Citation Nr: 21060927 Decision Date: 09/28/21 Archive Date: 09/28/21 DOCKET NO. 16-25 423 DATE: September 28, 2021 ORDER Entitlement to service connection for fibromyalgia, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, is granted. Entitlement to service connection for erectile dysfunction, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, and/or as secondary to a service-connected disability, is denied. Entitlement to service connection for acid reflux, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, and/or as secondary to service-connected PTSD and/or irritable bowel syndrome is denied. Entitlement to service connection for bilateral hearing loss is granted. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for left leg pain, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, is denied. Entitlement to service connection for right leg pain, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, is denied. Entitlement to service connection for neck pain, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, is denied. Entitlement to service connection for right foot pain, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, is denied. Entitlement to service connection for left foot pain, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, is denied. Entitlement to a compensable initial disability rating for irritable bowel syndrome is denied. Entitlement to an effective date prior to September 23, 2013 for the grant of service connection for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for a left forearm disorder, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for a right forearm disorder, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for chronic fatigue syndrome, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for overall body pains, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for inflammatory arthritis of the right shoulder, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for inflammatory arthritis of the left shoulder, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for inflammatory arthritis of the right hip, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for inflammatory arthritis of the right hand, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for inflammatory arthritis of the left hand, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, is remanded. Entitlement to special monthly compensation (SMC) based upon the need for aid and attendance or at the housebound rate is remanded. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) prior to September 23, 2013 is remanded. FINDINGS OF FACT 1. The Veteran has a diagnosis of fibromyalgia, which is presumptively due to his Persian Gulf War service. 2. The preponderance of the evidence of record is against finding that the Veteran has or has had at any time during the appeal period, a current diagnosis of erectile dysfunction; the preponderance of the evidence is also against finding that the Veteran's erectile dysfunction symptoms are the result of an undiagnosed illness or a medically unexplained chronic multisymptom illness. 3. The preponderance of the evidence of record is against finding that the Veteran has or has had at any time during the appeal period, a current diagnosis of acid reflux; the preponderance of the evidence is also against finding that the Veteran's acid reflux symptoms are the result of an undiagnosed illness or a medically unexplained chronic multisymptom illness. 4. Resolving reasonable doubt in the Veteran's favor, bilateral hearing loss is related to the Veteran's in-service acoustic trauma. 5. The probative evidence of record does not show that the Veteran's tinnitus is related to his active service. 6. The preponderance of the evidence of record is against finding that the Veteran's left leg pain is etiologically related to his active duty service or that it is the result of an undiagnosed illness or medically unexplained chronic multisymptom illness. 7. The preponderance of the evidence of record is against finding that the Veteran's right leg pain is etiologically related to his active duty service or that it is the result of an undiagnosed illness or medically unexplained chronic multisymptom illness. 8. The preponderance of the evidence of record is against finding that the Veteran's neck pain is etiologically related to his active duty service or that it is the result of an undiagnosed illness or medically unexplained chronic multisymptom illness. 9. The preponderance of the evidence of record is against finding that the Veteran's right foot pain is etiologically related to his active duty service or that it is the result of an undiagnosed illness or medically unexplained chronic multisymptom illness. 10. The preponderance of the evidence of record is against finding that the Veteran's left foot pain is etiologically related to his active duty service or that it is the result of an undiagnosed illness or medically unexplained chronic multisymptom illness. 11. Regarding IBS, the Veteran, without good cause, failed to report for the scheduled August 2019 VA examination necessary to decide his increased rating claim. The record shows no more than mild disturbances of bowel function with occasional episodes with no abdominal distress. 12. On September 23, 2013, the Veteran filed a claim seeking service connection for PTSD. 13. The evidence of record does not show that a formal or informal claim for entitlement to service connection for PTSD was received prior to September 23, 2013. 