Citation Nr: 21023952 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 04-12 096A DATE: April 21, 2021 ORDER Entitlement to service connection for the residuals of heat stress is DENIED. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is DENIED. REMANDED Entitlement to service connection for anemia, to include as secondary to service-connected polycystic ovarian syndrome with endometriosis, is REMANDED. Entitlement to compensation under the provisions of 38 U.S.C. § 1151 for abdominal scarring is REMANDED. Entitlement to service connection for a lower back disability, to include as due to undiagnosed illness, is REMANDED. Entitlement to service connection for a right knee disability, to include as due to undiagnosed illness, is REMANDED. Entitlement to service connection for an ulcer disorder, to include as due to undiagnosed illness, is REMANDED. Entitlement to service connection for appendectomy and partial loss intestines, to include as due to undiagnosed illness, is REMANDED. Entitlement to service connection for a skin disability, to include as due to undiagnosed illness, is REMANDED. Entitlement to service connection for migraine headaches, to include as due to undiagnosed illness, is REMANDED. Entitlement to service connection for chronic fatigue syndrome (CFS), to include as due to undiagnosed illness, is REMANDED. Entitlement to service connection for tuberculosis, to include as due to undiagnosed illness, is REMANDED. Entitlement to service connection for insomnia, to include as due to undiagnosed illness, is REMANDED. Entitlement to service connection for respiratory disease, to include tonsillitis, bronchitis, sinus problems, and sleep apnea, to include as due to undiagnosed illness, is REMANDED. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran endured heat stress during active duty service in the United States Army. 2. The preponderance of the evidence is against a finding that any current acquired psychiatric disorder was incurred in or aggravated by service; additionally, any current acquired psychiatric disorder is not proximately due to, or aggravated by, the service-connected polycystic ovarian syndrome with endometriosis. CONCLUSIONS OF LAW 1. The criteria for service connection for the residuals of heat stress have not been satisfied. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2020). 2. The criteria for service connection for an acquired psychiatric disability, to include PTSD, have not been satisfied. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty in the United States Army from December 1990 to May 1991. The certificate of release from active duty (DD214) reflects that the Veteran served in South West Asia from December 1990 to April 1991 in support of Operation Desert Shield / Storm. The Board has thoroughly reviewed all the evidence in the Veteran’s claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted while in the active military, naval, or air service. 38 U.S.C. § 1110. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d). In order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In each case where service connection for any disability is sought, due consideration shall be given to the places, types, and circumstances of the Veteran’s service as shown by the Veteran’s service record, the official history of each organization in which the Veteran served, the Veteran’s medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154 (a). In making these determinations, the Board must consider and assess the credibility and weight of all evidence in the claim file, including the medical and lay evidence, to determine its probative value. In doing so, the Board must provide its reasoning for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Barr v. Nicholson, 21 Vet. App. 303 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board must give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Service connection may also be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See id; Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or aggravated by, a service-connected disease or injury. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury, will be service-connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). (This standard of assessing aggravation of disability under 38 C.F.R. § 3.310 was established in 2006. See 71 Fed. Reg. 52744-47 (Sept. 7, 2006) (codified at 38 C.F.R. § 3.310)). Although VA indicated that the purpose of the regulation was merely to apply the Court’s 1995 ruling in Allen, it was made clear in the comments to the regulation that the 2006 changes were intended to place the burden on the claimant to establish a pre-aggravation baseline level of disability for the nonservice-connected disability before an award of service connection based on aggravation may be made. This had not been VA’s practice, which strongly suggests that the revision amounted to a substantive change in the regulation. Because the Veteran’s claim was received after the regulatory change, his claim will be adjudicated under the current version of the regulation. The VA is responsible for determining whether the evidence supports the claim or is in relative equipoise (with the Veteran prevailing in either event) or whether a preponderance of the evidence is against the claim (in which case the claim is denied). Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (b). 1. Entitlement to service connection for the residuals of heat stress is denied. In February 2004, the agency of original jurisdiction (AOJ) denied service connection for the residuals of heat stress. The AOJ found that the Veteran did not endure heat stress residuals that were caused by and/or incurred during active duty service. Again, direct service connection is warranted when the probative evidence reflects: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson, 12 Vet. App. at 253. On multiple occasions in November 1998, and once in March 2004, the Veteran’s service treatment records (STRs) were associated with the claims file. After deliberate review, the Board notes that the STRs do not indicate that the Veteran was seen and/or treated for heat stress while deployed (on active duty) in Saudi Arabia. In August 2020, the Veteran supplied sworn testimony to the undersigned Veterans’ Law Judge (VLJ). The Veteran testified that she served in Saudi Arabia during Desert Storm. The Veteran testified that did not remember whether she suffered heat stroke, or was a heat casualty, during service in Saudi Arabia. The Veteran testified that she did not “pass out or anything” while in Saudi Arabia. As noted below, the record reflects that the Veteran endures multiple current disorders. Consequently, the Board finds that the first requisite element for direct service connection has been substantiated. See Hickson, 12 Vet. App. at 253. However, the Board finds that appellate record does not reflect that the Veteran was a heat casualty while performing active duty service, to include while deployed in Saudi Arabi. In fact, during Board testimony, the Veteran relayed that she did not recall treatment as a heat casualty in Saudi Arabia. Consequently, the preponderance of the evidence is against the Veteran’s claim for service connection for the residuals of an active-duty service heat stress injury. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran’s claim for service connection for the residuals of an active-duty service heat stress injury. Since the preponderance of the evidence is against this claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran’s claim for service connection for the residuals of an active-duty heat stress injury must be denied, because the preponderance of the evidence weighs against her claim. 2. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is denied. In March 2001, correspondence from the Veteran was associated with the claims file. Therein, the Veteran initiated a claim for service connection for PTSD. The Veteran relayed that she endured continued psychological trauma from a deployment during Desert Storm. In addition to the direct and secondary requirements for service connection identified above, service connection for PTSD has unique evidentiary requirements. It generally requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a) (i.e., DSM-IV or DSM-5); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). In November 1998, the Veteran’s service treatment records (STRs) were associated with the claims file. After review, the Board observes that a military provider identified depression in December 1990, which is during the Veteran’s period of active duty service. In June 2003, the Veteran submitted a PTSD Questionnaire. Therein, the Veteran relayed that she had been diagnosed with depression and anxiety. The Veteran reported that, during her deployment, it required four Patriot missiles to end a SCUD Missile attack on her compound and, thereafter, she was ordered to wear a gas mask and chemical suit. In June 2003, two letters the Veteran sent while deployed in Saudi Arabia were associated with the claims file. Therein, the Veteran described the effect of Patriot Missile defense of a SCUD attack. The Veteran relayed that, at that time, the “great big bangs” terrified her. In June 2003, a letter the Veteran sent while deployed in Saudi Arabia was associated with the claims file. Therein, the Veteran relayed that she completed casualty reports for people that died during a SCUD missile attack. In June 2003, the Veteran submitted a VA Form 21-4138. Therein, the Veteran reported that she was asked to complete casualty reports for those who died when a SCUD Missile hit a barracks area during her deployment. The Veteran reported that, “over the years my depression, panic attacks and anxiety have increased. I panicked as soon as I heard they were going to war again.” In August 2003, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured PTSD. At that time, the Veteran reported that psychiatric