Citation Nr: 25014167 Decision Date: 11/20/25 Archive Date: 11/20/25 DOCKET NO. 15-26 361 DATE: November 20, 2025 REMANDED Entitlement to an evaluation in excess of 30 percent disabling for service-connected major depression, recurrent, claimed as depression, for the period prior to March 28, 2014, and in excess of 50 percent disabling, thereafter, is remanded. Entitlement to service connection for a respiratory disability, however diagnosed, claimed as fatigue, chronic allergies, respiratory condition, and pulmonary condition, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1981 to September 2001. In June 2018, the Veteran and C., testified under oath at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In January 2023, this appeal was before the Board. The Board acknowledges that the issue of service connection for sinusitis was granted in a June 2024 rating decision and is no longer before the Board. ? 1. Entitlement to an increased evaluation for service-connected major depression, recurrent. In the January 2023 remand, "the Board ask[ed] that the Veteran be notified of the status of" a March 2019 records request. BVA Decision, January 2023 (Directive 1). It is unclear to the Board that the Veteran was so notified. Accordingly, the Board repeats the request upon remand. In addition, the Board finds that there may be recent VA treatment records outstanding. For example, the most recent VA treatment records associated with the claim file are from September 2023, over two years ago. See CAPRI, October 2023. The Board asks that any outstanding treatment records be obtained and associated with the claim file. Also, in the January 2023 remand, the Board sought military personnel records. It is unclear to the Board that the Veteran's military personnel file was obtained. Therefore, the Board repeats the request upon remand. Further, the Board asks that the Veteran be scheduled for a new medical examination for the following reasons. A VA examination evaluating the Veteran's mental health disability was conducted in December 2021, almost four years ago. That VA examination report notes a diagnosis of major depressive disorder (MDD) and indicates that the Veteran does not "have more than one mental disorder diagnosed". VA Examination Report, December 2021. A September 2023 VA treatment record indicates diagnoses of MDD, recurrent, "Recurrent episode in full remission", and generalized anxiety disorder. CAPRI, October 2023. In addition, the VA treatment record reflects anger management treatment. The Board does not see anger management treatment identified in the December 2021 VA examination report. Accordingly, the Board finds that remand is needed in order to clarify the current severity of the Veteran's disability. ? 2. Entitlement to service connection for a respiratory disability, however diagnosed, claimed as fatigue, chronic allergies, respiratory condition, and pulmonary condition. The Board notes that in the January 2023 remand, the Board remanded the issue of entitlement to service connection for a respiratory disability, however diagnosed, claimed as fatigue, chronic sinus (sinusitis), chronic allergies, respiratory condition, and pulmonary condition. As noted above, following the remand, the issue of service connection for sinusitis was granted in a June 2024 rating decision and is no longer before the Board. However, the issue as written in the Board remand otherwise remains on appeal. Accordingly, a supplemental statement of the case (SSOC) is needed. In addition, the Board finds that the following clarification is needed. A February 2024 VA examination report indicates that the Veteran does not currently have chronic fatigue syndrome (CFS). However, in the January 2023 remand, the Board asked that an examiner: . . . explain whether the Veteran's claimed disability pattern is (a) an undiagnosed illness; (b) a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as [CFS]; (c) a diagnosable chronic multisymptom illness with a partially understood etiology; or (d) a disease with a clear and specific etiology and diagnosis. BVA Decision, January 2023 (Directive 2). The Board does not see that the Veteran's claimed fatigue was fully evaluated under the above. For example, it is unclear to the Board whether the Veteran's claimed fatigue is "an undiagnosed illness". BVA Decision, January 2023 (Directive 2). Accordingly, remand is again needed. In addition, the Board seeks clarification of the following. One of the February 2024 VA opinions states: "Furthermore, the Veteran's reported symptoms, such as respiratory difficulty and choking episodes, as well as the presence of periodic leg movements during sleep, are consistent with respiratory impairment and obstructive sleep apnea." VA Opinion, February 2024. The Veteran is service-connected for obstructive sleep apnea (OSA), sinusitis, and allergic rhinitis. Accordingly, the Board seeks clarification as to whether the Veteran's claimed fatigue is a separate disability or a symptom of a service-connected disability. The matters are REMANDED for the following action: 1. After securing any necessary consent forms from the Veteran, conduct the following development: (a) In particular, the Board notes that in March 2019, the Veteran identified treatment from a number of providers; however, his request for records was rejected and it is unclear to the Board that the Veteran was notified. See Docket, April 2019. The Board acknowledges that a development letter was sent to the Veteran in April 2020. However, the Board does not see that these specific records were addressed. The Board also notes that the April 2020 remand was "Returned Mail". See Returned Mail, May 2020. Accordingly, upon remand, the Board asks that the Veteran be notified of the status of the records request. (b) Obtain any outstanding relevant treatment records, to include any private and/or VA treatment records, to include records contained in repositories accessible through VA, pertaining to the issues on appeal. (c) Obtain any outstanding military personnel records. Obtain all necessary consent. All efforts should be documented in the claim file. If any records could not be obtained, this should be noted in the claim file. 2. Upon completion of the above, schedule the Veteran for a medical examination for the following examinations: (a) Schedule the Veteran for an examination in order to evaluate the severity of the service-connected mental health disability. (b) Schedule the Veteran an examination in order to clarify the claimed fatigue. After evaluating the Veteran, the examiner is asked address the following: 1. The examiner is asked to address whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the claimed fatigue is a separate disability or a symptom of a service-connected disability. 2. For each disability, the examiner is asked to explain whether the Veteran's claimed disability pattern is (a) an undiagnosed illness; (b) a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as CFS; (c) a diagnosable chronic multisymptom illness with a partially understood etiology; or (d) a disease with a clear and specific etiology and diagnosis. The examiner is asked to discuss when symptoms and/or disability arose, their severity, and whether they persisted chronically for at least six (6) months. 3. If the Veteran is not diagnosed with a medically unexplained chronic multisymptom illness, such as, CFS, but another disability pattern or diagnosis, then for each disability pattern or diagnosis, the examiner is asked to address whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that a current disability is related to service. 4. If appropriate, a Toxic Exposure Risk Activity (TERA) opinion should be obtained. Obtain all necessary consent. The examiner should be given access to the claim file. The examiner should state that a review of the claim file was completed. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. A detailed rationale is requested for all opinions provided. 3. If upon completion of the above action the issues are denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans' Appeals 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.