14. Entitlement to service connection for PTSD arose on May 6, 2015. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for fibromyalgia have been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.303, 3.317. 2. The criteria for entitlement to service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.317. 3. The criteria for entitlement to service connection for acid reflux have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.317. 4. The criteria for entitlement to service connection for bilateral hearing loss have been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.385. 5. The criteria for entitlement to service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. § 3.303. 6. The criteria for entitlement to service connection for left leg pain have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.317. 7. The criteria for entitlement to service connection for right leg pain have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.317. 8. The criteria for entitlement to service connection for neck pain have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.317. 9. The criteria for entitlement to service connection for right foot pain have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.317. 10. The criteria for entitlement to service connection for left foot pain have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.317. 11. The claim for entitlement to a compensable initial disability rating for irritable bowel syndrome is denied. 38 C.F.R. §§ 3.655(b), 4.3, 4.7, 4.114, Diagnostic Code 7319. 12. The criteria for entitlement to an effective date earlier than September 23, 2013 for the award of service connection for PTSD have not been met. 38 U.S.C. §§ 5110, 5107; 38 C.F.R. §§ 3.102, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from October 1989 to June 1992, including service in Southwest Asia from January 1991 to May 1991. Service Connection Service connection may be established for a disability resulting from disease or injury which was clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may be awarded on a presumptive basis to a Persian Gulf veteran who (1) exhibits objective indications; (2) of a chronic disability such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10% or more not later than December 31, 2021; and (4) such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. Gutierrez v. Principi, 19 Vet. App. 1, 7 (2004); 38 U.S.C. § 1117; 38 C.F.R. § 3.317; 76 Fed. Reg. 81834 -81836 (Dec. 29, 2011). Objective indications of a 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. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from the VA's Schedule for Rating Disabilities for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. A disability referred to in this section shall be considered service-connected for the purposes of all laws in the United States. 38 C.F.R. § 3.317(a)(3-5). Signs or symptoms which may be manifestations of an undiagnosed illness include, but are not limited to, fatigue, signs or symptoms involving the skin, headaches, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317(b). In addition to certain chronic disabilities from undiagnosed illness, service connection may also be given for medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs and symptoms, as well as for any diagnosed illness that the VA Secretary determines by regulation warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2)(i)(B). The term "Persian Gulf Veteran" means a Veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(d). The record confirms that the Veteran had active duty service in Southwest Asia from January 11, 1991 to May 11, 1991. Accordingly, he is a Persian Gulf Veteran. 1. Entitlement to service connection for fibromyalgia, to include as a chronic qualifying disability under 38 C.F.R. § 3.317 The Veteran's service treatment records are negative for any complaints of or treatment for widespread musculoskeletal pain. However, an August 2015 private treatment record reflects a diagnosis of fibromyalgia. Although the Veteran was scheduled for a VA examination to assess the etiology of his fibromyalgia, he failed to report for the examination. When a claimant fails without good cause to report for a necessary 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(a), (b). Examples of good cause include the illness or hospitalization of the claimant, the death of an immediate family member, etc. The Veteran has not provided good cause for his failure to report to the scheduled VA examination; accordingly, the Board will proceed with a decision based on the evidence of record. Having carefully reviewed the record, the Board concludes that service connection for fibromyalgia is warranted. As noted above, an August 2015 private treatment record confirms a diagnosis of fibromyalgia. Fibromyalgia is a medically unexplained chronic multisymptom illnesses pursuant to 38 C.F.R. § 3.317(a)(2)(i)(B) for which service connection on a presumptive basis may be granted. In sum, the record supports a finding that the Veteran has fibromyalgia which manifested after his time in the Persian Gulf. There is no probative evidence in the claims file suggesting that this disorder can be attributed to any known clinical diagnosis. Accordingly, the service connection for fibromyalgia on a presumptive basis is warranted. 