Citation Nr: 21041735 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 11-21 300A DATE: July 10, 2021 ORDER Entitlement to service connection for neuropathy-like neurological disability of the right lower extremity, claimed as due to undiagnosed illness and/or environmental exposures in Southwest Asia during the Persian Gulf War, is granted. Entitlement to service connection for neuropathy-like neurological disability of the left lower extremity, claimed as due to undiagnosed illness and/or environmental exposures in Southwest Asia during the Persian Gulf War, is granted. Entitlement to service connection for peripheral neuropathy or neuropathy-like neurological disability of the left upper extremity, 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, is denied. Entitlement to service connection for peripheral neuropathy or neuropathy-like neurological disability of the right upper extremity, 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, is denied. Entitlement to service connection for a skin disability of the lower extremities to include stasis dermatitis, including as an undiagnosed illness or medically unexplained chronic multisymptom illness incurred as a result of service in Southwest Asia during the Persian Gulf War, is denied. Entitlement to service connection for hypertension, including as an undiagnosed illness or medically unexplained chronic multisymptom illness incurred as a result of service in Southwest Asia during the Persian Gulf War, is denied. Entitlement to service connection for headaches, diagnosed as migraine headaches, 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, is denied. Entitlement to service connection for a disability claimed as Gulf War Syndrome (apart from neuropathy-like neurological symptoms of the lower extremities), to include a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome), is denied. REMANDED The issue of entitlement to a total disability evaluation based upon individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. In December 2019, the Veteran did not report to scheduled examinations without good cause shown. 2. Resolving reasonable doubt in the Veteran's favor, the evidence is sufficient to show that (a) the Veteran has had medically unexplained neuropathy-like neurological symptoms of his left lower and right lower extremities beyond what can be medically attributed to a known medical diagnosis and etiology, and (b) the neuropathy-like neurological symptoms have been medically determined by process of exclusion to be attributable to the Veteran's Gulf War Southwest Asia service. 3. Due in part to the Veteran not reporting for scheduled VA examinations, the evidence is insufficient to establish that the Veteran's claimed peripheral neuropathy or neuropathy-like neurological disabilities of the left and right upper extremities are related to service, or whether they represent a medically unexplained illness or undiagnosed illness that cannot be attributed to a known clinical diagnosis. 4. Due in part to the Veteran not reporting for scheduled VA examinations, the evidence is insufficient to establish that the Veteran's claimed skin disability, to include stasis dermatitis, is related to service, or whether it represents a medically unexplained illness or undiagnosed illness that cannot be attributed to a known clinical diagnosis. 5. The Veteran's diagnosed hypertension is not shown to have been incurred during service or within a year following service; due in part to the Veteran not reporting for scheduled VA examinations, the evidence is insufficient to establish that the Veteran's diagnosed hypertension is otherwise etiologically linked to his service. 6. The Veteran's headaches have been attributed to the known diagnosis of migraine headaches and are not shown to have been incurred during service; due in part to the Veteran not reporting for scheduled VA examinations, the evidence is insufficient to establish that the Veteran's diagnosed migraine headache pathology is otherwise etiologically linked to his service. 7. Due in part to the Veteran not reporting for scheduled VA examinations, the evidence is insufficient to establish that the Veteran has Gulf War Syndrome (apart from neuropathy-like neurological symptoms of the lower extremities), to include a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome). CONCLUSIONS OF LAW 1. The criteria for service connection for neuropathy-like neurological symptoms of the left lower extremity, claimed as due to undiagnosed illness and/or environmental exposures in Southwest Asia during the Persian Gulf War, are met. 38 U.S.C. §§ 1110, 1117, 1118, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 2. The criteria for service connection for neuropathy-like neurological symptoms of the right lower extremity, claimed as due to undiagnosed illness and/or environmental exposures in Southwest Asia during the Persian Gulf War, are met. 38 U.S.C. §§ 1110, 1117, 1118, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 3. The criteria for entitlement to service connection for peripheral neuropathy or neuropathy-like neurological disability of the left upper extremity, 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), 1131, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.317, 3.655. 4. The criteria for entitlement to service connection for peripheral neuropathy or neuropathy-like neurological disability of the right upper extremity, 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), 1131, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.317, 3.655. 5. The criteria for entitlement to service connection for a skin disability of the lower extremities to include stasis dermatitis, 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), 1131, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.317, 3.655. 6. The criteria for entitlement to service connection for hypertension, 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. §§ 1101, 1110, 1112, 1113, 1117(d), 1131, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309, 3.317, 3.655, 4.104. 