Citation Nr: 21012683 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 14-39 128 DATE: March 4, 2021 ORDER Service connection for a lumbar spine disability, diagnosed as degenerative arthritis and a disc herniation, is granted. Service connection for bilateral hearing loss is granted. Service connection for tinnitus is granted. Service connection for a psychiatric disorder, diagnosed as an unspecified anxiety disorder and an unspecified depressive disorder, as secondary to service-connected fibromyalgia, is granted. REMANDED Entitlement to service connection for chronic fatigue syndrome, with all over joint pain, is remanded. Entitlement to service connection for a gastrointestinal disorder, to include acid reflux, is remanded. Entitlement to service connection for a respiratory disorder, to include emphysema, asthma, and bronchitis, is remanded. Entitlement to service connection for sinusitis is remanded. Entitlement to service connection for rhinitis is remanded. Entitlement to service connection for bilateral otitis media is remanded. Entitlement to an initial rating higher than 10 percent for a right ankle disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s lumbar spine disability, diagnosed as degenerative arthritis and a disc herniation, had its onset in service. 2. The Veteran’s bilateral hearing loss had its onset in service. 3. The Veteran’s tinnitus had its onset in service. 4. The Veteran’s psychiatric disorder, diagnosed as an unspecified anxiety disorder and an unspecified depressive disorder, is caused by his service-connected fibromyalgia. CONCLUSIONS OF LAW 1. The criteria for service connection for lumbar spine disability, diagnosed as degenerative arthritis and a disc herniation, have been met. 38 U.S.C. §§ 101(24), 1101, 1110, 1112, 1113, 1117, 1131, 1137, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.317. 2. The criteria for service connection for bilateral hearing loss have been met. 38 U.S.C. §§ 101(24), 1110, 1117, 1131, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.317, 3.385. 3. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 101(24), 1110, 1117, 1131, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.317, 3.385. 4. The criteria for service connection for a psychiatric disorder, diagnosed as an unspecified anxiety disorder and an unspecified depressive disorder, as secondary to service-connected fibromyalgia, have been met. 38 U.S.C. §§ 101(24), 1101, 1110, 1112, 1113, 1117, 1131, 1137, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from May 1986 to May 1989 and from September 1990 to April 1991, including service in Southwest Asia. He also apparently had service in the Army Reserve. This matter is before the Board of Veterans’ Appeals (Board) on appeal of April 2013, February 2014, and March 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. The April 2013 RO decision denied service connection for a lumbar spine disability (listed as degenerative disc disease); chronic fatigue syndrome, with all over joint pain (listed as chronic fatigue syndrome/all over joint pain); a gastrointestinal disorder, to include acid reflux (listed as acid reflux and a stomach condition); and for chronic diarrhea (listed as diarrhea). The February 2014 RO decision granted service connection and a noncompensable rating for a right ankle disability (right ankle arthritis, status post chronic sprains and an avulsion fracture), effective September 14, 2013. In July 2016, the Veteran appeared at a Board videoconference hearing before the undersigned Veterans Law Judge. The March 2017 RO decision denied service connection for a respiratory disorder, to include emphysema, asthma, and bronchitis (listed as emphysema, asthma, and bronchitis); sinusitis; rhinitis; bilateral hearing loss; tinnitus; and for bilateral otitis media. By this decision, the RO also denied service connection for a psychiatric disorder, to include PTSD, an anxiety disorder, and a depressive disorder (listed as PTSD, an unspecified anxiety disorder, and an unspecified depressive disorder). As there are multiple other psychiatric diagnoses of record, the Board finds that it is more appropriate to characterize the claim broadly as one of entitlement to service connection for a psychiatric disorder, to include PTSD, an anxiety disorder, and a depressive disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In September 2018, the Board remanded the issues of entitlement to service connection for a lumbar spine disability; chronic fatigue syndrome, with all over joint pain; a gastrointestinal disorder, to include acid reflux; chronic diarrhea; a respiratory disorder, to include emphysema, asthma, and bronchitis; sinusitis; rhinitis; bilateral hearing loss; tinnitus; bilateral otitis media; and for a psychiatric disorder, to include PTSD, an anxiety disorder, and a depressive disorder, as well as the issues of entitlement to an initial rating higher than 10 percent for a right ankle disability and entitlement to a TDIU, for further development. The Board notes that a February 2019 RO decision implemented a September 2018 Board decision (which granted an initial rating of at least 10 percent for a right ankle disability), and increased the rating for the Veteran’s service-connected right ankle disability to 10 percent, effective September 14, 3013. The RO incorrectly listed such grant as a full grant of benefits on appeal. In August 2019, the Veteran filed a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), on issues, including the issue of entitlement to an initial rating higher than 10 percent for a right ankle disability. The Board notes, however, that the partial grant of an initial 10 percent rating for a right ankle disability was not an initial decision, pursuant to 38 C.F.R § 19.2(b). Therefore, the issue of entitlement to an initial rating higher than 10 percent remains a legacy appealed issue, and is not properly addressed, pursuant to the Appeals Modernization Act (AMA). A September 2020 RO decision granted service connection and a noncompensable rating for irritable bowel syndrome. Therefore, the issue of entitlement to service connection for chronic diarrhea is no longer on appeal. 1. Lumbar Spine Disability Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). The term “active military, naval, or air service” includes active duty, any period of active duty for training during which the individual was disabled or died from a disease or injury incurred in or aggravated in the line of duty, and any period of inactive duty training during which the individual was disabled or died from an injury incurred in or aggravated in the line of duty. 38 U.S.C. § 101 (24). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA’s policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by an established service-connected disability. 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War, on or after August 2, 1990. 38 U.S.C. § 1110. Therefore, service connection may also be established under 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Under those provisions, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest 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. 