Citation Nr: 21040748 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 17-16 896 DATE: July 6, 2021 ORDER Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a lumbar spine disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is granted. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a skin disorder, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is granted. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for sinus headaches/migraine headaches, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is granted. Whether new and material evidence has been received to reopen the claim of entitlement to service connection right hip bursitis, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is granted. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for right knee disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is granted. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a central nervous system disease, claimed as Parkinson's disease or tremors, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is granted. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a right shoulder disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is granted. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a cervical spine disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is granted. Entitlement to service connection for sinus headaches/migraine headaches, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is granted. Entitlement to service connection for a gastrointestinal disorder, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is granted. REMANDED Entitlement to service connection for a lumbar spine disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. Entitlement to service connection for a skin disorder, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. Entitlement to service connection right hip bursitis, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. Entitlement to service connection for right knee disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. Entitlement to service connection for a central nervous system disease, claimed as Parkinson's disease or tremors, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and anxiety is remanded. Entitlement to service connection for a right shoulder disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. Entitlement to service connection for a cervical spine disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. FINDINGS OF FACT 1. In an unappealed decision, dated November 2001, the AOJ denied claims of service connection for migraines and degenerative disc disease (DDD) and arthritis of the musculoskeletal system. 2. In an unappealed decision, dated November 2008, the AOJ denied claims of service connection for skin lesions, Parkinson's disease, multiple joint arthritis affecting back, neck, hips, knees, and shoulders, and chronic sinusitis. 3. Evidence associated with the claims file after the November 2001 and November 2008 rating decision is neither cumulative nor redundant and raises a reasonable possibility of substantiating the claims on appeal. 4. The Veteran is a Persian Gulf veteran based on her verified, 1990 to 1991 active service in the Southwest Asia theater of operations during the Persian Gulf War. 5. The evidence is at least in equipoise that her current diagnosis of sinus headaches has manifested to a compensable degree during the relevant period. 6. The evidence is at least in equipoise that her acute cholecystitis manifested to a compensable degree during the relevant period. CONCLUSIONS OF LAW 1. The November 2001 rating decision that denied entitlement to service connection for migraines and degenerative disc disease (DDD) and arthritis of the musculoskeletal system was final. 38 U.S.C. § 7105 (c) (2012); 38 C.F.R. §§ 19.52, 20.1103 (2019). 2. The November 2008 rating decision that denied entitlement to service connection for skin lesions, Parkinson's disease, multiple joint arthritis, and chronic sinusitis was final. 38 U.S.C. § 7105 (c) (2012); 38 C.F.R. §§ 19.52, 20.1103 (2019). 3. New and material evidence has been received since the November 2001 and November 2008 rating decisions, thus the claims seeking service connection for migraines, multiple joint arthritis, chronic sinusitis, skin lesions, and Parkinson's disease are reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2019). 4. The criteria for service connection for sinus headaches/migraine headaches as a qualifying chronic disability resulting from an undiagnosed illness have been met. 38 U.S.C. §§ 1110, 1117, 1118 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2019). 5. The criteria for service connection for a gastrointestinal disorder as a qualifying chronic disability resulting from an undiagnosed illness have been met. 38 U.S.C. §§ 1110, 1117, 1118 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from November 1990 to April 1991, including service in Southwest Asia Theater of Operations. This case comes before the Board on appeal of a January 2016 rating decision. In August 2019, the Veteran had a hearing before the undersigned Veterans Law Judge (VLJ) at the New Orleans regional office. A transcript of the proceeding has been associated with the record. The Board notes that as the scope of the Veteran's claim of service connection for PTSD encompasses other psychiatric disorders that have been raised by the record, such as major depressive disorder, insomnia, and anxiety, the Board has recharacterized the issue on appeal as reflected on the title page. