Citation Nr: 21041517 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 15-42 641 DATE: July 9, 2021 ORDER Entitlement to service connection for a traumatic brain injury (TBI) is granted. Entitlement to service connection for Dercum's disease, to include as due to undiagnosed illness and/or environmental exposures in Southwest Asia during the Persian Gulf War, is denied. Entitlement to service connection for acromegaly, to include as due to undiagnosed illness and/or environmental exposures in Southwest Asia during the Persian Gulf War, is denied. Entitlement to service connection for right wrist carpal tunnel syndrome (claimed as right wrist condition), to include as secondary to claimed Dercum's disease, is denied. Entitlement to service connection for left wrist carpal tunnel syndrome (claimed as left wrist condition), to include as secondary to claimed Dercum's disease, is denied. Entitlement to service connection for hypermobility syndrome, to include as secondary to claimed Dercum's disease, is denied. Entitlement to service connection for a testicular/inguinal hernia, to include as secondary to claimed Dercum's disease, is denied. Entitlement to service connection for a male hypogonadism, to include as secondary to claimed Dercum's disease, is denied. Entitlement to service connection for a respiratory disability (claimed as dyspnea), to include as secondary to claimed Dercum's disease and/or service-connected fibromyalgia, is denied. Entitlement to service connection for mast cell disorder, to include as secondary to claimed Dercum's disease, is denied. Entitlement to service connection for hemolytic anemia (claimed as narcotic-induced anemia), to include as secondary to claimed Dercum's disease, is denied. Entitlement to service connection for temporomandibular joint disorder (TMJ), to include as secondary to claimed Dercum's disease, is denied. REMANDED The issue of entitlement to service connection for a seizure disability, to include as secondary to a claimed TBI, is remanded. The issue of entitlement to service connection for vertigo, to include as secondary to a claimed TBI, is remanded. The issue of entitlement to service connection for a bilateral hearing loss disability is remanded. The issue of entitlement to service connection for bilateral tinnitus is remanded. The issue of entitlement to special monthly compensation (SMC) based upon housebound status is remanded. FINDINGS OF FACT 1. Without good cause shown, the Veteran declined to report to VA compensation examinations arranged in compliance with the Board's April 2019 remand directives. 2. Resolving reasonable doubt in the Veteran's favor, the evidence is sufficient to show that the Veteran has been diagnosed with a TBI etiologically related to in-service blast exposures suffered during service in Iraq. 3. Due in part to the Veteran not reporting for arranged VA examinations, the evidence is insufficient to establish that the Veteran's diagnosed Dercum's disease is related to service. 4. Due in part to the Veteran not reporting for arranged VA examinations, the evidence is insufficient to establish that the Veteran's diagnosed acromegaly is related to service. 5. Due in part to the Veteran not reporting for arranged VA examinations, the evidence is insufficient to establish that the Veteran has had right wrist carpal tunnel syndrome during the pendency of the claim, or any claimed right wrist disability related to service or to service-connected disability. 6. Due in part to the Veteran not reporting for arranged VA examinations, the evidence is insufficient to establish that the Veteran has had left wrist carpal tunnel syndrome during the pendency of the claim, or any claimed left wrist disability related to service or to service-connected disability. 7. Due in part to the Veteran not reporting for arranged VA examinations, the evidence is insufficient to establish that the Veteran's diagnosed hypermobility syndrome is related to service or to service-connected disability. 8. Due in part to the Veteran not reporting for arranged VA examinations, the evidence is insufficient to establish that the Veteran's diagnosed testicular/inguinal hernia (diagnosed as left inguinal fat pad hernia) is related to service or to service-connected disability. 9. Due in part to the Veteran not reporting for arranged VA examinations, the evidence is insufficient to establish that the Veteran's diagnosed male hypogonadism is related to service or to service-connected disability. 10. Due in part to the Veteran not reporting for arranged VA examinations, the evidence is insufficient to establish that the Veteran has a respiratory disability that is related to service or to service-connected disability. 11. Due in part to the Veteran not reporting for arranged VA examinations, the evidence is insufficient to establish that the Veteran's diagnosed mast cell disorder is related to service or to service-connected disability. 12. Due in part to the Veteran not reporting for arranged VA examinations, the evidence is insufficient to establish that the Veteran has hemolytic anemia related to service or to service-connected disability. 13. Due in part to the Veteran not reporting for arranged VA examinations, the evidence is insufficient to establish that the Veteran has TMJ related to service or to service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for TBI are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for Dercum's disease, to include as an undiagnosed illness or medically unexplained chronic multisymptom illness incurred as a result of service in Southwest Asia during the Persian Gulf War, have not been met. 38 U.S.C. §§ 1110, 1117(d), 5107; 38 C.F.R. §§ 3.159, 3.303, 3.317, 3.655. 3. The criteria for entitlement to service connection for acromegaly, to include as an undiagnosed illness or medically unexplained chronic multisymptom illness incurred as a result of service in Southwest Asia during the Persian Gulf War, have not been met. 38 U.S.C. §§ 1110, 1117(d), 5107; 38 C.F.R. §§ 3.159, 3.303, 3.317, 3.655. 4. The criteria for entitlement to service connection for right wrist carpal tunnel syndrome, to include as secondary to Dercum's disease or as an undiagnosed illness or medically unexplained chronic multisymptom illness incurred as a result of service in Southwest Asia during the Persian Gulf War, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1117(d), 5107; 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310, 3.317, 3.655. 