illness / symptoms began in 2002 when she started infertility medications. The VA examiner noted a 4-day admission to the Indianapolis VA hospital for generalized anxiety disorder, undifferentiated somatoform disorder, and histrionic and obsessive-compulsive disorder. The Veteran reported that she believed an inability to bear a child was the source of the psychological impairment(s). The VA examiner relayed that the Veteran met the criteria for somatoform and generalized anxiety disorders. In April 2005, the Veteran’s treatment notations from Meridian Psychological Associates were associated with the claims file. Therein, a provider noted that the Veteran underwent 12 psychotherapy sessions for a history that included PTSD and depression. In November 2007, the Veteran’s social security administration (SSA) records were associated with the claim file. Therein, it was reported that the Veteran underwent a psychological evaluation in January 2007. At that time, the SSA examiner relayed that the Veteran had a well-established psychiatric treatment history at the VAMC in Indianapolis, and she had been treated for an unusual psychiatric condition at Meridian Psychological Associates. The VA examiner relayed that, “she also appears to have some features that are suggestive of Posttraumatic Stress Disorder symptoms, but these do not lead definitively to the latter diagnosis.” The SSA examiner relayed a medical impression for recurrent and intermittent depression AND anxiety disorder, not otherwise specified. In September 2010, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured PTSD. At that time, the VA examiner noted that the Veteran’s symptoms did not satisfy the criteria for a PTSD diagnosis under the DSM-4. The VA examiner noted diagnoses for depression and somatoform disorder by history. At that time, the Veteran reported depressive symptoms that became problematic with infertility issues. In June 2011, the Veteran supplied sworn testimony to a Veterans’ Law Judge (VLJ) that is no longer with the Board. The Veteran testified that a SCUD missile struck within one mile of her location, and inside the military compound, while deployed. The Veteran testified that thunder and lightning took her back to the SCUD attack in Saudi Arabia. In August 2011, the Board addressed the Veteran’s claim for service connection for a psychiatric disorder, to include PTSD. At that time, the Board noted that the Veteran reported that infertility and gynecological issues were the source of the psychological symptoms during the September 2010 VA examination. The Board remanded the Veteran’s claim to obtain a VA examination report that addressed the Veteran’s secondary contention for this service connection claim. In May 2014, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured PTSD. At that time, the VA examiner reported that the Veteran did not satisfy the criteria for a PTSD diagnosis under the DSM-5. The VA examiner noted a diagnosis for an unspecified depressive disorder. The VA examiner opined that, “(t)he exact etiology and date of onset of the Vet's Unspecified Depressive Disorder cannot be determined without resorting to mere speculation, but it does not appear related to any events from the Vet's military service as she did not report any symptoms or seek treatment for a mental health condition until 2003, many years after her military service. The Veteran's Unspecified Depressive Disorder is less likely than not (less than 50 percent probability) ‘caused or aggravated by her service-connected gynecological disability’ as the Vet notes continuing depressive symptoms despite having successfully conceived and borne a child. While the Vet initially presented to mental health treatment in 2003 reporting excessive focus on her infertility and her strong belief that she would never be able to conceive a child due to infertility caused by exposure to uncertain toxins prior to her time in the Gulf, she has been able to give birth to a healthy child 8 years ago, yet still continues to report symptoms of depression. This makes it unlikely that her continued depressive symptoms are in any way ‘caused’ by her initial fears about infertility. While she noted today that she continues to have irregular menses, this problem appears to be well-managed with hormone therapy and there is no reason to suspect that her ongoing depressive symptoms are directly related to this condition. It should be noted that in many cases depression cannot be tied to a specific event or date of onset, and this appears to be the case with (the Veteran).” In August 2014, a statement from the Veteran was associated with the claims file. Therein, the Veteran relayed that, while deployed, she was in constant fear of, and exposure to, death. The Veteran relayed that she had recurring, vivid and disturbing dreams of her deployment. The Veteran relayed that thunder and lightning reminded her of airstrikes, which resulting in fear and defensiveness. In September 2017, the Board