FLATFOOT BILATERAL ACQUIRED

SHEREEN M. MARCUS · 2025 · Case ID: A25084934

MIXED

Summary

The veteran, who served in the U.S. Army from July 2011 to March 2019 as a petroleum supply specialist, appeals the denial of service connection for multiple conditions, including TBI, chronic headaches, CFS, functional abdominal pain syndrome, dermatosis, respiratory insufficiency, bilateral RLS, and bilateral hand tremors. The veteran also sought increased ratings for bilateral pes planus, recurrent back strain, and pseudofolliculitis barbae (PFB). The Board denied the claims for increased ratings because the veteran failed to attend scheduled VA examinations without good cause, and the submitted private chiropractor opinions lacked probative value due to insufficient analysis and reliance solely on the veteran's self-reported history. For the service connection claims, the Board found no diagnosis or pertinent complaints during service or post-service in the available records. The private chiropractor's opinions were again deemed insufficient, lacking clinical testing and medical analysis. The Board denied service connection for TBI, chronic headaches, CFS, functional abdominal pain syndrome, dermatosis, respiratory insufficiency, RLS, and hand tremors. However, the Board remanded claims for an increased rating for adjustment disorder with depressed mood and service connection for PTSD due to a pre-decisional duty to assist error. The Board noted that a VA PTSD examination and a new VA psychiatric examination were necessary for these remanded claims.

Rationale

Veteran failed to attend scheduled VA examination without good cause.; Private chiropractor opinion lacked probative value due to insufficient analysis.; No current pathology supporting contention.

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

230425-342049

Full Decision Text

Citation Nr: A25084934
Decision Date: 10/01/25 Archive Date: 10/01/25

DOCKET NO. 230425-342049
DATE: October 1, 2025

ORDER

Entitlement to a rating greater than 10 percent for bilateral pes planus is denied.

Entitlement to a rating greater than 10 percent for recurrent back strain is denied.

Entitlement to a compensable rating for pseudofolliculitis barbae (PFB) is denied.

Entitlement to service connection for traumatic brain injury (TBI) is denied.

Entitlement to service connection for chronic headaches is denied.

Entitlement to service connection for chronic fatigue syndrome (CFS) is denied.

Entitlement to service connection for functional abdominal pain syndrome is denied.

Entitlement to service connection for dermatosis of the chest, back, and hands is denied.

Entitlement to service connection for respiratory insufficiency is denied.

Entitlement to service connection for left lower extremity (LLE) restless leg syndrome (RLS) is denied.

Entitlement to service connection for right lower extremity (RLE) RLS is denied.

Entitlement to service connection for left hand tremors is denied.

Entitlement to service connection for right hand tremors is denied.

REMANDED

Entitlement to a rating greater than 30 percent for adjustment disorder with depressed mood is remanded.

Entitlement to service connection for post-traumatic stress disorder (PTSD) is remanded.

FINDINGS OF FACT

1. Entitlement to increased ratings for the Veteran's service-connected bilateral pes planus, recurrent back strain, and PFB could not be established without a current VA examination.

2. The Veteran failed to attend scheduled VA examinations for his bilateral pes planus, recurrent back strain, and PFB without good cause.

3. The persuasive evidence of record is against a finding that the Veteran has been diagnosed with TBI that is the result of active service.

4. The persuasive evidence of record is against a finding that the Veteran has been diagnosed with chronic headaches that are the result of active service.

5. The persuasive evidence of record is against a finding that the Veteran has been diagnosed with CFS that is the result of active service.

6. The persuasive evidence of record is against a finding that the Veteran has functional abdominal pain syndrome that is the result of active service.

7. The persuasive evidence of record is against a finding that the Veteran has been diagnosed with dermatosis that is the result of active service.

8. The persuasive evidence of record is against a finding that the Veteran has been diagnosed with respiratory insufficiency that is the result of active service.

9. The persuasive evidence of record is against a finding that the Veteran has been diagnosed with LLE and RLE RLS that is the result of active service.

10. The persuasive evidence of record is against a finding that the Veteran has been diagnosed with left hand and right hand tremors that are the result of active service.

CONCLUSIONS OF LAW

1. The criteria for a rating greater than 10 percent for bilateral pes planus have not been met. 38 U.S.C. § 501; 38 C.F.R. §§ 3.1(p), 3.160(b), 3.655.