5. The criteria for entitlement to service connection for left wrist carpal tunnel syndrome, to include as secondary to Dercum's disease or as an undiagnosed illness or medically unexplained chronic multisymptom illness incurred as a result of service in Southwest Asia during the Persian Gulf War, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1117(d), 5107; 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310, 3.317, 3.655. 6. The criteria for entitlement to service connection for hypermobility syndrome, to include as secondary to Dercum's disease, have not been met. 38 U.S.C. §§ 1110, 1117(d), 5107; 38 C.F.R. §§ 3.159, 3.303, 3.317, 3.655. 7. The criteria for entitlement to service connection for testicular/inguinal hernia, to include as secondary to Dercum's disease, have not been met. 38 U.S.C. §§ 1110, 1117(d), 5107; 38 C.F.R. §§ 3.159, 3.303, 3.317, 3.655. 8. The criteria for entitlement to service connection for male hypogonadism, to include as secondary to Dercum's disease, have not been met. 38 U.S.C. §§ 1110, 1117(d), 5107; 38 C.F.R. §§ 3.159, 3.303, 3.317, 3.655. 9. The criteria for entitlement to service connection for respiratory disability, to include as secondary to Dercum's disease or service-connected fibromyalgia, have not been met. 38 U.S.C. §§ 1110, 1117(d), 5107; 38 C.F.R. §§ 3.159, 3.303, 3.317, 3.655. 10. The criteria for entitlement to service connection for mast cell disorder, to include as secondary to Dercum's disease, have not been met. 38 U.S.C. §§ 1110, 1117(d), 5107; 38 C.F.R. §§ 3.159, 3.303, 3.317, 3.655. 11. The criteria for entitlement to service connection for hemolytic anemia, to include as secondary to Dercum's disease, have not been met. 38 U.S.C. §§ 1110, 1117(d), 5107; 38 C.F.R. §§ 3.159, 3.303, 3.317, 3.655. 12. The criteria for entitlement to service connection for TMJ, to include as secondary to Dercum's disease, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1117(d), 5107; 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.317, 3.655. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 2005 to May 2007. This case comes before the Board of Veterans' Appeals (Board) on appeal of a September 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. This case was previously before the Board in April 2019, when the Board resolved some of the issues on appeal with a final appellate decision at that time and remanded the remaining issues for additional development of the evidentiary record. The case has now returned to the Board and been reassigned to the undersigned Veterans Law Judge (VLJ) for further appellate review. The issues remanded by the Board in April 2019 have now returned to the Board for further appellate review with the exception of the issue of entitlement to service connection for a psychiatric disability to include posttraumatic stress disorder (PTSD). The psychiatric disability issue was fully resolved by a September 2020 Agency or Original Jurisdiction (AOJ) rating decision that granted service connection for PTSD; that issue is no longer in appellate status and is not before the Board at this time. As discussed in the Board's April 2019 remand, the Veteran indicated that he no longer wished to pursue his claim for SMC based on the need for aid and attendance on the November 2015 VA Form 9; that issue is no longer in appellate status. The Veteran did not explicitly withdraw his SMC claim based on housebound status. Therefore, the Veteran's SMC claim at the housebound rate has remained at issue as part of this appeal. Also, on his November 2015 VA Form 9, the Veteran indicated that he wished to have a Board Hearing in Washington, DC. A hearing was scheduled in July 2017, but the Veteran did not appear. As discussed in the Board's April 2019 remand, the Board has concluded that the Veteran withdrew his request for a Board hearing. The Board notes that an issue on appeal has been characterized by the AOJ as entitlement to service connection for "testicular/inguinal hernia (also claimed as male hypogonadism)." The AOJ has recognized both "testicular/inguinal hernia" and "male hypogonadism" as contained within the scope of the Veteran's appeal, and the Board notes that the Veteran has been separately diagnosed with both of these non-interchangeable disabilities. April 2013 VA treatment records show the Veteran diagnosed with a left inguinal hernia, and December 2012 VA treatment records show the Veteran is also diagnosed with hypogonadism. The Board notes that these separate diagnoses are not synonymous or interchangeable. The Board accordingly recognizes the distinct diagnosed disabilities as separate issues in this case. Additionally, an issue on appeal has previously been characterized as entitlement to service connection for "acromegaly (also claimed as Decrums disease)" and later "Dercum's disease (also claimed as acromegaly)." The AOJ has recognized both "acromegaly" and "Dercum's disease" as contained within the scope of the Veteran's appeal, and the Board notes that the Veteran has been separately diagnosed with both of these non-interchangeable disabilities. For instance, a December 2012 VA treatment report shows separate diagnoses of (1) "Acromegaly 253.0" and (2) "Dercum's disease 272.8." The Board notes that these separate diagnoses are not synonymous or interchangeable. The Board accordingly recognizes the distinct diagnosed disabilities as separate issues in this case. The Veteran's claims involve contentions regarding Gulf War exposures and associated medically unexplained illness. The Board notes that the Veteran has already established entitlement to service connection for fibromyalgia and irritable bowel syndrome as medically unexplained illnesses presumptively linked to his Gulf War service, and a number of other disabilities attributed to environmental hazards and undiagnosed illness associated with his Gulf War service. The Board's analysis of the claims of appeal is conducted in this context in mind. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Disorders diagnosed after discharge may still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To establish service connection for the claimed disorder, there must be evidence of (1) a current disability, (2) incurrence or aggravation of a disease or injury in service, and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Notwithstanding the lack of evidence of disease or injury during service, service connection may still be granted if all of the evidence, including that pertinent to service, establishes that the disability was incurred in service. See 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503 (1992). Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability, by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Service connection is limited to those cases where disease or injury has resulted in a disability. In the absence of proof of a present disability for which service connection is sought, there is no valid claim of service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992). A disability under 38 U.S.C. § 1110 refers to functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356. The United States Court of Appeals for Veterans Claims (Court) has held the requirement that a current disability be present is satisfied when a claimant has a disability at the time of a claim for VA disability compensation is filed or at any time during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 19 (2007). Certain specifically-listed chronic diseases (such as arthritis and organic diseases of the nervous system) may be presumed to have been incurred during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). The theory of continuity of symptomatology under 38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be established for a chronic disability resulting from an undiagnosed illness that manifested either during active service in the Southwest Asia Theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1)(i). The Board briefly notes that the Veteran's service records confirm that he had Persian Gulf War service in Southwest Asia qualifying for application of the provisions of 38 C.F.R. § 3.317. Service connection may 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 multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) 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). A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) irritable bowel syndrome; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a)(2)(i). For purposes of this section, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). For purposes of this section, objective indications of chronic disability include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). The Board also notes that signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) include, but are not limited to, enumerated examples presented in 38 C.F.R. § 3.317(b). In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness in such claims. Id. For the purposes of evaluating lay evidence, competent evidence is limited to that which the witness has actually observed, and is within the realm of the personal knowledge of the witness. Layno v. Brown, 6 Vet. App. 465, 469-470 (1994). For example, although a lay person is competent to report observable symptomatology of an injury or illness, a lay person is not competent to opine as to medical etiology or render medical opinions. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). In each case where a veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of such veteran's service as shown by such veteran's service record, the official history of each organization in which such veteran served, such veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154(a). It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists which does not satisfactorily prove or disprove the claim. Reasonable doubt is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Board notes that it has reviewed all of the evidence properly of record for this appeal, with an emphasis on the evidence pertinent to the issues on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. See 38 U.S.C. § 5107(b). Veteran Declining to Report for VA Examinations The Board's April 2019 remand directed that the Veteran be afforded new VA examinations to provide the evidentiary record with adequate evidence determining the nature and likely cause of his claimed disabilities on appeal. A December 2019 VA "Report of General Information" documents VA telephone contact with the Veteran in which the VA employee "spoke extensively with this veteran .... In communicating with the veteran, it was determined that the veteran is somewhat apprehensive about any exams due to potential, unique health concerns over any invasive procedures." The VA employee "informed the veteran that if he feels uncomfortable with anything requested by a doctor, to state that he does not wish to continue and why. I also let the veteran know that I will add in the exam request that he requests that no invasive procedure be conducted." The Veteran "requested information necessary in order to complete DBQ [disability benefits questionnaire] with his own private doctor." The next day (also in December 2019), VA sent a letter to the Veteran informing him of the steps underway to arrange VA examinations for him in connection with the claims, and explaining that "When a claimant, without good cause, fails to report for an examination or reexamination, the claim shall be rated based on the evidence of record, or even denied. Examples of good cause include, but are not limited to, illness or hospitalization, death of a family member, etc." Multiple February 2020 VA "Report of General Information" forms document that VA attempted to reach the Veteran after he did not report for scheduled examinations. The Veteran did report for a January 2020 VA PTSD examination, but did not report for any of the other compensation examinations arranged around this time; the January 2020 VA PTSD examination report served as a basis for the grant of service connection for PTSD in a September 2020 RO rating decision. A September 2020 Supplemental Statement of the Case (SSOC) was also sent to the Veteran, noting "Notification of Failure to RSVP for several examinations," and discussing for each remaining service connection issue on appeal that "We attempted to schedule you for an examination, and we have been informed that you have missed the VA examination scheduled in support of your claim. There is no information presently indicating good cause for absence on the scheduled appointment date." Also for each remaining service connection issue, the SSOC instructed the Veteran: "As a result, medical evidence that could have been used to support your claim was not available to us. Please notify us when you are ready to report for an examination, or you may submit a disability benefits questionnaire (DBQ) which must be completed and signed by a physician." When necessary or requested, the Veteran must cooperate with VA in obtaining evidence. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) ("The duty to assist is not always a one-way street."). When entitlement to a benefit cannot be established or confirmed without a current VA examination and a claimant, without good cause, fails to report for such examination, action shall be determined under 38 C.F.R. § 3.655. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and the death of an immediate family member. 38 C.F.R. § 3.655(a). When a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be based on the evidence of record. 38 C.F.R. § 3.655(b). In a June 2021 Appellate Brief, the Veteran's representative argued that VA "has failed to demonstrate lack of good cause and further, there has been insufficient notice to the Veteran of the result of his failure to report for examination under 38 C.F.R. § 3.665(b)." The representative argued that "the remand-ordered examinations should be rescheduled, and the veteran notified of the regulations which would apply should he again fail to report." These arguments are unavailing. First, VA informed the Veteran of the consequences of failing to attend his examinations in a December 2019 letter discussing the examination arrangements. There is no indication in the record that this mailed letter was returned undelivered or that the letter was not sent to the correct address on file. The letter was sent the day following confirmation of the Veteran's new mailing address used for the mailing, as documented in a December 2019 VA Report of General Information documenting contact with the Veteran. VA fulfilled its duty to assist by doing its due diligence to contact the Veteran. Further, the applicable regulation requires the claimant to furnish good cause for why an examination should be rescheduled, not VA. The Veteran has not provided good cause for his non-attendance at his examinations. Therefore, the claim will be decided by the evidence of record. 38 C.F.R. § 3.655. The Board acknowledges that the record does not contain a final scheduling letter for the examinations in question, and there is no published guidance establishing the presumption of regularity in such a situation. See Kyhn v. Shinseki, 716 F.3d 572 (Fed. Cir. 2013). Failure to receive notice of an examination could provide good cause for the failure to report. See Kyhn, supra. Although the claims file does not include a copy of the letter notifying the Veteran of the date of each scheduled VA examination, this fact alone (the lack of documentation of the notice in the claims-file) does not constitute good cause for failure to cooperate with the scheduling of a VA examination. The Board finds that the facts of this case are distinguishable from the facts considered in Kyhn as the Veteran has not asserted that he did not receive notice of the examinations; rather, the Veteran's representative argues that there has been insufficient notice "of the result of his failure to report for examination under 38 C.F.R. § 3.655(b)." As discussed just above, the claims-file does contain clear documentation that VA provided notice to the Veteran of the result / consequence of his non-attendance of VA examinations. Neither the Veteran nor his representative has otherwise indicated the Veteran had good cause for missing the examinations. The Board cannot find that the Veteran's expressed concerns regarding invasive procedures represent good cause for non-attendance as (1) there is no indication of invasive procedures being required as part of the directed VA examinations in question, and (2) the documented communication between the Veteran and VA on this subject in December 2019 shows that VA informed the Veteran that his preference would be incorporated into the examination request instructions and the Veteran could selectively decline any aspects of examination that might involve invasive procedures. Critically, the Veteran has not disputed the report in the SSOC that he did not report for the needed VA examination, or asserted that he did not receive notice of the AOJ's attempt to schedule the examinations. Neither the Veteran nor his attorney has otherwise provided an explanation of good cause for the Veteran's non-attendance at the VA examinations in this matter. Thus, the Board finds that the provisions of 38 C.F.R. § 3.655(b) apply, and that the Veteran's original claims of entitlement to service-connected compensation must be analyzed based on the evidence of record. (The Board notes that it has sympathetically reviewed the available evidentiary record and considered the Veteran's contentions with care, finding that one of the claims on appeal can be granted on the basis of the available evidence even without the additional development sought by the Board to further assist the Veteran in this appeal.) 1. Entitlement to service connection for a TBI is granted. As discussed in the Board's prior April 2019 remand of this issue, the Veteran asserts that he has a TBI that was incurred during active service. See November 2015 Form 9. Although he identifies no specific blow to the head, he asserts that while serving in the Persian Gulf, he was exposed to multiple blasts from improvised explosive devices (IEDs). VA and private treatment reports support a finding that the Veteran has a current TBI disability. See September 2009 VA TBI Second Level Evaluation Report (diagnosing the Veteran with a TBI); September 2009 VA Addendum (placing the Veteran on the National TBI Registry in a verified status); September 2012 VA Neurology Admission Note (indicating a possible TBI); February 2013 DDS Psychological Evaluation (diagnosing the Veteran with a TBI). However, the Veteran underwent a VA examination for a TBI in July 2013. The examiner opined that the Veteran did not have a TBI, based largely on a finding that there was no documented treatment of a head injury in service. The examiner failed to address the reports and diagnoses in the Veteran's post-service treatment records of a TBI, and offered no opinion as to whether any of the Veteran's claimed residuals had onset in, or are otherwise related to service. The TBI examination was also conducted by a nurse practitioner and not a specialist, as is required by VA for TBI examinations. In April 2019, the Board remanded this issue to