38 C.F.R. § 3.317(a)(1). 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). This means that 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 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. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran’s demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also 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.”). The Veteran contends that he has a lumbar spine disability that is related to service. He specifically maintains that he was treated for low back problems during and since his periods service. The Veteran reports that he strained his low back in Korea in 1988 after doing some digging. He further contends that his lumbar spine disability is the result of his service in Southwest Asia and should be considered under the provisions of 38 C.F.R. § 3.317. The Veteran served on active duty in the Army from May 1986 to May 1989 and from September 1990 to April 1991, including service in Southwest Asia. He also apparently had service in the Army Reserve. The Veteran’s service treatment records for his first period of active duty from May 1986 to May 1989 show that he was treated for back problems. A May 1988 treatment entry notes that the Veteran had a chief complaint of low back pain. He reported that he was trimming a sidewalk with a shovel when he felt sharp pain in his lower back. The assessment was rule out muscle strain. A March 1989 treatment entry notes that the Veteran reported a chief complaint of a back injury one day earlier. He stated that he lifted heavy objects and that he suffered lower back pain on the right side and right side of the groin area. The examiner reported that the Veteran would be referred to a physician. A March 1989 treatment report, on that same day, notes that the Veteran reported a one-day history of low back pain that radiated to his right inguinal region and right scrotum. The assessment was musculoskeletal pain, with a referral for the right inguinal region. The Veteran’s service treatment records for his period of active duty from September 1990 to April 1991 also include a reference to low back problems on one occasion. On a medical history form at the time of a March 1991 separation examination, the Veteran checked that he had recurrent back pain. The reviewing examiner stated that the Veteran had a right ankle injury in 1986, but that he was otherwise healthy. The objective March 1991 separation examination report includes a notation that the Veteran’s spine, and other musculoskeletal systems, were normal. Post-service VA treatment records, including VA examination reports, show treatment for lumbar spine problems, including a lumbar disc herniation, and degenerative arthritis of the lumbar spine. A January 2013 VA 2013 VA back conditions examination report includes a notation that the Veteran’s claims file was reviewed. The Veteran reported that he had been treated for his lower back privately, and that he had suffered strains and pulls. It was noted that he did not report any specific injury during active duty, other than lumbar strain while digging in Korea. The Veteran stated that he suffered pulls and strains while working for the Heinze Company, and that he worked in general labor, with lifting and in the pack department for years. The diagnosis was a lumbar disc herniation. The examiner indicated that the degenerative changes found on the lumbar spine x-ray were most likely a biology of aging. The examiner stated that the Veteran was treated for osteopenia with Vitamin D supplementation, and that such, and the biology of aging, would not be secondary to his active service. The examiner maintained that the Veteran’s lumbar strain during service would have been muscular in nature, that it would not have caused a disc herniation, and that the Veteran was not symptomatic for radicular symptoms. A July 2020 VA back conditions examination report includes a notation that the Veteran’s claims file was reviewed. The Veteran reported that he strained his low back in Korea after some digging, and that his lumbar spine problems had stayed the same since that time. The diagnoses were degenerative of the lumbar spine and right lower extremity radiculopathy. The examiner indicated that it was less likely than not that the Veteran’s disability pattern or diagnosed disease was related to a specific exposure event experienced during his service in Southwest Asia. The examiner reported that the Veteran’s condition was caused by age-related wear and tear. The examiner also stated that the symptoms were attributed to a known clinical diagnosis. The examiner further indicated that the claimed condition was less likely than not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner reported that the Veteran’s pelvic films of his sacroiliac joints were going to be checked, but that his sacroiliac joints reviewed on a recent lumbosacral spine film appeared normal. The examiner also maintained that the Veteran’s degenerative arthritis of the lumbar spine was caused by the normal aging process and wear and tear. The examiner stated that such condition would not be caused by any type of exposure event. It was noted that there were no hardships that would cause such condition given the lack of complaints, diagnoses, and treatment during service. The examiner also indicated that the claimed condition was less likely than not (less than 50 percent probability) proximately due to, or the result of, the Veteran’s service-connected conditions. The examiner reported that degenerative arthritis of the lumbar spine was caused by age-related and tera/normal aging process. The examiner stated that there was no evidence or peer reviewed literature to support that obstructive sleep apnea; right ankle arthritis, status post chronic ankle sprains and an avulsion fracture; fibromyalgia; and tension headaches could cause degenerative arthritis of the lumbar spine. The examiner maintained that, therefore, it was less likely than not that the Veteran’s lumbar spine condition was caused by his service-connected conditions. The Board observes that the Veteran’s service treatment records for his period of active duty from May 1986 to May 1989 indicate that he was treated for lumbar spine problems, and that he was diagnosed with muscle strain and musculoskeletal pain. It was also noted on one occasion that the Veteran had radiating pain into his right inguinal area and right scrotum area. Additionally, the Veteran’s service treatment records for his period of active duty from September 1990 to April 1991 show that he reported that he had recurrent back pain at the time of a March 1991 separation examination. Post-service treatment records, including VA examination reports, indicate that the Veteran was treated for lumbar spine problems, including a lumbar disc herniation, and degenerative arthritis of the lumbar spine. The Board observes that a January 2013 VA back conditions examination report relates a diagnosis of a lumbar disc herniation. The examiner, following a review of the claims file, indicated that the degenerative changes found on the lumbar spine x-ray