2. The criteria for a rating greater than 10 percent for recurrent back strain have not been met. 38 U.S.C. § 501; 38 C.F.R. §§ 3.1(p), 3.160(b), 3.655.

3. The criteria for a compensable rating for PFB have not been met. 38 U.S.C. § 501; 38 C.F.R. §§ 3.1(p), 3.160(b), 3.655.

4. The criteria for service connection for TBI have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.

5. The criteria for service connection for chronic headaches have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.

6. The criteria for service connection for CFS have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317.

7. The criteria for service connection for functional abdominal pain syndrome have not been met. 38 U.S.C. §§ 1110, 1154
. The criteria for service connection for chronic headaches have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.

6. The criteria for service connection for CFS have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317.

7. The criteria for service connection for functional abdominal pain syndrome have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317.

8. The criteria for service connection for dermatosis of the chest, back, and hands have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317.

9. The criteria for service connection for respiratory insufficiency have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317.

10. The criteria for service connection for LLE RLS have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317.

11. The criteria for service connection for RLE RLS have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317.

12. The criteria for service connection for left hand tremors have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317.

13. The criteria for service connection for right hand tremors have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Army from July 2011 to March 2019.

These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2023 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO).

In an April 2023 VA Form 10182, Notice of Disagreement (NOD), the Veteran elected the evidence submission docket. Therefore, the Board may only consider the evidence of record before the Agency of Original Jurisdiction (AOJ) at the time of its decision on the issues on appeal, as well as any evidence submitted by the Veteran or his representative with the NOD or within 90 days following receipt of the NOD. 38 C.F.R. §§ 20.300(a), 303. If additional evidence was submitted between the dates of the AOJ decision and VA's receipt of the NOD, the Board will not consider it unless it is resubmitted during the 90 days following VA's receipt of the NOD. If evidence is not resubmitted, the Veteran is welcome to file a supplemental claim to have this evidence considered. Id.; Cook v. McDonough, 36 Vet. App. 175 (2023). However, because the Board is remanding the increased rating claim for adjustment disorder and the service connection claim for PTSD, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

The Board has limited the discussion below to the relevant evidence required to support its finding of facts and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008).

Missed Examinations

Under 38 C.F.R. § 3.655(a), when entitlement to
by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

Missed Examinations

Under 38 C.F.R. § 3.655(a), when entitlement to a benefit cannot be established without a current VA examination or reexamination and a claimant, without good cause, fails to report for such examination or reexamination, action shall be taken in accordance with 38 C.F.R. § 3.655(b) or (c) as appropriate. 38 C.F.R. § 3.655(b) applies to original or reopened claims or claims for increase, and 38 C.F.R. § 3.655(c) applies to running awards, when the issue is continuing entitlement. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, and death of an immediate family member. 38 C.F.R. § 3.655(a). 38 C.F.R. § 3.655(b) holds 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. When the examination was scheduled in conjunction with any other original claim, a supplemental claim for a benefit which was previously disallowed, or a claim for increase, the claim shall be denied.

Service connection for the Veteran's bilateral pes planus (10 percent disabling), recurrent back strain (10 percent disabling), and PFB (0 percent disabling) were granted in an April 2019 rating decision, effective March 15, 2019. The ratings were based on the results of February 2019 VA examinations.

The Veteran submitted a claim for increased ratings for the disabilities on December 16, 2022. Accompanying the claim, a private opinion from a chiropractor was completed in November 2022. The opinion suggested a progression, worsening, or extension of all three disabilities. However, the opinion only contained short summaries regarding the disabilities. It did not contain important information needed to determine whether the rating criteria under each relevant diagnostic code for higher evaluations had been met. On the basis of the opinion alone, higher ratings could not be determined.

Therefore, the AOJ proceeded to schedule new VA examinations to evaluate the current extent and severity of the disabilities. Multiple attempts (four telephone calls, one couriered letter, and two emails) were made to inform the Veteran of the scheduled examinations in January 2023. The Veteran's correct telephone number, physical address, and email address were used for each communication, as identified on his December 2022 claim for increase. The couriered letter was successfully delivered and there are no indications that the emails were not successful. Therefore, it is clear that the Veteran was informed of the upcoming examination appointments.

Each examination for bilateral pes planus, recurrent back strain, and PFB was cancelled due to the Veteran not attending the examination. No communications were received from him providing any cause for the missed examinations, either prior to the March 2023 rating decision or during the evidence submission period following the NOD.