develop another VA TBI examination to clarify whether a diagnosis exists and, if so, whether such had onset in, or is related to service. As discussed above, the Veteran did not attend the arranged examination and the Board must consider the claim of entitlement to service connection on the basis of the available evidence of record. The Veteran has not submitted any medical evidence or medical opinion indicating that any current claimed impairment is medically etiologically linked to his military service. However, the Board's review of the record has particularly noted the September 2009 VA "TBI Second Level Evaluation" that presents a diagnosis of a TBI linked to the Veteran's description of blast injuries during service. The report notes injuries in "2006-2007" involving "5 or more" instances of "Primary" blast injuries of "Distance: 50 feet or more" and "3" instances of "Quarternary" blast injuries. These events were described as involving "Rocket Propelled Grenade," "Mortar," and "Unknown" sources. There was no loss of consciousness, but "2" occurrences of "Disorientation or Confusion" the longest of which was "Less than 30 minutes" in duration. The Veteran reported that he was evacuated from the theatre "for other medical reasons." The report indicates that the Veteran reported that he had "been told they are acting differently," and the report includes an accounting of numerous neurobehavioral symptoms. The clinician concluded that "the findings are consistent with diagnosis of TBI," and "most consistent with Traumatic Brain Injury (TBI) residual problems," and referred the Veteran to "Neuropsychology / Neuropsychological assessment" and "Speech-Language Pathology." The Veteran's active duty military service ended in May 2007, and a September 2020 RO rating decision granted entitlement to service connection for PTSD on the basis of accepting evidence that the Veteran suffers from PTSD "incurred in or caused by the fear of hostile military or terrorist activity while serving in Kuwait and Iraq as a human intelligence collector." The Board finds that the documentation of the Veteran's service otherwise supports that the nature and circumstances of the Veteran's service in Iraq are reasonably compatible with potential exposure to the elements described in his testimony regarding exposure to blasts (the Veteran's DD Form 214 shows that the Veteran served in a designated "imminent danger pay area // service in Iraq 20060927-20070512"). The Board notes that the September 2009 medical evidence indicates that TBI screening supported a diagnosis of TBI at that time, and there is no significant indication of a brain injury occurring during the time between the Veteran's separation from service in May 2007 and the TBI screening conducted in 2009. Subsequent medical evidence contains mixed indications regarding TBI diagnosis, but with repeated references to a diagnosis of TBI accepted by a number of treatment providers without any clear and persuasive contrary evidence. Resolving reasonable doubt in the Veteran's favor, the Board finds that the evidence sufficiently indicates that the Veteran has had at least some manner of disabling impairments attributed to a diagnosed TBI, and that such TBI is medically associated with the Veteran's military service in Iraq. The Board finds that the evidence reasonably supports the Veteran's claim that he suffers from a TBI causally associated with his military service. Accordingly, after resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for TBI is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. To this extent, the appeal is granted. 2. Entitlement to service connection for Dercum's disease, to include as due to undiagnosed illness and/or environmental exposures in Southwest Asia during the Persian Gulf War, is denied. 3. Entitlement to service connection for acromegaly, to include as due to undiagnosed illness and/or environmental exposures in Southwest Asia during the Persian Gulf War, is denied. As discussed in the Board's prior April 2019 remand of this issue, the Veteran has been diagnosed with Dercum's disease. See December 2012 VA Endocrinology Attending Note. He asserts that it either had in-service onset, or is related to an in-service anthrax inoculation. The Board also notes that a diagnosis of acromegaly is included in the Veteran's VA treatment records. See December 2012 VA Endocrinology Attending Note. In April 2019, the Board remanded this issue to develop a VA examination to clarify whether the Veteran's claimed disability had onset in, or is related to service. As discussed above, the Veteran did not attend the arranged examination and the Board must consider the claim of entitlement to service connection on the basis of the available evidence of record. The Veteran has not submitted any medical evidence or medical opinion indicating that the Veteran's Dercum's disease or any acromegaly is medically etiologically linked to his military service. As the Veteran's Dercum's disease and any acromegaly represent diagnosed conditions, they cannot be considered an undiagnosed illness; there is furthermore no evidence indicating that the Veteran's Dercum's disease or any acromegaly is medically unexplained or otherwise a MUCMI. 38 C.F.R. § 3.317(a)(1)(ii), (a)(2)(ii). Based on the evidence of record, the Board concludes that service connection is not warranted for the Veteran's currently diagnosed Dercum's disease or any acromegaly. The Veteran's service treatment records do not suggest any onset of Dercum's disease, or acromegaly, or any similar disorder during service. There is no medical evidence of record indicating that the Veteran's diagnosed Dercum's disease or any acromegaly is etiologically linked to his military service on any basis. Unfortunately, the Veteran did not report for the scheduled VA compensation examination that may have shed more light on the question of whether the Veteran's current Dercum's disease or any acromegaly is etiologically linked to his military service on any basis. Accordingly, the Board is compelled to review the Veteran's claims on the basis of the available evidence without the benefit of the potentially clarifying information that may have been obtained through the VA examination arranged to assist the Veteran with the claim on appeal. The evidence available to the Board does not include a competent medical opinion indicating that the Veteran's current Dercum's disease or any acromegaly diagnosis is etiologically linked to his military service, and neither the Board's lay sensibilities nor the Veteran's lay contentions are competent to establish such a medical conclusion in the absence of medical evidence indicating as much. In summary, the Veteran did not report for the arranged VA examination and did not otherwise provide the evidence necessary to support his claim, despite bearing the burden to substantiate each element of his claim. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) ("The duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence."). When a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. 38 C.F.R. § 3.655. Here, following the Veteran's non-attendance at the examination, the evidence is insufficient to establish that his Dercum's disease or any acromegaly is related to service. The evidence of record does not show that the Veteran had onset of Dercum's disease or acromegaly during active service. The evidence of record does not otherwise show that the Veteran's current diagnosed disability of Dercum's disease or any acromegaly is otherwise etiologically linked to any aspect of his military service. The available evidence does not support a basis for an award of service connection for Dercum's disease or acromegaly in this case. Accordingly, service connection for Dercum's disease and acromegaly must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. at 53. 4. Entitlement to service connection for right wrist carpal tunnel syndrome (claimed as right wrist condition), to include as secondary to claimed Dercum's disease, is denied. 5. Entitlement to service connection for left wrist carpal tunnel syndrome (claimed as left wrist condition), to include as secondary to claimed Dercum's disease, is denied. As discussed in the Board's prior April 2019 remand of these issues, the Veteran was diagnosed with carpal tunnel syndrome during service. Service connection for carpal tunnel syndrome of either wrist was denied by the AOJ in an October 2009 Rating Decision. This determination was based largely on a finding that post-service neurological testing did not support the diagnosis. See October 2009 VA examination report; September 2009 EMG/NCV report. In essence, the AOJ determined that the Veteran had no current wrist disability. Within one year of the October 2009 determination, the Veteran submitted a lay statement from his wife indicating that the Veteran's wrists hurt during normal activities such as cleaning the house or giving a back massage. She observed that his wrists grind and make popping noises. See a December 27, 2009 statement from the Veteran's wife, submitted in January 2010. Such evidence is considered new and material evidence, and serves to continue the original service-connection claim under the provisions of 38 C.F.R. § 3.156(b). Accordingly, the Board need not reopen the claim before addressing its merits. More recent VA treatment records indicate the presence of symptoms resembling carpal tunnel syndrome, with an atypically positive Tinel's sign. The Veteran has also been diagnosed with Dercum's disease, which the Veteran asserts may be causing or aggravating his right and left wrist neurological disability. See November 2015 Form 9; October 2012 VA Rheumatology Note; December 2012 VA Endocrinology Attending Note. In April 2019, the Board remanded this issue to develop another VA compensation examination to clarify whether a current carpal tunnel syndrome diagnosis exists. As discussed above, the Veteran did not attend the arranged examination and the Board must consider the claim of entitlement to service connection on the basis of the available evidence of record. The Veteran has not submitted any medical evidence or medical opinion showing a diagnosis of carpal tunnel syndrome from during the pendency of this appeal. If the Veteran does have carpal tunnel syndrome, such represents a diagnosed condition and it cannot be considered an undiagnosed illness; there is furthermore no evidence indicating that the Veteran's claimed carpal tunnel syndrome is medically unexplained or otherwise a MUCMI. 38 C.F.R. § 3.317(a)(1)(ii), (a)(2)(ii). Based on the evidence of record, the Board concludes that service connection is not warranted for the Veteran's claimed carpal tunnel syndrome. There is no medical evidence of record indicating that the Veteran has been diagnosed with carpal tunnel syndrome during the pendency of the claim on appeal. Unfortunately, the Veteran did not report for the scheduled VA compensation examination that may have shed more light on the question of whether the Veteran has carpal tunnel syndrome or any similar disability associated with his claimed impairments. Accordingly, the Board is compelled to review the Veteran's claims on the basis of the available evidence without the benefit of the potentially clarifying information that may have been obtained through the VA examination arranged to assist the Veteran with the claims on appeal. The evidence available to the Board does not include a competent medical diagnosis or opinion indicating that the Veteran's claimed carpal tunnel syndrome is a currently shown diagnosis or represents another pathology productive of functional impairment, and neither the Board's lay sensibilities nor the Veteran's lay contentions are competent to establish such a medical conclusion in the absence of medical evidence indicating as much. In summary, the Veteran did not report for the arranged VA examination and did not otherwise provide the evidence necessary to support his claim, despite bearing the burden to substantiate each element of his claim. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) ("The duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence."). When a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. 38 C.F.R. § 3.655. Here, following the Veteran's non-attendance at the examination, the evidence is insufficient to establish that he has a current diagnosis of carpal tunnel syndrome nor any other pathology productive of the claimed functional impairment. The available evidence does not support a basis for an award of service connection for carpal tunnel syndrome (or similar disability) in this case. Accordingly, the claim of entitlement to service connection for carpal tunnel syndrome must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. at 53. 6. Entitlement to service connection for hypermobility syndrome, to include as secondary to claimed Dercum's disease, is denied. 