Citation Nr: 21022801 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 11-03 461 DATE: April 19, 2021 REMANDED Entitlement to service connection for a fatigue disorder, to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness, is remanded. REASONS FOR REMAND The Veteran had several years of Army National Guard/Reserves service, with a period of active duty from January 1991 to April 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2009 rating decision. The Veteran provided sworn testimony before the undersigned Veterans Law Judge during a September 2016 Travel Board hearing. In April 2019, the Board remanded the claim of service connection for a mental health condition for further development. The RO granted service connection for PTSD in a January 2021 rating decision. As that is a full grant of the appeal, the issue of service connection for a mental health condition is not before the Board. The January 12, 2021 notice letter advised him of his appeal rights. In the April 2019 remand, the Board instructed the RO to obtain a medical opinion on whether the Veteran had a fatigue disorder and, if so, whether it was caused or aggravated by his mental health disorder. In January 2020, a VA examiner opined that “fatigue is a symptom and not a diagnosis, and the veteran has no psychiatric diagnosis, therefore any claimed fatigue cannot be due to a mental condition.” In October 2020, VA obtained a Chronic Fatigue Syndrome (CFS) examination. In Section I of the examination report, the examiner documented the Veteran currently has CFS and it was diagnosed in 1991. In the accompanying medical opinion, however, the examiner opined that the Veteran’s fatigue was caused by his hypothyroidism. He did not render a direct nexus opinion. VA requested clarification in light of the CFS diagnosis and, in December 2020, the examiner wrote “the response was meant to indicate in section I of the DBQ that the veteran does have other disease which can explain his fatigue.” He further stated that “to eliminate those causes, he would need to have the symptoms mentioned in the Section 1 and have a sleep diary with proof that he is using the CPAP over 70% of the time and a normal TSH in the last 6 months.” While the examiner’s addendum opinion suggests that the Veteran would only have a diagnosis of CFS with proof that his sleep apnea and hypothyroidism were controlled, he wrote in Section II that the Veteran “developed insidious onset of fatigue in 1991,” “he continued to have this problem after separation from service,” and his thyroidism and sleep apnea are regulated but he “continues to have underlying fatigue.” Thus, the Board finds that the clarification opinion is not adequate. If the Veteran has CFS, or if he has fatigue due to undiagnosed illness, then he could be awarded presumptive service connection. However, if his fatigue is due to his thyroid disease or sleep apnea, neither of which are service-connected, that is a different analysis. The opinions are internally inconsistent as to whether the Veteran has a distinct fatigue disorder, such as chronic fatigue syndrome, or whether his fatigue is a symptom attributable to other diagnosed disorders. The matters are REMANDED for the following action: Forward the claims file to a VA examiner for an opinion. An in-person examination is unnecessary unless otherwise determined by the examiner. After review of the file, the examiner should respond to the following: (a.) Does the Veteran have a current diagnosis of a fatigue disorder? Does he meet the criteria for a chronic fatigue syndrome diagnosis? In answering this question, please expressly discuss whether his fatigue is a separate and distinct medical condition, or if his complaints are part of the symptom complex for another medical disorder. (b.) If a fatigue disorder is diagnosed, then please answer the following: • is it at least as likely as not that it began in or is otherwise related to service? • is it at least as likely as not that it was caused by his service-connected PTSD? • is it at least as likely as not that it was aggravated by his service-connected PTSD? (c.) If a fatigue disorder is not diagnosed, then is it at least as likely as not that his fatigue is a manifestation of an undiagnosed illness? MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Lavan 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.