Citation Nr: 21012016 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 16-36 443 DATE: March 3, 2021 ORDER Entitlement to service connection for chronic fatigue syndrome (CFS) is denied. REMANDED Entitlement to service connection for hypertension is remanded. FINDING OF FACT The weight of evidence is against finding that the Veteran has a current diagnosis of chronic fatigue syndrome. The evidence supports that such symptoms are attributable to the Veteran’s service-connected ischemic heart disease. CONCLUSION OF LAW The criteria for entitlement to service connection for chronic fatigue syndrome have not been met.  38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1963 to June 1967. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In March 2019, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of this hearing is of record. In September 2019 and June 2020, the Board remanded these issues for additional development. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). In order to establish entitlement to service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998).   Chronic Fatigue Syndrome The Veteran contends that he experiences chronic fatigue as secondary to medication prescribed to treat his service-connected ischemic heart disease. See March 2019 Board Hearing. For VA purposes, the diagnosis of CFS specifically requires: (1) new onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least six months; (2) the exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms; and (3) six or more of the following: acute onset of the condition; low grade fever; nonexudative pharyngitis; palpable or tender cervical or axillary lymph nodes; generalized muscle aches or weakness; fatigue lasting 24 hours or longer after exercise; headaches (of a type, severity, or pattern that is different from headaches in the pre-morbid state); migratory joint pains; neuropsychologic symptoms; sleep disturbance. See 38 C.F.R. § 4.88a. The Veteran was afforded a VA examination in November 2020. The examiner noted that the Veteran had reports of fatigue, joints pains, inadequate sleep, feelings of exhaustion, and difficulty concentrating. The examiner observed that the Veteran did not have an acute onset of CFS. The examiner indicated the Veteran had no treatment and that the Veteran’s primary care physician determined these symptoms were caused by blood pressure medicine and encouraged the Veteran to exercise more. The examiner opined that the Veteran’s had no CFS pathology because the CFS criteria was not met. Rather, the examiner concluded that the Veteran’s fatigue is due to his ischemic heart disease and his joint pain is due to gouty arthritis. The examiner further concluded that the Veteran’s CFS was less likely than not aggravated by medication taken to treat ischemic heart disease because the Veteran did not have a current or past diagnosis of CFS. The Board conducted a review of the Veteran’s medical records, which do not diagnose CFS. Rather, the Veteran’s treating cardiologist, Dr. C.D., who diagnosed the Veteran with heart disease, high blood pressure, stroke, arthritis, and tuberculosis, but did not diagnose the Veteran with CFS. Indeed, in an October 2019 note, Dr. E.D. writes that the Veteran is being treated for chronic fatigue and that the medication prescribed to him for his ischemic heart disease is the cause of his chronic fatigue. Notably, the Veteran’s physician did not diagnose him with CFS and attributed his fatigue symptoms to his prescribed medication to include nitroglycerine and losartan potassium. After a careful review of the evidence, the Board determines the Veteran does not have a current diagnosis of CFS, including for VA purposes, and has not had one at any time during the pendency of the claim. See Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). While there is evidence that the Veteran experiences fatigue, he does not have an established CFS diagnosis. The clinical findings in the medical records do not adequately establish a diagnosis of CFS. Further, the VA examination report from November 2020 indicated the Veteran’s symptoms do not fit with CFS. The Board assigns the VA examiner’s significant probative weight because its conclusions are consistent with the clinical findings of the Veteran’s treatment records that do not diagnose CFS but do diagnose CFS as a side effect of the Veteran’s heart disease medications. The Veteran is already service connected for ischemic heart disease. The Board takes note of the Veteran’s contentions and the severity of his symptoms, including fatigue and joint pain. Further, he is competent to testify as to his observations. However, establishing a diagnosis that meets the criteria of CFS is a complex medical question which falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Young v. McDonald, 766 F.3d 1348, 1353 (Fed. Cir. 2014). Moreover, the criteria for a diagnosis of CFS is expressly set forth by VA in the regulations. Therefore, the Veteran’s lay opinions as to a current diagnosis are afforded less probative weight than the November 2020 VA medical opinion. Accordingly, the preponderance of the evidence is against the claim of service connection for CFS. The current disability element of the claim is not established. Therefore, the benefit-of-the-doubt doctrine is not applicable and service connection for CFS is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND The Veteran contends that his hypertension is due to his active service or due to being proximately caused by his service-connected ischemic heart disease. The Board observes that the Veteran served at Royal Thai Airforce Bases during the Vietnam War Era, and herbicide exposure was conceded in a September 2019 Board decision. The National Academy of Sciences/Institute of Medicine (IOM) reports, Veterans and Agent Orange: Update 2006, 2008, 2010, 2012, and 2014, suggest that there is limited evidence of a relationship between hypertension and herbicide exposure. See also 75 Fed. Reg. 32,540, 32,549 (June 8, 2010). The IOM reports indicates there may be a nexus between currently diagnosed hypertension and the Veteran’s established herbicide exposure. Therefore, the Board finds that a remand is warranted to secure an adequate medical opinion addressing the relationship between the Veteran’s hypertension and in-service herbicide exposure. Further, the Board finds the November 2020 medical opinion regarding if the Veteran’s service-connected ischemic heart disease proximately caused his hypertension to be inadequate. The examiner’s rationale was simply this lack of association is “common medical knowledge” without further elaboration. A rationale must be provided in support of a medical opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that a medical opinion obtains probative weight from “factually accurate, fully articulated, sound reasoning for the conclusion”). Accordingly, the Board requests an addendum opinion addressing the etiology of the Veteran’s hypertension. The matters are REMANDED for the following action: 1. After performing any further development deemed appropriate, provide a supplemental medical opinion regarding the etiology of the Veteran’s hypertension. The need for another VA examination is left to the discretion of the examiner. After reviewing the claims file, the examiner should render an opinion regarding whether it is at least as likely as not (50 percent or more probability) that hypertension was caused OR aggravated by exposure to herbicide agent(s) during service. In rendering the opinion, the examiner is to specifically address the NAS Institute of Medicine’s Veteran’s and Agent Orange: Update. The examiner should also provide an opinion as to whether if it is at least as likely as not (50 or percent or more probability) that any currently diagnosed hypertension is caused OR aggravated by his service-connected ischemic heart disease. All opinions expressed by the examiner must be accompanied by a complete rationale. 2. After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran should be furnished a supplemental statement of the case and be afforded the opportunity to   respond. Thereafter, the case should be returned to the Board for appellate review, if in order. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Keogh, Associate 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.