7. The criteria for entitlement to service connection for headaches, diagnosed as migraine headaches, 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), 1131, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.317, 3.655. 8. The criteria for entitlement to service connection for Gulf War Syndrome (apart from neuropathy-like neurological symptoms of the lower extremities), to include a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome), 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), 1131, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.317, 3.655. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from June 1988 to June 1992. This case comes before the Board of Veterans' Appeals (Board) on appeal of March, May, and November 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. This case was previously before the Board, most recently in November 2018 when the Board remanded all of the issues on appeal 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. As explained in the Board's prior remand, in the June 2011 Statement of the Case (SOC) addressing the matters on appeal, the RO did not specifically address a claim of entitlement to service connection for disability claimed as Gulf War Syndrome. However, a review of the SOC shows that the RO considered the applicable provisions relating to chronic multi-symptom undiagnosed illnesses in rendering a decision. See 38 C.F.R. § 3.3217. Nevertheless, the Board has included the issue on appeal because it was addressed separately in the May 2009 rating decision on appeal. As discussed in the Board's prior remand, in May 2017 the Board remanded the issues on appeal as the Veteran had indicated that he wanted a Board hearing. In June 2017 the Veteran was notified that his hearing had been scheduled for July 2017. In July 2017 the Veteran requested that his hearing be rescheduled due to his medical condition. In February 2018, the Veteran was notified of his rescheduled hearing for July 2018. The Veteran did not appear for his scheduled hearing. In a letter from the Veteran's representative received in August 2018, the Veteran indicated that he still wanted a hearing. In a notice issued in August 2018, the Veteran was informed that he had not timely requested a new hearing and that his hearing would not be rescheduled. The Board finds the Veteran's request for a hearing withdrawn. See 28 C.F.R. § 20.704. In July 2018, the RO issued a rating decision which denied the Veteran's claims of entitlement to service connection for posttraumatic stress disorder, dysthymia, fibromyalgia, insomnia, irritable bowel syndrome, and memory loss. As the Veteran has not filed a disagreement with the decision, the issues are not before the Board from that adjudication. However, to the extent that the Veteran's claims of entitlement to service connection for fibromyalgia and irritable bowel syndrome were essentially already encompassed by the appeal seeking entitlement to service connection for Gulf War Syndrome featuring a medically unexplained chronic multisymptom illness featuring similar impairments, the Board notes that this appeal was pending prior to the July 2018 RO adjudication and the Veteran's contentions regarding such impairments are within the scope of consideration for the appeal before the Board. The Board's November 2018 remand directed that the Veteran be afforded new VA examinations to provide the evidentiary record with more adequate evidence determining the nature and likely cause of his claimed disabilities on appeal. A November 2019 report in the claims-file shows that arrangements were made for new VA examinations to cover: "Hypertension," "Skin," "Gulf War (including burn pits)," "Headaches (including migraine headaches)," "Peripheral nerves," and "Chronic fatigue syndrome." However, the AOJ was notified that the Veteran did not report for the December 2019 examinations scheduled in conjunction with his claims (documentation of the notification was added to the claims-file in June 2020). The Veteran was notified that he missed the scheduled VA examination in the June 2020 supplemental statement of the case (SSOC). The Veteran's representative now asserts, as presented in May 2021 written argument, that "in light of the Federal Circuit's ruling in Kyhn and the absence of verification that the veteran received proper notification of his VAE, an additional examination must be scheduled, the veteran must be provided the required notice and copies of the notification must be included in the veteran's VA file." The Board acknowledges that the record does not contain a notice letter for the December 2019 examination, 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). However, 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 examination; rather, the Veteran's representative simply asserts that the absence of evidence demonstrating such notice is sufficient to warrant scheduling the examinations again. Neither the Veteran nor his representative has otherwise indicated the Veteran had good cause for missing the examinations. Non-receipt of notice of an examination could provide good cause for a 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 his scheduled VA examination, this fact alone does not constitute good cause for failure to cooperate with the scheduling of a VA examination. Critically, the Veteran has not disputed the report in the SSOC that he missed the VA examination appointment without good cause, nor asserted that he did not receive notice of the AOJ's attempt to schedule the examination. Neither the Veteran nor his attorney has provided an explanation for the fact that the Veteran did not report for the scheduled VA examination 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 claim of compensation for service connection must be rated 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 some 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.) 