7. Entitlement to service connection for a testicular/inguinal hernia, to include as secondary to claimed Dercum's disease, is denied. 8. Entitlement to service connection for a male hypogonadism, to include as secondary to claimed Dercum's disease, is denied. 9. Entitlement to service connection for a respiratory disability (claimed as dyspnea), to include as secondary to claimed Dercum's disease and/or service-connected fibromyalgia, is denied. 10. Entitlement to service connection for mast cell disorder, to include as secondary to claimed Dercum's disease, is denied. 11. Entitlement to service connection for hemolytic anemia (claimed as narcotic-induced anemia), to include as secondary to claimed Dercum's disease, is denied. 12. Entitlement to service connection for TMJ, to include as secondary to claimed Dercum's disease, is denied. As discussed in the Board's prior April 2019 remand of these issues, the Veteran has been diagnosed with hypermobility syndrome, which he asserts is proximately due to his claimed Dercum's disease. See December 2012 VA Endocrinology Attending Note; November 2015 VA Form 9. The Veteran has also been diagnosed with a tiny left inguinal fat pad hernia. See April 2013 VA General Surgery Consult. Further, in December 2012, Dr. K.H. indicated that the Veteran may have narcotic-induced male hypogonadism, and listed "Male hypogonadism" as a diagnosis at that time. See December 2012 VA Endocrinology Attending Note. The Veteran asserts that such may be due to Dercum's disease. The Veteran asserts that he has a respiratory disability, manifested by dyspnea, that is proximately due to his diagnosed Dercum's disease and/or his service-connected fibromyalgia. See January 2014 Notice of Disagreement; November 2015 VA Form 9. The Veteran asserts that he has been diagnosed with mast cell disorder, hemolytic anemia, and TMJ by Dr. K.H. at the San Diego VAMC. See November 2015 VA Form 9. VA treatment records show diagnoses of "mast cell disorder" (also discussed as "mast cell activation disorder") and a medical assessment of "anemia" and medical discussion of a history of "Hemolytic anemia." See December 2012 VA Endocrinology Attending Note. The Veteran asserts all three of these disabilities are also due to Dercum's disease. In April 2019, the Board remanded these issues to develop VA examinations to clarify whether the Veteran's claimed disabilities had onset in, or are related to service or to a service-connected disability. As discussed above, the Veteran did not attend the arranged examinations and the Board must consider the claims of entitlement to service connection on the basis of the available evidence of record. The Veteran has not submitted any medical evidence or medical opinion indicating that the claimed disabilities are medically etiologically linked to his military service or to a service-connected disability. To the extent that the Veteran's claims involve known medical diagnoses, diagnosed conditions cannot be considered undiagnosed illness; there is furthermore no evidence indicating that the Veteran's claimed impairments (including unspecified respiratory disability) are medically unexplained or otherwise a MUCMI. 38 C.F.R. § 3.317(a)(1)(ii), (a)(2)(ii). Based on the evidence of record, the Board concludes that service connection is not warranted for the Veteran's claimed hypermobility syndrome, testicular/inguinal hernia, male hypogonadism, respiratory disability, mast cell disorder, hemolytic anemia, and TMJ. The Veteran's service treatment records do not suggest any onset of these disabilities, or any similar disorders, during service. There is no medical evidence of record indicating that any of the Veteran's claimed disabilities is etiologically linked to his military service on any basis nor is there evidence indicating that any is etiologically linked to a service-connected disability. Unfortunately, the Veteran did not report for the arranged VA compensation examinations that may have shed more light on the questions of whether any of the Veteran's claimed disabilities is etiologically linked to his military service on any basis, or etiologically linked to service-connected disability. Accordingly, the Board is compelled to review the Veteran's claims on the basis of the available evidence without the benefit of the potentially clarifying information that may have been obtained through the VA examinations arranged to assist the Veteran with the claims on appeal. The evidence available to the Board does not include a competent medical opinion indicating that the Veteran's claimed disabilities are etiologically linked to his military service or to service-connected disability, and neither the Board's lay sensibilities nor the Veteran's lay contentions are competent to establish such a medical conclusion in the absence of medical evidence indicating as much. In summary, the Veteran did not report for the arranged VA examinations and did not otherwise provide the evidence necessary to support his claims, despite bearing the burden to substantiate each element of his claims. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) ("The duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence."). When a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. 38 C.F.R. § 3.655. Here, following the Veteran's non-attendance at the examination, the evidence is insufficient to establish that any of these claimed disabilities is related to service. The evidence of record does not show that the Veteran had onset of any of these claimed disabilities during active service. The evidence of record does not otherwise show that the any of these claimed disabilities is otherwise etiologically linked to any aspect of his military service or to a service-connected disability. The available evidence does not support a basis for an award of service connection for any of these claimed disabilities in this case. Accordingly, service connection for these disabilities (hypermobility syndrome, testicular/inguinal hernia, male hypogonadism, respiratory disability, mast cell disorder, hemolytic anemia, and TMJ) must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. at 53. REASONS FOR REMAND 1. The issue of entitlement to service connection for a seizure disability, to include as secondary to a claimed TBI, is remanded. 2. The issue of entitlement to service connection for vertigo, to include as secondary to a claimed TBI, is remanded. 