addressed the Veteran’s claim for service connection for an acquired psychiatric disability, to include PTSD. At that time, the Board remanded the Veteran’s claim for additional development. The Board found that the May 2014 VA examination report was not adequate. The Board remanded the Veteran’s claim for an addendum VA examination report. The Board relayed that the VA examiner should address the December 1990 report of depression in the STRs. In April 2019, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured mental disorders. The VA examiner reported that the Veteran did not meet the criteria for a diagnosis for a mental disorder under the DSM-5. When questioned about the December 1990 STR that indicated depression, the Veteran relayed that, “I was overwhelmed going to a foreign place, never been out of the country, would say scared, there was nobody, knew the people I was in the reserve with, but those weren't people that I knew, this took on a whole different meaning. . ..” The Veteran relayed that a SCUD missile struck within a mile of her location during the deployment. The Veteran relayed that there were times during the deployment that she did not know if she would see tomorrow. The VA examiner relayed that, “the veteran has not opined to meet criteria for a depressive disorder, with such clearly in remission, with her no longer needing or taking psych meds, and despite any recent MH dxs cited above, the veteran no longer endorses sxs suggesting the current presence of depression. The veteran clearly stated that the December 1990 endorsement of depression PRIOR TO ANY DEPLOYMENT was tied to her anticipation of the stress of having to go overseas and serve, and hence was determined to be a situational adjustment reaction to the demands of military service being placed on her, rather than the emergence of an actual full depressive disorder. Additionally, the veteran described a subsequent return from deployment where she went on to work, go out to clubs and socialize, have relationships, etc., which would not suggest that she was suffering from depression or other significant MH disorders in the intervening years. Hence, no mental disorders were found that could be opined to be secondary to her SC gynecological disability. The veteran likely did meet criteria for depression in the past, in the early to mid-2000s, tied to ongoing life distress at that time (was in abusive relationship, had legal problems per above, had ongoing fertility txs that eventually produced daughter in 2006, with none of these events tied to military service or any SC condition). ” The VA examiner relayed that, “PTSD is an easily feigned disorder, and the results of MMPI2RF assessment, along with inconsistencies found in cited MH records above, indicate it is unlikely for the veteran to suffer from this disorder.” During the claim period, the Board notes that a PTSD diagnosis has been reported in the Veteran’s treatment records. However, none of the references to PTSD have identified whether the treatment diagnosis was consistent with either the DSM-IV or DSM-V. See 38 C.F.R. § 4.125. Moreover, the August 2003, September 2010, May 2014, and April 2019 VA examiners relayed that the Veteran did not satisfy the DSM criteria for a PTSD diagnosis. Consequently, service connection for a PTSD disability is unavailable based on the evidence in the claims file. However, at various times during the claim period, the Veteran has been assigned DSM diagnoses for different acquired psychiatric conditions, to include depression, anxiety, and somatoform disorders. Consequently, the first requisite element for direct and secondary service connection has been substantiated. See Hickson, 12 Vet. App. at 253; Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. The Board observes that the Veteran’s STRs reflect that the she reported depression while on active duty in December 1990. Consequently, the secondary requisite element for direct service connection has been substantiate. See Hickson, 12 Vet. App. at 253. However, the Veteran’s direct service connection claim must be denied, because there is not a competently identified medical nexus between any currently endured depression and the pre-deployment depression identified in December 1990. The Board observes that the Veteran has been service connected for polycystic ovarian syndrome with endometriosis since December 1997. Consequently, the second requisite element for secondary service connection is substantiated. See Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. However, the Veteran’s secondary service connection claim must be denied, because the claims file does not contain a competently identified nexus between the Veteran’s service-connected gynecological disability and a diagnosed acquired psychiatric disorder. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran’s claim for service connection for an acquired psychiatric disability, to include PTSD. Since the preponderance of the evidence is against this claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran’s claim for service connection for an acquired psychiatric disability, to include PTSD must be denied, because the preponderance of the evidence weighs against her claim. REASONS FOR REMAND Upon review of the record, the Board concludes that further evidentiary development is necessary. Although the Board sincerely regrets this delay and is appreciative of the Veteran’s service to her country, a remand is necessary to ensure VA provides the Veteran with appropriate assistance in developing her claims prior to final adjudication. 1. Entitlement to service connection for anemia, to include as secondary to service-connected polycystic ovarian syndrome with endometriosis, is remanded. In March 2001, correspondence from the Veteran was associated with the claims file. Therein, the Veteran initiated a claim for service connection for anemia. The Veteran relayed that she endured heavy bleeding for a month or more at a time, which is abnormal. The Board notes that service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See id; Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or aggravated by, a service-connected disease or injury. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). The Board notes that the Veteran has been service connected for polycystic ovarian syndrome with endometriosis since February 2004. In January 2014, the Veteran’s treatment records from the Indianapolis VAMC were associated with the claims file. After review, the Board observes that the Veteran was prescribed iron supplements to treat anemia. In May 2014, the Veteran underwent a VA examination that addressed the severity of gynecological conditions. Important to this analysis, the VA examiner reported that the Veteran had not been diagnosed with anemia. In January 2019, the Veteran underwent a VA examination that addressed the severity of gynecological conditions. Important to this analysis, the VA examiner reported that the Veteran had not been diagnosed with anemia. In March 2020, the Veteran’s treatment records from the Roudebush VAMC were associated with the claims file. Therein, on multiple occasions, VA providers noted a diagnosis for anemia. In July 2020, the Veteran underwent a VA examination that addressed the severity of gynecological conditions. Important to this analysis, the VA examiner did not note a diagnosis for anemia. Moreover, the VA examiner did not report anemia caused by endometriosis. In August 2020, the Veteran supplied sworn testimony to the undersigned VLJ. At that time, the Veteran testified that she is currently treated for anemia with Vitamin B12. The Veteran’s representative relayed that the irregular and heavy menses that accompanies the service-connected ovarian disability could be the cause of anemia. The Board again notes that the May 2014, January 2019, and July 2020 VA examiners reported that the Veteran did not currently endure anemia. However, Board review of the Veteran’s medical treatment records reveal that anemia has been identified, and medications have been prescribed for treatment. Consequently, the Board finds that the previous VA examinations were not adequate for this analysis. On remand, the AOJ should secure a VA examination report that addresses the nature and etiology of any anemia currently endured by the Veteran. 2. Entitlement to compensation under the provisions of 38 U.S.C. § 1151 for abdominal scarring is remanded. In March 2001, correspondence from the Veteran was associated with the claims file. Therein, the Veteran initiated an entitlement claim for compensation for post-operative scar tissue, which resulted from surgeries performed “haphazardly” at a VA Medical Clinic (VAMC) in 2000. Under 38 U.S.C. § 1151, compensation is awarded for a “qualifying additional disability” in the same manner as if such additional disability or death were service connected. The purpose of the statute is to award benefits to those veterans who were disabled as a result of VA treatment or vocational rehabilitation. 38 U.S.C. § 1151 (a). To be considered a “qualifying additional disability,” a disability must meet two criteria. First, it must not be the result of the Veteran’s willful misconduct. Second, the disability must have been either: (a) caused by hospital care, medical or surgical treatment, or examination furnished to the Veteran under any law administered by the Secretary, either by a Department employee or in a Department facility, and the proximate cause of the disability was either (i) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or (ii) an event not reasonably foreseeable; or b) proximately caused by the provision of training and rehabilitation services by the Secretary as part of an approved rehabilitation program. Id. To determine whether the Veteran has an additional disability, VA compares the condition immediately before the beginning of the medical or surgical treatment upon which the claim is based to the condition after such treatment has stopped. 