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). New and Material Evidence Generally, a claim that has been denied in a final unappealed RO decision may not be reopened and readjudicated. 38 U.S.C. § 7105(c) (2012). An exception to that rule is that if new and material evidence is presented or secured with respect to a claim, which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108 (2012). A claim may be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Evidence is considered "new" if it was not previously submitted to agency decision makers. "Material" evidence is existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. "New and material evidence" can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, the "credibility" of newly presented evidence is to be presumed unless the evidence is inherently incredible or beyond the competence of the witness). The language of 38 C.F.R. § 3.156(a) creates a low threshold for finding new and material evidence and views the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." Evidence "raises a reasonable possibility of substantiating the claim," if it would trigger VA's duty to provide an examination in adjudicating a non-final claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). 1. Whether new and material evidence has been received to reopen claims of entitlement to service connection for sinus headaches/migraine headaches and DDD and arthritis of the musculoskeletal system, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) At the outset, the November 2001 rating decision, which among other issues, denied the Veteran's claims of service connection for migraine headaches and DDD and arthritis of the musculoskeletal system, was final. The Veteran filed a timely notice of disagreement (NOD) but failed to file a substantive appeal after the issuance of the March 2002 statement of the case (SOC). Thus, the appeal was not perfected, and the November 2001 rating decision became final. At the time of the November 2001 rating decision, the evidence of record consisted of the Veteran's service treatment records (STRs), VA examination from August and September 2000, VA outpatient treatment records, and a report of Dr. J.G. from January 2001. In the November 2001 rating decision, the AOJ explained that in the August and September 2000 VA examinations was negative for a diagnosis of migraines. X-ray of skull showed no significant osseous abnormality and computed tomography scan of brain was normal. Additionally, the report from Dr. J.G. was negative for diagnosis of migraines. Moreover, the AOJ explained that the STRs were negative for any complaints of migraine headaches. Thus, the claim was denied. Regarding DDD and arthritis of the musculoskeletal system, the AOJ explained that X-ray of thoracic and lumbar spine done in June 1990 showed slight dextro-scoliosis of the thoracic and lumbar spine and slight kyphosis of the thoracic spine. The AOJ stated that records were negative for diagnosis or treatment for DDD or arthritis. Additionally, x-ray of the right knee was normal, but x-rays of the left knee showed mild joint effusion. X-ray of the thoracic spine showed mild convexity left upper thoracic spine, generalized mild hypertrophic spurring. Rheumatoid factor was negative. The AOJ added that a May 1996 outpatient treatment record showed that the Veteran was advised she had degenerative disc disease (DDD). At that time, the Veteran complained of pain between shoulders, pain of lower back and pain of both knees. X-ray of thoracic spine showed mild spondylosis of the thoracic spine. X-ray of lumbar spine was normal. X-ray of cervical spine showed hydro lordosis of the cervical spine suggestive of acute cervical muscle strain. Diagnosis was arthritis, mild scoliosis, rule out early rheumatoid arthritis. Then, in July 2000, Veteran was seen for bursitis of the right hip. Follow-up on August 2000, showed right trochanteric bursitis, rule out inflammatory arthritis. The AOJ concluded that DDD and arthritis was denied because the condition was neither occurred in nor caused by service. The AOJ added that there was no evidence of arthritis or degenerative disc disease manifested to a compensable degree within one year of the Veteran's discharge from service. However, since the November 2001 rating decision, evidence has been received which raises a reasonable possibility of substantiating the claims on appeal. Specifically, regarding the issue of chronic migraines, private treatment records from June 2006 show that the Veteran complained of migraine headaches for the past six months with worsening intensity. At that time, the examiner speculated that her headaches were the result of cerebrospinal fluid (CSF) leak. Additionally, in a VA treatment record from June 2006, the Veteran was assessed with headaches syndromes. Then, in the November 2015 VA examination, it was shown that the Veteran suffered from frequent sinus headaches that lasted