were most likely a biology of aging. The examiner stated that the Veteran was treated for osteopenia with Vitamin D supplementation, and that such, and the biology of aging, would not be secondary to his active service. The examiner maintained that the Veteran’s lumbar strain during service would have been muscular in nature, that it would not have caused a disc herniation, and that the Veteran was not symptomatic for radicular symptoms. The Board observes that the examiner did not specifically address the Veteran’s reports of low back problems during service and since service. The Veteran is competent to report lumbar spine problems during service and since service. See Davidson, 581 F.3d 1313 (Fed. Cir. 2009). Additionally, the examiner did not address the Veteran’s claimed disorder pursuant to the provisions of 38 C.F.R. § 3.317. Therefore, the Board finds that the examiner’s opinions, pursuant to the January 2013 VA back conditions examination report, are not very probative in this matter. The Board notes that a July 2020 VA back conditions examination report relates diagnoses of degenerative of the lumbar spine and right lower extremity radiculopathy. The examiner, following a review of the claims file, indicated that it was less likely than not that the Veteran’s disability pattern or diagnosed disease was related to a specific exposure event experienced during his service in Southwest Asia. The examiner reported that the Veteran’s condition was caused by age-related wear and tear. The examiner also stated that the symptoms were attributed to a known clinical diagnosis. The examiner also found that the claimed condition was less likely than not incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner maintained that the Veteran’s general arthritis of the lumbar spine was caused by the normal agin process and wear and tear. The examiner stated that such condition would not be caused by any type of exposure event. It was noted that there were no hardships that would cause such condition given the lack of complaints, diagnoses, and treatment during service. The examiner further stated that the claimed condition was less likely than not proximately due to, or the result of, the Veteran’s service-connected conditions. The examiner stated that there was no evidence or peer reviewed literature to support that obstructive sleep apnea; right ankle arthritis, status post chronic ankle sprains and an avulsion fracture; fibromyalgia; and tension headaches could cause degenerative arthritis of the lumbar spine. The Board observes that the examiner did not specifically address the Veteran’s reports of low back problems during and since service. See Davidson, 581 F.3d 1313 (Fed. Cir. 2009). Additionally, the Board notes that the examiner specifically stated that that there were no hardships that would cause such condition given the lack of complaints, diagnoses, and treatment during service. The Board notes, however, that the Veteran was treated for back complaints during his period of active duty from May 1986 to May 1989, and that during his period of active duty from September 1990 to April 1991, he indicated that he had recurrent back pain at the time of his separation examination. Therefore, the Board finds that the opinions by the examiner, pursuant to the July 2020 VA back conditions examination report, are not probative in this matter. The Board observes that the Veteran is currently diagnosed with a lumbar spine disability, diagnosed as degenerative arthritis and a disc herniation. The Board finds the Veteran’s reports of low back problems during and since his periods of service to be credible. See Jandreau v. Nicholson, 492 F.3d 1372 (2007) (holding that lay evidence can be competent and sufficient to establish a diagnosis of a condition when a lay person is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). Resolving any doubt in the Veteran’s favor, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s lumbar spine disability, diagnosed as degenerative arthritis and a disc herniation, commenced during his periods of service. In light of the evidence, the Board cannot conclude that the preponderance of the evidence is against granting service connection for a lumbar spine disability, diagnosed degenerative arthritis and a disc herniation. Therefore, service connection for a lumbar spine disability, diagnosed as degenerative arthritis and a disc herniation, is warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. As the Board has granted direct service connection in this matter, it need not address other theories of service connection. 2. Bilateral Hearing Loss and Tinnitus Impaired hearing will be considered to be a disability for VA purposes when the thresholds for any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz are 40 decibels or more; the thresholds for at least three of these frequencies are 26 decibels; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2016). One requirement for service connection is the current existence of the claimed disability. With regard to hearing loss, 38 C.F.R. § 3.385 defines what constitutes the current existence of a hearing loss disability. For service connection, it is not required that a hearing loss disability by the standards of 38 C.F.R. § 3.385 be demonstrated during service, although a hearing loss disability by the standards of 38 C.F.R. § 3.385 must be currently present, and service connection is possible if such current hearing loss disability can be adequately linked to service. Ledford v. Derwinski, 3 Vet. App. 87 (1992). The Veteran contends that he has bilateral hearing loss and tinnitus that are related to service. He specifically maintains that he has bilateral hearing loss and tinnitus as a result of acoustic trauma while serving in Saudi Arabia during the Persian Gulf War. The Veteran reports that he was exposed to loud noise from Scud missiles, bombs, diesel trucks and generators during his military service. He also indicates that he served as a machine gunner and that he was exposed to machine gun fire. The Veteran further reports that he has a history of ear infections, including during service. The Veteran served on active duty in the Army from May 1986 to May 1989 and from September 1990 to April 1991, including service in Southwest Asia. He also apparently had service in the Army Reserve. His DD Form 214 for his period of active duty from May 1986 to May 1989 indicates that he had one year and two months of foreign service. His occupational specialty is listed as an administrative specialist for two years and seven months. The Veteran’s DD Form 214, and DD Form 215, for his period of active duty from September 1990 to April 1991 reflect that he served in Southwest Asia from November 1990 to April 1991, and that he was ordered to active duty in support of Operation Desert Shield/Desert Storm. His occupational specialty is listed as an administrative specialist for seven months. The Veteran’s service treatment records for his period of active duty from May 1986 to May 1989 do not show a hearing loss disability in either ear as defined by 38 C.F.R. § 3.385. There is no specific