2. Entitlement to service connection for erectile dysfunction, to include as secondary to a service-connected disability, and/or as a chronic qualifying disability under 38 C.F.R. § 3.317; and entitlement to service connection for acid reflux, to include as a chronic qualifying disability under 38 C.F.R. § 3.317, and/or as secondary to service-connected PTSD and/or irritable bowel syndrome The Veteran contends that service connection for erectile dysfunction is warranted either on a secondary basis as due to arm, leg, and hip pain, or as due to an undiagnosed illness. He also alleges that he is entitled to service connection for acid reflux either on a secondary basis as due to PTSD or irritable bowel syndrome, or as due to an undiagnosed illness. The Veteran does not have a current diagnosis of erectile dysfunction or acid reflux, and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The Veteran's VA medical treatment records do not show any complaints of or treatment for erectile dysfunction or acid reflux. Further, the Veteran has not provided any lay statements or other evidence suggesting that he experiences symptoms of erectile dysfunction or acid reflux. Also, the Veteran's service treatment records do not document complaints of or treatment for erectile dysfunction or acid reflux. Although the Veteran was scheduled for a VA examination to assess the existence and etiology of his alleged erectile dysfunction and acid reflux, he failed to report for the examination. When a claimant fails without good cause to report for a necessary 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(a), (b). Examples of good cause include the illness or hospitalization of the claimant, the death of an immediate family member, etc. The Veteran has not provided good cause for his failure to report to the scheduled VA examination; accordingly, the Board will proceed with a decision based on the evidence of record. Service connection for erectile dysfunction and acid reflux is not warranted on a direct or secondary basis, as the evidence of record does not document a current diagnosis of erectile dysfunction or acid reflux. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110; see Degmetich, 104 F.3d at 1332 (holding that interpretation of section 1110 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As there is no evidence showing that the Veteran has diagnosed erectile dysfunction or acid reflux and there is no evidence suggesting that he experiences symptoms of such a disorder, the preponderance of the evidence is against the claim for entitlement to service connection for erectile dysfunction and acid reflux on a direct or secondary basis. Additionally, service connection is not warranted for erectile dysfunction or acid reflux as a qualifying chronic disability under 38 C.F.R. § 3.317. As noted above, the Veteran failed to report for a VA examination scheduled to determine the existence and etiology of his alleged erectile dysfunction and acid reflux. In the absence of any evidence showing that the Veteran' erectile dysfunction or acid reflux symptoms are due to an undiagnosed illness or unexplained chronic multisymptom illness, service connection for erectile dysfunction and acid reflux as chronic qualifying disabilities under 38 C.F.R. § 3.317 is not warranted. Because the preponderance of the evidence is against the claims, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for bilateral hearing loss The Board finds that the evidence of record supports a grant of service connection for bilateral hearing loss. First, there is evidence of a current bilateral hearing loss disability. A January 2014 VA audiogram showed puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 25 35 40 LEFT 25 20 40 35 30 The Veteran's Maryland CNC speech recognition scores were 100 percent in each ear. As the auditory thresholds for at least one of the frequencies was 40 decibels or greater in each ear, the evidence establishes a bilateral hearing loss disability for VA purposes. See 38 C.F.R. § 3.385. Parenthetically, the Board acknowledges that the results of an August 2019 VA examination did not reveal hearing loss for VA purposes in the right ear. In that regard, puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 25 35 35 LEFT 20 15 35 35 35 However, because right ear hearing loss for VA purposes was documented in the January 2014 VA examination during the pendency of the Veteran's claim, the criteria for establishing a current disability have been met. See McClain v. Nicholson, 21 Vet. App. 319, 323 (2007) (holding that the requirement of a current disability is met when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim). Accordingly, a current bilateral hearing loss disability is established. Second, there is evidence of an in-service event, disease, or injury, as the Veteran has provided competent and credible lay statements of in-service noise exposure. Further, comparison of the audiograms conducted during active duty service document an upward shift in puretone thresholds. Specifically, the June 1989 entrance examination showed puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 5 10 5 LEFT 5 5 5 5 5 An April 1990 audiogram showed puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 5 5 10 LEFT 5 0 10 5 5 An October 1990 audiogram reveals puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 5 10 15 LEFT 5 5 5 5 5 A March 1992 separation examination documents puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 5 5 10 15 LEFT 15 5 5 10 15 Thus, comparison of the Veteran's service entrance examination and his separation examination reveals an upward shift in puretone thresholds during active duty service. Additionally, the Veteran has provided lay statements of in-service acoustic trauma, which are supported by the evidence of record. Specifically, the Veteran's service records show that he worked as a field artillery firefighter radar operator; thus, he had a high probability of hazardous noise exposure during service. Accordingly, there is evidence of an in-service event Last, the evidence is at least in equipoise as to whether the Veteran's current bilateral hearing loss is related to his active duty service. In that regard, there are medical opinions both in favor of and against the Veteran's claim. In a January 2014 VA examination, the examiner opined that the Veteran's hearing loss was not a result of his active duty service because there was not a permanent positive threshold shift greater than normal measurement variability and because a 2005 Institute of Medicine Report concluded that a prolonged delay in the onset of noise-induced hearing loss was unlikely and that there was insufficient scientific basis to conclude that permanent hearing loss was directly attributable to noise exposure when the hearing loss presents long after noise exposure. In contrast, a July 2020 VA examiner opined that it was at least as likely as not that the Veteran's hearing loss is related to his active duty service. The examiner explained that the Veteran was "routinely . . . exposed to hazardous noise . . ." and that comparison of his entrance examination audiogram to his separation examination audiogram showed a "significant shift" in hearing thresholds which is "indicative of acoustic trauma." Although the July 2020 VA examiner stated that the Veteran's right ear "does not meet the criteria for hearing loss . . . ," the rationale provided by the examiner applies equally to both ears, as the examiner described a worsening of hearing acuity in both ears when noting that the shifts were "considered significant and are indicative of acoustic trauma." Both the January 2014 and the July 2020 VA examinations are probative, as they are each based upon review of the pertinent medical evidence. Further, each provides supporting rationale for their opinion. The Board acknowledges that the July 2020 VA opinion was provided by an otolaryngologist rather than an audiologist. While federal regulations require that audiograms be conducted by a state-licensed audiologist, the regulations do not require that etiological opinions be provided solely by a state-licensed audiologist. Accordingly, the Board affords probative weight to both the January 2014 and the July 2020 VA opinions. With consideration of the July 2020 positive nexus opinion, and resolving reasonable doubt in the Veteran's favor, the Board concludes that the evidence is at least in equipoise as to whether the Veteran's bilateral hearing loss is etiologically related to his active duty service. Accordingly, service connection for bilateral hearing loss is warranted. 4. Entitlement to service connection for tinnitus The Veteran contends that service connection is warranted for tinnitus based on exposure to acoustic trauma during service. The Veteran's service treatment records are silent as to any complaints of or treatment for tinnitus during service. Initially, the Board observes that there is evidence of a current diagnosis of tinnitus, as shown in January 2014 and August 2019 VA examinations. Additionally, the Board acknowledges that the Veteran experienced acoustic trauma during military service, as discussed above. However, there is no medical evidence or credible lay evidence relating the Veteran's tinnitus to his service. The only medical evidence of record addressing the etiology of the Veteran's tinnitus are January 2014, August 2019, and July 2020 VA opinions. While the January 2014 and August 2019 VA examiners concluded that an opinion regarding the etiology of the Veteran's tinnitus could not be provided without resorting to speculation, the July 2020 VA opinion concluded that it was less likely than not that the Veteran's tinnitus was related to his in-service acoustic trauma. The July 2020 VA examiner explained that the Veteran reported the onset of his tinnitus "15-20 years prior which puts it around 2000." The examiner noted that this would place the onset of tinnitus 10 years after service discharge, which makes it less likely than not that the tinnitus is related to service. The examiner acknowledged that "several papers" have linked a delayed onset in problems following acoustic trauma, "that is not the accepted position based on the entire body of literature." In the absence of any medical evidence or any credible lay evidence relating the Veteran's tinnitus to service, the preponderance of the evidence is against the claim, and service connection is not warranted. There is no doubt to be resolved, and service connection is not warranted. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). 