Citation Nr: 21007318 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 16-63 045 DATE: February 9, 2021 REMANDED Entitlement to service connection for chronic fatigue syndrome, to include as due to an undiagnosed illness attributable to service in the Southwest Asia theater of operations, is remanded. Entitlement to service connection for narcolepsy, to include as due to an undiagnosed illness attributable to service in the Southwest Asia theater of operations, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1976 to June 1979 and from January 1991 to June 1991, to include service in the Southwest Asia theater of operations during the Gulf War Era. 1. Entitlement to service connection for chronic fatigue syndrome The Veteran contends that he has chronic fatigue syndrome that is directly attributable to his service, to specifically include his exposure to hazardous chemical agents while service in the Southwest Asia theater of operations during the Gulf War Era. In the alternative, he contends that his chronic fatigue symptomatology is secondary to his service-connected post-traumatic stress disorder (PTSD). As a second alternative, he also asserts that his daytime somnolence and fatigue symptomatology are manifestations of an undiagnosed illness attributable to his service in the Southwest Asia theater of operations. The Veteran underwent a VA examination in June 2015 to evaluate the nature and likely etiology of the claimed chronic fatigue syndrome, during which the VA examiner declined to endorse a diagnosis, instead attributing the Veteran’s symptomatology to his diagnosed sleep apnea and narcolepsy. In a corresponding Gulf War disease examination, also in June 2015, the examiner again stated that the Veteran’s chronic fatigue symptomatology was attributable to one or both of either sleep apnea or narcolepsy. Regarding the sleep apnea, the examiner stated that this was likely attributable to weight gain that occurred after the Veteran’s discharge from service. In summation, since the Veteran’s symptomatology was wholly attributable to a diagnosable condition, the examiner did not find that the Gulf War presumption applied to allow for service connection. The Board cannot rely on these examinations and opinion for a variety of reasons. To begin, the Veteran asserted during the December 2020 hearing that his chronic fatigue symptomatology continued after he underwent gastric bypass surgery and lost a significant amount of weight, which is counter to the June 2015 VA examiner’s conclusion that the Veteran’s fatigue symptoms were attributable to sleep apnea which in turn was attributable to weight gain. Moreover, recent VA medical records dating from 2018 and 2019 reflect that the Veteran’s daytime fatigue and somnolence persist despite his use of a chronic positive airway pressure (CPAP) machine nightly. Those records also cast doubt on the prior diagnosis of narcolepsy. In addition, the Veteran has submitted a November 2017 evaluation by a J.C., a physician’s assistant who appears to have been treating him through the VA medical system, within which a diagnosis of chronic fatigue syndrome was endorsed. Finally, the Veteran has raised the possibility that his weight gain, which in turn possibility led to his sleep apnea and his fatigue symptomatology, is attributable to his service-connected PTSD. The June 2015 examination does not address this theory of entitlement whatsoever. On remand, the Veteran should be afforded a new VA examination to clarify these matters. 2. Entitlement to service connection for narcolepsy The Veteran contends that his narcolepsy is directly attributable to his service. He underwent a June 2015 VA narcolepsy examination, during which the diagnosis of narcolepsy was confirmed; however, the VA examiner did not set forth any opinion as to whether the diagnosed narcolepsy was incurred in or otherwise attributable to service. In the corresponding June 2015 VA Gulf War examination, the examiner also did not set forth any opinion as to the likely etiology of the claimed narcolepsy condition. As such, on remand, after a thorough examination to determine the proper diagnosis or diagnoses that account for the Veteran’s daytime somnolence and fatigue symptoms, if a diagnosis of narcolepsy is still appropriate, the chosen VA examiner must opine as to the likelihood that the narcolepsy is attributable to service, to include as due to the Veteran’s exposure to hazardous chemical agents during his service in the Southwest Asia theater of operations. The matters are REMANDED for the following action: Schedule the Veteran for a VA medical examination to evaluate the nature and likely etiology of his claimed narcolepsy and chronic fatigue syndrome conditions. The electronic claims file and any other information deemed pertinent must be provided to and reviewed by the examiner, who must address the following matters: A) First, please determine whether there is a diagnosable disability and/or disabilities to account for the Veteran’s reported daytime somnolence and chronic fatigue symptomatology. The examiner is specifically asked to identify whether the Veteran has diagnosable narcolepsy. Furthermore, regardless of whether narcolepsy is deemed to be diagnosable, the examiner must also identify whether the Veteran has chronic fatigue syndrome that is a distinct disease pattern or whether the Veteran’s documented daytime fatigue is a symptom of other diagnosed disabilities (namely, obstructive sleep apnea and/or narcolepsy). If a diagnosis of narcolepsy and/or chronic fatigue syndrome is deemed inappropriate, the examiner must provide a thorough rationale to support such a conclusion with an explicit discussion of the medical evidence in support of both diagnoses, that is, the long-standing history of diagnosis and treatment for narcolepsy as well as the November 2017 disability benefits questionnaire which included a diagnosis of chronic fatigue syndrome. B) If a diagnosable condition (known clinical diagnosis) is identified that accounts for some or all of this symptomatology, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that any such diagnosed condition or conditions (to specifically include narcolepsy and/or chronic fatigue syndrome) is/are: 1) etiologically related to the Veteran’s service, to include as due to exposure to hazardous materials while serving in the Southwest Asia theater of operations; or 2) caused or aggravated by PTSD, or weight gain therefrom. C) If a diagnosable condition is not appropriate to account for any or all of the daytime somnolence or chronic fatigue symptoms detailed by the Veteran, please note whether the Veteran has a medically unexplained chronic multisymptom illness corresponding to those symptoms detailed by the Veteran for which there is no diagnosable condition that accounts for that symptomatology. D) Furthermore, if the answer to (C) is negative for any or all of these symptoms, please describe whether any of the symptoms were chronic in nature since service and thus would constitute a qualifying chronic disability under 38 C.F.R. § 3.317(a)(2)(i)(B). If this question is answered in the negative, an explanation for this determination is needed. If this question is answered in the positive, please address the possible etiologies of such chronic disability. If a chronic disability is found to be attributable to a supervening condition or event that occurred between the Veteran’s departure from active duty in the Southwest Asia theater of operations and the onset of the illness, the examiner should so state. The examiner must provide any and all opinions as to etiology in the form of a probability and must provide a complete rationale for any opinion expressed. The Board recognizes the practical difficulties of scheduling an examination in view of the COVID-19 epidemic, and requests flexibility and understanding in affording the Veteran an opportunity to report for an examination. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher M. Collins, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.