evidence of hearing loss within the year after service as required for the presumption of service connection. Such records do show treatment for ear infections and for tinnitus on one occasion. A June 1988 treatment report notes that the Veteran was seen for a chief complaint of possible bilateral ear infections. The Veteran reported that he had bilateral ear pain, tinnitus, and bilateral discharges for two days. The assessment was bilateral otitis externa and rule out otitis media. The Veteran’s service treatment records for his period of active duty from September 1990 to April 1991 do not show a hearing loss disability in either ear as defined by 38 C.F.R. § 3.385. There is no specific evidence of hearing loss within the year after service as required for the presumption of service connection. Such records also do not show treatment for tinnitus. A post-service VA examination report shows that the Veteran has bilateral hearing loss under the provisions of 38 C.F.R. § 3.385, and that he also has tinnitus. The evidence of record does show that the Veteran was exposed to in-service acoustic trauma and that he has been currently diagnosed with bilateral hearing loss, under the provisions of 38 C.F.R. § 3.385, and with tinnitus. The Board notes that there are negative opinions of record, as to the etiology of the Veteran’s bilateral hearing loss and tinnitus, pursuant to a February 2017 VA audiological examination report. A February 2017 VA audiological examination report includes a notation that the Veteran’s claims file was reviewed. The Veteran reported that he was exposed to noise from Scud missiles, bombs, diesel trucks, and generators during his military service. He also stated that he was a machine gunner. The Veteran indicated that he used hearing protection on the firing range, but not in a wartime theatre. He related that he had bilateral otalgia, which he described as a sharp pain. He also stated that he had a history of ear infections, but he denied that he had suffered from recent ear infections. The Veteran reported that he had periodic, bilateral tinnitus. He was unable to recall the exact onset of his tinnitus. The Veteran maintained that he worked in a factory, but that he was complaint with the use of hearing protection. He denied that he had any recreational noise exposure. The examiner reported that while the Veteran’s occupational specialty as an administrative specialist had a low probability for hazardous noise exposure, his noise exposure was conceded due to his military service in Saudi Arabia and his lay statements. The examiner reported results that were indicative of bilateral hearing loss as defined by 38 C.F.R. § 3.385. The Veteran’s speech recognition ability, using the Maryland CNC Test, was 92 percent in his right ear and 84 percent in his left ear. As to diagnoses, the examiner incorrectly indicated that the Veteran had normal hearing in his right ear and normal hearing in his left ear. Tinnitus was diagnosed. The examiner indicated that the Veteran’s right ear hearing loss and left ear hearing loss were not at least as likely as not (50 percent probability) caused by, or a result of, an event during his military service. The examiner reported that noise exposure was conceded due to the Veteran’s military service in Saudi Arabia and his reports of his duties. The examiner stated that normal hearing sensitivity was documented at 500-6000 Hertz in both ears at an enlistment examination in March 1986, and at the time of an annual audiogram in November 1988, and at the time of the Veteran’s separation examination in “April” 1991. The examiner indicated that the Veteran’s service treatment records were silent for objective audiometric thresholds obtained at separation from his first period of active duty in May 1989, and at reenlistment in September 1990. The examiner stated that without objective audiometric thresholds obtained at separation in May 1989, and reenlistment in September 1990, for comparison, significant shifts/variability to the Veteran’s hearing could not be confirmed or ruled out. The examiner maintained that no significant shifts to the Veteran’s hearing were identified when comparing the objective audiometric thresholds obtained at the enlistment examination in May 1986, and the separation examination from the Veteran’s second period of service in “April” 1991, to support a noise injury to the ears. The examiner stated that hearing loss was not measured on the current examination or considered a disability for VA purposes. The examiner indicated that, therefore, the Veteran’s hearing sensitivity was less likely than not caused by, or the result of, his military service. The examiner also found that the Veteran’s tinnitus was less likely than not (less than 50 percent probability) caused by, or a result of, his military noise exposure. The examiner reported that the Veteran’s service treatment records were silent for subjective reports and/or diagnoses of a condition of tinnitus. The examiner stated that audiometric thresholds remained in a normal sensitivity range and that no significant threshold shifts/variability to the Veteran’s hearing was identified when comparing objective audiometric thresholds obtained at an enlistment examination in March 1986, and at a separation in “April” 1991, to support a noise injury to the ears. The examiner maintained that, therefore, the Veteran’s tinnitus was less likely than not caused by, or a result of, his military service. The Board observes that the examiner related diagnoses of normal hearing in the Veteran’s right ear and normal hearing in his left ear, and tinnitus. The Board notes that although the examiner found that the Veteran had normal hearing in his bilateral ears, the Veteran actually had bilateral hearing loss as defined by 38 C.F.R. § 3.385, because the speech recognition ability, using the Maryland CNC Test, was 92 percent in the right ear and 84 percent in the left ear. The examiner, following a review of the claims file, indicated that the Veteran’s right ear hearing loss and left ear hearing loss were not at least as likely as not caused by, or a result of, an event during his military service. The examiner reported that noise exposure was conceded due to the Veteran’s military service in Saudi Arabia and his reports of his duties. The examiner maintained that no significant shifts to the Veteran’s hearing were identified when comparing the objective audiometric thresholds obtained at the enlistment examination in May 1986, and the separation examination from the Veteran’s second period of service in “April” 1991, to support a noise injury to the ears. The examiner stated that hearing loss was not measured on the current examination or considered a disability for VA purposes. The examiner further found that the Veteran’s tinnitus was less likely than not caused by, or a result of, his military noise exposure. The examiner specifically reported that the Veteran’s service treatment records were silent for subjective reports and/or diagnoses of a condition of tinnitus. The Board notes that the examiner incorrectly found that the Veteran did not have bilateral