Citation Nr: 21025057 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 13-25 987 DATE: April 27, 2021 ORDER Entitlement to service connection for hypogeusia, claimed as residuals of oral surgery, is granted. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for a bilateral shoulder strain, claimed as joint pain, to include as a manifestation of an undiagnosed illness or a medically unexplained chronic multi-symptom illness (MUCMI), is denied. Entitlement to service connection for a bilateral wrist strain, claimed as joint pain, to include as a manifestation of an undiagnosed illness or a MUCMI, is denied. Entitlement to service connection for a bilateral ankle disability, claimed as joint pain, to include as a manifestation of an undiagnosed illness or a MUCMI, is denied. Entitlement to service connection for a bilateral elbow disability, claimed as joint pain, to include as a manifestation of an undiagnosed illness or a MUCMI, is denied. REMANDED Entitlement to service connection for hypertension, to include as due to exposure to environmental hazards, is remanded. Entitlement to service connection for a low back disability, claimed as joint pain, to include as a manifestation of an undiagnosed illness or a MUCMI, is remanded. Entitlement to service connection for cervical spine disability, claimed as joint pain, to include as a manifestation of an undiagnosed illness or a MUCMI, is remanded. Entitlement to service connection for a disability of the toes, claimed as joint pain, to include as a manifestation of an undiagnosed illness or a MUCMI, is remanded. FINDINGS OF FACT 1. The Veteran’s hypogeusia is etiologically due to his in-service oral surgery. 2. The Veteran does not have a current bilateral hearing loss disability, as defined by VA regulations. 3. The Veteran’s bilateral shoulder joint pain has been attributed to a known clinical diagnosis of bilateral shoulder strain, and the evidence does not show that a bilateral shoulder strain is a manifestation of an undiagnosed illness or a MUCMI, or is otherwise causally or etiologically due to service. 4. The Veteran’s bilateral wrist joint pain has been attributed to a known clinical diagnosis of bilateral wrist strain, and the evidence does not show that a bilateral wrist strain is a manifestation of an undiagnosed illness or a MUCMI, or is otherwise causally or etiologically due to service. 5. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a bilateral ankle disability, to include as a manifestation of an undiagnosed illness or a MUCMI. 6. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a bilateral elbow disability, to include as a manifestation of an undiagnosed illness or a MUCMI. CONCLUSIONS OF LAW 1. The criteria for service connection for hypogeusia, claimed as residuals of oral surgery, other than hyposmia and a sinus disorder, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. 3. The criteria for service connection for a bilateral shoulder strain, claimed as joint pain, to include as a manifestation of an undiagnosed illness or a MUCMI, are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 4. The criteria for service connection for a bilateral wrist strain, claimed as joint pain, to include as a manifestation of an undiagnosed illness or a MUCMI, are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 5. The criteria for service connection for a bilateral ankle disability, claimed as joint pain, to include as a manifestation of an undiagnosed illness or a MUCMI, are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 6. The criteria for service connection for a bilateral elbow disability, claimed as joint pain, to include as a manifestation of an undiagnosed illness or a MUCMI, are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from August 1987 to August 1990 and November 1990 to June 1991, with additional service in the Army Reserves. The Veteran had service in Southwest Asia from January 1991 to May 1991. This matter comes before the Board of Veterans’ Appeals (BVA or Board) from March 2011 and June 2011 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a hearing before the Board. The requested hearing was conducted in August 2016 by the undersigned Veterans Law Judge. A transcript is associated with the claims file. In March 2018, the Board granted the issues of entitlement to service connection for irritable bowel syndrome, hyposmia, eczema of the bilateral lower extremities, gastroesophageal reflux disease, and headaches, which were effectuated in a March 2019 rating decision. In the March 2018 decision, the Board also remanded the claims of entitlement to service connection for hypertension, residuals of oral surgery other than hyposmia and a sinus disorder, joint pain, a bilateral knee disability, bilateral hearing loss, tinnitus, and a sinus disability for additional development. In a June 2020 rating decision, the issues of entitlement to service connection for a bilateral knee disability, tinnitus, chronic sinusitis, and a bilateral hip disability, were granted; as such, these issues are no longer before the Board. The Board notes that the majority of the Veteran’s service treatment records are unavailable. See January 2011 Memorandum. The Board recognizes that in such cases where service records are missing, there is a heightened obligation to assist the Veteran in the development of his case, a heightened obligation to explain findings and conclusions, and a heightened duty to consider carefully the benefit of the doubt rule. Service Connection The Veteran seeks entitlement to service connection for residuals of oral surgery, bilateral hearing loss, and joint pain. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be granted for a Persian Gulf Veteran with objective indications of a qualifying chronic disability that manifested either during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). A qualifying chronic disability is a chronic disability that may result from an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317(a)(2)(i). The term chronic means that the disability has existed for 6 months or more, to include intermittent episodes of improvement or worsening over that period. 38 C.F.R. § 3.317(a)(4). Here, the Veteran had active service in Southwest Asia from January 1991 to May 1991. Therefore, he is considered a Persian Gulf Veteran. 38 C.F.R. § 3.317(e). 1. Entitlement to service connection for residuals of oral surgery, other than hyposmia and a sinus disability. The Veteran seeks entitlement to service connection for residuals of oral surgery. He asserts the residuals he suffers from are loss of sense of smell, loss of sense of taste and sinus problems. The Veteran is currently service connected for loss of sense of smell as well as chronic sinusitis. First, the Board notes the Veteran is diagnosed with loss of sense of taste, or hypogeusia. See December 2019 VA examination. As noted in the December 2019 VA examination, service records indicate the Veteran had tooth #6 extracted in 1990, with post-operative notes indicating there was some nerve injury during the procedure. The December 2019 VA examiner stated that there is a radiolucency on the PAN image that is consistent with the extraction of impacted #6, which leads to the conclusion that the outcome is 50 percent or greater probability related to the in-service oral surgery treatment and post-surgical outcome of the Veteran not being able to smell or partially taste due to the extraction taking place in close proximity to the nasal cavity. The examiner opined that the Veteran’s anosmia and hypogeusia are due to nerve damage from the surgical procedure of extraction of impaction of #6. Based on the evidence of record, the Board finds that service connection for loss of sense of taste, or hypogeusia, is established. The Veteran has a current diagnosis, an in-service injury, and a medical opinion linking the Veteran’s diagnosis to his in-service injury. The Board acknowledges that this issue was not included in the June 2020 supplemental statement of the case. As noted, however, the Veteran reported his current residuals are loss of sense of smell, loss of sense of taste and sinus problems. Given that the Veteran is currently service connected for loss of sense of smell (anosmia), and chronic sinusitis, the Board finds the Veteran is not prejudiced by adjudication of this appeal in that the grant of service connection for loss of sense of taste in this decision is a complete grant of the benefits sought on appeal. 2. Entitlement to service connection for bilateral hearing loss. The Veteran seeks entitlement to service connection for bilateral hearing loss. For purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies at 500, 1000, 2000, 3000, and 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. First, as noted in the July 2013 statement of the case, it is conceded that the Veteran was potentially exposed to hazardous noise during active service due to his military occupation specialty (MOS) as a petroleum supply specialist. It was also noted that the Veteran served in the Gulf War Theater where there was a high probability of loud noise exposure. Unfortunately, the medical evidence of record does not demonstrate the Veteran has a current bilateral hearing loss disability, as defined by VA regulations. An April 2010 private treatment note states an audiogram was completed at a prior visit, which was normal. Although he was diagnosed with tinnitus, the physician stated that the audiogram did not show any significant hearing loss. The Veteran was afforded a VA examination in February 2011. The Veteran stated he had no perception of hearing loss. An audiogram revealed clinically normal hearing and word recognition abilities were judged to be excellent/normal, bilaterally. The examiner stated that the Veteran’s hearing was within normal limits. The Veteran was afforded a VA examination in October 2019. After examination, the Veteran was noted to have normal hearing, bilaterally. The Board notes the Veteran submitted a private medical opinion, dated March 2018, which opined that the Veteran’s hearing loss was caused or incurred due to acoustic trauma related to his military occupation specialty. The Board also acknowledges that an in-service hearing test revealed some hearing loss. Although the private physician opined that the Veteran’s hearing loss is due to service, unfortunately, post-service examination results do not indicate that the Veteran’s bilateral hearing loss is of the severity to be considered a hearing loss disability, as defined by VA regulations. As such, the Board finds that the Veteran does not have a diagnosis of bilateral hearing loss for VA purposes. There are no audiological evaluations of record that demonstrate a bilateral hearing loss, as defined by VA regulations. Full consideration has been given to the Veteran’s assertions. Although lay persons are competent to provide opinions on some medical issues, the specific issue in this case, the presence of a hearing loss disability for VA purposes, falls outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). Although the Veteran is competent and credible to report diminished hearing, he is not competent to report specific results of audiometric and word recognition testing, as required by 38 C.F.R. § 3.385. Nor is there any indication he is competent to provide a diagnosis of sensorineural hearing loss, or that he received any special training or acquired medical expertise in evaluating hearing disorders. King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Thus, the Board finds the medical evidence of record, including audiometric and speech recognition testing, is of greater probative value than the Veteran’s lay statements. As the competent, credible medical evidence of record shows that the Veteran does not have a post-service diagnosis of a bilateral hearing loss disability as defined by VA regulations at any time during the current appeal, the preponderance of the evidence weighs against the claim and it must be denied. 