Citation Nr: 21040452 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 16-63 045 DATE: July 3, 2021 REMANDED Entitlement to service connection for chronic fatigue syndrome is remanded. Entitlement to service connection for narcolepsy is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1976 to June 1979 and from January 1991 to June 1991, to include service in the Southwest Asia theater of operations during the Gulf War Era. These matters were last before the Board in February 2021, whereupon they were remanded to the Agency of Original Jurisdiction (AOJ) for further development of the record. Following the issuance of an April 2021 supplemental statement of the case continuing the denial of both claims, the case was returned to the Board for its adjudication. 1. Entitlement to service connection for chronic fatigue syndrome is remanded. The Board in its prior February 2021 remand instructed the AOJ to schedule the Veteran for an examination in order to determine a diagnosis or diagnoses that would account for his claimed symptomatology, to include chronic fatigue, headaches, muscle and joint soreness, and daytime somnolence. That Board remand specified that the chosen examiner was to reconcile any determination as to a diagnosis with the Veteran's history of medical treatment for both narcolepsy and chronic fatigue syndrome. In addition, the AOJ was directed to secure an opinion responsive to a series of questions intended to ascertain whether any such diagnosis or diagnoses was attributable to service, with specific instructions to evaluate the likelihood that a diagnosed condition was caused by the Veteran's exposure to environmental and chemical hazards during service. In an April 2021 VA examination, the examiner declined to endorse a diagnosis of chronic fatigue syndrome, instead finding that all of the Veteran's symptomatology was accounted for by his separately diagnosed obstructive sleep apnea. Other findings included that the Veteran did not require the use of medication for control of claimed chronic fatigue syndrome as well as a finding that sleep apnea and narcolepsy were possible alternative etiological causes of the Veteran's symptomatology. As a clarification, the examiner acknowledged that the Veteran was prescribed methylphenidate for relief of daytime hypersomnolence and fatigue but noted that the drug had not been prescribed specifically for the treatment of chronic fatigue syndrome. In a separate document also dated in April 2021, the VA examiner further stated that the Veteran's symptoms were better explained by the separately diagnosed obstructive sleep apnea. However, the examiner did not offer any rationale for this conclusion. The Board in its prior remand instructions highlighted numerous discrepancies with a prior June 2015 VA examination in which it was also determined that the Veteran's symptomatology was wholly attributable to the Veteran's separately diagnosed obstructive sleep apnea. First, the Veteran's physicians have on multiple occasions found that the sleep apnea was caused by the Veteran's obesity despite the fact that he has last considerable weight since being diagnosed with sleep apnea and his symptomatology has persisted. Moreover, his symptomatology has persisted even though he reports consistent nighttime use of his prescribed continuous positive airway pressure (CPAP) machine. In addition, the Board noted that the Veteran was diagnosed with chronic fatigue syndrome as recently as in a November 2017 evaluation through VA. The examiner did not address these discrepancies in either April 2021 examination document uploaded to the Veteran's claim file. Without a diagnostic evaluation supported by a clear rationale, the Board cannot proceed with its adjudication of this appeal. The examiner's perfunctory dismissal of the chronic fatigue diagnosis did not take into account the Veteran's medical history, to include the progression of his sleep apnea and the symptomatology noted above; moreover, the examiner did not even discuss the prior diagnosis of chronic fatigue syndrome from November 2017. As such, remand is necessary in order to secure an addendum examination and opinion addressing all of the queries outlined in the prior remand instructions, which are copied in large part below. 2. Entitlement to service connection for narcolepsy is remanded. For many of the same reasons detailed in the previous section, the Board finds that the appeal seeking service connection for narcolepsy must also be remanded. Specifically, the Board notes that the Veteran has been treated for both narcolepsy and obstructive sleep apnea concurrently for many years due to the fact that a series of sleep studies and other tests reflect that he has several of the markers for a narcolepsy diagnosis in addition to his diagnosed obstructive sleep apnea. As stated above, the Board in its February 2021 remand instructions highlighted that the Veteran's claimed symptomatology has continued throughout the appeal period despite the fact that his sleep apnea was considered to have been caused by his obesity, and he has lost significant weight since he was diagnosed with the condition. While the April 2021 examiner dismissed a diagnosis of narcolepsy on the grounds that the symptoms of the condition were wholly accounted for by the separately diagnosed sleep apnea, the examiner did not address the fact that the Veteran lost significant weight during the appeal period. The examiner also did not discuss the longstanding history of concurrent diagnoses of both sleep apnea and narcolepsy. Indeed, the examiner offered little rationale whatsoever to support the dismissal of the narcolepsy diagnosis. Accordingly, remand is necessary in order to secure an addendum examination and opinion that addresses all of the queries outlined in the prior remand instructions, which are copied in large part below. The matters are REMANDED for the following action: Schedule the Veteran for a VA medical examination to evaluate the nature and likely etiology of his claimed narcolepsy and chronic fatigue syndrome conditions. The electronic claims file and any other information deemed pertinent must be provided to and reviewed by the examiner, who must address the following matters: A) First, please determine whether there is a diagnosable disability and/or disabilities to account for the Veteran's reported daytime somnolence and chronic fatigue symptomatology. The examiner is specifically asked to identify whether the Veteran has diagnosable narcolepsy. Furthermore, regardless of whether narcolepsy is deemed to be diagnosable, the examiner must also identify whether the Veteran has chronic fatigue syndrome that is a distinct disease pattern or whether the Veteran's documented daytime fatigue is a symptom of other diagnosed disabilities (namely, obstructive sleep apnea and/or narcolepsy). If a diagnosis of narcolepsy and/or chronic fatigue syndrome is deemed inappropriate, the examiner must provide a thorough rationale to support such a conclusion with an explicit discussion of the medical evidence in support of both diagnoses, that is, the long-standing history of diagnosis and treatment for narcolepsy as well as the November 2017 disability benefits questionnaire which included a diagnosis of chronic fatigue syndrome. B) If a diagnosable condition (known clinical diagnosis) is identified that accounts for some or all of this symptomatology, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that any such diagnosed condition or conditions (to specifically include narcolepsy and/or chronic fatigue syndrome) is/are: 1) etiologically related to the Veteran's service, to include as due to exposure to hazardous materials while serving in the Southwest Asia theater of operations; or 2) caused or aggravated by PTSD, or weight gain therefrom. C) If a diagnosable condition is not appropriate to account for any or all of the daytime somnolence or chronic fatigue symptoms detailed by the Veteran, please note whether the Veteran has a medically unexplained chronic multisymptom illness corresponding to those symptoms detailed by the Veteran for which there is no diagnosable condition that accounts for that symptomatology. D) Furthermore, if the answer to (C) is negative for any or all of these symptoms, please describe whether any of the symptoms were chronic in nature since service and thus would constitute a qualifying chronic disability under 38 C.F.R. § 3.317(a)(2)(i)(B). If this question is answered in the negative, an explanation for this determination is needed. If this question is answered in the positive, please address the possible etiologies of such chronic disability. If a chronic disability is found to be attributable to a supervening condition or event that occurred between the Veteran's departure from active duty in the Southwest Asia theater of operations and the onset of the illness, the examiner should so state. The examiner must provide any and all opinions as to etiology in the form of a probability and must provide a complete rationale for any opinion expressed. The Board recognizes the practical difficulties of scheduling an examination in view of the COVID-19 epidemic, and requests flexibility and understanding in affording the Veteran an opportunity to report for an examination. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christopher M. Collins, 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.