5. Entitlement to service connection for left leg pain, to include as a chronic qualifying disability under 38 C.F.R. § 3.317; entitlement to service connection for right leg pain, to include as a chronic qualifying disability under 38 C.F.R. § 3.317; entitlement to service connection for neck pain, to include as a chronic qualifying disability under 38 C.F.R. § 3.317; entitlement to service connection for right foot pain, to include as a chronic qualifying disability under 38 C.F.R. § 3.317; and entitlement to service connection for left foot pain, to include as a chronic qualifying disability under 38 C.F.R. § 3.317 The Veteran contends that he is entitled to service connection for bilateral leg pain, bilateral foot pain, and neck pain resulting from his military service. Specifically, he asserts that his pain is due to an undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. The Veteran's service treatment records note treatment for a left leg injury while playing football in September 1991 and a report of foot trouble in a report of medical history completed in conjunction with his March 1992 separation examination. The remainder of the service treatment records are silent for any complaints of or treatment for bilateral leg pain, bilateral foot pain, and neck pain. Thus, while there is evidence of an in-service left leg injury and foot pain, there is no evidence of an in-service right leg or neck event or injury. The post-service medical evidence of record is silent for any complaints of or treatment for bilateral leg pain, bilateral foot pain, and neck pain. Following appellate review in November 2018, the Board concluded that a VA examination was necessary to adjudicate the Veteran's claims. However, the Veteran failed to report for scheduled August 2019 VA examinations without good cause. 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. In the absence of a competent medical opinion linking the Veteran's claimed disabilities manifested by bilateral leg pain, bilateral foot pain, and neck pain with his active duty service or to an undiagnosed illness associated with his service in the Persian Gulf, service connection cannot be granted. The Board has fully considered the Veteran's lay statements that his bilateral leg pain, bilateral foot pain, and neck pain are related ot his active duty service, including as due to an undiagnosed illness. The Board notes that while the Veteran is competent to relay his experience, lay persons are generally not competent to diagnose illnesses or establish a causal connection. The Veteran has not been shown to be competent, by experience or training, to provide medical conclusions, especially as to complex medical diagnoses and opinions of etiology. As such, the Board cannot use the Veteran's statements to establish the medical nexus required to establish service connection or to establish that they are a manifestation of an undiagnosed illness. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). In sum, upon careful review and weighing of the evidence, with reasoning as detailed above, the Board finds that the preponderance of the evidence is against the claims for service connection for a bilateral leg disorder, a bilateral foot disorder, or a neck disorder, and the benefit of the doubt doctrine is not for application. Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). The claims must therefore be denied. Increased Rating 6. Entitlement to a compensable initial disability rating for irritable bowel syndrome Service connection for irritable bowel syndrome was granted in an August 2013 rating decision, which assigned a noncompensable disability rating, effective October 19, 2011. The Veteran filed a notice of disagreement in November 2013 contesting the disability rating assigned, and perfected his appeal in May 2016. In November 2018, the Board remanded the Veteran's claims for additional development, including additional VA examinations. Pursuant to the November 2018 Board remand, the Veteran was scheduled for a VA examination to assess the severity of his irritable bowel syndrome in August 2019; however, he failed to report for the examination. Neither the Veteran nor his representative have presented good cause for his failure to appear. Thereafter, the Veteran was scheduled for another VA examination to assess his irritable bowel syndrome. However, a June 2021 Report of General Information reflects that the Veteran requested that VA make a decision on his claim based off of the evidence of record and that he was not willing "to chance going to in person appointments." In July 2021, VA was notified that the Veteran's examination was cancelled at his request. VA regulations provide that, 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(b). An appeal from an original assignment of a disability rating is an original claim, rather than an increased rating claim. Turk v. Peake, 21 Vet. App. 565 (2008). The Veteran's irritable bowel syndrome (IBS) is rated under 38 C.F.R. § 4.114, DC 7319. Per DC 7319, a noncompensable rating is assigned for mild disturbances of bowel function with occasional episodes of abdominal distress; a 10 percent rating is assigned for moderate irritable colon syndrome with frequent episodes of bowel disturbance with abdominal distress; and a maximum 30 percent rating is assigned for severe irritable colon syndrome with diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. Id. A review of the record shows that the Veteran's IBS is productive of no more than mild impairment. VA examination in July 2013 shows that the Veteran experienced watery stools approximately 3 days per week, 2 to 3 times per day, although occasionally up to 6 bowel movements a day and