less than one day but affected both sides of her head. The Veteran reported that her sinus headaches were weekly and near constant with sinus pressure and pain. The examiner remarked that the sinus headaches were an undiagnosed chronic illness. Likewise, evidence has been received which raises a reasonable possibility of substantiating the claim regarding DDD and arthritis of the musculoskeletal system. First, treatment records associated with the claims file after the November 2001 rating decision, showed that the Veteran complained of pain in her neck and back prior to November 1993. The Veteran was assessed with chronic mechanical back/neck pain. Additionally, the Veteran complained of intermittent bilateral knee pain since 1992, without a history of trauma or injury. Treatment records showed that the Veteran continued to complain of musculoskeletal pain up until she was diagnosed with DDD and arthritis. Then, in the November 2015 VA examination, the examiner opined that the Veteran's right shoulder, knee, hip, lumbar spine, and cervical spine condition were less likely than not related to an exposure in Gulf War. The examiner reasoned that the conditions were more likely related to her exposure to lifting and strenuous work over years, aging process, and diagnosis of rheumatoid arthritis. As will be explained in further detail below, the Board finds this opinion to inadequate and thus of little probative value. In short, the examiner's opinion did not account for the Veteran's competent lay statements as well as pertinent evidence. Furthermore, in the August 2019 hearing, the Veteran provided competent and credible testimony regarding the onset of her musculoskeletal issues. The Veteran testified that she did not have any issues with her back, neck, knees, shoulder, or hips prior to active duty service. She explained that within a couple of years of discharge from active duty service she was diagnosed with degenerative disc disease although she was under 25 years old. The Board finds that the evidence associated with the record after the November 2001 rating decision coupled with the Veteran's hearing testimony is new and material. The evidence is "new," as it was not previously before the AOJ during the November 2001 rating decision. Likewise, the evidence is "material" as it relates to unestablished facts that raise the possibility of substantiating the claims on appeal. Moreover, evidence "raises a reasonable possibility of substantiating the claim," if it would trigger VA's duty to provide an examination in adjudicating a non-final claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). As discussed above, the November 2015 VA examination was inadequate; thus, an addendum is warranted. Furthermore, the Board notes that the that the language of 38 C.F.R. § 3.156(a) creates a low threshold for finding new and material evidence and views the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." Accordingly, as the evidence received following the November 2001 rating decision is new and material, the Veteran's claims of service connection for chronic migraines and DDD and arthritis of the musculoskeletal system are reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). 2. Whether new and material evidence has been received to reopen claims of entitlement to service connection for a skin disorder, Parkinson's disease, multiple joint arthritis affecting back, neck, hips, knees and shoulders, and chronic sinusitis, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) Similarly, the claims of service connection for a skin disorder, Parkinson's disease (claimed as tremors), and chronic sinusitis are reopened. The Board notes that the issue of multiple joint arthritis affecting back, neck, knees and shoulders is reopened as discussed above. At the outset, the November 2008 rating decision, which among other issues, denied the Veteran's claims of service connection for skin lesions, Parkinson's disease, multiple joint arthritis, and chronic sinusitis, was final. The Veteran received notification of the rating decision in December 2008 but failed to file a timely NOD. Thus, the rating decision became final. At the time of the November 2008 rating decision, the evidence consisted of the Veteran's July 2008 statement in support, private medical records, military hospital records from November 2007 to September 2008, VA treatment records from September 2006 to January 2007, STRs, and personnel records. First, regarding the claim for skin lesions, the AOJ explained that the STRs were silent for any diagnosis, treatment, or complaint of any skin diseases. The AOJ noted that the Veteran was treated for dermatitis and cellulitis based on VA and private treatment records. Thus, the AOJ concluded that the skin lesions were determined to result from a known clinical diagnosis of dermatitis and cellulitis, which neither occurred in nor was caused or aggravated by service. Then, regarding the Veteran's claim of Parkinson's disease, the AOJ explained that STRS showed no diagnosis, treatment, or complaint of any neurological problems during service. However, the AOJ noted that available treatment records showed evidence of Parkinson's-type symptoms, as well as a diagnosis of Parkinson's