1. Entitlement to a rating greater than 10 percent for bilateral pes planus is denied.

2. Entitlement to a rating greater than 10 percent for recurrent back strain is denied.

3. Entitlement to a compensable rating for PFB is denied.

Based on the foregoing, the Board finds that the increased ratings claims must be denied.

Entitlement to increased ratings for bilateral pes planus, recurrent back strain, and PFB could not be established without a current VA examination. 38 C.F.R. § 3.655(a). The November 2022 private opinion suggested a worsening of each disability. However, there was insufficient information to establish whether the diagnostic criteria for a higher rating was met from the short summaries provided by the chiropractor.

The Veteran was clearly informed of the scheduled examinations. No good cause has been provided for the failure to attend the examinations. Therefore, and in accordance with 38 C.F.R. § 3.655(b), the claims must be denied.

Service Connection

Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in
, and PFB could not be established without a current VA examination. 38 C.F.R. § 3.655(a). The November 2022 private opinion suggested a worsening of each disability. However, there was insufficient information to establish whether the diagnostic criteria for a higher rating was met from the short summaries provided by the chiropractor.

Service Connection

Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § § 1110; 38 C.F.R. § 3.303(a).

Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. 38 C.F.R. § 3.303. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a).

Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. See 38 C.F.R. § 3.310; but see Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (holding all that is needed is a "but for" causation or aggravation to show entitlement to secondary service connection).

Further, special service connection rules exist for Gulf War Veterans. 38 U.S.C. § § 1117; 38 C.F.R. § 3.317. 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(e)(2). Additional locations were added in August 2022, including Afghanistan, Israel, Egypt, Turkey, Syria, or Jordan. 38 U.S.C. § 1117(f).

Under that section, service connection may be warranted for a Gulf War veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Gulf War. For disability due to undiagnosed illness and medically unexplained chronic multi-symptom illness, the disability must have been manifest either during active military service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2026. See 38 C.F.R. § 3.317(a)(1).

For purposes of 38 C.F.R. § 3.317, there are two types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a diagnosed medically unexplained chronic multi-symptom illness (MUCMI) that is defined by a cluster of signs or symptoms such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding gastrointestinal diseases). With regard to "functional gastrointestinal disorders," this would include, but are not limited to, irritable bowel syndrome, functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, and functional dysphagia. 38 C.F.R. § 3.317(a)(2)(i)(B).

An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. 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
gastrointestinal disorders," this would include, but are not limited to, irritable bowel syndrome, functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, and functional dysphagia. 38 C.F.R. § 3.317(a)(2)(i)(B).

An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. 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. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006).

On the other hand, the term "MUCMI" refers to 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 MUCMIs of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered "medically unexplained." Id.

For purposes of section 3.317, 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. 38 C.F.R. § 3.317(a)(4).

Additionally, effective August 5, 2021, under 38 C.F.R. § 3.320, for veterans with qualifying service in the Southwest Asia theater of operations during the Persian Gulf War, service connection may be presumed for certain listed chronic diseases associated with exposure to fine, particulate matter, which listed diseases include: asthma, rhinitis, and sinusitis (to include rhinosinusitis).

Service connection may be presumed under 38 C.F.R. § 3.320 even though there is no evidence of a listed disease during the period of service if it becomes manifest to any degree (including noncompensable) at any time following separation. Exposure to fine, particular matter shall be presumed under 38 C.F.R. § 3.320 for veterans with qualifying service in the Southwest Asia theater of operations during the Persian Gulf War.

Notwithstanding the foregoing presumption provisions, a claimant is not precluded from establishing service connection for a disability due to Gulf War exposures with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom, Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998).

On August 10, 2022, a statute known as "the PACT Act" was signed into law expanding the scope of presumed in-service toxic exposures. See Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), Pub. L. 117-168 (August 10, 2022). The PACT Act established standards for veterans exposed to toxic exposure risk activities (TERA).

In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d at 1376-77. When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1376-77.

In rendering this decision, the Board has reviewed all evidence of record whether discussed in detail. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007) (holding the Board must only discuss the evidence which is relevant to the issues on appeal).

A veteran is entitled to the benefit of the doubt when the evidence is in approximate balance or "nearly equal," and does not require that the evidence be in exact equipoise. Evidence is in approximate balance when the evidence in favor of and opposing the veteran's claim is found to be almost exactly or nearly equal. Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021).

1. TBI / Headaches

The Veteran has contended that he has TBI and chronic headaches that are due to active service.