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, 1131; 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). 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 (2018). 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 hypertension, 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 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 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 term "chronic" means that the disability has existed for 6 months or more, to include intermittent episodes of improvement or worsening over that period. 38 C.F.R. § 3.317(a)(4). 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 of record in the Veteran's claims-file with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss in detail every piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis 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). 1. Entitlement to service connection for neuropathy-like neurological disability of the right lower extremity, claimed as due to undiagnosed illness and/or environmental exposures in Southwest Asia during the Persian Gulf War, is granted. 2. Entitlement to service connection for neuropathy-like neurological disability of the left lower extremity, claimed as due to undiagnosed illness and/or environmental exposures in Southwest Asia during the Persian Gulf War, is granted. The evidentiary record is replete with documentation of the Veteran's functional impairments of his lower extremities, and it is generally documented that numerous medical professionals have been unable to determine the nature and etiology of his significant impairments. A report from a private medical doctor with expertise in neurology ("Neurological Consultant American College of Surgeons, Fellow") received by VA in May 2010 states: "[H]e is significantly disabled because of his gait and because of his ongoing pain.... He has seen a neurologist in the past but no specific diagnosis has been entertained.... I cannot tell you the reason for his neuropathy which is limited to the lower extremities on each side." Furthermore, the expert continues: "Specifically, he has diffuse dense neuropathy. He has been tested with nerve conduction studies which are abnormal, but no light is shed upon the cause for his neuropathic difficulties at the present time." Finally, the expert concludes: "I do not believe he shows the picture of multiple sclerosis. He does not have any myotrophic lateral sclerosis. Once again, I am in a quandary as to the specific cause of his difficulties today." The Board finds it significant that this neurology expert has clearly noted objective evidence of neurological abnormality associated with the Veteran's noted lower extremity dysfunction, and has expressed that the precise nature and etiology of the problem has eluded explanation despite clinical investigation. Additionally notable is the April 2009 opinion (added to the claims-file in May 2009) of a VA medical doctor who examined the Veteran for a Persian Gulf Registry evaluation. The examining VA doctor discussed the Veteran's "chief complaint" of "chronic aching in both his legs below the knees," that he "does not know sometimes the direction his leg is going." The VA doctor examined the Veteran and remarked: "These findings are, I feel, rather unusual for a 40+ year old patient. Etiology is unclear to me. He had an MRI of the brain.... It would appear that he may be having some form of cerebellar lesion of unclear etiology, at least, at present." Significantly, the VA examiner then stated: "I am of the opinion that this patient may be having an unexplained illness secondary to his tour of duty in the Gulf Theater." Additionally notable are the reports of the Veteran's private primary care physician (Dr. Segnitz). In a July 2009 written statement, the doctor states that the Veteran "currently suffers from severe disabling peripheral neuropathy of the lower extremities. This includes motor and sensory disabilities. By process of exclusion through testing and history, the patient's diagnosis is peripheral neuropathy secondary to Gulf War Syndrome." The Board notes that the authoring physician indicated that he had been treating the Veteran for three years at the time of this statement. A September 2009 statement from the same private treating physician discusses the Veteran's "lower extremity disabling pain, disabling weakness and significant balance problems." The doctor describes that "VA testing as well as private sector testing have been unable to determine even remotely the cause of patient's disability except for Gulf War exposures. Recent MRI of the head[:] 2 done 11 months apart reveal stable finding excluding central nervous system disease causing lower extremity problems." The above-discussed reports are accompanied by an additional quantity of evidence from additional medical professionals indicating an inability to etiologically explain the Veteran's lower extremity disabilities, even if not then suggesting attribution to Gulf War exposures. A November 2008 report from a different medical doctor presents the impression of "Diffuse symptoms including paresthesias involving hands, legs and feet, weakness in his legs ... of unknown etiology," and then discusses the author's doubt that central nervous system etiologies are involved, and notes that "imaging studies and clinical presentations do not support diagnosis of MS." A February 2009 report (added to the claims-file in March 2009) from another private expert neurologist discusses examining the Veteran and finding that "I cannot definitively attribute his current syndrome to his likely exposure to unknown toxins during his service.... Unfortunately, he fits into the category of a patient for which there is no clear explanation for his symptoms." The neurologist adds: "At this point, I am not sure how much more diagnostic testing I can recommend...." The Board has noted that the author of this February 2009 report suggests, in expressly speculative terms, that the Veteran "may have evidence of pre-diabetes" and that this "may also be a