UNDIAGNOSED ILLNESSES

Summary

The Veteran, a U.S. Marine Corps Veteran who served from May 1988 to May 1992, appeals the denial of service connection for a fatigue disorder and an increased rating for tinnitus. The Veteran also sought service connection for headaches secondary to tinnitus, which was remanded for adjudication. Regarding the fatigue disorder, the Veteran claimed it was due to service in the Southwest Asian Theater of Operations and met the criteria for Chronic Fatigue Syndrome (CFS). However, multiple VA examinations and opinions from 2015 through 2025 concluded that the Veteran did not meet the diagnostic criteria for CFS. While fatigue was noted, examiners attributed it to other conditions like depression or PTSD, for which the Veteran is already service-connected. The Board found the VA examinations adequate and the examiners' negative opinions for CFS to be well-reasoned, thus denying service connection for the fatigue disorder. For tinnitus, the Veteran sought an increased rating beyond the maximum schedular 10 percent evaluation, including an extraschedular rating. The Board found that the Veteran's tinnitus, while constant and causing headaches, did not meet the criteria for an increased rating or an extraschedular rating, as it did not markedly interfere with employment or present an exceptional disability picture. The Board denied the increased rating for tinnitus. The claim for headaches secondary to tinnitus was remanded for adjudication by the agency of original jurisdiction, as the Veteran's testimony indicated a link between his tinnitus and headaches.

Rationale

No current diagnosis of CFS; Fatigue symptoms attributed to PTSD/depression; Did not meet diagnostic criteria for CFS

Full Decision Text

Citation Nr: 26004914
Decision Date: 04/23/26	Archive Date: 04/23/26

DOCKET NO. 17-39 948A
DATE: April 23, 2026

ORDER

Entitlement to service connection for a disorder manifested by fatigue is denied.

Entitlement to service connection for a gastrointestinal disorder is granted.

Entitlement to an initial disability rating in excess of 10 percent for tinnitus, to include on an extraschedular basis, is denied. 

REMANDED

Entitlement to service connection for headaches, to include as secondary to service-connected tinnitus.

FINDINGS OF FACT

1. The Veteran does not have a current diagnosis of chronic fatigue syndrome (CFS); the current symptom of fatigue is accounted for by another service-connected disability.

2. The Veteran's gastrointestinal disorder, to include constipation, is aggravated by his service-connected posttraumatic stress disorder (PTSD). 

3. The current 10 percent disability rating assigned for evaluation of tinnitus is the maximum schedular rating, and there are no unusual or exceptional circumstances rendering application of the rating schedule impractical.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for a disorder manifested by fatigue have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.317, 4.88a, 4.130.

2. The criteria for entitlement to service connection for a gastrointestinal disorder have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

3. The criteria for entitlement to an initial disability rating in excess of 10 percent for tinnitus, to include on an extraschedular basis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.87, Diagnostic Code (Code) 6260.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active duty service with the U.S. Marine Corps from May 1988 to May 1992. This case comes before the Board of Veterans' Appeals (Board) on appeal from an August 2015 and September 2015 rating decision of the Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ).

The Veteran testified at a January 2023 hearing held before the undersigned. A transcript of the hearing is associated with the electronic claims file.

In April 2023 and April 2024, the Board remanded this matter for additional development, which has been completed. See Stegall v. West, 11 Vet. App. 268 (1998). 

Further, as a result of the development conducted with those remands, the Board has inferred a claim of service connection for headaches as secondary to tinnitus, addressed further in the Remand section, below.

Service Connection

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(1) the existence of a present disability; (2) 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-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).

Service connection may be granted for disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d).

For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or aggravated by a service-connected disability. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc).

Some chronic diseases may be presumed to have been incurred in service, if they become manifest to a degree of ten percent or more within the applicable presumptive period. 38 U.S.C. §§ 1101(3), 1112(a
, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d).

For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or aggravated by a service-connected disability. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc).

Some chronic diseases may be presumed to have been incurred in service, if they become manifest to a degree of ten percent or more within the applicable presumptive period. 38 U.S.C. §§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013).

Under 38 C.F.R. § 3.317, service connection may be granted on a presumptive basis if there is evidence (1) that the claimant is a Persian Gulf Veteran; (2) who exhibits objective indications of chronic disability resulting from an undiagnosed illness, a medically unexplained chronic multisymptom illness (MUCMI) (such as CFS, fibromyalgia, or IBS) that is defined by a cluster of signs or symptoms, or resulting from an illness or combination of illnesses manifested by one or more signs or symptoms 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 percent or more not later than December 31, 2026; and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. §§ 1117, 1118; 38 C.F.R. § 3.317. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). A January 2023 memorandum established the Veteran is a Parisian Gulf Veteran as defined by 38 U.S.C. §§ 1117.

Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a).

The Veteran contends that he has CFS that is due to his service in the Southwest Asian Theater of Operations.

For VA purposes, the diagnosis of CFS requires: (1) the new onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least 6 months, and (2) the exclusion, by history, physical examinations, and laboratory tests, of all other clinical conditions that may produce similar symptoms, and (3) 6 or more of the following: (i) acute onset of the condition, (ii) low grade fever, (iii) nonexudative pharyngitis, (iv) palpable or tender cervical or axillary lymph nodes, (v) generalized muscle aches or weakness, (vi) fatigue lasting 24 hours or longer after exercise, (vii) headaches (of a type, severity or pattern that is different from headaches in the pre-morbid state), (viii) migratory joint pains, (ix) neuropsychologic symptoms, and (x) sleep disturbance. 38 C.F.R. § 4.88a.

Service treatment records (STRs) documented no complaints, treatment, or diagnosis of a disorder manifested by fatigue. An April 1992 examination on release from active duty documented a normal clinical evaluation. 

In August 2015, the Veteran was afforded a VA examination. The Veteran was not diagnosed with CFS. The Veteran reported that he was tired all the time and went to sleep when sitting still. The Veteran had not discussed his symptoms with his primary care physician. The examiner noted that the record was silent for any complaints of fatigue. 

In August 2015 VA Gulf War opinion, the examiner concluded that the Veteran did not have an "undiagnosed illness." The examiner remarked that the Veteran did not meet the diagnostic criteria for CFS
Service treatment records (STRs) documented no complaints, treatment, or diagnosis of a disorder manifested by fatigue. An April 1992 examination on release from active duty documented a normal clinical evaluation. 

In August 2015, the Veteran was afforded a VA examination. The Veteran was not diagnosed with CFS. The Veteran reported that he was tired all the time and went to sleep when sitting still. The Veteran had not discussed his symptoms with his primary care physician. The examiner noted that the record was silent for any complaints of fatigue. 

In August 2015 VA Gulf War opinion, the examiner concluded that the Veteran did not have an "undiagnosed illness." The examiner remarked that the Veteran did not meet the diagnostic criteria for CFS. The Veteran did not have a diagnosable chronic multi-symptom illness with a partially explained etiology. 

An August 2019 VA treatment note documented that the Veteran complained of fatigue. The examiner stated that the Veteran's fatigue could be due to his depression. The Veteran complained that he had a fatigue problem for many years, he felt depressed, and had problems with PTSD. 

An October 2019 VA mental health treatment note documented under symptoms of other mental disorders: major depressive disorder, "fatigue or loss of energy, nearly every day."

In January 2023, the Veteran testified that he started to have fatigue issues soon as he was out of service. The Veteran stated that he felt tired all the time. The Veteran indicated that he was not having problems while he was in the Persian Gulf. He indicated his problem started after he started taking his medications for diabetes. 

During the October 2023 VA examination, the Veteran was not diagnosed with a fatigue disorder. The Veteran was morbidly obese and complained of snoring. The examiner remarked that the Veteran had a sleep study in September 2019 and it showed no sleep apnea. The Veteran did not have any findings, signs, or symptoms attributable to CFS. The examiner provided a negative nexus opinion. The examiner's rationale was that the Veteran did not have a disorder manifested by fatigue. 

In December 2023 a VA addendum opinion was obtained to address the Veteran's lay statements. The examiner acknowledged the Veteran's indicated that he had a disability manifested by symptoms of drowsiness. The examiner concluded that there was no pathology to render a diagnosis on the day of the CFS examination.

In April 2024, the Veteran's September 2019 sleep study was uploaded to his file. The sleep study demonstrated that the Veteran did not have sleep apnea. The Veteran's October 2019 polysomnography report was also uploaded to his file. The polysomnography report showed that the Veteran did not have obstructive sleep apnea. 

During the April 2024 CFS examination, the Veteran was not diagnosed with CFS. The Veteran reported that his symptoms started around 1991 to 1992. He indicated that his chronic fatigue started around the same time as his gastrointestinal problems. He described feeling tired quickly and sometimes falling asleep suddenly. The only finding, sign, or symptom attributable to CFS was debilitating fatigue. The examiner provided a negative direct, secondary, and toxic exposure activities (TERA) opinion. The examiner's rationale was that the Veteran did not have a diagnosis of CFS. 

In a January 2025 VA opinion, the examiner noted that the Veteran was diagnosed with PTSD and alcohol use disorder. The examiner indicated that the Veteran's symptoms of fatigue were subsumed under his PTSD diagnosis and did not warrant a separate diagnosis. The examiner concluded that the Veteran did not have a disorder manifested by fatigue. 