A May 2011 service enlistment examination reflected a normal head and neurological system. On a report of medical history, he denied frequent or severe headaches, head injury, seizures, period of unconsciousness or concussion, loss of memory, amnesia, and neurological symptoms.

On October 2011, May 2012, and September 2012 dental questionnaires, the Veteran denied frequent headaches.

A TBI questionnaire was conducted in September 2013. Clinicians found that no referral for TBI was needed.

An October 2013 dental questionnaire was also negative for frequent headaches.

Another TBI screening performed in December 2013 had negative results.

On another dental questionnaire in January 2015 the Veteran denied frequent headaches. On an April 2015 review of systems, clinicians noted no headaches. Another dental questionnaire in May 2016 was negative for frequent headaches. A July 2016 review of systems reflected no headaches. In January 2018, a dental questionnaire noted no frequent headaches. Another review of systems in February 2018 stated no headaches.

In August 2018 and October 2018, TBI / concussion screens had negative results.

A November 2018 review of systems and dental questionnaire were negative for frequent headaches.

In December 2018, the Veteran was asked whether he had ever sustained a brain injury or concussion which caused him to lose consciousness or to become dazed and confused. He answered no. He also denied headaches.

A separation examination was conducted in December 2018. The Veteran's head and neurological system were all normal. On an accompanying report of medical history, he denied frequent or severe headaches, head injury, seizures, period of unconsciousness or concussion, loss of memory, amnesia, and neurological symptoms.

Just prior to separation, the Veteran underwent a VA general medical examination in February 2019. The examiner indicated that he had no neurological symptoms or history.

Service personnel records reflected the Veteran's military occupational specialty (MOS) of petroleum supply specialist. He was deployed to Afghanistan from February 2013 to August 2013. There is no evidence in the claims file of combat service.

Post-service, VA treatment records from March 2022 included a negative TBI screen and notation of no history of TBI. The Veteran also denied headaches.

A May 2022 treatment record was negative for headaches.

In July 2022, the Veteran reported mild or very
, amnesia, and neurological symptoms.

Just prior to separation, the Veteran underwent a VA general medical examination in February 2019. The examiner indicated that he had no neurological symptoms or history.

Post-service, VA treatment records from March 2022 included a negative TBI screen and notation of no history of TBI. The Veteran also denied headaches.

A May 2022 treatment record was negative for headaches.

In July 2022, the Veteran reported mild or very mild headache associated with prescribed Sertraline for psychiatric symptoms. Clinicians stated that it seemed to be resolving.

A private opinion from a chiropractor was completed in November 2022. She stated that the Veteran reported to her that he got struck in the head with a ratchet strap. He was rendered momentarily unconscious and then was very disoriented. He was evaluated by military medical personnel. He continued to suffer from chronic headaches, irritability, focus issues and difficulties with his eyes, and loss of memory. The chiropractor diagnosed TBI and found that it was as likely as not directly and causally related to the described injury.

The Veteran also told the chiropractor that he suffered from headaches during active duty. He was treated by military medical personnel. He had four or more headaches per week. She diagnosed chronic headaches and found that it was as likely as not that it was directly and causally related to military service.

A. Entitlement to service connection for TBI is denied.

B. Entitlement to service connection for chronic headaches is denied.

Based on the foregoing, the Board finds that service connection for TBI and chronic headaches is not warranted.

At the outset, the Board notes that the Veteran has not undergone VA examinations in connection with his claims. For the reasons outlined below, VA examinations were needed to establish entitlement to service connection for TBI and chronic headaches. 38 C.F.R. § 3.655(a).

Following his service connection claim, the AOJ scheduled VA examinations for TBI and chronic headaches. Multiple attempts (four telephone calls, one couriered letter, and two emails) were made to inform the Veteran of the scheduled examinations in January 2023. His correct telephone number, physical address, and email address were used for each communication, as identified on his December 2022 claim. The couriered letter was successfully delivered and there are no indications that the emails were not successful. Therefore, it is clear that the Veteran was informed of the upcoming examination appointments.

Both examinations were cancelled due to the Veteran not attending the examinations. No communications were received from him providing any cause for the missed examinations, either prior to the March 2023 rating decision or during the evidence submission period following the NOD.

The Veteran has not provided good cause for missing the examinations. As original claims for benefits, the issues must therefore be rated based on the evidence of record. 38 C.F.R. § 3.655(b). As such, the Board will proceed to a decision.