symptoms. Likewise, the Veteran had a diagnosis of "questionable ill-defined neurological condition." In a treatment report from October 2006 showed a diagnosis of Parkinson's disease versus Parkinson's-like syndrome. The AOJ concluded that service connection for Parkinson's-like symptoms/Parkinson's disease was denied because the condition was not associated with undiagnosed Gulf War illness. Moreover, Parkinson's disease was not diagnosed during service or within a year of discharge from active duty service. Likewise, recent medical treatment records did not indicate a confirmed chronic neurological disability. Regarding chronic sinusitis, the AOJ explained that STRs showed no diagnosis, treatment, or complaint of sinus problems during active duty. However, treatment records showed diagnoses of sinusitis, sinus problems, nasal septal deviation, vasomotor rhinitis, acute maxillary, and ethmoid sinusitis. By February 2007, the Veteran was diagnosed with chronic sinusitis. The AOJ concluded that chronic sinusitis was determined to result from a known clinical diagnosis of sinusitis, which neither occurred in nor was caused or aggravated by service. Thus, the claim was denied. However, since the November 2008 rating decision, new evidence has been received which raises a reasonable possibility of substantiating the claims on appeal. First, regarding the claim of service connection for skin lesions, the Board notes that the Veteran testified that her skin condition began upon her return from overseas service. She explained that it started out like bug bites but continued with periodic lesions. The Board notes that the Veteran's STRs showed an entry where the Veteran was treated after she complained of an insect bite. Moreover, in the November 2015 VA examination, it was shown that the Veteran had leukocytoclastic vasculitis, which caused chigger type lesions of her bilateral legs. The examiner noted that the Veteran had a long history of dermatological issues as shown in her STRs. The Board finds that the Veteran's competent testimony and the evidence associated with the record following the November 2008 rating decision is new and material. The Veteran's testimony, along with the November 2015 VA examination is new as it was not before the AOJ in November 2008. Likewise, the evidence is material as it relates to an unestablished fact, namely, that the Veteran's skin condition might have manifested during service. Regarding the claim for Parkinson's disease (claimed as tremors), the Board finds that new and material evidence has been associated with the record. Specifically, VA treatment records subsequent to the November 2008 rating decision showed diagnoses of Parkinson's disease or Parkinson's-like symptoms without a clear diagnosis or etiology of the Veteran's condition. The Veteran testified that she was diagnosed with "possible Parkinson's disease." This is reflected in the treatment records, but there is no clear etiology for any neurological issues. Moreover, in the November 2015 VA examination, there was no discussion of any neurological issues the Veteran suffered but the examiner indicated that there was no evidence of Parkinson's disease. The examiner remarked that the condition was an undiagnosed illness. As such, the evidence associated with the record following the November 2008 rating decision is new and material to reopen the claim. Finally, the claim of service connection for chronic sinusitis is reopened. The Board finds that new and material evidence regarding chronic sinusitis has been received following the November 2008 rating decision. Specifically, the Veteran testified that following her jaw surgery in 1993, she was told that a bunch of junk was cleaned out of her sinuses. She explained that from that point she had inflammation. She added that prior to deployment to Saudi Arabia, she did not have any problems other than normal colds with her sinuses. The Veteran explained that she underwent four surgeries to correct the condition of her sinuses with limited effectiveness. The Veteran's treatment records both VA and private support her contention that continued to suffer from chronic sinus issues since her discharge from active duty. Accordingly, as the evidence received following the November 2008 rating decision is new and material, the Veteran's claims of service connection for a skin disorder, Parkinson's disease (claimed as tremors), and chronic sinusitis are reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Service Connection Generally, to establish service connection a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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). Additionally, service connection may be established for a chronic disability resulting from an undiagnosed illness that became manifest either during active service in Southwest Asia during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1)(i). Service connection may also be established for a Persian Gulf Veteran who exhibits objective indications of "qualifying chronic disability," a chronic disability resulting from an undiagnosed illness, a medically unexplained chronic multi-symptom illness (MUCMI) that is defined by a cluster of signs or symptoms, or any diagnosed illness that the Secretary determines warrants a presumption of service connection. 