cause...." However, this speculation is followed by the author's statement that "there is no clear explanation for his symptoms," and this entire report was addressed specifically to the Veteran's primary care physician who was aware of it when subsequently reiterating the conclusion that there was no medical explanation for the Veteran's lower extremity impairments. Additionally, multiple other medical experts asserted the unexplained nature of the Veteran's lower extremity disabilities subsequent to this February 2009 speculation regarding a pre-diabetic neuropathy. While the Board observes that the Veteran's subsequent medical history has included progression of diabetic concerns, the evidence continues to indicate that the Veteran's lower extremity impairments are medically unexplained, with more recent treatment reports (such as an August 2018 VA treatment report) referring to the Veteran's "LE neuropathy of undiagnosed pathology," and without indication of revision of the previously repeated medical pronouncements that the lower extremity impairments are medically unexplained. The Board notes that there are two VA medical opinions that tend to weigh against the Veteran's lower extremity disability claims on appeal. A June 2011 VA Gulf War General Medical Examination report includes an opinion from a physician's assistant that presents a standardized generic paragraph stating: "There is no evidence for an undiagnosed illness .... All the veteran's conditions are consistent with a disease with a clear and specific etiology and diagnosis...." A June 2018 Gulf War General Medical Examination report includes an opinion from a nurse practitioner that features the same standardized generic paragraph with the same language. The Board has considered the findings of these VA medical professionals, but does not find that they present sufficient detailed discussion of the complex indications of record regarding the lower extremity disabilities to persuasively contradict the numerous prior specific statements from medical experts discussed above; the Board finds that the evidence of record does include significant and varied probative medical evidence indicating that the Veteran's lower extremity disabilities do represent an undiagnosed illness, and such evidence is not adequately addressed by the June 2011 and June 2018 medical opinions that indicate finding no such evidence. The Board finds that the evidence reasonably supports the Veteran's claim that he suffers from an undiagnosed illness manifested by signs and symptoms including neuropathy-like neurological impairment of his lower extremities. Accordingly, after resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for the Veteran's neuropathy-like neurological symptoms in the bilateral lower extremities is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. To these extents, the appeal is granted. 3. Entitlement to service connection for peripheral neuropathy or neuropathy-like neurological disability of the left upper extremity, 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, is denied. 4. Entitlement to service connection for peripheral neuropathy or neuropathy-like neurological disability of the right upper extremity, 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, is denied. As discussed above, the Board has found that reasonable doubt can be resolved in the Veteran's favor to find that the criteria for entitlement to service connection for disabilities of the lower extremities due to undiagnosed illness / Gulf War exposures have been met in this case. The Veteran furthermore claims entitlement to service connection for disabilities of the upper extremities. However, the evidence relied upon by the Board to find support for entitlement to service connection for disabilities of the lower extremities is predominantly specific to discussing the Veteran's impairments of the lower extremities. The evidence does not similarly establish that the Veteran has impairments of the upper extremities attributable to undiagnosed illness / Gulf War exposures. The Veteran's medical records include some references to the Veteran's complaint of upper extremity impairments and some associated medical impressions, such as a November 2008 private medical report noting "Impression: Diverse symptoms including paresthesias involving hands, legs and feet...." However, the most supportive medical evidence that indicates that some of the Veteran's impairments are medically unexplained and attributable to undiagnosed illness features evidence that is specific to the Veteran's identified lower extremity impairments (as discussed in the section of this decision addressing the lower extremity disability claims). The Board finds that the evidence of record does not establish that the Veteran's reported disabilities of the upper extremities represent functional impairment attributable to an undiagnosed illness. Based on the evidence of record, the Board concludes that service connection is not warranted for the Veteran's claimed impairments of the upper extremities, to include paresthesias. The Veteran's service treatment records do not suggest any onset of such a disability during service. There is no medical evidence of record indicating that the Veteran's current claimed upper extremity disabilities, including paresthesias, are etiologically linked to his military service on any basis. Unfortunately, the Veteran did not report for the scheduled December 2019 VA examinations, including for peripheral nerves and Gulf War syndrome, that may have shed more light on the questions pertinent to these issues, including whether the claimed impairments represent an undiagnosed illness, a medically unexplained chronic multisymptom illness, or a disability otherwise etiologically linked to service. 