constipation usually once a week. However, no abdominal tenderness, abdominal distension, anemia, nausea, vomiting, weight loss, malnutrition, or other serious complications were noted. The examiner also found no bowel disturbance with abdominal distress or exacerbation or attacks of the intestinal condition. Further, the Veteran reported that he had not seen a doctor or received treatment for the disorder, and the Veteran's medical reports do not show increased impairment in this regard. The record does not show moderate irritable colon syndrome with frequent episodes of bowel disturbance with abdominal distress or severe irritable colon syndrome with diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. Accordingly, entitlement to a compensable initial disability rating for irritable bowel syndrome is denied. The preponderance of the evidence weighs against the claim. 38 C.F.R. §§ 4.3, 4.7. Effective Date 7. Entitlement to an effective date prior to September 23, 2013 for the grant of service connection for PTSD In general, the effective date of an award of disability compensation, in conjunction with a grant of entitlement to service connection, shall be the day following separation from active service or the date entitlement arose if the claim is received within one year of separation from service; otherwise, the effective date shall be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400(b)(2)(i). VA amended its adjudication regulations on March 24, 2015 to require that all claims governed by VA's adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. See 79 Fed. Reg. 57660 (Sept. 25, 2014). The amendments, however, are only effective for claims and appeals filed on or after March 24, 2015. The Veteran's claim pertaining to the issue of entitlement to an earlier effective date for the grant of service connection for PTSD was initiated prior to that date; thus, the amendments are not applicable to that appeal and the regulations in effect prior to March 24, 2015 will be applied. Under the old regulations, "claim" is defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p); see also Brannon v. West, 12 Vet. App. 32, 34-35 (1998); Servello v. Derwinski, 3 Vet. App. 196, 199 (1992). Any communication or action indicating an intent to apply for one or more benefits under laws administered by the VA from a claimant may be considered an informal claim. Such an informal claim must identify the benefits sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. 38 C.F.R. § 3.155(a). To determine when a claim was received, the Board must review all communications in the claims file that may be construed as an application or claim. See Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992). VA has a duty to sympathetically interpret the filings of claimants. Szemraj v. Principi, 357 F.3d 1370, 1373 (Fed. Cir. 2004) (finding VA is obligated to sympathetically read the filings of a pro se Veteran); see also Comer v. Peake, 552 F.3d 1362, 1369-70 (Fed. Cir. 2009) (holding assistance by a Veterans Service Organization does not vitiate VA's duty to sympathetically review filings). The United States Court of Appeals for Veterans Claims (Court) has held that "a claimant's identification of the benefit sought does not require any technical precision." Brokowski v. Shinseki, 23 Vet. App. 79, 85 (2009); see also Ingram v. Nicholson, 21 Vet. App. 232, 256-57 (2007) ("It is the pro se claimant who knows what symptoms he is experiencing and that are causing him disability, . . . . [and] it is the Secretary who knows the provisions of title 38 and can evaluate whether there is a potential under the law to compensate an averred disability based on a sympathetic reading of the material in a pro se submission." (citations omitted)); see also Clemons v. Shinseki, 23 Vet. App. 1 (2009) (claims of service connection for psychiatric disability encompass claims for all psychiatric disorders that are reasonably raised by the record). Although the Board must interpret a claimant's submissions broadly, "the Board is not required to conjure up issues that were not raised by the claimant." Brannon, 12 Vet. App. at 35 (holding that before VA can adjudicate an original claim for benefits, "the claimant must submit a written document identifying the benefit and expressing some intent to seek it"); see also Criswell v. Nicholson, 20 Vet. App. 501, 504 (2006) ("The mere existence of medical records generally cannot be construed as an informal claim; rather, there must be some intent by the claimant to apply for a benefit."). After thorough consideration of the evidence of record, the Board concludes that an effective date prior to September 23, 2013 is not warranted for the grant of service connection for PTSD. 38 C.F.R. § 3.400(b)(2)(i). Review of the record reflects that the Veteran filed an initial claim seeking service connection for PTSD on September 23, 2013. In a January 2018 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for PTSD, and assigned an effective date of September 23, 2013, the date of receipt of the Veteran's claim. The Veteran's attorney argues that an earlier effective date for the grant of service connection for PTSD is warranted based upon the date that the Veteran filed a formal claim seeking service connection for chronic fatigue, overall body pain, diarrhea, headaches, and skin rashes, in October 2011. The attorney contends that chronic fatigue, body