3. The issue of entitlement to service connection for a bilateral hearing loss disability is remanded. 4. The issue of entitlement to service connection for bilateral tinnitus is remanded. As discussed in the Board's prior April 2019 remand, the Board believes that the Veteran's service-connection claims for a seizure disorder and for vertigo are intertwined with the Veteran's TBI claim. The evidence of record is conflicting as to whether the Veteran has been diagnosed with a seizure disability. See December 2009 VA Neuropsychology Evaluation Addendum (stating that seizures should be ruled out); February 2013 VA Education Note (indicating a history of frequent seizures); February 2013 DDS Psychological Evaluation (diagnosing the Veteran with seizures); November 2013 VA Neurology Addendum (reporting that the Veteran's symptoms could be complex partial seizures; however, the Veteran missed two scheduled video EEG appointments to further document and characterize these events.) Also as discussed in the Board's prior April 2019 remand, the AOJ initially denied the Veteran's service-connection claim for a hearing loss disability in an October 2009 rating decision. This determination was based largely on a finding that the evidence did not show a current hearing loss disability severe enough to qualify as a disability for VA purposes under the provisions of 38 C.F.R. § 3.385. In March 2010, within one year of this October 2009 determination, a VA Audiology Consult dated February 8, 2010 was associated with the file indicating that a 15 decibel drop for the left ear hearing acuity at 1000 Hertz existed, giving him a mild hearing loss at that frequency. The Veteran reported at that time that his hearing had become progressively worse. Such evidence is considered new and material evidence and serves to continue the original service-connection claim under the provisions of 38 C.F.R. § 3.156(b). Accordingly, the Board need not reopen the claim before addressing its merits. The February 2010 VA Audiology Consult report suggests a potential worsening of the Veteran's symptoms. A subsequent March 19, 2010, VA Otolaryngology Consult indicates that the Veteran had a recent audiogram and speech discrimination was 92 percent bilaterally. In April 2019, the Board remanded these issues to develop new VA examinations addressing these and other issues, including the claim of entitlement to service connection for TBI. As discussed above, the Veteran did not attend the arranged examinations and the Board must consider the claims of entitlement to service connection on the basis of the available evidence of record. However, the Board has determined that the existing evidence of record allows the Board to grant entitlement to service connection for TBI at this time; consequently, VA must now arrange a new compensation examination for the Veteran for the purpose of informing the initial disability rating determination for the grant of service connection for TBI. The Court has held that two issues are inextricably intertwined when they are so closely tied together that a final decision cannot be rendered unless both issues have been considered. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The TBI rating provisions of 38 C.F.R. § 4.124a, Diagnostic Code 8045, recognize three main areas of dysfunction that may result from TBIs and have profound effects on functioning: cognitive, emotional/behavioral, and physical. Subjective symptoms may be the only residual of a traumatic brain injury or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of a traumatic brain injury, whether or not they are part of cognitive impairment, are to be evaluated under the subjective symptoms facet in the TBI Table. Any residual with a distinct diagnosis that may be evaluated under another diagnostic code must be separately evaluated, even if that diagnosis is based on subjective symptoms, rather than under the TBI Table. Physical (including neurological) dysfunction is evaluated based on a provided list under an appropriate diagnostic code; the list includes: hearing loss and tinnitus; seizures; and gait, coordination, and balance problems. The Board finds that the Veteran's claims of entitlement to service-connected compensation for hearing loss, tinnitus, seizures, and vertigo are inextricably intertwined with the necessary forthcoming development and adjudication to assign a rating or ratings for the Veteran's newly service-connected TBI. With attention to the applicable rating provisions for TBI, the forthcoming development and adjudication concerning the TBI rating will need to address whether the Veteran suffers from hearing loss, tinnitus, seizures, and vertigo as manifestations of the service-connected TBI pathology, and thus it would be premature for the Board to issue a final appellate determination on those questions at this time. The pending TBI rating determination is inextricably intertwined with these claims of entitlement to service connection. Therefore, further consideration of these service connection claims must be deferred. 5. The issue of entitlement to SMC based upon housebound status is remanded. The Court has held that two issues are inextricably intertwined when they are so closely tied together that a final decision cannot be rendered unless both issues have been considered. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Thus, the Board must defer final adjudication of the claim seeking SMC until the separate matters regarding the Veteran's forthcoming initial rating assignment for newly service-connected TBI and claimed entitlements to service connection for additional disabilities have been fully developed and prepared for informed appellate review. A remand of the claim for SMC is required. The matters are REMANDED for the following action: After completion of the development and adjudication of the initial rating assignment determination for the Veteran's newly service-connected TBI has been completed, readjudicate (a) the inextricably intertwined appellate issues of entitlement to service connection for a bilateral hearing loss disability, tinnitus, a seizure disability, and vertigo; and (b) the further inextricably intertwined appellate issue of entitlement to SMC based upon housebound status. If any benefit sought on appeal is not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Barone, 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.