3. Entitlement to service connection for joint pain. The Veteran asserts he experiences multiple joint pain as a result of his time in service. The Veteran specified that he experiences widespread joint pain in his bilateral shoulders, wrists, ankles, and elbows. See December 2019 VA examination. A. Bilateral Shoulder Strain B. Bilateral Wrist Strain Regarding the Veteran’s claims of bilateral shoulder and bilateral wrist pain, February 2011 and December 2019 VA examinations show the Veteran has diagnoses of a bilateral shoulder strain and a bilateral wrist strain. As these are diagnosed conditions, they cannot be considered an undiagnosed illness, but they are eligible for consideration as a MUCMI. 38 C.F.R. § 3.317(a)(1)(ii), (a)(2)(ii). The term MUCMI refers to 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. 38 C.F.R. § 3.317 (a)(2)(ii). A multi symptom illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive. Stewart v. Wilkie, 30 Vet. App. 383, 389-90 (2018). A multi symptom illness is not a MUCMI where both the etiology and the pathophysiology of the illness are partially understood. Id. The determination of whether a MUCMI is “medically unexplained,” that is, the etiology and pathophysiology of the multi symptom illness, must be particular to the claimant’s case. Id. at 291. In connection with his claims, the Veteran was afforded a VA examination in February 2011, at which time he was diagnosed with a bilateral shoulder strain. The examiner noted that the currently available service treatment records are silent for any shoulder symptoms, including a reserve examination from October 2004, on which the Veteran checked no to any joint problems and he had a normal musculoskeletal examination. The examiner stated that although environmental exposures associated with Southwest Asia deployment can cause temporary joint symptoms and chronic joint conditions, the current medical literature does not support a cause and effect relationship between these exposures and individual joint conditions, such as a shoulder strain. The examiner opined that there is no current objective evidence that any bilateral shoulder strain could have been caused or aggravated to any degree by his environmental exposures during deployment. In December 2019, after examination, the Veteran was diagnosed with a bilateral wrist strain. The examiner specifically stated that the Veteran’s bilateral wrist strain is a disease with clear and specific etiology and diagnosis. The examiner explained that muscular strains are often a result of physical activity that leads to mechanical trauma or injury, and chronic overuse or injury leads to overstretching of the tendons and muscles leading to tears and inflammation, affecting the area in question. The examiner stated that while taking into consideration that the majority of the Veteran's service treatment records are missing and the Veteran has not been treated for a bilateral wrist condition since leaving the military, it is less likely than not that the Veteran's current claimed wrist condition with joint pain is etiologically related to the Veteran's active service, to include environmental exposures. In December 2019, a VA examiner opined that due to the mild nature of the left shoulder condition and the lack of chronic treatment for a left shoulder condition, it is less likely than not that the Veteran's diagnosed condition of left shoulder strain is due to or incurred in or caused by the Veteran's active duty service, to include environmental exposures. Regarding the right shoulder, the examiner noted that the majority of the Veteran's medical records are missing, however, the Veteran has not sought treatment for a right shoulder condition since leaving the military. The examiner stated that the physical exam performed was essentially normal, with minimal decreased range of motion, which is normal for the Veteran's age and body habitus. Therefore, due to the lack of objective evidence of a right shoulder condition it is less likely than not that the Veteran's claimed right shoulder condition was incurred in or caused by active duty service, to include environmental exposure. Here, the VA opinions of record find that the Veteran’s strains of the bilateral shoulders and bilateral wrists are disorders with a clear and specific etiology and diagnosis. The Board gives these opinions great probative weight as the examiners reviewed the medical record, examined the Veteran, and supported their opinions with information found in the medical record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Accordingly, as both the etiology and the pathophysiology of the Veteran’s bilateral shoulder strain and bilateral wrist strain are fully understood, they are not considered a MUCMI and presumptive service connection is not warranted. 