pain, diarrhea, headaches, and skin rashes may all be symptoms of mental health disabilities. Thus, the attorney alleges that the October 2011 formal claim should be construed as a claim for entitlement to service connection for PTSD. The Board finds that the Veteran did not reasonably raise a claim for a psychiatric disorder, to include PTSD, in the context of his October 2011 claim. A VA adjudicator is not required to anticipate a claim for benefits for disabilities that have not been identified in the record or by medical professionals or by competent lay evidence at the time that a claimant files a claim or during the claim's development. While the VA treatment records first show treatment for a psychiatric disorder in 2012 and the Veteran reported a history of psychiatric symptoms dating back to the 1990's, the mere existence of a disability or medical records generally cannot be construed as an informal claim for service connection. Brannon, 12 Vet. App. at 35. Rather, there must be some intent by the claimant to apply for a benefit. The requirement that a claimant identify the benefit that he is seeking makes it possible for VA to develop and adjudicate the claim. The Board has considered Clemons v. Shinseki, in which the U.S. Court of Appeals for Veterans Claims held that the scope of a disability claim includes any disorder that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and other information of record. 23 Vet. App. 1, 5 (2009). However, to apply Clemons in this case as broadly as the Veteran's attorney argues would be feasible and would have required the adjudicators to open a claim for all potential causes of the Veteran's symptoms. While the Veteran's October 2011 claim for chronic fatigue, body pain, diarrhea, headaches, and skin rashes identifies symptoms which some individuals with psychiatric disorders may also exhibit, a claim for such disabilities does not sufficiently identify an intent to seek service connection for a psychiatric disorder. Further, the medical evidence of record, including a February 2014 VA PTSD examination and private treatment records, does not identify chronic fatigue, overall body pain, diarrhea, headaches, and skin rashes as symptoms of the Veteran's service-connected psychiatric disorder. Giving a sympathetic reading to the Veteran's October 2011 claim for service connection, the Board does not find that a reasonable VA adjudicator would have found that the issue of entitlement to service connection for a psychiatric disorder was reasonably raised. Accordingly, the evidence of record does not reveal that a formal or informal claim for service connection for PTSD was received prior to September 23, 2013. See 38 C.F.R. § 3.155. As the earliest communication indicating an intent to apply for service connection for PTSD in the Veteran's claims file is the claim received by VA on September 23, 2013, that is the date of claim. Thus, an effective date prior to September 23, 2013 for the grant of service connection for PTSD is not warranted based upon the date of claim. In addition, an earlier effective date is not warranted based on the date entitlement to the benefit arose. The earliest evidence documenting a diagnosis of PTSD and nexus to active duty service is shown in a May 2015 private treatment record. Accordingly, entitlement to the benefit sought did not arise until May 6, 2015, after receipt of the Veteran's claim for service connection in September 2013. 38 C.F.R. § 3.400 is clear that the effective date for an award of service connection is the later of the date entitlement arose or the date the claim was received. Thus, an effective date earlier than September 23, 2013 for the award of service connection for PTSD is not warranted in this case. The pertinent legal authority governing effective dates in this case is clear and specific, and the Board is bound by this authority. Pursuant to this authority, the Board finds that there is no legal basis by which an effective date for the grant of service connection earlier than September 23, 2013 can be assigned; hence, the claim for an earlier effective date must be denied. 38 C.F.R. § 3.400(b)(2)(i). REASONS FOR REMAND 1. Entitlement to service connection for a left forearm disorder, to include as a chronic qualifying disability under 38 C.F.R. § 3.317 and entitlement to service connection for a right forearm disorder, to include as a chronic qualifying disability under 38 C.F.R. § 3.317 In its November 2018 Remand, the Board directed that VA obtain a VA examination to assess the etiology of the Veteran's right and left forearm disorders. The claims file reflects that the Veteran was scheduled for an examination in August 2019 and failed to report for such. However, the record does not establish that an examination was necessary, as opposed to merely a VA medical opinion. This is especially true in light of the fact that there is a July 2013 VA examination of record (which conducted a physical examination, but did not provide an etiological opinion). Thus, the AOJ should obtain a VA opinion, without the need for another examination, to determine the etiology of the Veteran's right and left forearm disorders. 