Citation Nr: 21029311 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 15-23 364A DATE: May 13, 2021 REMANDED Entitlement to service connection for chronic fatigue syndrome (CFS), also claimed as fatigue due to an undiagnosed illness, is remanded. REASONS FOR REMAND The Veteran had active military service from May 1988 to July 1998, with a tour of duty in the Persian Gulf from August 1990 to April 1991. This matter came before the Board of Veterans' Appeals (Board) on appeal from a July 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). By way of background, in March 2019, the Board granted the Veteran's petition to reopen his claim for entitlement to service connection for CFS; granted the Veteran's claim for entitlement to service connection for obstructive sleep apnea; and remanded the issues of entitlement to service connection for CFS and type II diabetes mellitus. During the appeal process, in an April 2020 rating decision, the Veteran was granted service connection for diabetes mellitus. As such, the only issue on appeal is entitlement to service connection for CFS. The Board finds that additional development is needed before the Veteran's claim can be decided, as the Board finds that VA did not substantially comply with the March 2019 Board remand order. Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for CFS, also claimed as fatigue due to an undiagnosed illness, is remanded. At the outset, the Board notes that in a July 2012 VA treatment record the Veteran was diagnosed with chronic fatigue syndrome in April 2001. See March 2015 CAPRI. A review of the service treatment records (STRs) shows that the Veteran complained of fatigue. Specifically, in an October 1997 Gulf War evaluation, the Veteran endorsed having chronic fatigue. The Veteran stated that on average he gets about six hours of sleep at night. In a November 1997 STR, the Veteran again endorsed having chronic fatigue. In a January 1998 STR, the Veteran stated that it did not matter how much sleep he got as he would wake up mentally exhausted and physically rested but tired. In a March 1998 STR, the Veteran complained of chronic fatigue and endorsed having frequent trouble sleeping. Within the first year after discharge, the Veteran sought treatment for his fatigue. In a January 1999 VA treatment record, the Veteran was diagnosed with fatigue. See October 1999 Medical Treatment Record Government Facility. In a March 1999 VA treatment record, the Veteran stated that his fatigue started around April 1994. In the June 1999 VA examination, the Veteran stated that he suffered with insomnia manifested by frequent awakenings associated with vivid dreams for the past five years. He reported that he wakes up tired, but he is able to get through the day despite awareness of mental fatigue. The Veteran recalled that his fatigue manifested around 1993 or 1994 after returning from Panama. The examiner noted that the Veteran has facial appearance of chronic fatigue. The examiner diagnosed the Veteran with chronic insomnia. In a February 2000 VA treatment record, the Veteran was diagnosed with fatigue syndrome with undetermined etiology. It was noted that the Veteran was examined extensively under the Gulf War Syndrome. The Veteran recalled that he saw a number of specialists, but it was determined that all of the symptoms he produced were not explainable on the basis of various disease processes. After some two years of testing and evaluation, the examiners could not come up with a reason to account for his symptomatology. In a July 2000 VA treatment record, it was noted that his continuous positive airway pressure (CPAP) machine was not effective for his fatigue syndrome after a 90-day trial. See January 2001 Medical Treatment Record Government Facility. In an April 2001 VA treatment record, the Veteran stated that he has symptoms of chronic fatigue and that a CPAP machine did not provide any significant relief of symptoms. See September 2001 Medical Treatment Record Government Facility. In the July 2012 VA examination for sleep apnea, the examiner noted that the Veteran has chronic fatigue which is attributable to sleep apnea. In March 2019, the Board remanded the issue as the evidence of record did not clearly indicate whether the Veteran's complaints of chronic fatigue are indicative of undiagnosed illness or chronic multi-symptom illness of the type contemplated by 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 or whether these symptoms are instead attributable to known clinical diagnoses. Pursuant to the March 2019 Board remand order, the Veteran was afforded another VA examination in February 2020. In the February 2020 VA examination, the examiner determined that the Veteran did not have a current diagnosis of chronic fatigue syndrome. The examiner stated that there is no objective evidence of chronic fatigue syndrome. The examiner also marked "N/A" on whether the Veteran has an undiagnosed illness; a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology; a diagnosable chronic multi-symptom illness with a partially explained etiology; or a disease with a clear and specific etiology and diagnosis. In the March 2020 Gulf War examination, the same examiner determined that there are no diagnosed illnesses for which no etiology was established. The examiner also determined that there are no additional signs and/or symptoms that may represent an 'undiagnosed illness' or 'diagnosed medically unexplained chronic multi symptom illness." The Board finds that the February 2020 and March 2020 VA examinations lack rationale and appear inconsistent with the records. As noted above, the Veteran consistently endorsed being fatigued in service and after service. The Veteran is service connected for obstructive sleep apnea but stated that a use of a CPAP machine does not alleviate his fatigue. As there was no meaningful rationale, the Board finds that a remand is warranted in order to obtain further clarification. The matter is REMANDED for the following action: 1. Obtain an addendum medical opinion from an appropriately qualified examiner to determine the nature and etiology of the Veteran's complaints of fatigue. The claims file, including a copy of this remand, must be made available to be reviewed by the examiner. a. The examiner must specify whether the Veteran's complaints of chronic fatigue are indicative of undiagnosed illness or chronic multi-symptom illness of the type contemplated by 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. To this end, specifically indicate whether these symptoms, instead, are attributable to known clinical diagnoses. The examiner should note that in a July 2012 VA treatment record indicated that the Veteran was diagnosed with chronic fatigue syndrome in April 2001. See March 2015 CAPRI. b. If the Veteran's chronic fatigue cannot be ascribed to any known clinical diagnosis, specify whether he has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that has either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. c. If the Veteran's fatigue disability can be ascribed to a known clinical diagnosis, for each diagnosis, the examiner is asked to address whether it is at least as likely as not (a 50 percent or greater probability) that the diagnosed disability was (i) incurred in service, or is otherwise etiologically related to service, or (ii) is caused by a service-connected disability, or (iii) aggravated by a service-connected disability. d. The examiner should also opine as to whether it is at least as likely as not that any fatigue is part of, or encompassed by his service-connected sleep apnea. (Continued on the next page) A full and complete rationale for all opinions expressed must be provided. If the examiner is unable to offer any of the requested opinions, a rationale should be provided for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Noh, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.