There was no evidence of any TBI or headache complaints during active service or within a year of separation. Importantly, the Veteran explicitly denied head injury, loss of consciousness or concussion, and frequent or severe headaches at separation. The Board finds the contemporaneous medical treatment records and statements to treating clinicians during service to be far more credible than the Veteran's lone statement to the private chiropractor that he had a head injury with unconsciousness and headaches during service, made in connection with claims for VA monetary benefits. Indeed, he stated he was treated by military medical personnel for the claimed conditions, which is directly contradicted by the service treatment records (STRs).

While the private opinion provided a positive nexus to service, it is evident that it was based only upon the Veteran's lay report of symptoms during active duty. The chiropractor did not review the STRs or post-service treatment records and did not provide any supporting medical rationale for her conclusory statement that the claimed conditions were likely related to service. Absent a rationale, a medical opinion has no probative value. See Horn v. Shinseki, 25 Vet. App. 231, 240-42 (2012) (stating that under case law, "an unexplained conclusory opinion is entitled to no weight in a service-connection context"). Therefore, the opinion is afforded no probative weight.

Accordingly, the most competent and credible evidence of record, namely the STRs and the Veteran's own contemporaneous statements to treating military clinicians, do not support service
chiropractor did not review the STRs or post-service treatment records and did not provide any supporting medical rationale for her conclusory statement that the claimed conditions were likely related to service. Absent a rationale, a medical opinion has no probative value. See Horn v. Shinseki, 25 Vet. App. 231, 240-42 (2012) (stating that under case law, "an unexplained conclusory opinion is entitled to no weight in a service-connection context"). Therefore, the opinion is afforded no probative weight.

2. CFS

The Veteran has contended that he has CFS that is due to active service, to include his verified Southwest Asia service.

The Veteran's STRs are negative for a diagnosis of CFS. On a September 2013 post-deployment questionnaire, he answered "bothered a little" to feeling tired or having low energy. In April 2015, he denied feeling tired or having little energy on a depression screening. An August 2018 depression screening noted that he felt tired or had little energy more than half the days.

The December 2018 separation examination and report of medical history were silent for any complaints of fatigue or CFS.

As noted above, the Veteran's MOS was petroleum supply specialist. He had service in Afghanistan and no combat service.

The Veteran reported mild tiredness and fatigue to VA clinicians in February 2019. He denied fatigue in March 2022.

On depression questionnaires in April 2022 and June 2022, the Veteran stated that he was tired and / or had low energy more than half the days. On May 2022, June 2022, July 2022, August 2022, September 2022, November 2022, and December 2022 depression questionnaires, he said he was tired and / or had low energy several days. In October 2022, he noted that he was tired or had low energy "not at all."

A private opinion from a chiropractor was completed in November 2022. She stated that the Veteran reported to her that he suffered with CFS since active duty. Based on this statement, she diagnosed CFS and found it was directly and causally related to Gulf War syndrome and therefore, the Veteran's service.

A. Entitlement to service connection for CFS is denied.

Based on the foregoing, the Board finds that service connection for CFS is not warranted.

Following his service connection claim, the AOJ scheduled a VA examination for CFS. Multiple attempts (four telephone calls, one couriered letter, and two emails) were made to inform the Veteran of the scheduled examination in January 2023. His correct telephone number, physical address, and email address were used for each communication, as identified on his December 2022 claim. The couriered letter was successfully delivered and there are no indications that the emails were not successful. Therefore, it is clear that the Veteran was informed of the upcoming examination appointment.

The examination was cancelled due to the Veteran not attending the examination. No communications were received from him providing any cause for the missed examination, either prior to the March 2023 rating decision or during the evidence submission period following the NOD.

The Veteran has not provided good cause for missing the examination. As an original claim for benefits, the issue must therefore be rated based on the evidence of record. 38 C.F.R. § 3.655(b). As such, the Board will proceed to a decision.

There was no diagnosis of CFS during active service or anywhere in VA treatment records. The Veteran has not identified outstanding private treatment records establishing a diagnosis. The only diagnosis was made by the chiropractor, based merely on the Veteran's report that he had CFS since service. No clinical testing was completed to make the diagnosis.

