Citation Nr: 21010606 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 19-20 167 DATE: February 25, 2021 ORDER Entitlement to a disability rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) and persistent depressive disorder, is granted. Entitlement to a compensable disability rating prior to June 19, 2019, for migraine and tension headaches is denied. Entitlement to a disability rating in excess of 30 percent from June 19, 2019, to October 26, 2020, for migraine and tension headaches is denied. Entitlement to a disability rating of 50 percent for migraine and tension headaches is granted from October 26, 2020. Entitlement to an effective date prior to July 23, 2018, for the grant of service connection for periodic limb movement sleep disorder (PLMSD) is denied. REMANDED Entitlement to service connection for chronic fatigue syndrome (CFS), to include as due to exposure to environmental hazards, a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected PTSD and persistent depressive disorder, is remanded. Entitlement to an initial compensable disability rating for PLMSD is remanded. FINDINGS OF FACT 1. The severity, frequency, and duration of the Veteran’s PTSD and persistent depressive disorder symptoms more closely approximate occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking or mood, but do not more closely approximate total occupational and social impairment. 2. Prior to June 19, 2019, the Veteran’s migraine and tension headaches did not manifest with characteristic prostrating attacks averaging one in 2 months over last several months. 3. From June 19, 2019, to October 26, 2020, the Veteran’s migraine and tension headaches did not manifest with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 4. Beginning on October 26, 2020, the Veteran’s migraine and tension headaches manifest with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 5. There is no legal or factual basis for the assignment of an earlier effective date for the grant of service connection for PLMSD. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 70 percent, but no higher, for PTSD and persistent depressive disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. Prior to June 19, 2019, the criteria for a compensable rating for migraine and tension headaches were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.31, 4.124(a), Diagnostic Code 8100. 3. From June 19, 2019, to October 26, 2020, the criteria for a rating in excess of 30 percent for migraine and tension headaches were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.31, 4.124(a), Diagnostic Code 8100. 4. From October 26, 2020, the criteria for a 50 percent disability rating for migraine and tension headaches have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.31, 4.124(a), Diagnostic Code 8100. 5. The criteria for an effective date prior to July 23, 2018, for the grant of service connection for PLMSD have not been met. 38 U.S.C. §§ 5107, 5110, 5121; 38 C.F.R. §§ 3.102, 3.151, 3.155, 3.160, 3.400, 3.816(c), 3.1000. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from November 1994 to August 2015, to include service in the Southwest Asia in the Persian Gulf War. As such, exposure to the hazardous environment associated with the Veteran’s service has been acknowledged by the VA. These matters come before the Board on appeal from a September 2018 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) which denied the issues of entitlement to service connection for CFS and OSA, continued a 50 percent disability rating for PTSD and persistent depressive disorder and a noncompensable evaluation for migraine and tension headaches, and granted service connection for PLMSD as noncompensable from July 23, 2018. The Veteran filed a Notice of Disagreement in April 2019. Subsequently, in a July 2019 rating decision, the RO increased the Veteran’s disability rating for his service-connected migraine and tension headaches to 30 percent from June 19, 2019. A Statement of the Case was issued in July 2019 and the Veteran filed a VA Form-9 in July 2019 and elected not to appear before the Board for an optional hearing. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.1. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board notes that the Veteran is appealing the initial assignment of a disability rating, and as such, the severity of the disability is to be considered during the entire period from the initial assignment of the evaluation to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). 1. Entitlement to a disability rating in excess of 50 percent for PTSD with persistent depressive disorder The Veteran contends that his psychiatric disability is more severe than what is represented by a 50 percent rating. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher. The Board concludes that the Veteran’s symptoms more closely approximate the symptoms associated with a 70 percent rating, but no higher, and result in a level of impairment that most closely approximates the level of impairment associated with a 70 percent rating. A 50 percent rating for PTSD with persistent depressive disorder is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. VA and private treatment records, VA and private examinations, and lay statements from the Veteran show that the Veteran’s psychiatric disability is manifested by symptoms associated with a 70 percent rating such as suicidal ideation, near-continuous panic or depression affecting the ability to function independently, neglect of personal appearance and hygiene, and inability to establish and maintain effective relationships. He also had symptoms that are not listed with a specific rating, such as hypervigilance. The Board finds the severity, frequency, and duration of the Veteran’s unlisted symptoms more closely approximate the symptoms contemplated by a 70 percent rating, but no higher. The symptoms for a 70 percent rating are less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. The level of impairment caused by the Veteran’s symptoms most closely approximates the level associated with a 70 percent rating. The Veteran experienced occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. Mental status examinations and medical treatment records indicate that the Veteran had mental health symptoms that are moderate to severe in nature and result in moderate to severe functional impairment. His quality of life is significantly lowered by his symptoms and his social functioning is negatively impacted. The Veteran’s condition impairs his ability to interact socially with others, including his friends and family members. The Veteran’s symptoms of depression have led to his lack of motivation and low energy, making it difficult for him to engage in daily living. His irritability and depressed mood have led his friends and family members to avoid him, resulting in his social isolation. The Veteran has also reported a loss of intimacy with his wife. His lack of motivation has resulted in his inability to maintain minimal personal hygiene. The Veteran also reported a decreased appetite. See October 2020 private examination. The Veteran expressed suicidal ideation, which is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran’s suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. The Veteran reports having thoughts of being better off dead and such passive ideation, though indicative of the severity of his depression, does not represent a persistent danger to himself or others. Further, the Veteran regularly denied thoughts, intent, or a plan involving self-harm in existing treatment records, and the September 2018 and June 2019 VA examinations. Although the evidence of record shows that the Veteran is socially impaired, he is not totally occupationally impaired. At the June 2019 VA examination, the Veteran reported that he is still working full time and he gets along with the people at work. He also reported working at his friend’s automotive shop part time. Accordingly, the Board finds that the requirements for a disability rating of 70 percent, but no higher, are met based on the symptoms manifested by the Veteran’s PTSD and persistent depressive disorder. 2. Entitlement to a compensable disability rating for migraine and tension headaches prior to June 19, 2019, and in excess of 30 percent thereafter The Veteran contends that his service-connected migraine and tension headaches are more severe than what is represented by the current ratings. The Veteran’s migraine and tension headaches are currently rated under 38 C.F.R. § 4.124(a), Diagnostic Code 8100. Diagnostic Code 8100 provides for a 50 percent rating for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124(a), General Rating Formula for Miscellaneous Diseases. A rating of 30 percent is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over last several months. Id. A rating of 10 percent is warranted for migraines with characteristic prostrating attacks averaging one in 2 months over last several months. Id. The rating criteria do not define “prostrating,” nor has the Court. See Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quotes DC 8100 verbatim but does not specifically address the matter of what is a prostrating attack). By way of reference, according to Webster’s New World Dictionary of American English, 3rd Col. Ed. (1986) “prostration” is defined as “utter physical exhaustion or helplessness.” A very similar definition is found in Dorland’s Illustrated Medical Dictionary 1367 (28th ed. 1994) in which “prostration” is defined as “extreme exhaustion or powerlessness.” The Veteran was provided with a VA headache examination in September 2018 where the Veteran reported severe headaches a minimum of five times a week. These headaches resulted in pain and sensitivity to light and noise. It was noted that they impaired the Veteran’s focus, concentration and ability to drive and that he has missed between “0-1 week” of work over the past 12 months due to his headaches. The examiner noted that these were not characteristic prostrating attacks of migraine/non-migraine headache pain. The Veteran did not have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability. The Veteran was provided with another VA headache examination in June 2019 where he reported migraines twice a week. He reported taking cambia, which works in about an hour and if that does not resolve his migraine, he stated that he would have to leave work. This would happen approximately once a year. The VA examiner noted that “this is very infrequent,” and “does not affect his work.” The Veteran reported that his headaches last more than two days, but they are not constant any longer. The examiner noted that the Veteran had characteristic prostrating attacks of headache pain once