38 C.F.R. § 3.361 (b). In January 2014, the Veteran’s treatment records from the Indianapolis VA Medical Clinic (VAMC) were associated with the claims file. The records indicate that the Veteran underwent appendectomy surgery in May 1999 at the facility. The records also indicate that the Veteran underwent a bilateral breast reduction surgery in June 2003 at the facility. In July 2020, the Veteran underwent a VA examination that addressed scars/disfigurement. The Board notes that the VA examiner identified an umbilicus scar that followed endometrial resection and bilateral salpingectomy scars. The VA examiner noted that the scars were not painful or unstable. The Board observes that the VA examiner did not address the scars that resulted from the appendectomy or breast reduction, which were done at a VA facility. In August 2020, the Veteran supplied sworn testimony to the undersigned Veterans’ Law Judge (VLJ). The Veteran testified that she underwent an appendectomy. The Veteran testified that a provider has not relayed that the she has excessive scarring from surgeries performed at VA facilities. The Veteran testified that her bra rubs the skin of two of the surgical scars. The Veteran testified that she had eight to ten surgical scars, and they irritated her on some days (but not all). The Board notes that the Veteran has testified that the VA-generated surgical scars are irritating. The Veteran is competent to report this irritation. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). After deliberate review of the claims file, the Board observes that the Veteran was not afforded a VA examination in relation to her claim for compensation, under 38 U.S.C. § 1151, for the scars resulting from her VA-provided appendectomy and breast reduction surgeries. Before a well-reasoned decision can be rendered on this entitlement claim for compensation, a medically competent report is necessary. 3. Entitlement to service connection for disabilities of the lower back, right knee, an ulcer, appendectomy (with partial loss of intestines), a skin disability, migraine headaches, chronic fatigue syndrome (CFS), tuberculosis, insomnia, and a respiratory disease, to include tonsillitis, bronchitis, sinus problems, and sleep apnea, is remanded. In December 2001, correspondence was associated with the claims file. Thereby, the Veteran initiated a claim for service connection for tuberculosis. In June 2003 , the Veteran submitted a VA Form 21-4138. Thereby, the Veteran initiated claims for service connection for lower back, right knee, headache, sinusitis, thyroid problems, and stomach problems. In October 2007, the Veteran submitted an article that addressed illnesses that could be attributed to service in the Gulf War. In October 2008, the Veteran’s representative submitted correspondence. Thereby, the Veteran initiated claims for service connection for reactive airway disease. Service connection may be established for a Persian Gulf Veteran who exhibits objective indications of chronic disability which cannot be attributed to any known clinical diagnosis, but which instead results from an undiagnosed illness that became manifest either during active 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, 2016. 38 C.F.R. § 3.317 (a)(1)(i). See also 76 Fed. Reg. 81834 (Dec. 29, 2011). A Persian Gulf Veteran is one who served in the Southwest Asia theater of operations during the Persian Gulf War. Id. Objective indications of a 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. A disability referred to in this section shall be considered service-connected for the purposes of all laws in the United States. 38 C.F.R. §§ 3.317 (a)(2)-(5). Effective March 1, 2002, the law affecting compensation for disabilities occurring in Persian Gulf War Veterans was amended. 38 U.S.C. §§ 1117, 1118. Essentially, these changes revised the term “chronic disability” to “qualifying chronic disability,” and involved an expanded definition of “qualifying chronic disability” to include: (a) an undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 38 U.S.C. § 1117 (a)(2)(B); 38 C.F.R. § 3.317. 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, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii). With claims based on undiagnosed illness, the Veteran is not required to provide competent evidence linking a current disability to an event during service. Gutierrez v. Principi, 19 Vet. App. 1 (2004). Signs or symptoms that may be a manifestation of an undiagnosed illness or a chronic multi-symptom illness include: fatigue, unexplained rashes or other dermatological signs or symptoms, headache, muscle pain, joint pain, neurological signs and symptoms, neuropsychological signs or symptoms, signs or symptoms involving the upper or lower respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C. § 1117 (g); 38 C.F.R. § 3.317 (b). Section 1117(a) of Title 38 of the United States Code authorizes service connection on a presumptive