hearing loss as defined by 38 C.F.R. § 3.385. Additionally, the examiner essentially based her opinion, that the Veteran’s bilateral hearing loss was not due to his periods of service, on the audiometric thresholds obtained during those periods. The Board notes, however, that in regard to the Veteran’s bilateral hearing loss, the absence of documented hearing loss, as defined by VA, while in service is not fatal to a claim for service connection. See Ledford, 3 Vet. App. at 87. Additionally, when a Veteran does not meet the regulatory requirements for a disability at separation, he can still establish service connection by submitting evidence that a current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155, 159-160 (1993). The Board further observes that the examiner maintained that the Veteran’s service treatment records were silent for objective reports and/or diagnoses of tinnitus during his periods of service. The Board notes, however, that the Veteran reported that he had tinnitus, pursuant to a June 1988 treatment report, during his period of active duty from May 1986 to May 1989. Therefore, the Board finds that the opinions provided by examiner, pursuant to the February 2017 VA audiological examination report, have no probative value. The Veteran is competent to report hearing problems and ringing in the ears during his periods of active duty and since that time. Additionally, the Veteran specifically reported that he had tinnitus at the time of a June 1988 treatment report during his period of active duty from May 1986 to May 1989. Moreover, the Board finds that the Veteran’s reports of noise exposure during his periods of service to be credible. See also Jandreau v. Nicholson, 492 F.3d 1372 (2007). Resolving any doubt in the Veteran’s favor, the Board finds that the Veteran has bilateral hearing loss and tinnitus that had their onset during his periods of service. Service connection for bilateral hearing loss and for tinnitus is warranted. As the Board has granted direct service connection in this matter, it need not address other theories of service connection. 3. Psychiatric Disorder, to include PTSD, an Anxiety Disorder, and a Depressive Disorder Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., under the criteria of DSM-IV); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f). Further, 38 C.F.R. § 3.304(f) provides that if a stressor claimed by a Veteran is related to the Veteran’s fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the Veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran’s service, the Veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. The Veteran is service-connected for fibromyalgia. He is also service-connected for obstructive sleep apnea; tension headaches; a right ankle disability (degenerative arthritis of the right ankle, with a history of an avulsion fracture and chronic sprains); and for irritable bowel syndrome. As discussed above, the Veteran is also now service-connected for a lumbar spine disability, diagnosed as degenerative arthritis and a disc herniation; bilateral hearing loss; and for tinnitus. The Veteran contends that he has as psychiatric disorder, to include PTSD, an anxiety disorder, and a depressive disorder, that is related to service, or, more specifically, that is related to his service-connected fibromyalgia. He further asserts that his claimed psychiatric disorder, to include PTSD, an anxiety disorder, and a depressive disorder, is the result of his service in Southwest Asia and should be considered under the provisions of 38 C.F.R. § 3.317. The Veteran served on active duty in the Army from May 1986 to May 1989 and from September 1990 to April 1991, including service in Southwest Asia. He also apparently had service in the Army Reserve. His DD Form 214 for his period of active duty from May 1986 to May 1989 indicates that he had one year and two months of foreign service. His occupational specialty is listed as an administrative specialist for two years and seven months. The Veteran’s DD Form 214, and DD Form 215, for his period of active duty from September 1990 to April 1991 reflect that he served in Southwest Asia from November 1990 to April 1991, and that he was ordered to active duty in support of Operation Desert Shield/Desert Storm. His occupational specialty is listed as an administrative specialist for seven months. The Veteran’s service treatment records for his period of active duty from May 1986 to May 1989 do not specifically show treatment for any psychiatric problems. His service treatment records for his period of active duty from September 1990 to April 1991 do include a reference to possible psychiatric problems on one occasion. On a medical history form at the time of a March 1991 separation examination, the Veteran checked that he had depression or excessive worry. The reviewing examiner indicated that the Veteran had a right ankle injury in 1986, and that he was otherwise healthy. The March 1991 objective separation examination report includes a notation that the Veteran’s psychiatric evaluation was normal. Post-service VA treatment records, including a VA examination report, show treatment for variously diagnosed psychiatric disorders, including an adjustment disorder; an adjustment disorder, with a mixed mood; possible PTSD; PTSD; anxiety; an anxiety disorder; an unspecified anxiety disorder; depression; a major depressive disorder; a depressive disorder; and an unspecified depressive disorder. A May 2015 VA treatment report notes, as to the Veteran’s psychiatric history, that he had been diagnosed with an unspecified anxiety disorder and a depressive disorder secondary to fibromyalgia. The diagnoses were an unspecified anxiety disorder and an unspecified depressive disorder. A July 2017 VA treatment report reflects an assessment that includes an unspecified anxiety disorder and an unspecified depressive disorder. The examiner reported that the Veteran had a history of an unspecified anxiety disorder and depression secondary to a medical condition (fibromyalgia). It was noted that the Veteran reported increased depression and a passive death wish in a setting of chronic pain and increased irritability. An October 2017 VA treatment report relates an assessment of an unspecified anxiety disorder, as well as depression secondary to a medical condition (fibromyalgia). A February 2017 VA psychiatric examination report includes a notation that the Veteran’s claims file was reviewed. The Veteran reported that he served from May 1986 to May 1989, and that he then went into the Army Reserve. He stated that he was activated again from September 1990 to April 1991, and that he stayed in the Army Reserve until 1992. The Veteran related that his occupational specialty was an administrative specialist, with a postal qualifier. He indicated that while serving in Saudi Arabia, he was with a military police company and stayed in the back at a POW information center. The Veteran reported that he handled information on prisoners and that he did not work in his occupational specialty. He maintained that there were 18,000 prisoners and that they were not allowed any