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 December 2019 VA examination scheduled 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 current claimed upper extremity disabilities are 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 scheduled December 2019 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 of the examination, the evidence is insufficient to establish that his claimed upper extremity disabilities are related to service. The evidence of record does not show that the Veteran had onset of peripheral neuropathy or neuropathy-like neurological disability of the left or right upper extremity during active service. The evidence of record does not otherwise show that the Veteran's current claimed upper extremity disabilities are 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 upper extremity disabilities in this case. Accordingly, service connection for upper extremity disabilities must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. at 53. 5. Entitlement to service connection for a skin disability of the lower extremities to include stasis dermatitis, including as an undiagnosed illness or medically unexplained chronic multisymptom illness incurred as a result of service in Southwest Asia during the Persian Gulf War, is denied. The Veteran has claimed entitlement to service connection for a skin disorder he alleges to be the result of Gulf War Syndrome. The Veteran's claim appears to contemplate the appearance of 'marks' or 'spots' on his skin, particularly involving his legs. A November 2008 VA medical record shows that the Veteran wanted to be "checked for desert storm syndrome, to see if these spots on my legs are from that." A June 2018 VA examination report notes that the Veteran's report of lower extremity symptoms included: "I have marks, I don't know where the marks come from." The Board observes that a June 2011 VA examination report includes a medical impression that the Veteran had the diagnosed pathology of "stasis dermatitis." The Veteran is competent to report that he has experienced skin symptoms. See McCartt v. West, 12 Vet. App. 164, 167-68 (1999) (a veteran is competent to observe skin conditions such as boils, blotches, and rashes). However, he is not competent to state that those symptoms are related to a specific diagnosis, or to state that such a diagnosis is related to in-service exposure to various agents in Southwest Asia. Davidson v. Shinseki, 581 F.3d 1313 (2009); Barr, 21 Vet. App. at 303. The Board's November 2018 remand sought to develop evidence with greater medical / diagnostic clarity than is provided by the evidence currently of record. Unfortunately, the Veteran did not report for the scheduled December 2019 VA examination that may have shed more light on this matter. 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 addressing the Veteran's contentions that may have been obtained at the December 2019 VA examination scheduled to assist the Veteran with the claims on appeal. A June 2018 VA Fibromyalgia examination report, informed by review of the claims-file and in-person examination of the Veteran, shows that the examining medical professional discusses the Veteran's report of "marks." The examining medical professional completed three VA examination reports based upon this consultation, and found no signs of an undiagnosed illness. In the June 2018 Gulf War General Medical Examination report, the VA examiner stated: "There is no evidence for an undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, or a diagnosable chronic multi-symptom illness with a partially explained etiology." Additionally, the June 2018 VA examiner stated: "It is my medical opinion that all the veteran's conditions as discussed above including disability patterns and diagnosed diseases are not related to a specific exposure event experienced by the veteran during service in Southwest Asia." This evidence weighs against the claim of entitlement to service connection for a skin disorder on the basis of undiagnosed illness or Gulf War exposures. The Board finds that the evidence does not otherwise show that the Veteran has had a skin disorder due to undiagnosed illness or Gulf War exposures. The Board finds that the evidence of record does not otherwise show that any claimed skin disability is etiologically linked to any other event, injury, or disease during military service. No basis of entitlement to service connection for a skin disability is supported by the evidence of record. Accordingly, the claim of entitlement to service connection for a skin disability must be denied. In summary, the Veteran did not report for the scheduled December 2019 VA examinations 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 of the examinations, the evidence is insufficient to establish that his claimed skin disability is related to service, or whether it represents an undiagnosed illness that cannot be attributed to any known clinical diagnosis, or a medically unexplained chronic multisymptom illness. Accordingly, service connection for a skin disability must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. at 53. 6. Entitlement to service connection for hypertension, including as an undiagnosed illness or medically unexplained chronic multisymptom illness incurred as a result of service in Southwest Asia during the Persian Gulf War, is denied. The evidence, including the Veteran's VA treatment records, repeatedly shows that the Veteran has a diagnosis of hypertension (including as documented in a May 2020 VA treatment report). As the Veteran's hypertension is a diagnosed condition, it cannot be considered an undiagnosed illness; there is furthermore no evidence indicating that the Veteran's hypertension 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 hypertension. The evidence does not show that hypertension was manifest in service or to a degree of 10 percent within 1 year of separation. For VA rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 mmHg or greater. The term isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mmHg or greater with a diastolic blood pressure of less than 90 mmHg. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). For VA purposes, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id. At the time of the Veteran's May 1992 service separation examination, the Veteran reported to the examining medical professionals that "No," he did not have nor had he ever had "High or low blood pressure." The Veteran's blood pressure was tested during the separation examination and was recorded as normal ("114/70"), no pertinent abnormalities were otherwise noted, and no diagnosis of hypertension was suggested. In September 2018, the Veteran's representative submitted a written log of numerous blood pressure readings recorded in examinations of the Veteran over the years; this was presented to support the assertion that "the data show that the first hypertensive readings were in service and that his blood pressure was consistently higher after enlistment." The submitted log highlights blood pressure readings of 142/71 and 144/90 on the same day in February 1991. The reported February 1991 data is followed by a March 4, 1991, reading of 114/72. The Veteran's representative then highlights two readings from consecutive days in July 1991 of 138/80 and 138/82. These are followed by two more readings from the same month of 118/54 and 120/86. The remaining reported blood pressure readings from the Veteran's active duty service are: 120/70 (September 1991); 132/82 (February 1992 - highlighted by the Veteran's representative); 118/80 (March 1992); 136/86 (March 1992 - highlighted by the Veteran's representative); 112/68 (April 1992); and finally the 114/70 from the May 1992 separation examination. Even as reported by the Veteran's representative, none of the systolic readings reach the VA definition threshold for hypertension of 160 mmHg, and only two reach 140 mmHg or greater. For a diagnosis of hypertension that conforms to VA regulations, the diagnosis must be based on readings taken at least 2 times on 3 or more days. The diastolic pressure must be predominantly 90 mmHg or more (or systolic pressure must be predominantly 160 mmHg or more). See 38 C.F.R. § 4.107, Diagnostic Code 7101, NOTE (1). In this case, the evidence including the single in-service 90 mmHg diastolic blood pressure reading highlighted by the Veteran's representative does not show in-service diastolic pressure predominantly 90 mmHg or more, nor does the evidence show systolic pressure predominantly 160 mmHg or more. Unfortunately, the Veteran did not report for the scheduled December 2019 VA hypertension compensation examination that may have shed more light on the question of whether the Veteran's current hypertension is etiologically linked to his military service. Accordingly, the Board is compelled to review the Veteran's claim on the basis of the available evidence without the benefit of the potentially clarifying information regarding the significance of the Veteran's in-service blood pressure readings to the etiology of his current hypertension that may have been obtained through the December 2019 VA examination scheduled 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 hypertension 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 scheduled December 2019 VA examinations 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 of the examination, the evidence is insufficient to establish that his hypertension is related to service. The evidence of record does not show that the Veteran had onset of hypertension during active service, nor within a year following separation from active service. The evidence of record does not otherwise show that the Veteran's current diagnosed disability of hypertension 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 hypertension in this case. Accordingly, service connection for hypertension must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. at 53. 7. Entitlement to service connection for headaches, diagnosed as migraine headaches, 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, is denied. The evidence, including the Veteran's VA treatment records, repeatedly shows that the Veteran has a diagnosis of migraine headaches (including as documented in a May 2020 VA treatment report). As the Veteran's migraine headaches represent a diagnosed condition, they cannot be considered an undiagnosed illness; there is furthermore no evidence indicating that the Veteran's headaches 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 currently diagnosed migraine headaches. The Veteran's service treatment records do not suggest any onset of migraine headaches, or any chronic headache disorder, during service. There is no medical evidence of record indicating that the Veteran's diagnosed migraine headaches are etiologically linked to his military service on any basis. Migraine headaches were not manifest to a compensable degree within a year of separation. Unfortunately, the Veteran did not report for the scheduled December 2019 VA headaches compensation examination that may have shed more light on the question of whether the Veteran's current migraine headache pathology 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 December 2019 VA examination scheduled 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 migraine headache 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 scheduled December 2019 VA examinations 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 of the examination, the evidence is insufficient to establish that his migraine headaches are related to service. The evidence of record does not show that the Veteran had onset of migraine headaches during active service. The evidence of record does not otherwise show that the Veteran's current diagnosed disability of migraine headaches 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 migraine headaches in this case. Accordingly, service connection for migraine headaches must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. at 53. 