In July 2025 VA addendum opinion, the examiner remarked that the Veteran had no formal diagnosis of CFS. The medical history over time demonstrated that his fatigue was a symptom caused by his psychological conditions, to include PTSD, depression, and alcohol use. The examiner noted that the Veteran was service connected for PTSD at a high level of severity. The Veteran's PTSD overtime caused reduced energy and fatigue.

The Board finds the October 2023 and April 2024 VA CFS examinations are adequate, to include the supplemental addenda. The VA examiners' findings and opinions that there is no current diagnosis of CFS are based on a thorough review of the Veteran's medical record and review of medical information concerning CFS as well as examination of the Veteran to include taking account of his reported history. Thus, the Board finds the January 2023 and April 2024 CFS examinations are entitled to probative weight. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); Nieves-Rodriquez v. Peake, 22 Vet. App. 295 (2008).

The Veteran does not meet the requirements of a diagnosis of CFS delineated in 38 C.F.R. § 4
enda. The VA examiners' findings and opinions that there is no current diagnosis of CFS are based on a thorough review of the Veteran's medical record and review of medical information concerning CFS as well as examination of the Veteran to include taking account of his reported history. Thus, the Board finds the January 2023 and April 2024 CFS examinations are entitled to probative weight. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); Nieves-Rodriquez v. Peake, 22 Vet. App. 295 (2008).

The Veteran does not meet the requirements of a diagnosis of CFS delineated in 38 C.F.R. § 4.88a. Specifically, the October 2023 and April 2024 examiners did not find the Veteran had at least 6 symptoms attributable to CFS or could exclude other clinical conditions that may produce similar symptoms.

To the extent that his identified fatigue could be service-connected as a separate condition, the evidence of record shows that the Veteran's fatigue symptoms are attributable to his already service-connected PTSD. The Board considered the January 2025 and July 2025 VA providers findings and his reported fatigue however, the Veteran's service-connected condition already compensates him for his fatigue related to the reported CFS.

The record contains no evidence of CFS or a separate disability entity manifested as fatigue for VA compensation purposes. Absent a valid diagnosis of CFS, service connection cannot be granted for the disorder on a direct, secondary, or presumptive basis. See Brammer v. Derwinski, 3 Vet. App. 223 (1992).

Gastrointestinal Disorder 

The Veteran contends that he has a gastrointestinal disorder related to service, to include service in Southwest Asia. 

During the August 2015 VA infectious intestinal disorder examination, the Veteran was diagnosed with persistent cramping and constipation with an onset date of 1992 or 1993. 

During the October 2023 VA infectious intestinal disorder examination, the Veteran was diagnosed with constipation due to diet. 

In April 2024 Remand, the Board noted that the AOJ acknowledged the deficiencies of the October 2023 VA examiner's opinions and requested an addendum medical opinion from the VA examiner. The VA examiner continued to be nonresponsive to the AOJ's directives in the addendum opinions which were obtained in December 2023. The Board remanded this matter to obtain an adequate VA examination and opinion. The examiner was to address the nature and etiology of reported abdominal cramping, diarrhea, heartburn, and reflux symptoms. The examiner was to opine for each disability, whether such was at least as likely as not caused or aggravated by service, to include Southwest Asia service and associated exposures.

During the April 2024 VA intestinal conditions examination, the Veteran was diagnosed with constipation due to diet. The Veteran reported that his symptoms of abdominal cramping, diarrhea, heartburn, and reflux symptoms started sometime in 1991 and 1992. The examiner provided a negative secondary service, gulf war, and TERA opinion. Her rationale was that there was no medical or scientific evidence showing a relationship between the Veteran's gastrointestinal condition and the TERA. 

In a December 2024 VA opinion, the examiner provided a negative secondary opinion regarding service-connected tinnitus and sinusitis. The examiner provided an opinion concerning aggravation but not causation. The examiner's rationale was that there was no data or research to support that the Veteran's sinusitis or tinnitus worsen a gastrointestinal condition. However, the examiner provided a positive secondary opinion regarding service-connected PTSD. The examiner indicated that gastrointestinal disorder was known to be associated with and was exacerbated by PTSD. She explained that PTSD was bi-directionally correlated with gastrointestinal diseases, and the symptoms of constipation and nausea/vomiting within Veterans who served during wartime periods. 

During the January 2025 VA intestinal conditions examination, the Veteran was not diagnosed with an intestinal disorder. The Veteran reported abdominal cramping, diarrhea, and acid reflux that had progressed over time. The Veteran reported that his symptoms now occurred multiple times per week. The examiner provided a negative direct service connection, gulf war, and TERA opinion. The examiner's rationale was that the Veteran did not have a gastrointestinal diagnosis. 