weapons. The Veteran stated that he received two Article 15s during his periods of service. As to the Veteran’s mental health history, the examiner reported that the Veteran denied mental health problems prior to his military service. The examiner reported that the Veteran denied that he had mental health treatment during service, but that his separation examination report in March 1991 indicated that he endorsed depression and excessive worry. The examiner reported that the Veteran first sought mental health treatment through the VA in 2013. The examiner stated that the Veteran was evaluated by a combat stress recovery clinic psychologist in 2014, and that he was found to not meet the criteria for PTSD because the level of exposure to his claimed stressor did not meet Criterion A. The examiner indicated that the Veteran was also evaluated in 2015, and that he was not diagnosed with PTSD at that time. The examiner maintained that the Veteran had been seeing a VA psychiatrist for a few years, and that he was diagnosed with an unspecified anxiety disorder and depression secondary to a medical condition (fibromyalgia). The diagnoses were an unspecified anxiety disorder and an unspecified depressive disorder. The examiner indicated that the claimed condition was less likely than not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner reported that the Veteran’s symptoms did not meet he DSM-5 criteria for PTSD. The examiner stated that based on the record review and the examination, the Veteran did not meet the DSM-5 criteria for PTSD. The examiner related that the Veteran’s stressor did not mee the DSM-5 Criterion A for the type of stressor and level of exposure that was required for a diagnosis of PTSD. It was noted that the Veteran was not in receipt of any combat medals, which would indicate exposure to a qualifying stressor. The examiner indicated that without a qualifying Criterion A stressor, the Veteran could not possibly have PTSD. The examiner reported that the Veteran also did not report having a full constellation of symptoms required for a diagnosis of PTSD. It was noted that the Veteran had been evaluated various times in the past and that he had been found not to meet the DSM-5 criteria for PTSD. The examiner indicated that the Veteran’s symptoms did meet the DSM-5 criteria for an unspecified anxiety disorder and for an unspecified depressive disorder, for which he was in treatment through the VA. The examiner reported that those diagnoses were first provided in 2015. The examiner maintained that since the Veteran’s condition was not diagnosed or treated during service, or shortly thereafter, his mental health conditions were less likely than not related to his military service. The Board observes that the Veteran’s service treatment records for his period of active duty from May 1986 to May 1989 do not show treatment for any psychiatric problems. The Board notes, however, that the Veteran’s service treatment records for his period of active duty from September 1990 to April 1991, do show that the Veteran reported he had depression or excessive worry at the time of his March 1991 separation examination report. The Board observes that post-service treatment records show that the Veteran was for treated for variously diagnosed psychiatric disorders, including an adjustment disorder; an adjustment disorder, with a mixed mood; possible PTSD; PTSD; anxiety; an anxiety disorder; an unspecified anxiety disorder; depression; a major depressive disorder; a depressive disorder; and an unspecified depressive disorder. Additionally, multiple VA treatment reports indicate that the Veteran has and unspecified anxiety disorder and an unspecified depressive disorder (or depressive disorder) secondary to a medical condition, his service-connected fibromyalgia. A February 2017 VA psychiatric examination report relates diagnoses of an unspecified anxiety disorder and an unspecified depressive disorder. The examiner, following a review of the claims file, indicated that the claimed condition was less likely than not incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner reported that the Veteran’s symptoms did not meet he DSM-5 criteria for PTSD. The examiner also maintained that the Veteran’s symptoms did meet the DSM-5 criteria for an unspecified anxiety disorder and for an unspecified depressive disorder. The examiner reported that those diagnoses were first provided in 2015. The examiner stated that since the Veteran’s condition was not diagnosed or treated during service, or shortly thereafter, his mental health conditions were less likely than not related to his military service. The Board observes that although the examiner found that the Veteran’s diagnosed unspecified anxiety disorder and unspecified depressive disorder were less likely than not related to his military service, she did not address whether those diagnosed disorders were caused or aggravated by his service-connected disabilities, to specifically include fibromyalgia. In El-Amin v. Shinseki, 26 Vet. App. 136 (2013), a decision issued by the United States Court of Appeals for Veterans Claims (Court), the Court vacated a decision of the Board where a VA examiner did not specifically opine as to whether a disability was aggravated by a service-connected disability. Additionally, the Board notes that the examiner reported, as to the Veteran’s mental health history, that he had been seeing a VA psychiatrist for a few years, and that he was diagnosed with an unspecified anxiety disorder and depression secondary to a medical condition (fibromyalgia). Therefore, the Board finds that the examiner’s opinions are not very probative in this matter. The Board observes that the medical evidence indicates that the Veteran currently has a psychiatric disorder, diagnosed as an unspecified anxiety disorder and an unspecified depressive disorder. As noted above, multiple VA treatment records show that the Veteran has and unspecified anxiety disorder and an unspecified depressive disorder (or depressive disorder) secondary to a medical condition, his service-connected fibromyalgia. The Board further notes that the examiner, pursuant to the February 2017 VA psychiatric examination report, indicated that the Veteran had been seeing a VA psychiatrist for a few years, and that he was diagnosed with an unspecified anxiety disorder and depression secondary to a medical condition (fibromyalgia). In light of the above, the Board finds that the Veteran’s psychiatric disorder, diagnosed as an unspecified anxiety disorder and an unspecified depressive disorder, is due to, or the result of, his service-connected fibromyalgia. Thus, secondary service connection for a psychiatric disorder, diagnosed as an unspecified anxiety disorder and an unspecified depressive disorder, is warranted. See 38 C.F.R. § 3.310. The Board notes that there is no probative evidence relating any other psychiatric disorders of record to the Veteran’s service-connected disabilities, or to his period of service. As the Board has granted secondary service connection it need not address direct service connection, or any other theories for service