the Board must find that the Veteran has a diagnosis of chronic fatigue syndrome, even if later examiners found no such disorder. See Romanowsky v. Shinseki, 26 Vet. App. 289, 293-94 (2013) (holding that when the record contains a recent diagnosis of a disability prior to filing a claim for benefits based on that disability, the Board must address whether current disability existed at the time the claim was filed or during its pendency). The Board observes, therefore, that the Veteran has been diagnosed with chronic fatigue syndrome, a known clinical diagnosis. Under section 3.317, presumptive service connection is available for chronic fatigue syndrome as a MUCMI. Thus, because the evidence shows that the condition is compensably disabling under 38 C.F.R. § 4.88b, Diagnostic Code 6354, service connection is warranted. The claim is granted. Granulomatous lung disease The Veteran asserts that he developed granulomatous lung disease as a result of his Southwest Asia service. Specifically, he contends that exposure to burn pits while serving in the Persian Gulf caused him to develop the condition. In September 2017, the Veteran underwent a VA Respiratory Conditions examination. At that time, he was diagnosed with granulomatous lung disease. Review of a September 2016 x-ray showed possible granulomatous densities on the right upper lobe of the lung. No other respiratory conditions were found to be present. On the question of etiology, the examiner determined that the Veteran's granulomatous lung disease was due to service. Specifically, he concluded that such a condition commonly developed due to exposure to contaminated air droplets and developing an infection, which was common in countries like those in the Gulf. Therefore, the condition was at least as likely as not a diagnosable but MUCMI of unknown etiology due to exposure environmental hazards in Southwest Asia. In explaining his conclusion, the examiner specifically noted the burn pits mentioned by the Veteran as a possible cause. In October 2018, the Veteran underwent a VA Gulf War Medical Examination. At that time, the diagnosis of granuloma was confirmed, based on review of the same September 2016 x-ray. On the question of etiology, the examiner conclude that the Veteran's granulomatous lung disease was not an undiagnosed condition, a MUCMI, or a chronic multisymptom illness with a partially explained etiology. It had a clear and specific etiology and diagnosis, and was less likely than not to have a correlation to any "exposures to any substances or agents." In December 2018, VA sought clarification from the October 2018 examiner. At that time, he concluded that it was less likely than not that the Veteran's granulomatous lung disease was due to environmental exposures in Southwest Asia. As rationale, he explained that the Veteran had a solitary benign pulmonary granuloma. A granuloma is a small area of inflammation, often found incidentally on an x-ray or other imaging test done for a different reason, which is how the Veteran's was found. The most common causes of the condition are sarcoidosis and infections such as histoplasmosis or tuberculosis. The Veteran did not have sarcoidosis, and tested negative for tuberculosis. Histoplasma is a fungus most commonly found in North and Central America, living in the U.S. in areas around the Ohio and Mississippi River Valleys, where the Veteran has lived his entire life. The Veteran did not have a disability pattern as defined by VA, or diagnosis of a disease that is related to Southwest Asia exposure. The Board affords the findings of each of the examiners equal probative weight on the question of etiology of the Veteran's granulomatous lung disease. As each examiner considered the relevant evidence of record, to include the Veteran's contentions, and offered an opinion with a detailed rationale, each of their opinions are entitled to equal probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). Here, one examiner explained in detail that the Veteran's condition developed as a result of environmental factors during his service in Southwest Asia; another explained in equal detail that it developed due to post-service environmental factors. Therefore, as the medical opinion evidence on the question of nexus is in relative equipoise, and resolving all reasonable doubt in the Veteran's favor, the Board thus concludes that the criteria for service connection for granulomatous lung disease have been met. The claim is granted. GERD The Veteran asserts that he has been diagnosed with GERD that is directly due to his military service and thus, service connection is warranted. At September 2017 VA intestinal conditions examination, the Veteran reported experiencing bowel disturbances. He was diagnosed at that time with irritable bowel syndrome (IBS). In October 2017, the Veteran was seen at VA for a pre-colonoscopy examination. At that time, he reported chest pains, dysphagia, diarrhea, gas and intermittent abdominal pain. A past history of gastritis was noted. At the time of the examination, an impression of possible GERD was noted. However, the Board notes that subsequent examinations have ruled out such a diagnosis. In November 2021, the Veteran again underwent a VA intestinal conditions examination. At that time, he reported diarrhea, constipation, abdominal distention, nausea and vomiting. Based on these symptoms, he was given diagnoses of IBS and gastritis. Thus, based on this evidence, the Board must find that the Veteran does not have a current diagnosis of acid reflux or GERD and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky, supra; McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Each of the VA examiners who evaluated the Veteran attributed his subjective symptoms of abdominal discomfort and diarrhea to IBS, for which the Veteran is already service-connected. Further, despite consistent gastroenterology treatment, VA treatment records do not contain a diagnosis of GERD. The Board finds the Veteran is competent to describe his gastrointestinal pain, diarrhea, and gas as he can perceive the symptoms through his senses. Layno, supra. While the Veteran believes he has a current diagnosis of GERD, distinct from his diagnosis of IBS, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Even if the Board were able to find that the Veteran had a diagnosis of GERD, which it has not, granting service connection for the condition would not be possible. While VA's rating schedule recognizes that a single disability may result from more than one distinct injury or disease, rating the same disability or its manifestation(s) under different Diagnostic Codesa practice known as pyramidingis prohibited. See 38 C.F.R. § 4.14. The critical element in permitting the assignment of several evaluations under various Diagnostic Codes is that none of the symptomatology for any one of the disorders is duplicative or overlapping with the symptomatology of the other disorder. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). However, 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 do not lend themselves to distinct and separate disability evaluations without violating the rule against pyramiding. 38 C.F.R. § 4.113. Ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such evaluation. 38 C.F.R. § 4.114. IBS is rated as analogous to irritable colon syndrome (spastic colitis, mucous colitis, etc.) under DC 7319. GERD is rated as analogous to hiatal hernia. See 38 C.F.R. § 4.20. Therefore, it must be reiterated that even if the Board could find that the Veteran had a formal diagnosis of GERD, the prohibition against pyramiding would not allow for consideration of a separate grant of service connection. 38 C.F.R. § 4.14. The existence of a current disability is the cornerstone of a claim for VA disability compensation, and without a current diagnosis, service connection for GERD is not warranted. 38 U.S.C.§ 1110; see also Brammer, supra. As there is no diagnosed disease or disability to which the gastrointestinal symptoms have been attributed, service connection cannot be established for GERD. The claim is denied. Testosterone disorder and skin conditions The Veteran seeks service connection for a low testosterone condition and skin conditions. At the outset, the Board notes that throughout the claim, the Veteran has provided no information concerning a theory of entitlement for service connection for either disability. Thus, the Board will consider generally whether the evidence supports a finding of service connection. VA treatment records for the appeal period show that the Veteran has been diagnosed with hypogonadism, which he has treated throughout the appeal period with weekly testosterone injections. He has also been diagnosed with dermatitis and paresthesia. The record does not contain a medical opinion concerning the cause of any of these conditions, however. The Veteran also has not asserted that he sustained any injury or incident in service to which he believes his hypogonadism or skin conditions are related. Indeed, other than applying for service connection for what was initially characterized as a "disorder of testosterone" and "skin conditions," the Veteran has provided no information regarding the specifics of his claims and the evidence does not otherwise in any way suggest that these conditions may be attributable to service. Even if the Board considered the Veteran's application for service connection as a statement that there is a service-based reason for the conditions, there is no evidence that the Veteran has expertise or training in determining the cause of hypogonadism or dermatological disorders. Whether lay nexus evidence is competent evidence cannot be determined categorically. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Rather, such a determination depends on the facts of the case. See Jandreau, supra; Layno, supra. Here, whether his diagnosed hypogonadism and skin conditions are due to service is not determinable by observation with the five senses and is not within the realm of knowledge of a lay person. Such a determination requires medical expertise and knowledge. Consequently, the Board finds that the Veteran's assertions are not competent evidence. In short, there is no basis upon which to conclude that the Veteran's hypogonadism or skin conditions are in any way directly attributable to his military service. The Veteran has not indicated any specific event or injury in service to which he attributes the conditions and the record as it stands contains no indication of any link between such. To the extent that Board can infer a claim that the Veteran's testosterone levels or skin conditions are due to his service in Southwest Asia, the medical evidence shows that the Veteran's low testosterone levels have been attributed to a known clinical diagnosis, specifically hypogonadism, and his skin is due to dermatitis and paresthesia. Accordingly, service connection under 38 C.F.R. § 3.317 is not permitted as a matter of law. Thus, in light of the Veteran's own statements and the medical evidence of record, there is no basis to establish service connection, as two crucial elements of service connection have not been shown for either claim. See Davidson, supra (service connection requires evidence of in-service incurrence or aggravation of a disease or injury and a nexus between the claimed in-service disease or injury and the present disability). The preponderance of evidence is therefore against a finding of service connection, and there is no reasonable doubt to be resolved in this case. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. The claims are denied. REASONS FOR REMAND Service connection neck condition Service connection TBI The Veteran asserts that he was a passenger in a personnel carrier which crashed into a ditch while he was service in Saudi Arabia. He indicated that he was thrown from the vehicle, landing on his head. His attorney indicated at the August 2021 hearing that the Veteran lost consciousness as a result of the accident. The Veteran contends that this accident caused him to develop a neck condition, manifested as arthritis, and a TBI. There is no record of the accident, or treatment for such injuries, in the Veteran's service treatment or personnel records, nor is there any mention of the accident in recent post-service treatment records. However, the Veteran has submitted a statement from the driver of the carrier, describing the accident and indicating that the Veteran was a passenger. Thus, the Board finds that this lay evidence is sufficient to trigger VA's duty to assist the Veteran by providing him an examination and nexus opinion. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Service connection - neurological disorder The Veteran contends that he developed neurological symptomology due to his service in Southwest Asia. Specifically, he described developing numbness in his arms and down one of his legs. Despite surgery to the nerves on his arms, the symptoms persisted. He also described weakness in his extremities, sometimes to the point that he is unable to use his arms. The Board notes that the Veteran has been granted service connection for fibromyalgia; however, it lacks the skill and ability to parse symptoms and determine a relationship, if any, between the Veteran's reported symptomology and any diagnosed, service-connected disabilities. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). The Board notes that neurological signs or symptoms may be manifestations of an undiagnosed illness or a MUCMI. 38 C.F.R. § 3.317. As established supra, the Veteran served in Southwest Asia. Therefore, it finds that the low evidentiary threshold of McLendon, supra, has arguably been met, warranting a VA examination. Service connection for a respiratory condition, claimed as allergies The Veteran has asserted that he has an allergy disorder that is due to his military service. Review of the evidence shows a May 2016 VA treatment note in which he was diagnosed with rhinitis. See Romanowsky, supra. As the Board has granted service connection for sinusitis, above, and there is a suggestion from the record that an additional respiratory condition is present, it finds that further examination is warranted. Specifically, an examination is needed to determine if the Veteran has a respiratory condition, other than sinusitis, for which service connection is warranted. Further, a medical opinion is needed to address whether or not the Veteran has a respiratory condition which is caused by or aggravated by his service-connected sinusitis. Increased disability rating PTSD Increased disability rating Fibromyalgia Increased disability rating Headaches The Board observes that the issue of an increased disability rating for the Veteran's PTSD, fibromyalgia and headaches were each was last adjudicated in statements of the case (SOC) issued in February 2019. Since the issuance of the SOC, and certification of the appeal to the Board, new evidence pertinent to the claims has been added to the record without a waiver of agency of original jurisdiction (AOJ) consideration. Specifically, in November 2021 the Veteran underwent examinations in relation to his service-connected PTSD, fibromyalgia and headaches. Therefore, remand is necessary for the AOJ to consider the additional evidence in the first instance. See 38 C.F.R. §§ 19.31, 19.37(a). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of any neck disorder. The examiner should review the record and perform any tests deemed necessary. Following such, the examiner is asked to identify all current diagnoses related to the Veteran's neck. Then, in regard to each, the examiner is asked to address whether it is at least as likely as not (i.e., a 50 percent probability or greater) that each diagnosed neck condition is caused by, or related to, the Veteran's period of active service? In so doing, the examiner is asked to specifically consider and discuss the Veteran's assertions that he was involved in a motor vehicle accident that caused him to suffer a head and neck injury in service. All findings should be reported in detail and all opinions must be accompanied by a clear rationale. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's claimed TBI. The examiner should review the record and perform any tests deemed necessary. Following such, the selected examiner is asked to address the following: a) Does the Veteran currently, or at any time during the course of the appeal, manifested residuals of TBI? b) If the answer to (a) is yes, is it at least as likely as not that any diagnosed TBI is etiologically related to the Veteran's service? In answering this question, the examiner must specifically address the Veteran's assertions that he was involved in a motor vehicle accident that caused him to suffer a head and neck injury in service. All findings should be reported in detail and all opinions must be accompanied by a clear rationale. 3. Schedule the Veteran for an examination to determine whether any current neurological symptomology is related to service. The clinician must opine whether any neurological symptoms experienced by the Veteran are a manifestation of an identifiable disability. If so, the clinician must identify the disability and opine as to whether the disability at least as likely as not: a) began during active service; b) manifested within one year after separation from service (in the case of any currently diagnosed arthritis or organic disease of the nervous system); c) is related to an injury or disease during service; d) is caused by service-connected fibromyalgia; or e) is aggravated by service-connected fibromyalgia. If any symptoms are not a manifestation of an identifiable disability, the examiner must opine whether the symptom at least as likely as not represents an objective indication of chronic disability resulting from an undiagnosed illness related to service in Southwest Asia or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms. If so, the clinician should also describe the extent to which the illness has manifested. All findings should be reported in detail and all opinions must be accompanied by a clear rationale. 4. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his claimed respiratory condition (other than sinusitis), claimed as allergies. The examiner should review the record and perform any tests deemed necessary. Following such, the selected examiner is asked to address the following: a) Does the Veteran have a current diagnosis of a respiratory condition, other than service-connected sinusitis, to include rhinitis or an allergy disorder? b) If so, is it at least as likely as not (i.e., a 50 percent probability or greater) that the Veteran's respiratory condition is caused by, proximately due to, or the result of his service-connected sinusitis? c) If so, is it at least as likely as not that the Veteran's respiratory condition is aggravated by or worsened by his service-connected sinusitis? All findings should be reported in detail and all opinions must be accompanied by a clear rationale. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jeremy J. Olsen, 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.