basis only for disability arising in Persian Gulf Veterans due to “undiagnosed illness” and may not be construed to authorize presumptive service connection for any diagnosed illness, regardless of whether the diagnosis may be characterized as poorly defined. See VAOPGCPREC 8-98 (Aug. 3, 1998). Compensation may be paid under 38 C.F.R. § 3.317 for disability which cannot, based on the facts of the particular veteran’s case, be attributed to any known clinical diagnosis. The fact that the signs or symptoms exhibited by the veteran could conceivably be attributed to a known clinical diagnosis under other circumstances not presented in the particular veteran’s case does not preclude compensation under § 3.317. Id. Before assessing the merits of each individual claim, the Board finds that the Veteran is a “Persian Gulf Veteran” for VA compensation purposes. 38 U.S.C. § 1117. The Veteran served as a member of the United States Army, with active duty service during the Persian Gulf War. The Veteran’s DD 214 confirms that she served in Southwest Asia. As such, the Veteran is considered a Persian Gulf Veteran. In August 2020, the Veteran supplied sworn testimony to the undersigned VLJ. The Veteran testified that she served in Saudi Arabia during Desert Storm. The Veteran testified that she did not endure migraines before joining the military, and they developed during the Gulf War. The Veteran testified that she was treated for headaches during the Gulf War, and migraines have persisted after separation from active duty. The Veteran testified that she endured a calcium phosphate deposition disorder, and providers have not been able to identify the etiology. The Veteran testified that she has been treated for fatigue. The Veteran testified that she endured insomnia and sinus-related symptoms while serving in Saudi Arabia. The Veteran testified that she was exposed to the smoke from burn pits while in Saudi Arabia; she relayed that ash landed on her uniform. The Veteran testified that she had witnessed smoke from oil-well fires. The Veteran testified that she began having skin problems, respiratory problems, and sleep apnea after exposure to the burn pits and oil. The Veteran testified that she was not diagnosed with tuberculosis, but she did have a positive PPD. The Veteran relayed that she could not identify when she began having gastrointestinal problems. The Veteran testified that providers have prescribed different medications for insomnia; however, she remained fatigued throughout the day. The Board observes that the Veteran has not been afforded a VA examination for the symptoms reported during sworn testimony, and those medically reported during the claim period. Thus, the Board finds that a remand for a VA examination and opinion(s) is warranted. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board also notes that a medical opinion is warranted to determine whether the Veteran suffers from an unexplained chronic multi-symptom illness resulting in lower back, right knee, an ulcer disorder, appendectomy (with partial loss of intestines), a skin disability, migraine headaches, CFS, tuberculosis, insomnia, and respiratory disease problems associated with her Persian Gulf service. Accordingly, the AOJ should arrange for the Veteran to undergo a VA Gulf War examination by an appropriate physician. Consequently, the matters are REMANDED to the AOJ for the following action: 1. The Veteran should be scheduled for a VA examination with the appropriate physician, to determine the nature and etiology of any currently endured acquired anemia. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results, the examiner is requested to provide an opinion as to the following questions: (a) Does the Veteran currently have, or has she had at any time since March 2001 a disability manifested by anemia? (b) For any anemia (or disability manifested by anemia) identified is it at least as likely as not (i.e. a 50 percent probability or greater) that the anemia had its clinical onset during military service, or is otherwise related to the Veteran’s active duty service? (b) Is it at least as likely as not (i.e. a 50 percent probability or greater) that any anemia either currently present or present at any time since March 2001 was either (i) caused by or (ii) aggravated by the Veteran’s service-connected for polycystic ovarian syndrome with endometriosis? Governing regulations provide that service connection is permissible on a secondary basis if a claimed disability is proximately due, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310. The term aggravation is defined as any incremental increase in disability attributable to the service-connected disability, i.e., any additional impairment of earning capacity that is above the degree of disability existing before the increase, regardless of its permanence. See Ward v. Wilkie, No. 16-2157, 2019 U.S. App. Vet. Claims LEXIS 994 (June 14, 2019). If the examiner determines there has been