connection, in this matter. REASONS FOR REMAND The remaining issues on appeal are entitlement to service connection for chronic fatigue syndrome, with all over joint pain; a gastrointestinal disorder, to include acid reflux; a respiratory disorder, to include emphysema, asthma, and bronchitis; sinusitis; rhinitis; and for bilateral otitis media, as well as the issues of entitlement to an initial rating higher than 10 percent for a right ankle disability and entitlement to a TDIU. As discussed above, the Board has granted service connection for a lumbar spine disability, diagnosed as degenerative arthritis and a disc herniation; bilateral hearing loss; tinnitus; and for a psychiatric disorder, diagnosed as an unspecified anxiety disorder and an unspecified depressive disorder. Given this change in circumstances, and to accord the Veteran due process, the RO should readjudicate the issues of entitlement to service connection for chronic fatigue syndrome, with all over joint pain; a gastrointestinal disorder, to include acid reflux; a respiratory disorder, to include emphysema, asthma, and bronchitis; sinusitis; rhinitis; and for bilateral otitis media, as well as the issue of entitlement to a TDIU. Additionally, this case was last remanded in September 2018, partly to schedule the Veteran for a VA examination to determine the nature and likely etiology of his claimed chronic fatigue syndrome, with all over joint pain, and gastrointestinal disorder, to include acid reflux. Then, based on the results of the examination, the examiner was to address a number of questions. Pursuant to the September 2018 Board remand, the Veteran was afforded a VA chronic fatigue syndrome examination in July 2020. There is a notation that the examiner reviewed the Veteran’s claims file. The examiner found that the Veteran did not meet the criteria for a diagnosis of chronic fatigue syndrome at that time. The examiner reported that the Veteran did not have an undiagnosed illness because no diagnosis was rendered. The examiner also stated, as to whether the symptoms of the claimed condition were attributable to a known clinical diagnosis, and if the Veteran did not presently have, but previously had, any such condition, when did it resolve, that there was no known clinical diagnosis of chronic fatigue syndrome. The examiner further maintained that the Veteran had fibromyalgia and sleep apnea, which both caused fatigue and joint pain, but that there was no known clinical diagnosis of chronic fatigue syndrome at that time. The examiner also indicated that the claimed condition was less likely than not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner stated that there was no diagnosis of chronic fatigue syndrome, and that, therefore, it was less likely than not caused by service. The examiner further maintained that the claimed condition was less likely than not (less than 50 percent probability) proximately due to, or the result of, the Veteran’s service-connected conditions. The examiner stated that as there was no diagnosis of chronic fatigue syndrome, it was less likely than not caused by the service-connected conditions. The Board observes that the examiner’s opinions do not properly address the Veteran’s claimed chronic fatigue syndrome, with all over joint pain, under the provisions of 38 C.F.R. § 3.317, as requested in the September 2018 Board remand. Additionally, the examiner stated that the Veteran had fibromyalgia and sleep apnea, which both caused fatigue and joint pain, but that there was no known clinical diagnosis of chronic fatigue syndrome. It is unclear if the examiner was indicating that the Veteran had an actual illness of fatigue and joint pain. Additionally, since the July 2020 VA chronic fatigue examination report, the Board has granted service connection for additional disorders, including a lumbar spine disability, diagnosed as degenerative arthritis and a disc herniation, and a psychiatric disorder, diagnosed as an unspecified anxiety disorder and an unspecified depressive disorder. The examiner was unable to address whether those conditions caused or aggravated the claimed chronic fatigue syndrome, with all over joint pain. In El-Amin v. Shinseki, 26 Vet. App. 136 (2013), a decision issued by the United States Court of Appeals for Veterans Claims (Court), the Court vacated a decision of the Board where a VA examiner did not specifically opine as to whether a disability was aggravated by a service-connected disability. The Veteran was also afforded a VA esophageal conditions examination in July 2020. There is a notation that the Veteran’s claims file was reviewed. The diagnoses were gastroesophageal reflux disease (GERD) and a hiatal hernia. The examiner stated that GERD was a disease with a clear and specific etiology and diagnosis. The examiner appeared to indicate that a hiatal hernia was a diagnosable, but medically unexplained chronic multisymptom illness of unknown etiology. The examiner stated that the Veteran’s GERD was less likely than not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. The examiner reported that a hiatal hernia occurred when weakened muscle tissue allowed the stomach to bulge up through the diaphragm. The examiner stated that it was not always clear why such occurred, but that a hiatal hernia might be caused by age-related changes in the diaphragm; an injury to the area such as after trauma or certain types of surgery; being born with an unusually large hiatus; and/or persistent and intense pressure no the surrounding muscles such as while coughing, vomiting, straining during a bowel movement, exercising, or lifting heavy objects. The examiner stated that GERD was caused by frequent acid reflux. It was noted that when swallowing, a circular band of muscle around the esophagus relaxed, allowing food and liquid to flow to the stomach. The examiner stated that such a constant backwash of acid irritated the lining of the esophagus, often causing it to become inflamed. The examiner also indicated that the claimed condition was less likely than not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner reported that the exact cause of a hiatal hernia was not understood, but that it was thought to be caused by age-related changes in the diaphragm, injury to the area, and/or constant pressure to the muscles around the area. It was noted that GERD was caused by frequent acid reflux, and the examiner listed risk factors for GERD. The examiner maintained that there was no evidence or peer reviewed literature to support that a hiatal hernia or GERD would be caused by an exposure event of some sort, and that, therefore, such conditions were less likely than not caused by hardships in service. The examiner further found that the claimed condition was less likely than not (less than 50 percent probability) proximately due to, or the result of, the Veteran’s service-connected disabilities. The examiner indicated that there was no evidence or peer reviewed literature to support that obstructive sleep apnea; right ankle arthritis, status post an avulsion fracture and chronic sprains; fibromyalgia; and/or tension headaches could cause GERD