Citation Nr: 21042758 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 17-08 617 DATE: July 13, 2021 ORDER Service connection for fibromyalgia, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is denied. Service connection for a blood disorder (to include anemia, pernicious anemia and/or multifactorial pancytopenia), to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is denied. FINDINGS OF FACT 1. There is insufficient evidence upon which to diagnose the Veteran with fibromyalgia. 2. The Veteran's anemia, pernicious anemia, and multifactorial pancytopenia are diagnosed conditions that did not manifest in service and are not otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for fibromyalgia, to include as due to exposure to environmental hazards in the Persian Gulf, have not been satisfied. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 2. The criteria for service connection for a blood disorder (to include anemia, pernicious anemia and/or multifactorial pancytopenia), to include as due to exposure to environmental hazards in the Persian Gulf, have not been satisfied. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Procedurally, the Veteran served in the U.S. Army Reserve from May 1988 to May 1996, to include active duty for training from October 11, 1988, to May 4, 1989. In a May 2006 application for compensation, the Veteran reported that she also had active service with the Army Reserve from September 1992 to July 1994 in Saudi Arabia. However, during a November 2018 BVA Travel Board hearing in New Orleans, Louisiana, the Veteran testified that although she was uncertain of the year due to memory loss, she was deployed twice to Desert Storm while assigned to the Army Reserve unit 331st MMC TAACOM (Material Management Center). In a June 2020 letter, the Veteran reiterated that she was in Desert Storm twice, but that she may have served in Saudi Arabia in 1990. In this appeal, the Veteran contends that she was exposed to some type of chemical or gas that affected her blood during her period of service from 1992 to 1994. She states that her blood disorder began in 1994. The Veteran also reports being deployed to Kuwait. She essentially contends that she developed symptoms akin to fibromyalgia after she left Desert Storm; and that she believes her medical condition was caused by her exposure to explosives, tear gas, dead animals, and all types of chemicals that were mixed in the air that she inhaled while on active duty. The Veteran's service in Desert Storm has been confirmed to the extent that the evidence shows the Veteran had active duty for training in Saudi Arabia for 22 days in 1991, as she received an Operation Desert Storm-Army Reserve Components Overseas Training Ribbon for service from November 10, 1991, to November 21, 1991. There are also orders in the claims file for "Active Duty Special Work" (ADSW) Training Days for 17 days in Southwest Asia beginning in March 1992. However, despite numerous attempts to obtain service treatment records and records confirming the Veteran's initial assertions that she served on active duty/active duty for training from September 1, 1992 to July 1, 1994, this period of service has not been verified. In fact, the available evidence in the claims file rebuts the Veteran's contentions. Specifically, the claims file contains service personnel records dated in April 1992 that reflect the Veteran began missing her scheduled Army Reserve unit training assemblies. In July 1992, she was assigned as a Clerk Typist for the 321st MMC, Baton Rouge, LA (WVK1AA). Medical records reveal that from August 5, 1992 to August 10, 1992, the Veteran was hospitalized with depression. After a September 1992 unexcused absence in the Army Reserve (a time the Veteran reports she was Saudi Arabia), the Veteran was reduced in grade of rank for inefficiency. Thereafter, in January 8, 1993, (a time when she also reports being in Saudi Arabia), she was reassigned to the "U.S. Army Reserve Control Group" that only required an annual training (AT) commitment because she accrued nine unexcused absences from unit training assemblies within a 12-month period. The Veteran was discharged from the U.S. Army Reserves on May 7, 1996, while still assigned to the U.S. Army Reserve Control Group. Of note, the claims file also contains two "Information Reports" dated in June 2016 and June 2021 that reflect a military history from the VA/DoD Identity Repository (VADIR) that the Veteran had a reserve service period from May 5, 1988, to May 31, 1996. No dates are listed under "deployment periods." In the June 2016 report, under the Guard/Reserve Active Service (GRAS) section, no dates are provided. However, under military history from the beneficiary identification and records locator subsystem (BIRLS), the Veteran is listed as having army service from October 11, 1988, to March 4, 1989, and from September 1, 1992, to July 1, 1994. In the June 2021 information report, the information is reversed in that it shows the Veteran's service dates as October 11, 1988, to March 4, 1989, and from September 1, 1992, to July 1, 1994. However, neither GRAS nor BIRLS