The Board notes that the Veteran has contended he has CFS and has reported some tiredness to treating clinicians. However, there is no current pathology supporting that contention. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that they observed and that are within the realm of their personal knowledge, such as feeling tired or low energy. But lay persons are not competent to establish that which would require specialized knowledge or training, as would be required to diagnose a complex condition such as CFS. See Layno v. Brown, 6 Vet. App. 465, 469 - 470 (1994); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). The Board notes that although the Veteran's statements are competent to describe his symptomology, as the cause of such symptomology involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, he is not competent to render such a complex medical opinion regarding etiology. As such, the question of diagnosis and etiology in this case may not be competently addressed by lay evidence. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Clyburn v. West, 12 Vet. App. 296, 301 (1999); Savage v. Gober, 10 Vet. App. 488, 496-97 (1997).

Further, the private chiropractor's opinion is not based on any analysis of the Veteran's medical history, current presentation, or clinical testing results. The chiropractor just determined that he had CFS because he said he had it. The Board may reject a medical opinion that is conclusory, lacks supporting analysis, and is not based on the veteran's relevant medical history. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007); D'Aries v. Peake, 22 Vet. App. 97, 104 (2008). The chiropractor did not review the STRs or post-service treatment records, did not perform any clinical testing, and provided zero medical analysis to make her diagnosis. Therefore, the Board finds that the opinion holds no probative value.

The Board finds the contemporaneous medical treatment records during service and post-service which are silent for a CFS diagnosis to be highly probative. With no competent or credible evidence providing a CFS diagnosis, the claim must be denied.

3. Abdominal Pain

The Veteran has contended that he has functional abdominal pain syndrome that is due to active service, to include his verified Southwest Asia service.

A May 2011 service enlistment examination reflected a normal abdomen and viscera. On a report of medical history, the Veteran denied frequent indigestion, heartburn, or stomach or intestinal trouble.

An August 2013 STR noted that the Veteran had no gastrointestinal symptoms. On a review of systems conducted in April 2015, July 2016, February 2018, August 2018, and November 2018, clinicians indicated that he had no abdominal pain or other gastrointestinal symptoms.

At a December 2018 separation examination, the Veteran's abdomen and viscera were normal. On an accompanying report of medical history, he denied frequent indigestion, heartburn, or stomach or intestinal trouble.

A February 2019 VA general medical examination indicated that she had no digestive or abdominal wall history.

As noted above, the Veteran's MOS was petroleum supply specialist. He had service in Afghanistan and no combat service.

Post-service, gastrointestinal symptoms were denied to VA treating clinicians in March 2022, May 2022, and July 2022.

A private opinion from a chiropractor was completed in November 2022. She stated that the Veteran reported to her that he suffered from functional abdominal pain syndrome, abdominal pain and bloating, and diarrhea since Gulf War service. She determined it was as likely as not that the conditions were directly and causally related to service.

A. Entitlement to service connection for functional abdominal pain syndrome is denied.

Based on the foregoing, the Board finds that service connection for functional abdominal pain syndrome is not warranted.

At the outset, the Board notes that the
service in Afghanistan and no combat service.

Post-service, gastrointestinal symptoms were denied to VA treating clinicians in March 2022, May 2022, and July 2022.

A. Entitlement to service connection for functional abdominal pain syndrome is denied.

Based on the foregoing, the Board finds that service connection for functional abdominal pain syndrome is not warranted.

Following his service connection claim, the AOJ scheduled a VA examination for functional abdominal pain syndrome. Multiple attempts (four telephone calls, one couriered letter, and two emails) were made to inform the Veteran of the scheduled examination in January 2023. His correct telephone number, physical address, and email address were used for each communication, as identified on his December 2022 claim. The couriered letter was successfully delivered and there are no indications that the emails were not successful. Therefore, it is clear that the Veteran was informed of the upcoming examination appointment.

There was no diagnosis of functional abdominal pain syndrome nor any pertinent gastrointestinal complaints during active service or anywhere in VA treatment records. The Veteran has not identified outstanding private treatment records establishing a diagnosis or containing relevant complaints. The only diagnosis was made by the chiropractor, based merely on the Veteran's report that he had the condition since service. No clinical testing was completed to make the diagnosis.