38 C.F.R. § 3.317. Although service connection based on Gulf War exposure is not warranted on a presumptive basis, service connection may still be established by proof of direct causation. See Combee v. Brown, 34 F.3d at 1042. The Board notes that the Veteran specifically asserts that his joint pains are due to exposure to environmental hazards. See July 2016 BVA Hearing Transcript, page 9. Here, the available service treatment records do not indicate any joint problems, however, as exposure to Gulf War environmental hazards has been found on the record, this may serve as an in-service injury, disease, or event. The question then becomes whether there is a nexus between the Veteran’s claimed conditions and his exposure. In this case, apart from the Veteran’s lay statements, there is no evidence of record that tends to associate his bilateral shoulder strain and bilateral wrist strain with such exposure. The Board notes that the Veteran has not asserted he suffered any physical injuries to the shoulders or wrists during service. While the Veteran is competent to provide statements regarding what he has experienced, he is not competent to relate his current symptoms to exposure to environmental toxins, as that is an inherently medical question, involving the interaction of complex body systems with complex chemicals. The Board finds that a correlation is beyond the competence of any lay person. Therefore, the Veteran’s opinion as to a nexus is afforded no probative value. Without competent evidence of a nexus, direct service connection, to include as due to Gulf War exposures, must be denied. In light of the above, the preponderance of the evidence is against the claims and the benefit-of-the-doubt doctrine is not for application. C. Bilateral Ankle Pain D. Bilateral Elbow Pain The Veteran asserts he suffers from bilateral ankle and bilateral elbow pain. Unfortunately, the preponderance of the evidence indicates the Veteran is not diagnosed with a disability manifested by bilateral ankle and bilateral elbow pain. The Veteran was afforded a VA examination in December 2019, at which time he reported symptoms of bilateral ankle pain and bilateral elbow pain. It was noted that he denied injury or trauma to his ankles or elbows but attributed his symptoms to “Airborne.” However, there was no objective evidence of any ankle or elbow disability. The examiner specifically noted that despite subjective reports of pain and functional impairment, the Veteran did not have any ankle or elbow disorder. The examiner stated that due to the lack of current evidence of a left or right ankle condition in the Veteran’s current medical records and the normal bilateral ankle physical examination with no objective evidence of pain, decreased range of motion, instability or functional loss, no diagnosis is warranted; all reports of pain and functional loss are subjective in nature with no objective evidence of the claimed disorders. Similarly, the examiner stated that physical examination of the left and right elbows did reveal a slightly decreased range of motion, however, it was normal for the Veteran and of no clinical significance. The examiner stated that although the Veteran reported intermittent pain, flare ups, and functional loss, these claims are subjective in nature and there was no objective evidence of pain or functional loss during the exam; therefore, no diagnosis is warranted. As noted, service connection can also be awarded for certain disabilities occurring in Persian Gulf Veterans. 38 C.F.R. § 3.317. However, one of the requirements for service connection under that regulation is that indications of a qualifying chronic disability, which could include joint pain, must manifest to a degree of 10 percent or more. 38 C.F.R. § 3.317 (a)(1)(i). The December 2019 VA examiner specifically noted that the Veteran had no findings, signs, or symptoms attributable to a diagnosis of a fibromyalgia. Additionally, in this case, the Veteran was noted to have a normal range of motion of the ankles and elbows during examination, with no objective functional impairment; these results would not warrant compensable ratings based on the criteria for rating the ankles and elbows. See 38 C.F.R. § 4.71a, Diagnostic Codes 5205-5213, 5270-5274. A compensable rating can also be awarded based on painful motion of the joint. 38 C.F.R. § 4.59. However, at the examination the examiner specifically noted there was no objective evidence of painful motion. While the Veteran asserts pain, pain alone does not constitute functional loss, but is just one fact to be considered when evaluating functional impairment. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). There is no credible persuasive evidence that the Veteran suffers from pain that affects some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance that constitutes functional loss. As the Veteran’s joint pain has not manifested to a degree of 10 percent or more, service connection cannot be awarded under 38 C.F.R. § 3.317. The Board has considered the Veteran’s arguments. The Board notes that the Veteran is competent to give evidence about what he experiences; for example, he is competent to discuss current pain and other experienced symptoms. See Layno v. Brown, 6 Vet. App. 465 (1994). However, because no functional impairment has been demonstrated, there are no post-service diagnoses of a disability manifested by pain of the bilateral ankles and bilateral elbows, and the Veteran’s symptoms have not manifested to a degree of 10 percent, the Board finds that the Veteran does not have a current disability of the bilateral ankles or bilateral elbows. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (holding that a “disability” under 38 U.S.C. § 1110 refers to functional impairment of earning capacity). The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. §§ 1110, 1131; see also 38 C.F.R. §§ 3.303, 3.304. Thus, as no disability or functional impairment is shown, there can be no valid claim for service connection. In the absence of a disability, the other elements of service connection need not be discussed, and service connection must be denied for joint pain of the bilateral ankles and bilateral elbows. REASONS FOR REMAND 4. Entitlement to service connection for hypertension, to include as due to exposure to environmental hazards. The Veteran has a current diagnosis of hypertension and asserts that his hypertension is due to exposure to environmental hazards. The Board notes that in addition to environmental hazards such as oil well fire smoke, there is evidence the Veteran was exposed to hydrogen sulfide. To date, a medical opinion has not yet been obtained as to whether the Veteran’s diagnosed hypertension is causally or etiologically due to his time in service, to include exposure to environmental hazards and/or hydrogen sulfide. On remand, a medical opinion should be obtained. 5. Entitlement to service connection for a low back disability, claimed as joint pain, to include as a manifestation of an undiagnosed illness or a MUCMI. 6. Entitlement to service connection for a cervical spine disability, claimed as joint pain, to include as a manifestation of an undiagnosed illness or a MUCMI. 7. Entitlement to service connection for a disability of the toes, claimed as joint pain, to include as a manifestation of an undiagnosed illness or a MUCMI. As noted, the Veteran asserts that he experiences widespread joint pain. He specified during the December 2019 VA examination that this joint pain included his low back and neck, and during an August 2016 BVA Hearing, he indicated he experienced joint pain in the toes of his feet. To date, the Veteran has not yet been afforded VA examinations for these joints. On remand, the Veteran should be afforded VA examinations and medical opinions must be obtained. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated treatment records. 2. Obtain an addendum opinion for the Veteran’s hypertension. The examiner is requested to review all pertinent records associated with the claims file. The examiner should state that the claims file was reviewed. The examiner should respond to the following: Please identify the likely cause for the Veteran’s hypertension. Specifically, is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s hypertension had its onset during service or within a year after discharge, or is any way causally or etiologically related to his active service, to include exposure to environmental hazards, hydrogen sulfide and/or as due to an undiagnosed illness? A detailed explanation (rationale) is requested for all opinions provided, citing to supporting clinical data and/or medical literature, as appropriate. 3. Afford the Veteran VA examinations for his claimed low back pain, cervical spine pain, and bilateral foot (toe) pain. The examiner must review the entire claims file, including a copy of this remand. The examiner should conduct all appropriate diagnostic testing. The examiner should then record all noted signs and reported symptoms, document all clinical findings, and provide diagnoses if possible. The examiner is asked to provide responses to the following: A) Identify the Veteran’s objective indications of a disability. “Objective indications” of a qualifying chronic disability include both objective evidence perceptible to an examining physician and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Non-medical indicators include evidence such as time lost form work, the Veteran having sought treatment for his symptoms, and change in the Veteran’s appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995). B) By history, physical examination, or laboratory testing, can the Veteran’s objective indications of a disability be attributed to a known clinical diagnosis? If the signs and symptoms are not characteristic of a known clinical diagnosis, the examiner should so indicate. There is no requirement that the examiner provide a diagnosis of undiagnosed illness. C) If the Veteran’s objective indications cannot be attributed to a known clinical diagnosis, is there affirmative evidence that the undiagnosed illness is not incurred during active service during the Persian Gulf War or that it was caused by a supervening condition or event that occurred since the Veteran’s departure from service during the Persian Gulf War? The examiner should note that a positive response to this question requires affirmative evidence. The mere absence of evidence is not sufficient. D) If the Veteran’s objective indications can be attributed to a known clinical diagnosis, is the etiology of the Veteran’s condition (1) inconclusive, (2) partially understood, or (3) fully understood? This determination as to each must be based on the Veteran’s specific case and cannot be based on the etiology of the disease or disability population as a whole. E) If the Veteran’s objective indications can be attributed to a known clinical diagnosis, is the pathophysiology of the Veteran’s condition (1) inconclusive, (2) partially understood, or (3) fully understood? This determination as to each must be based on the Veteran’s specific case and cannot be based on the pathophysiology of the disease or disability population as a whole. F) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s diagnosed condition(s) was incurred in, or is otherwise related to, his active service, to include performing jumps as a parachutist? A complete rationale must be provided for all opinions expressed. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Andersen, 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.