2. Entitlement to service connection for overall body pains, to include as a chronic qualifying disability under 38 C.F.R. § 3.317; entitlement to service connection for inflammatory arthritis of the right shoulder, to include as a chronic qualifying disability under 38 C.F.R. § 3.317; entitlement to service connection for inflammatory arthritis of the left shoulder, to include as a chronic qualifying disability under 38 C.F.R. § 3.317; entitlement to service connection for inflammatory arthritis of the right hip, to include as a chronic qualifying disability under 38 C.F.R. § 3.317; entitlement to service connection for inflammatory arthritis of the right hand, to include as a chronic qualifying disability under 38 C.F.R. § 3.317; entitlement to service connection for inflammatory arthritis of the left hand, to include as a chronic qualifying disability under 38 C.F.R. § 3.317; and entitlement to service connection for chronic fatigue syndrome, to include as a chronic qualifying disability under 38 C.F.R. § 3.317 In its November 2018 Remand, the Board requested that the AOJ obtain "addendum medical opinions" from the July 2013 VA chronic fatigue syndrome examiner to determine the etiology of the Veteran's "inflammatory arthritis (joint pains)." The claims file reflects that the Veteran was scheduled for VA examinations with regard to these symptoms in August 2019, and that he failed to report for the scheduled examinations. Thereafter, he was scheduled for another examination in July 2020, and cancelled the examination. However, the AOJ did not obtain the requested addendum opinions, as directed by the November 2018 Remand. Accordingly, the issues of entitlement to service connection for inflammatory arthritis of the bilateral shoulders, right hip, and bilateral hands, entitlement to service connection for chronic fatigue syndrome, and entitlement to service connection for overall body pains are remanded to the AOJ to obtain the requested VA opinions. 3. Entitlement to SMC based upon the need for aid and attendance or at the housebound rate and entitlement to a TDIU prior to September 23, 2013 The Veteran's claims for entitlement to SMC and entitlement to a TDIU prior to September 23, 2013 are intertwined with the claims remanded herein; accordingly, they must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). The matters are REMANDED for the following action: 1. Obtain a VA opinion by an appropriate clinician to determine the etiology of the Veteran's right and left forearm disorders, diagnosed in a July 2013 VA examination as lateral epicondylitis. Based upon a complete review of the evidence of record, to include the Veteran's service treatment records, the post-service treatment records, VA examinations, and the lay statements of record, the VA examiner is asked to address the following: (a.) Can the Veteran's right and/or left elbow symptoms be attributed to a known clinical diagnosis (other than a symptom-based diagnosis)? (b.) For any diagnosed disability, the examiner is asked to opine whether it is at least as likely as not (e.g., a 50 percent probability or greater) that the Veteran's disability was caused by or incurred during service. (c.) Are the Veteran's right and/or left elbow symptoms a manifestation of: (i) an undiagnosed illness; (ii) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology; (iii) a diagnosable chronic multisymptom illness with a partially explained etiology; or (iv) a disease with a clear and specific etiology? A complete rationale for all opinions must be provided. The examiner must consider and discuss all pertinent evidence in the claims file, to include the Veteran's lay statements. Also, the examiner is advised that the Veteran is competent to report observable symptomatology. 2. Obtain a supplemental opinion from the examiner who conducted the July 2013 VA chronic fatigue syndrome examination, if available, to determine the etiology of the Veteran's inflammatory arthritis of the bilateral shoulders, right hip, and bilateral hands, as well as the alleged chronic fatigue syndrome and overall body pains. Based upon a complete review of the evidence of record, to include the Veteran's service treatment records, the post-service treatment records, VA examinations, and the lay statements of record, the VA examiner is asked to address the following: (a.) Can the Veteran's bilateral shoulder, right hip, bilateral hand, chronic fatigue, and/or overall body pain symptoms be attributed to a known clinical diagnosis (other than a symptom-based diagnosis)? (b.) For any diagnosed disability, the examiner is asked to opine whether it is at least as likely as not (e.g., a 50 percent probability or greater) that the Veteran's disability was caused by or incurred during service. (c.) Are the Veteran's bilateral shoulder, right hip, bilateral hand, chronic fatigue, and/or overall body pain symptoms a manifestation of: (i) an undiagnosed illness; (ii) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology; (iii) a diagnosable chronic multisymptom illness with a partially explained etiology; or (iv) a disease with a clear and specific etiology? If the examiner who conducted the July 2013 VA examination is not available, the AOJ should obtain a new VA opinion addressing the above questions. (Continued on the next page) A complete rationale for all opinions must be provided. The examiner must consider and discuss all pertinent evidence in the claims file, to include the Veteran's lay statements. Also, the examiner is advised that the Veteran is competent to report observable symptomatology C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Katz, 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.