every month, but it was not productive of severe economic inadaptability. In a September 2020 statement, the Veteran stated that his headaches have increased in severity, noting that he experiences “headaches probably every other day on average, and once they start, they tend to last for the rest of the day.” The Veteran added that about “once per week, I will need to be in a dark room due to my light sensitivity.” He reported that “there have been times that I’ve had this type of headache while I’m at work and I’ll have to leave early.” The Veteran submitted an October 2020 private psychological assessment noting that the Veteran has nonstop headaches. The psychologist noted that the Veteran had visual issues with his headaches. The psychologist added that “the constant pain from his headaches prevents him from engaging with others,” and that “his migraines with vision changes also make it difficult for him to drive.” The Veteran’s headaches were noted to “have increased in severity over the years,” with the Veteran reporting “headaches every other day on average that tend to last for the entire day once they start.” He was noted to need to “be in a dark room about once per week as a result.” The Veteran reported that his headaches “interfere with his ability to drive,” and “about once a day, he experiences episodes where his vision ‘blurs out’ for about 20-60 seconds.” The psychologist found that the Veteran’s migraine and tension headaches “cause very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability,” from July 2017 to the present. She added that the Veteran “has almost unremitting pain with headaches occurring, at a minimum, five times a week.” Additionally, “about two times per week, he will need to lie down in a dark room due to light sensitivity.” She added that she disagreed with the September 2018 and June 2019 DBQs that found that the Veteran’s headaches did not produce economic inadaptability. For the period prior to June 19, 2019, the Board finds that the Veteran’s headaches were not manifested by prostrating attacks. Although the Veteran reported constant headaches, they have not been shown by the record to be prostrating. During this period the Veteran’s headaches impaired his concentration, focus, and ability to drive, but there is no indication that he had to retreat to a dark room or lay down. During this time period he missed between 0-1 week of work over the past 12 months. The Board agrees with the September 2018 VA examiner who found no characteristic prostrating attacks of the Veteran’s migraine and tension headaches; the Board finds that the noncompensable rating is appropriate for the period prior to June 19, 2019. From June 19, 2019, to October 26, 2020, the Board finds that the Veteran’s prostrating attacks were not productive of severe economic inadaptability. Although the June 2019 VA examination indicated that the Veteran had prostrating attacks occur once every month and the Veteran reported that his headaches last more than two days, he also reported that they were no longer constant. Additionally, the June 2019 examiner specifically noted that the Veteran’s disability was not productive of severe economic inadaptability as he would only need to leave work about once a year, therefore not affecting his work. From October 26, 2020, the Board finds that the Veteran’s prostrating attacks were productive of severe economic inadaptability. The private psychologist that completed the October 2020 examination report noted that the Veteran’s migraines and tension headaches had increased in severity and occurred every other day. Further, this resulted in the Veteran needing to lie in a dark room about once a week, resulting in severe economic inadaptability. As such, the Board finds that a 50 percent rating is warranted from the date of the private examination report finding that the Veteran’s disability was productive of severe economic inadaptability. A 50 percent rating is the maximum rating allowed under Diagnostic Code 8100. The Board is cognizant that the October 2020 private psychologist opined that the Veteran’s migraine and tension headaches resulted in severe economic inadaptability from July 2017 to the present. However, the Board finds the contemporaneous medical evidence of record to be more probative on this point. The Board notes that the September 2018 examiner found no characteristic prostrating attacks, thus, the issue of economic inadaptability would not have warranted an increased rating. Additionally, the June 2019 examiner specifically found that the Veteran’s disability did not result in severe economic inadaptability and noted that his job was not affected. He was noted to need to leave work very infrequently, about once a year. As the June 2019 examiner provided an explanation supporting her opinion, the Board finds this examination report to be more probative than the October 2020 examination report. The Board is aware that the evidence has varied regarding the Veteran’s migraines and tension headaches throughout the period on appeal. However, the Veteran has stated numerous times that his disability has worsened over the years since his separation from service. As such, the Board finds that the staged ratings accurately reflect the timeline of any worsening of the Veteran’s disability. Accordingly, the Board finds that a noncompensable rating prior to June 19, 2019, a rating of 30 percent from June 19, 2019 to October 26, 2020, and a rating of 50 percent thereafter adequately compensates the Veteran for his symptoms related to his service-connected migraine and tension headaches under Diagnostic Code 8100. Additionally, the Board finds no other applicable diagnostic codes that would afford the Veteran a higher disability rating. Earlier Effective Date Except as otherwise provided, the effective date of an evaluation and award of pension, compensation or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. See 38 U.S.C. § 5110; 38 C.F.R. § 3.400. An exception to that rule provides that the effective date of an award of an increase shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if the application is received within one year from such date. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). 3. Entitlement to an effective date prior to July 23, 2018, for the grant of service connection for PLMSD The Veteran contends that he should be granted an earlier effective date than July 23, 2018, for the award of service connection for his PLMSD. The Veteran filed a claim for bilateral periodic limb movements on July 23, 2018. In September 2018, the RO granted service connection for PLMSD with a noncompensable evaluation effective July 23, 2018, the date of his claim. The Board has thoroughly reviewed the evidence of record to determine if the Veteran filed a claim, an informal claim, or expressed a written intent to file a claim for PLMSD prior to July 23, 2018. However, the Board can find no evidence that there was a pending, unadjudicated claim for service connection prior to July 23, 2018. See Servello v. Derwinski, 3 Vet. App. 196, 198-200 (1992). A specific claim must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA. See 38 C.F.R. § 3.151(a). The Veteran has also not pointed to any communication or document that could serve as an earlier, unadjudicated claim for benefits regarding his PLMSD. Having determined that the Veteran’s only claim for PLMSD was filed on July 23, 2018, the Board must now determine when entitlement to service connection arose. As noted above, an effective date is assigned based on the date of the receipt of a claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400. Thus, even if the Veteran had PLMSD that was linked to his service prior to the date of his claim, his July 2018 claim is clearly the later of two dates specified by law. Hence, on this record, an earlier effective date is not assignable by law. The Board acknowledges that the Veteran’s claim regarding an increased rating for his PLMSD is being remanded, in part, to obtain an addendum medical opinion. However, the issue of an earlier effective date for the award of service connection for the Veteran’s PLMSD is not intertwined with the issue being remanded. Any additional development regarding the Veteran’s increased rating claim would not affect the Veteran’s effective date for the award of service connection for his PLMSD. Therefore, the Board finds no prejudice to the Veteran in proceeding with a decision on this claim. In sum, the Board finds that that an earlier effective date than July 23, 2018, for the grant of service connection for PLMSD is not warranted here. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim and his appeal must be denied. REASONS FOR REMAND 1. Entitlement to service connection for chronic fatigue syndrome (CFS), to include as due to exposure to environmental hazards, a qualifying chronic disability under 38 C.F.R. § 3.317 The Veteran contends that he suffers from a qualifying chronic disability, to include CFS, as a result of his service in the Persian Gulf War. As noted above, the Veteran’s exposure to the hazardous environment associated with service in Southwest Asia has been acknowledged by the VA. The Veteran’s service treatment records show that he was treated for insomnia in May 2004. In August 2014, he reported constant fatigue for several years. In September 2014, he reported feeling tired. In December 2014, he reported having problems with unrestful sleep. On his May 2015 Report of Medical History, he reported frequent trouble sleeping. The Veteran was provided with a VA CFS examination in September 2018 where he reported “that after his last deployment in 2007 he began feeling tired and sleepy all the time.” The VA examiner noted treatment in the Veteran’s service treatment records for symptoms of fatigue in September 2006, November 2007, March 2009, and August 2014. However, the examiner found that this “was shown to be associated with related mental disorders including PTSD and related medication use.” She found that the Veteran did not have a diagnosis for CFS. The examiner added that “the Veteran has claimed a disability pattern related to PTSD with related mental health disorder and medication use, that meets TL10-01 criteria for a disease with clear and specific etiology and diagnosis.” The examiner opined that this was “less likely than not caused by or related to GW environmental exposure.” She added that “the noted fatigue is a symptom that is a part and parcel of PTSD which is also associated with multiple mental health disorders/symptoms,” noting that “the treatment for same also causes that noted symptom of fatigue.” The Veteran was provided with a VA Gulf War examination in September 2018 where the VA examiner found no diagnosed