8. Entitlement to service connection for a disability claimed as Gulf War Syndrome (apart from neuropathy-like neurological symptoms of the lower extremities), to include a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome), is denied. The Veteran has claimed entitlement to service connection for various impairments he alleges to be the result of Gulf War Syndrome. Several of the Veteran's claimed impairments have been addressed as individual issues, and the AOJ's May 2009 rating decision on appeal further considered entitlement to service connection for a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) as a claim for service connection for Gulf War Syndrome. The Board's November 2019 decision explained that this issue is part of the appeal before the Board at this time. The Board's November 2018 remand sought to develop evidence with greater medical / diagnostic clarity than is provided by the evidence currently of record. Unfortunately, the Veteran did not report for the scheduled December 2019 VA examination that may have shed more light on this matter. Accordingly, the Board is compelled to review the Veteran's claim on the basis of the available evidence without the benefit of the potentially clarifying information addressing the Veteran's contentions that may have been obtained at the December 2019 VA examination scheduled to assist the Veteran with the claim on appeal. A June 2018 VA Fibromyalgia examination report, informed by review of the claims-file and in-person examination of the Veteran, shows that the examining medical professional responded "No," when asked "Does the Veteran now have or has he/she ever been diagnosed with fibromyalgia?" The Board notes that this report shows that the Veteran's symptom complaints alleged to represent fibromyalgia were "bilateral LE [lower extremity] ache and hurt all the time," other sensory disturbance of the lower extremities, and "marks" on his lower extremities. These impairments are contemplated in the separate issues of entitlement to service connection for lower extremity disabilities (granted in this Board decision) and entitlement to service connection for a skin disorder (denied in this Board decision). The June 2018 VA Fibromyalgia examination report otherwise indicates no basis for finding that the Veteran has had fibromyalgia. The Board finds that the evidence of record does not otherwise show that the Veteran has had fibromyalgia. A June 2018 VA Intestinal Conditions examination report, informed by review of the claims-file and in-person examination of the Veteran, shows that the examining medical professional responded "No," when asked "Does the Veteran now have or has he/she ever been diagnosed with an intestinal condition (other than surgical or infectious)?" The examining medical professional explained that "there is no diagnosis of IBS, there are complaints of abdominal discomfort and diarrhea after eating and medication was started at that visit but no diagnosis given." The June 2018 VA Intestinal Conditions examination report otherwise indicates no basis for finding that the Veteran has had irritable bowel syndrome. The Board finds that the evidence of record does not otherwise show that the Veteran has had irritable bowel syndrome. A June 2018 VA Gulf War General Medical Examination report, informed by review of the claims-file and in-person examination of the Veteran, shows that the examining medical professional responded "No," when asked if there was any "Functional impact of additional signs and/or symptoms that may represent an 'undiagnosed illness' or 'diagnosed medically unexplained chronic multisymptom illness." Additionally, the June 2018 VA examiner stated: "It is my medical opinion that all the veteran's conditions as discussed above including disability patterns and diagnosed diseases are not related to a specific exposure event experienced by the veteran during service in Southwest Asia." The June 2018 VA examination report otherwise indicates no basis for finding that the Veteran has had medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome). Apart from the Board's grant of benefits for neurological disability of the lower extremities (addressed in a separate section of this decision), the Board finds that the evidence of record does not otherwise show that the Veteran has had a "Gulf War Syndrome" or a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome). In summary, the Veteran did not report for the scheduled December 2019 VA examinations 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 of the examinations, the evidence is insufficient to establish that his claimed impairments / symptoms are related to service, or whether they represent an undiagnosed illness that cannot be attributed to any known clinical diagnosis, or a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome). Accordingly, service connection for Gulf War Syndrome 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 a TDIU is remanded. The forthcoming AOJ rating and effective date determinations for the new grants of service connection presented in this Board decision, could significantly impact a decision on the issue of entitlement to a TDIU. Accordingly, the issues are inextricably intertwined. A remand of the issue of entitlement to a TDIU is required. 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 TDIU until the AOJ's forthcoming development and adjudications concerning the pending rating and effective date assignments for the grants of service connection in this Board decision have been completed. A remand of the claim for TDIU is required. The matters are REMANDED for the following action: 1. The AOJ should obtain an updated set of the Veteran's VA medical records (those records not already associated with the claims-file) pertinent to the TDIU issue currently remaining on appeal. 2. After completion of the initial rating and effective date determinations for the new grants of service connection presented in this Board decision, and after any additionally indicated development has been completed, readjudicate the inextricably intertwined issue of entitlement to a TDIU. 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.