indicates service in the Gulf War; or reflect Gulf War service start or end dates. To the extent that the Veteran specifically claims her anemia and fibromyalgia developed as a result of her exposure to chemicals or other hazardous materials in Saudi Arabia from September 1, 1992, to July 1, 1994, the Board finds her assertions to be less persuasive than the evidence contained in her service personnel records and medical records. Regardless, for the purposes of the decision, the specific dates the Veteran served in Southwest Asia are not definitive to the outcome of her claims. As set forth above, the evidence indicates that the Veteran served in Southwest Asia in 1991 and 1992 for approximately 39 days. The Board assumes that she was exposed to hazardous materials during these two periods of active duty for training. SERVICE CONNECTION Service connection may be granted on a direct basis for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Generally, service connection requires: (1) the existence of a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). In addition, service connection may be established for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability resulting from an undiagnosed illness that became manifest 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, 2016, and cannot be attributed to any known clinical diagnosis by history, physical examination, or laboratory tests. 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1). The applicable presumptive period specified in 38 C.F.R. § 3.317 (a)(1)(i) has been extended several times, and currently ends December 21, 2021. See 81 Fed. Reg. 71382 (October 17, 2016). A qualifying chronic disability means a chronic disability resulting from (A) an undiagnosed illness or (B) a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms. 38 C.F.R. § 3.317 (a)(2)(i). The term "medically unexplained chronic multi-symptom 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 multi-symptom illnesses of partially understood etiology and pathophysiology are not considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii). Examples of medically unexplained chronic multi-system illness that are defined by a cluster of signs or symptoms include: (1) chronic fatigue syndrome; (2) fibromyalgia; and (3) functional gastrointestinal disorders (excluding structural gastrointestinal diseases), such as irritable bowel syndrome. Id. Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317 (b). "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). 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. Id. 1. Service connection for fibromyalgia Notably, other than the Veteran's November 2018 BVA hearing testimony and statements, there is scant evidence upon which to adjudicate the Veteran's claims. Unfortunately, the current evidence of record does not support the Veteran's assertion that she has fibromyalgia. During her BVA hearing, the Veteran testified that she is a nurse and that she believed she started having symptoms of fibromyalgia as early as four-to-five months after she returned from overseas to late-2000s/late-2010s. In her testimony and statements, the Veteran reported experiencing generalized weakness, fatigue, shortness of breath, rapid heartbeat, irritability, and tiring easily. She also reported having sleep problems and using a CPAP machine for sleep apnea. In pertinent part, the claims file contains medical records dated from 2015 to 2017 that fail to reflect complaints associated with, treatment for, or a diagnosis of fibromyalgia. The only comment regarding the Veteran experiencing shortness of breath occurred during a Medical Center visit in which she was being treated for anemia. At that time, this symptom was noted as being progressive during the previous week before care, not noted to be a consistent symptom potentially related to fibromyalgia or another disorder. The claims file also contains VA medical examination reports dated in February 2015 and February 2020 that are unsupportive of the Veteran's claims. Regarding these reports, it should initially be noted that the Board previously found that the February 2015 examination reports required an addendum opinion. Specifically, the Board remanded the February 2015 Gulf War General Medical Examination DBQ because, while the medical doctor who examined the Veteran diagnosed her as having a chronic multisymptom illness with a partially explained etiology, he failed to provide any insight as to what the "partially explained etiology" was. Additionally, although the doctor provided a medical opinion that it was less likely as not that the Veteran's medical problems were related to a specific environmental exposure event experienced by the Veteran during her service in Southwest Asia, he failed to provide a supporting rationale for his opinion. The February 2015 fibromyalgia DBQ report was also found to be confusing and inconsistent and required remand. The doctor who examined the Veteran found that she did not have a diagnosis of fibromyalgia, although she had "findings, signs and symptoms" that were attributable to fibromyalgia. However, when asked about the