The persuasive weight of the evidence shows that the Veteran's intestinal conditions, to include symptoms of constipation is aggravated due to his service-connected PTSD. The December 2024 VA examiner opined that the Veteran's service-connected PTSD was associated and exacerbated his gastrointestinal symptoms. Accordingly, service connection for a gastrointestinal disorder, to include constipation as secondary to the Veteran's service-connected PTSD, is warranted.  

Increased Rating

Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability
. The examiner provided a negative direct service connection, gulf war, and TERA opinion. The examiner's rationale was that the Veteran did not have a gastrointestinal diagnosis. 

The persuasive weight of the evidence shows that the Veteran's intestinal conditions, to include symptoms of constipation is aggravated due to his service-connected PTSD. The December 2024 VA examiner opined that the Veteran's service-connected PTSD was associated and exacerbated his gastrointestinal symptoms. Accordingly, service connection for a gastrointestinal disorder, to include constipation as secondary to the Veteran's service-connected PTSD, is warranted.  

Increased Rating

Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and, above all, coordination of rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21.

To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007).

The Veteran contends that he is entitled to a rating in excess of 10 percent for his service-connected tinnitus. The Veteran was granted an initial 10 percent evaluation pursuant to 38 C.F.R. § 4.87, Diagnostic Code 6260, the maximum evaluation assignable under that diagnostic code. A single evaluation is assigned for recurrent tinnitus whether it is present in one or both ears. 38 C.F.R. § 4.87, Diagnostic Code 6260, Note (2). See also Smith v. Nicholson, 451 F.3d. 1344 (Fed. Cir. 2006).

During the July 2015 VA examination, the Veteran reported bilateral intermittent ringing type tinnitus. The Veteran's tinnitus occurred off and on, all day, and every day. The examiner opined that the Veteran's tinnitus impacted ordinary conditions of daily life, including the ability to work. The Veteran reported that he could not hear his radio at work (police officer) because of his tinnitus.

In January 2023, the Veteran testified that he had ringing in his ears all the time. He indicated that he had headaches because of the ringing in his ears.

In a January 2024 VA Memorandum, the Director of Compensation determined that the medical evidence did not support a higher evaluation than the schedular maximum of 10 percent for tinnitus. The Director indicated that there was no unusual or exceptional disability pattern demonstrated that would render application of the regular rating criteria as impractical. 

There is a three-part test, based on the language of § 3.321(b)(1), for determining whether a veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008).

The Board recognizes that he reports his tinnitus is constant and causes headaches. However, to the extent that the Veteran's tinnitus impacts the ordinary conditions of daily life, there is no evidence to support a finding that such a symptom markedly interferes with employment. The schedular criteria is not impractical. Therefore, an extraschedular rating is not warranted. Because there is no legal basis upon which to award a higher schedular rating for tinnitus, the appeal must be denied. Sabonis v. Brown, 6 Vet. App
ization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008).

The Board recognizes that he reports his tinnitus is constant and causes headaches. However, to the extent that the Veteran's tinnitus impacts the ordinary conditions of daily life, there is no evidence to support a finding that such a symptom markedly interferes with employment. The schedular criteria is not impractical. Therefore, an extraschedular rating is not warranted. Because there is no legal basis upon which to award a higher schedular rating for tinnitus, the appeal must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994).

REASONS FOR REMAND

The Veteran contends that his headaches are caused by his service-connected tinnitus. The issue of service connection for headaches has been adjudicated by the AOJ in a September 2015 rating decision. However, the AOJ has not adjudicated the claim on a secondary basis. The Board finds that the issue has been "reasonably raised" by the record as being within the scope of the appeal of entitlement to an increased rating for tinnitus. See, e.g., Morgan v. Wilkie, 31 Vet. App. 162, 167-168 (2019); Bailey v. Wilkie, 33 Vet. App. 188, 203 (2021) (in which the United States Court of Appeals for Veterans Claims (Court) held that "VA is required to develop and adjudicate related claims for secondary service connection for disabilities that are reasonably raised during the adjudication of a formally initiated claim for the proper evaluation level for the primary service-connected disability.").

In January 2023, the Veteran testified that he had headaches because of the ringing in his ears. As the Board is an appellate tribunal with limited original jurisdiction, see Jarrell v. Nicholson, 20 Vet. App. 326, 331 (2006), the AOJ is tasked with adjudicating new claim in the first instance. 

The matters are REMANDED for the following action:

Undertake any additional development deemed necessary and then adjudicate the issue of entitlement to service connection for headaches as secondary to service-connected tinnitus. 

 

WILLIAM H. DONNELLY

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Baxter, Sikenah

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.