38 U.S.C. § 1117. An "undiagnosed illness" is one that by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317 (a)(1)(ii). If signs or symptoms have been medically attributed to a diagnosed illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98 (Aug. 3, 1998). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Likewise, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be more persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b) (2012). 3. Entitlement to service connection for sinus headaches/migraine headaches, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) Here, the Veteran contends that her sinus headaches/migraine headaches were caused by Persian Gulf War illness. Based on the evidence, the Board agrees. At the outset, the Veteran served during the Persian Gulf War in the Southwest Asia theater of operations from November 1990 to April 1991. See DD 214 and personnel records. Thus, she is a Persian Gulf veteran for purposes of VA disability compensation under 38 C.F.R. § 3.317. Moreover, she has a current diagnosis of chronic sinus headaches/migraines headaches, a qualifying chronic disability under 38 C.F.R. § 3.317. See November 2015 VA examination. The Board notes that headaches are specifically listed a sign or symptoms which may be manifestations of an undiagnosed illness or MUCMI. 38 C.F.R. § 3.317 (a)(2)(i)(B)(3). Furthermore, in the November 2015 examination, the examiner remarked that the Veteran's sinus headaches/migraine headaches were part of an undiagnosed chronic illness. A compensable disability rating for migraine headaches requires characteristic prostrating attacks averaging one in two months over the last several months. 38 C.F.R. § 4.124a, DC 8100. Affording the Veteran, the benefit of the doubt, the evidence is at least in equipoise that her headaches manifested to a compensable degree during the applicable period after her verified Gulf War service in Southwest Asia. See VA treatment records and November 2015 VA examination. Therefore, service connection for sinus headache/migraine headaches is granted as a Gulf War illness under 38 C.F.R. § 3.317. 4. Entitlement to service connection for a gastrointestinal disorder, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. Here, the Veteran contends that her gastrointestinal disorder was caused by Gulf War illness. Based on the evidence, the Board agrees. As discussed above, the Veteran is a Persian Gulf veteran for purposes of VA disability compensation under 38 C.F.R. § 3.317. Moreover, she has a current diagnosis of gastrointestinal reflex disease (GERD) as well as acute cholecystitis post cholecystectomy. The Board notes that Veteran's gastrointestinal symptoms included abdominal distress, nausea, and indigestion, which is listed a sign or symptom of functional gastrointestinal disorder. November 2015 VA examination; see also 38 C.F.R. § 3.317 (a)(2)(i)(B)(3) Note. A compensable disability rating for removal of gall bladder requires mild symptoms. 38 C.F.R. § 4.114, DC 7318. Affording the Veteran, the benefit of the doubt, the evidence is at least in equipoise that her gastrointestinal disorder manifested to a compensable degree during the applicable period after her verified Gulf War service in Southwest Asia. See VA treatment records and November 2015 VA examination. Therefore, service connection for a gastrointestinal disorder is granted as a Gulf War illness under 38 C.F.R. § 3.317. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2019). 1. Entitlement to service connection for a lumbar spine disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. 2. Entitlement to service connection right hip bursitis, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. 3. Entitlement to service connection for right knee disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. 4. Entitlement to service connection for a right shoulder disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. 5. Entitlement to service connection for a cervical spine disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. Here, the Veteran contends that her musculoskeletal disabilities were caused by environmental exposure that caused Gulf War illness. Based on the evidence, a remand is necessary. Specifically, in the November 2015 VA examination, the Veteran had diagnoses of right knee strain, cervical strain and intervertebral disc syndrome (IVDS), right shoulder strain, right hip bursitis, lumbosacral strain and degenerative arthritis (DA) of lumbar spine. The examiner opined that the Veteran's conditions were less likely than not related to any exposure in Gulf War. She reasoned that the conditions were more likely related to her exposure to lifting and strenuous work over years, aging process, and diagnosis of rheumatoid arthritis condition. The Board finds the opinion to be inadequate and thus of little probative value. Specifically, the examiner failed to account for the Veteran's competent lay statements regarding the onset of her musculoskeletal pain. The Veteran reported problems with joint pain starting in 1992, that affected her back, neck, bilateral knee, ankles and fingers and wrists. She reported constant aching especially when she woke up and went to bed. She added that the pain had fluctuating intensity and occasionally caused her to be unable to get up or stop what she was doing. See VA treatment records. Likewise, the Veteran reported right knee pain with swelling but there was no fluid when right knee drainage was attempted. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (a medical opinion is inadequate where the examiner fails to properly account for competent lay evidence). Moreover, the examiner did not opine on direct service connection. Furthermore, treatment records were inconclusive on whether the Veteran was diagnosed with rheumatoid arthritis. As such, the Board finds that an addendum opinion is necessary to determine the etiology of the Veteran's musculoskeletal conditions. 6. Entitlement to service connection for a skin disorder, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. Here, the Veteran contends that her skin disorder was caused by a Gulf War illness. Based on the evidence, a remand is necessary. In the November 2015 VA examination, it was shown that the Veteran had leukocytoclastic vasculitis. The Veteran reported flares of chigger type lesions of her bilateral legs. On examination, there were no characteristic lesions present. However, the examiner indicated that the Veteran had a long history of dermatological issues based on review of her STRs. In fact, the Veteran reported skin rashes that started on her left finger and bilateral forearms. See September 1994 VA treatment record. Additionally, in her hearing testimony the Veteran explained that her skin issues began immediately upon her return from the Persian Gulf. As delineated in 38 C.F.R. § 3.159 (c)(4), a VA examination to address the question of etiology as related to service is required when the Veteran presents a claim for service connection in which there was a pertinent event, injury, or disease in service; there is evidence of current disability; the medical evidence of record does not contain sufficient competent medical evidence to decide the claim; and the Veteran indicates that the claimed disability or symptoms may be associated with service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this instance, although the Veteran was provided a VA examination, there was no opinion regarding the onset of the Veteran's skin condition. As such, a remand to determine the etiology of the Veteran's skin condition is warranted. 7. Entitlement to service connection for chronic sinusitis, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. Here, the Veteran contends that her chronic sinusitis is due to a Gulf War illness. Based on the evidence, a remand is necessary. As discussed above, the Veteran testified that following her jaw surgery in 1993, she was told that a bunch of junk was cleaned out of her sinuses. She explained that from that point she had inflammation. She added that prior to deployment to Saudi Arabia, she did not have any problems other than normal colds with her sinuses. The Veteran explained that she underwent four surgeries to correct the condition of her sinuses with limited effectiveness. The Veteran's treatment records both VA and private support her contention that continued to suffer from chronic sinus issues since her discharge from active duty. Yet, the Veteran has not been afforded a VA examination to determine the etiology her condition. As delineated in 38 C.F.R. § 3.159 (c)(4), a VA examination to address the question of etiology as related to service is required when the Veteran presents a claim for service connection in which there was a pertinent event, injury, or disease in service; there is evidence of current disability; the medical evidence of record does not contain sufficient competent medical evidence to decide the claim; and the Veteran indicates that the claimed disability or symptoms may be associated with service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, a remand is necessary to determine the nature and etiology of the Veteran's chronic sinusitis. 8. Entitlement to service connection for a central nervous system disease, claimed as Parkinson's disease or tremors, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. Similarly, the Veteran underwent a VA examination for her complaints of a central nervous system disability. In the November 2015 VA examination, the examiner indicated that the Veteran's Parkinson's disease was part of an undiagnosed illness. However, the medical evidence on record in inconclusive on whether the Veteran has Parkinson's disease or a central nervous system disease. The examiner indicated that the Veteran did not have any symptoms of Parkinson's disease. Yet, the Veteran's VA and private treatment records show Parkinson's-like symptoms and diagnosis of Parkinson's disease. Based on the conflicting medical evidence, a remand is necessary to determine whether the Veteran has Parkinson's disease or any central nervous system disease, to include as due to an undiagnosed illness or MUCMI. 9. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and anxiety is remanded. Lastly, in the November 2015 VA examination, it was shown that the Veteran had unspecified anxiety disorder and unspecified somatic symptom and related disorder. The psychologist summarized the Veteran's psychiatric condition as causing occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. During the examination, the Veteran reported stressors of seeing burning oil fields, hearing explosions in the distance, and having to be accompanied wherever she went. Additionally, she described general apprehension about alarms going off, being away from her normal unit and being deployed to the Persian Gulf during Desert Storm. The Veteran endorsed symptoms of anxiety, chronic sleep impairment, and mild memory loss. The examiner indicated that she did not meet the criteria for PTSD. The examiner remarked that it was less likely than not that her current diagnoses were directly caused by or related to her military service. He stated that her condition appeared to have later onset. The Board finds the psychologist's opinion to be inadequate and thus of little probative value. The psychologist's opinion failed to account for the pertinent evidence of record. The Veteran's private treatment records showed that she had a diagnosis of major depressive disorder. The psychologist failed to mention her other diagnoses or treatment of her psychological condition as shown in her private treatment records. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). As such, a remand is necessary for an addendum opinion to determine the etiology of the Veteran's psychiatric condition. The matters are REMANDED for the following action: 1. Obtain all relevant outstanding VA treatment records, and any private treatment records identified by the Veteran. All records and/or responses received should be associated with the claims file. 2. After all outstanding treatment records have been associated with the claims file, obtain a VA addendum opinion to determine the nature and etiology of the Veteran's (a) lumbar spine disability; (b) cervical spine disability; (c) right knee disability; (d) right hip disability; and (e) right shoulder disability. 3. Additionally, obtain a VA addendum opinion to determine the nature and etiology of the Veteran's acquired psychiatric disorder. 4. Then, schedule the Veteran for a VA examination to determine the etiology of her skin condition and any central nervous systems disorder (Parkinson's disease or tremors). A copy of this REMAND must also be provided to the VA examiner(s). All necessary tests and studies should be accomplished, and all clinical findings reported in detail. The VA examiner(s) should address the following: (a.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's lumbar spine disability had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service, to include as part of undiagnosed illness or MUCMI. (b.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's cervical spine disability had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service, to include as part of undiagnosed illness or MUCMI. (c.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's right knee disability had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service, to include as part of undiagnosed illness or MUCMI. (d.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's right hip disability had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service, to include as part of undiagnosed illness or MUCMI. (e.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's right shoulder disability had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service, to include as part of undiagnosed illness or MUCMI. (f.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's acquired psychiatric disorder had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service. (g.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's skin disorder had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service, to include as part of undiagnosed illness or MUCMI. (h.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's chronic sinusitis had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service, to include as part of undiagnosed illness or MUCMI. (i.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's central nervous system disorder (claimed as Parkinson's disease or tremors) had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service, to include as part of undiagnosed illness or MUCMI. The examiner(s) is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 5. The examiner(s) should cite to the pertinent medical and competent lay evidence of record and explain the rationale for all opinions given. If after consideration of all pertinent factors it remains that the opinion sought cannot be given without resort to speculation, it should be so stated, and the provider must (to comply with governing legal guidelines) explain why the opinion sought cannot be offered without resort to speculation 6. After undertaking any additional development deemed necessary, the AOJ must readjudicate the claims on appeal. If any claim remains denied, the Veteran and her representative should be furnished a supplemental statement of the case and afforded the requisite opportunity to respond before the case is returned to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board I. Umo, 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.