frequency of fibromyalgia symptoms, the doctor marked the answer indicating that the Veteran did not have any fibromyalgia symptoms. At the end of the report, the doctor was asked if the Veteran's "fibromyalgia" impacted her ability to work, to which the doctor marked the answer 'yes." He then went on to describe the "impact of the Veteran's fibromyalgia." According to a medical doctor who examined the Veteran in February 2020, there is insufficient information to establish a diagnosis of fibromyalgia. The doctor noted that the Veteran's complaints of myalgias, arthralgias, and generalized weakness were nonspecific; and that the Veteran was a poor historian. He stated that the Veteran's symptoms were complicated by her history of pancytopenia in 2017 and the continued need for intermittent blood transfusions (discussed below). He reported that, by definition, anemia and/or pancytopenia are not associated with fibromyalgia but can be seen in other conditions with similar complaints such as collagen vascular diseases including rheumatoid arthritis and systemic lupus erythematosus. As the Veteran had no recent medical records to review, he stated that her illness(es) were undiagnosed. While viewing the February 2015 VA examination reports to be of questionable value in-and-of themselves in regard to the Veteran's claim for fibromyalgia, the Board finds that when they are considered in conjunction with the February 2020 addendum medical opinion, they are still of some probative weight. The Board specifically finds, however, that the February 2020 addendum medical examination report and opinion to be of significant probative value. In this regard, the February 2020 doctor reviewed the Veteran's claims file and available medical records, obtained a medical history from the Veteran, and conducted a physical examination. Thereafter, he opined that there the evidence was not sufficient to establish a diagnosis of fibromyalgia. Notably, none of the competent medical evidence of record refutes the February 2020 doctor's conclusion, and the Veteran has not presented or identified any such existing medical evidence or opinion. To the extent that the Veteran contends that a medical relationship exists between her myalgias, arthralgias, and generalized weakness and service, the Board takes note that the Veteran is a nurse who has experience in working with nursing home patients, and therefore has some medical knowledge and training. She is also competent to testify as to her observations as a lay person. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In this regard, the Board also observes that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). In the instant case, however, the Veteran's assertions that she believes she has fibromyalgia to be of less probative value than the opinion of the February 2020 medical doctor. A medical doctor has significantly more training and experience in an area involving general complaints that can be associated with fibromyalgia than a nurse experienced in elder care. Fibromyalgia is not a disability subject to lay diagnosis as this diagnosis requires specific specialized medical training. In this regard, the Board observes that where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). Thus, the Veteran's assertions that there is a relationship between her generalized complaints of myalgias, arthralgias, and generalized weakness are symptoms of fibromyalgia are of no probative value. To the extent that the Veteran may assert that her myalgias, arthralgias, and generalized weakness are signs and symptoms of an undiagnosed illness related to her exposure to hazardous material during her Persian Gulf service, the Board finds that her assertions are not sufficient in this instance and are outweighed by other probative evidence of record. Regarding the argument that may be made that the statement by the February 2020 medical doctor that the Veteran's "illness(es) are undiagnosed and require her most recent medical records for review" constitutes evidence supportive of her claim, the Board disagrees. Viewing the doctor's statement in the context of his entire examination report and medical opinion, it is clear to the Board that the statement relates to the lack of evidence upon which to make an informed determination of the basis of the Veteran's illness(es) rather than the Veteran's symptoms constituting a diagnosis of an "undiagnosed illness" in the context of VA's regulations. Thus, the Board has little choice but to conclude that the Veteran does not have a current diagnosis of fibromyalgia and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The evidence also does not show that the Veteran suffers from an undiagnosed illness as defined under 38 C.F.R. § 3.317. Lastly, to the extent that the Veteran may argue that she should be granted service connection on the basis of pain alone, the Board observes that the United States Court of Appeals for the Federal Circuit (Fed. Court) has held that "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability" if it "reaches the level of a functional impairment of earning capacity." Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Such is not applicable in this case, however, because according to the medical doctor who examined the Veteran in February 2020, her complaints of myalgias, arthralgias, and generalized weakness did not impact her ability to work. In sum, service connection for fibromyalgia must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Service connection for a blood disorder Although the Veteran has been diagnosed with anemia, pernicious anemia and multifactorial pancytopenia (anemia), the Board finds that the preponderance of the evidence is against finding that anemia began during service, were aggravated during active service or are at least as likely as not related to her service in the Persian Gulf. For the record, anemia is defined as the condition of having less than the normal number of red blood cells or less than normal quantity of hemoglobin in the blood. https://medicinenet.com/search/mni/anemia. Pernicious anemia (also called Addison's anemia) is defined as a low blood cell count caused by inadequate vitamin B12. https://medicinenet.com/pernicious_anemia/definition.htm. Lastly, multifactorial pancytopenia is defined as a decrease of all three hematologic cell lines. The condition is not a disease in itself, but a common pathway caused by a multitude of etiologies that can be infectious, autoimmune, genetic, nutritional, and/or malignant. https://ncbi.nlm.nih.gov/books/NBK563146. As mentioned previously, there is little evidence in the claims file upon which to adjudicate the Veteran's claim. The Veteran testified during her BVA hearing that she could not remember exactly when she was diagnosed with anemia, but that she began experiencing weakness and tiredness four-to-five months after she left the Persian Gulf. However, she also testified that she believed her anemia was made worse by her exposure to chemicals overseas while serving in Desert Storm. Complicating the Veteran's claim are medical records in the claims file indicating that the Veteran was diagnosed with anemia in July 2000, and medical records indicating that she did not start seeing a hematologist until approximately 2003. Thus, the Board is uncertain whether the Veteran claims that she had anemia prior to service or that it began during service and was diagnosed thereafter. Limited post-service medical records in the claims file reflect only that the Veteran received treatment for systematic anemia, primary pancytopenia, and febrile neutropenia in 2017. The only other pertinent evidence in the claims file regarding this issue is the February 2015 Gulf War General Medical examination medical opinion referenced above. Although the Board deemed this opinion to be less persuasive in the context of the Veteran's claim of entitlement to service connection for fibromyalgia, the Board finds it sufficient upon which to adjudicate the Veteran's anemia claim. In this regard, the Board notes that the VA medical doctor who examined the Veteran in February 2015 interviewed her and reviewed her claims file. He noted the Veteran's chronic anemia, that she was being followed by a hematologist (a fact contradicted by the Veteran's 2017 medical records in which she reported that she had not been seen by a hematologist for several years), and that she had had several blood transfusions. Thereafter, the doctor ultimately opined that it was less likely than not that the Veteran's medical problems were related to a specific environmental exposure event experienced during her service in Southwest Asia. Although the Board is of the opinion that the above-referenced February 2015 medical opinion could have been more specific in terms of addressing the Veteran's anemia claim, a remand of the claim for the purpose of obtaining a more specific opinion is not warranted given the limited evidence upon which such a medical opinion can be based and when viewed in conjunction with the Veteran's inconsistent medical history. To the extent that the Veteran contends that there is a relationship between her anemia and service, the Board again takes note that the Veteran is a nurse, and therefore has some medical knowledge expand training. She is also competent to testify as to her observations as a lay person. Jandreau v. Nicholson, supra. In the instant case, however, the Board finds that the Veteran's beliefs that there is such a relationship to be of less probative value than the opinion of the February 2015 medical doctor. A medical doctor has significantly more training and experience in an area involving hematological disorders in comparison to a nurse experienced in elder care. Additionally, anemia is not a disability subject to lay diagnosis as this diagnosis requires specific specialized medical training. Thus, the Veteran's assertions that there is a relationship between her anemia and Persian Gulf service is of no probative value. Given the evidence set forth above, the Board must find that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for anemia. Therefore, the appeal must be denied. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Talpins 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.