aggravation, he or she should try and quantify the amount of additional disability the Veteran had, above and beyond that she had prior to the aggravation. It should be noted that the Veteran, is competent to attest to matters of which she has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the lay history provided by the Veteran, the examiner should provide a fully reasoned explanation. In the report, the VA examiner must specifically address the multiple notations for anemia in the Veteran’s post-service medical records. Explanations for all opinions must be provided. While providing the requested rationale, the examiner is asked to cite to the pertinent evidence of record, including clinical records and the Veteran’s statements regarding the onset of her anemia. 2. The claims file should be provided to an appropriate medical professional to render an opinion on the Veteran’s claim for compensation under 38 U.S.C. § 1151. The need for an examination of the Veteran is left to the discretion of the clinician selected to write the opinion. The examiner should offer an opinion on whether the proximate cause of the Veteran’s “irritating” surgical scars was: a) Carelessness; b) Negligence; c) Lack of proper skill; d) Error in judgment; e) Similar instance of fault on part of VA in furnishing the treatment (i.e., VA failed to exercise the degree of care that would be expected of a reasonable health care provider OR VA furnished the medical treatment without the Veteran’s informed consent for the entitlement claim listed on the title page); or f) An event not reasonably foreseeable. A rationale must be provided for the opinion offered and, if the requested opinion cannot be provided on a medical or scientific basis and without invoking processes relating to guesses or judgment based upon mere conjecture, the reviewing physician should clearly and specifically so specify and explain why this is so. 3. The Veteran should be scheduled for a VA examination with the appropriate physician, to determine the nature and etiology of any current lower back, right knee, ulcer disorder, appendectomy (with partial loss of intestines), skin disease, migraine headaches, CFS, tuberculosis, insomnia, and respiratory disease problems. The claims file, including a copy of this remand, must be made available to and reviewed by the examiner. The VA examiner should conduct all necessary testing to rule out a diagnosis for the claimed signs and symptoms for: lower back, right knee, ulcer disorder, appendectomy (with partial loss of intestines), skin disease, migraine headaches, CFS, tuberculosis, insomnia, and respiratory disease problems. The examiner should characterize the Veteran’s claimed disabilities as belonging to one of four disability patterns: (1) undiagnosed illness, (2) a diagnosable, but medically unexplained chronic multisymptom illness of unknown etiology, (3) a diagnosable chronic, multisymptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology. With regard to any diagnosed disorder, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current disability is related to service, to include the Veteran’s service in the Persian Gulf. The examiner must provide a complete rationale for all opinions expressed. As part of this rationale, the examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). A discussion of the facts and medical principles involved would be of considerable assistance to the Board. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results, the examiner is requested to provide an opinion as to the following questions: (a) Is it at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s lower back, right knee, ulcer disorder, appendectomy (with partial loss of intestines), skin disease, migraine headaches, CFS, tuberculosis, insomnia, and respiratory disease problems had their/its clinical onset during military service, or is otherwise related to her active duty service? (b) Is at least as likely as not (i.e. a 50 percent or greater probability) that the Veteran’s lower back, right knee, ulcer disorder, appendectomy (with partial loss of intestines), skin disease, migraine headaches, CFS, tuberculosis, insomnia, and respiratory disease problems are part of a diagnosable, but medically unexplained chronic multisymptom illness of unknown etiology? It should be noted that the Veteran, is competent to attest to matters of which she has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the lay history provided by the Veteran, the examiner should provide a fully reasoned explanation. 4. After completing any other development that may be warranted, the AOJ should readjudicate the claims on appeal. If the benefits sought are not granted, the Veteran and her representative must be given a supplemental statement of the case (SSOC) and a reasonable   opportunity to respond before the record is returned to the Board. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board RLBJ, 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.