or a hiatal hernia. The Board observes that the examiner provided negative opinions, as to the diagnosed GERD and a hiatal hernia. The examiner did not address the Veteran’s treatment for gastroenteritis during his first period of active duty from May 1986 to May 1989. Additionally, since the July 2020 VA esophageal conditions examination report, the Board has granted service connection for additional disorders, including a lumbar spine disability, diagnosed as degenerative arthritis and a disc herniation, and a psychiatric disorder, diagnosed as an unspecified anxiety disorder and an unspecified depressive disorder. The examiner was unable to address whether those conditions caused or aggravated the diagnosed GERD and a hiatal hernia. See El-Amin, 26 Vet. App. at 136. As to the Veteran’s claimed respiratory disorder, to include emphysema, asthma, and bronchitis; sinusitis; rhinitis; and bilateral otitis media, the Board notes that the Veteran was afforded a VA respiratory conditions examination in February 2017; and a VA sinusitis, rhinitis, and other conditions of the nose, throat larynx and pharynx examination in February 2017. The Board finds that the opinions provided, pursuant to those examination reports, respectively, are inadequate. For example, none of the respective opinions addressed whether any diagnosed conditions were caused or aggravated by the Veteran’s service-connected disabilities. In light of the above, the Board finds that the Veteran should be afforded a VA examination with the opportunity to obtain responsive etiological opinions, following a thorough review of the record, as to his claims for service connection for chronic fatigue syndrome, with all over joint pain; a gastrointestinal disorder, to include acid reflux; a respiratory disorder, to include emphysema, asthma, and bronchitis; sinusitis; rhinitis; and for bilateral otitis media. Such an examination must be accomplished on remand. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006); Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007); see also Stegall v. West, 11 Vet. App. 268, 271 (1998). As to the Veteran’s claim for a higher rating for his service-connected right ankle disability, the Board notes that the Veteran was afforded a VA ankle conditions examination in September 2020. The diagnoses were degenerative arthritis, and chronic sprains and an avulsion fracture of the right ankle. The Board notes that the Veteran was last issued a statement of the case addressing the issue of entitlement to an initial higher rating for a right ankle disability in September 2014. The Board notes that, at that time, the Veteran’s right ankle disability was rated as noncompensable. The Veteran’s right ankle disability is now rated as 10 percent disabling. Additionally, the Board notes that there is no indication that the September 2020 VA ankle conditions examination report, noted above, was considered by the RO, as to the claim for a higher rating for a right ankle disability. The Board observes that the Veteran has not submitted a waiver with regard to initial RO consideration of the September 2020 VA ankle conditions examination report. Thus, the case will be remanded to allow for initial RO consideration of the evidence and for a supplemental statement of the case to be issued regarding the Veteran’s claim for an initial rating higher than 10 percent for his service-connected right ankle disability. 38 C.F.R. 20.1304; see also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F. 3d 1339 (Fed. Cir. 2003). Finally, as the Veteran’s claim for a TDIU rating is inextricably intertwined with his claims for service connection, and for a higher rating for a right ankle disability, on appeal, those matters must be addressed together on remand. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Ask the Veteran to identify all medical providers who have treated him for chronic fatigue syndrome, with all over joint pain; a gastrointestinal disorder, to include acid reflux; a respiratory disorder, to include emphysema, asthma, and bronchitis; sinusitis; rhinitis; bilateral otitis media, and for a right ankle disability, since May 2020. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service symptoms of his claimed chronic fatigue syndrome, with all over joint pain; gastrointestinal disorder, to include acid reflux; respiratory disorder, to include emphysema, asthma, and bronchitis; sinusitis; rhinitis; and bilateral otitis media, as well as the nature, extent, and severity of his right ankle disability and the impact of that condition on his ability to work. He should be afforded an appropriate amount of time to submit this lay evidence. 3. Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) to determine the nature, onset and etiology of his claimed chronic fatigue syndrome, with all over joint pain; gastrointestinal disorder, to include acid reflux; respiratory disorder, to include emphysema, asthma, and bronchitis; sinusitis; rhinitis; and bilateral otitis media. The claims file must be reviewed by the examiner. Based on the results of the examination, the examiner is asked to address each of the following questions: (a) Please state whether the symptoms of each claimed condition are attributable to a known clinical diagnosis. If the Veteran does not now have, but previously had any such condition, when did that condition resolve? (b) Is the Veteran’s disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (2) a diagnosable chronic multisymptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis? (c) If, after examining the Veteran and reviewing the claims file, it is determined that the Veteran’s disability pattern is either (1) a diagnosable chronic multisymptom illness with a partially explained etiology, or (2) a disease with a clear and specific etiology and diagnosis, then please provide an expert opinion as to whether it is related to a presumed environmental exposures experienced by the Veteran during service in Southwest Asia. (d) Is it at least as likely as not that any diagnosed disorder had its onset directly during the Veteran’s service or is otherwise causally related to any event or circumstance of his service, including environmental exposures during service in Southwest Asia during the Persian Gulf War? (e) If not directly related to service on the basis of questions (b)-(d), is any medical condition proximately due to, the result of, or caused by any service-connected disability(ies)? (f) If not caused by another medical condition, has any disorder been aggravated (made permanently worse or increased in severity) by any service-connected disability(ies)? If yes, was that increase in severity due to the natural progress of the disease. In responding to the above inquiries, please acknowledge and discuss the Veteran’s treatment for gastroenteritis; respiratory problems; rhinitis; possible sinusitis; and bilateral ear infections, during service, and any reports of the Veteran of treatment for his claimed disabilities during and since service. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. D. Regan, 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.