illness with no etiology. However, the examiner noted that the Veteran had additional signs and/or symptoms that may represent an undiagnosed illness or diagnosed medically unexplained multi-symptom illness, noting the symptom of fatigue. The Board finds that the issue should be remanded for the Veteran to be provided with a new VA Gulf War examination in order to consider the Veteran’s cluster of symptoms, including fatigue, neurological symptoms, respiratory symptoms, and sleep disturbances and opine whether this could warrant service connection under the presumption of an undiagnosed illness or medically unexplained chronic multi-symptoms illness for Persian Gulf Veterans. See 38 C.F.R. § 3.317(b) (listing fatigue, headaches, neurological signs or symptoms, signs or symptoms involving the respiratory system, and sleep disturbances and sleep disturbances as symptoms that can be manifestations of an undiagnosed illness).” The examiner should also consider the Veteran’s treatment while in service for insomnia, fatigue, and unrestful sleep. 2. Entitlement to service connection for OSA, to include as secondary to service-connected PTSD and persistent depressive disorder The Veteran contends that he suffers from OSA as a result of exposure to burn pits while serving in the Persian Gulf War. In the alternative, the Veteran contends that his OSA is secondary to his service-connected psychiatric disability. The Veteran’s service treatment records show that in August 2014, he reported that his wife has woken him up in the past because she thought that he was not breathing. At the time, he was unsure if he snored. A sleep study in September 2014 did not show any evidence of sleep disordered breathing but diagnosed the Veteran with PLMSD. On an undated Berlin Sleep Questionnaire, the Veteran reported that he noticed he quit breathing during his sleep. He also reported feeling fatigue every day. The Veteran’s post-service treatment records include private treatment records from March 2018 indicating a diagnosis of OSA following a home sleep study. The Veteran was provided with a Sleep Apnea DBQ in September 2018 where he was noted to have a diagnosis for OSA. The VA examiner opined that the Veteran’s OSA was less likely than not due to his service because “no sleep study documenting diagnosis of mild sleep apnea during service was found.” The examiner added that the sleep study in service found “no sleep disordered breathing condition.” In January 2021, the Veteran, through his representative, argued that his OSA is secondary to his service-connected psychiatric disability. In support of his claim, the Veteran submitted articles indicating a relationship between psychiatric illness and OSA. As such, the Board finds that an addendum medical opinion is required prior to adjudication of this issue. The opinion should address whether the Veteran’s OSA is secondary to his psychiatric disability, to include a discussion of the articles submitted by the Veteran in January 2021. Additionally, the addendum opinion should address the Veteran’s reports of stopped breathing while sleeping in service and opine whether this was an early symptom of OSA. 3. Entitlement to an initial compensable disability rating for PLMSD The Veteran contends that his service connected PLMSD is more severe than what is represented by a noncompensable rating. In this case, the Veteran’s PLMSD is currently assigned a noncompensable (zero percent) evaluation pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8199-8103. Hyphenated Diagnostic Codes are used when a rating under one Diagnostic Code requires the use of an additional Diagnostic Code to identify the basis for the rating assigned. See 38 C.F.R. § 4.27. An unlisted disease, injury, or residual condition is rated by analogy with the first two digits selected from that part of the rating schedule that most closely identifies the part or system of the body involved; the last two digits will be “99” for all unlisted conditions. The Veteran’s PLMSD is rated by analogy as a compulsive tic under 38 C.F.R. § 4.124a, Diagnostic Code 8103. A mild tic is rated at 0 percent, a moderate tic is rated at 10 percent, and a severe tic is rated at 30 percent. The Note to Diagnostic Code 8103 directs the Board to assign a disability rating depending upon the frequency, severity, and muscle groups involved. The Veteran was provided with a Central Nervous System and Neuromuscular Diseases Disability Benefits Questionnaire (DBQ) in September 2018 where he reported “poor quality of sleep related in part to frequent episodes of limb movement while sleeping.” The Veteran’s wife reported that the “Veteran is very active every night with episodes of moving all his limbs-legs more than arms.” The Veteran was noted to have persistent daytime hypersomnolence. The Board notes that the Veteran has been awarded service connection for PTSD and persistent depressive disorder, which includes symptoms of chronic sleep impairment. See September 2018 and June 2019 PTSD DBQs. Additionally, the Board notes that the Veteran has been diagnosed with OSA and he claims to have CFS. A September 2018 Sleep Apnea DBQ listed persistent daytime hypersomnolence as a symptom attributed to sleep apnea. The Board finds that the record is unclear as to whether the Veteran’s symptom of persistent daytime hypersomnolence is attributed to his PLMSD, PTSD and depressive disorder, OSA, or his claimed CFS. As such, an addendum medical opinion is required prior to adjudication of this issue. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA Gulf War General Medical Examination. Any studies, tests, or evaluations deemed necessary by the examiner should be performed. The examiner is requested to review the entire claims file, including this Remand in its entirety, paying particular attention to the Veteran’s statements pertaining to in-service experiences and symptoms made throughout the adjudication of his claim. The examiner must obtain a full history from the Veteran, which must be recorded in the report. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as observable symptomatology and in-service experiences. 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 Veteran has reported symptoms of fatigue, neurological symptoms, and respiratory symptoms, which he contends collectively constitute a qualifying chronic disability under 38 C.F.R. § 3.317. The examiner must evaluate the Veteran’s symptoms holistically in providing an opinion as to whether the Veteran’s clinical and disability picture as likely as not constitutes a qualifying chronic disability, i.e., a chronic disability resulting from any of or a combination of an undiagnosed illness or a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms. Once a complete list of symptoms is obtained, please correlate each symptom as appropriate to a diagnosis of a service-connected disability, diagnosis of a non-service-connected disability, or no diagnosis. Please identify those symptoms, if any, that serve to support more than one diagnosis. Based upon a review of the entire record, examination of the Veteran, and any additional medical evaluation undertaken, the examiner must provide opinions, responding to the following: (a) Are the Veteran’s symptoms and disability pattern collectively indicative of an undiagnosed illness? (b) Are the Veteran’s symptoms and disability pattern collectively attributable to a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms? (c) Are the Veteran’s symptoms and disability pattern collectively consistent with a diagnosable chronic multi-symptom illness with a partially explained etiology? (d) Are all the Veteran’s symptoms and disability pattern consistent with clear and specific etiologies? (e) If it is determined that the Veteran’s symptoms and disability pattern are manifestations of either (1) a diagnosable chronic multi-symptom illness with a partially explained etiology or (2) a disease with a clear and specific cause and diagnosis, then the examiner must provide an opinion as to whether it is as likely as not (50 percent or greater probability) that the disease or illness is proximately due to or aggravated by an in-service injury, event, or disease. In so opining, the examiner must discuss the Veteran’s service treatment records showing treatment for insomnia in May 2004, reports of fatigue for several years in August 2014, reports of feeling tired in September 2014, reports of having problems with unrestful sleep in December 2014, and frequent trouble sleeping in May 2015. For purposes of this examination, the examiner must consider the following: “Medically unexplained chronic multi-symptom illness” means a diagnosed illness without conclusive pathophysiology or cause that is characterized by overlapping signs and symptoms and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. “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 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. “Signs or symptoms” include, but are not limited to: fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper and lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and when applicable, menstrual disorders. A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The examiner should discuss the particulars of this Veteran’s medical history and the relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. 2. Obtain an addendum opinion from an appropriate clinician regarding the following: a) Is it at least as likely as not that the Veteran suffers from OSA that is related to any in-service disease, injury, or event, to include exposure to burn pits while serving in the Persian Gulf War? In so opining, the examiner must consider and discuss service treatment records from August 2014 indicating that the Veteran’s wife reported he would stop breathing in his sleep and the Berlin Sleep Questionnaire indicating that he would stop breathing during sleep. b) Is it at least as likely as not that the Veteran suffers from OSA that is (1) proximately due to his psychiatric disability or (2) is aggravated beyond its natural progression by his psychiatric disability? In so opining, the examiner must consider and discuss the articles submitted by the Veteran in January 2021 indicating that there is a relationship between psychiatric illnesses and OSA. A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The examiner should discuss the particulars of this Veteran’s medical history and the relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s symptom of persistent daily hypersomnolence is attributed to his PLMSD, PTSD and persistent depressive disorder, OSA or his claimed CFS. M. Donohue Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Morrad, 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.