The Board notes that the Veteran has contended he has functional abdominal pain syndrome. However, there is no current pathology supporting that contention. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that they observed and that are within the realm of their personal knowledge, such as abdominal pain. But lay persons are not competent to establish that which would require specialized knowledge or training, as would be required to diagnose a complex condition such as functional abdominal pain syndrome. See Layno v. Brown, 6 Vet. App. at 469 - 470; Kahana v. Shinseki, 24 Vet. App. at 435. The Board notes that although the Veteran's statements are competent to describe his symptomology, as the cause of such symptomology involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, he is not competent to render such a complex medical opinion regarding etiology. As such, the question of diagnosis and etiology in this case may not be competently addressed by lay evidence. See Davidson v. Shinseki, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d at 1372; see also Clyburn v. West, 12 Vet. App. at 301; Savage v. Gober, 10 Vet. App. at 496-97.

Further, the private chiropractor's opinion is not based on any analysis of the Veteran's medical history, current presentation, or clinical testing results. The chiropractor just determined that he had gastrointestinal complaints arising to functional abdominal pain syndrome because he said he had them. The Board may reject a medical opinion that is conclusory, lacks supporting analysis, and is not based on the veteran's relevant medical history. See Stefl v. Nicholson, 21 Vet. App. at 124-25; D'Aries v. Peake, 22 Vet. App. at 104. The chiropractor did not review the STRs or post-service treatment records, did not perform any clinical testing, and provided zero medical analysis to make her diagnosis. Therefore, the Board finds that the opinion holds no probative value.

The Board finds the contemporaneous medical treatment records during service and post-service which are silent for any gastrointestinal complaints to be highly probative. With no competent or credible evidence
. The Board may reject a medical opinion that is conclusory, lacks supporting analysis, and is not based on the veteran's relevant medical history. See Stefl v. Nicholson, 21 Vet. App. at 124-25; D'Aries v. Peake, 22 Vet. App. at 104. The chiropractor did not review the STRs or post-service treatment records, did not perform any clinical testing, and provided zero medical analysis to make her diagnosis. Therefore, the Board finds that the opinion holds no probative value.

4. Dermatosis

The Veteran has contended that he has dermatosis that is due to active service, to include his verified Southwest Asia service.

A May 2011 service enlistment examination reflected normal skin. On a report of medical history, the Veteran denied skin diseases.

The Veteran was seen by military clinicians for skin disorders in August 2011 but was only diagnosed with PFB. STRs from August 2013, July 2016, February 2018, November 2018, and December 2018 noted normal skin with no lesions.

At a December 2018 separation examination, the Veteran's skin was normal. On an accompanying report of medical history, he denied skin diseases.

Just prior to separation, a February 2019 VA skin examination indicated that the Veteran had PFB. No other diagnoses were made; however, the examiner did not discuss the claimed dermatosis.

As noted above, the Veteran's MOS was petroleum supply specialist. He had service in Afghanistan and no combat service.

Post-service, VA treating clinicians indicated in March 2022 that the Veteran did not have dermatitis or a history of such. He reported no persistent skin rash.

A private opinion from a chiropractor was completed in November 2022. She stated that the Veteran reported to her that he had chronic dermatitis which appeared on his chest, back, and hands and had been progressively symptomatic since Gulf War service. She determined it was as likely as not that the condition was directly and causally related to service.

A. Entitlement to service connection for dermatosis of the chest, back, and hands is denied.

Based on the foregoing, the Board finds that service connection for dermatosis is not warranted.

At the outset, the Board notes that the Veteran has not undergone a VA examination specifically for dermatosis in connection with his claim. For the reasons outlined below, an examination was needed to establish entitlement to the benefit sought. 38 C.F.R. § 3.655(a).

Following his service connection claim, the AOJ scheduled a VA examination for dermatosis. Multiple attempts (four telephone calls, one couriered letter, and two emails) were made to inform the Veteran of the scheduled examination in January 2023. His correct telephone number, physical address, and email address were used for each communication, as identified on his December 2022 claim. The couriered letter was successfully delivered and there are no indications that the emails were not successful. Therefore, it is clear that the Veteran was informed of the upcoming examination appointment.

There was no diagnosis of dermatosis nor any pertinent skin complaints (other than service-connected PFB) during active service or anywhere in VA treatment records. The Veteran has not identified outstanding private treatment records establishing a diagnosis or containing relevant complaints. The only diagnosis was made by the chiropractor, based merely on the Veteran's report that he had the condition since service. No clinical testing (or indeed, any physical examination) was completed to make the diagnosis.

The Board notes that the Veteran has contended he has dermatosis. However, there is no current pathology supporting that contention. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that they observed and that are within the realm of their personal knowledge, such as skin rash, redness, or itching. But lay persons are not competent to establish that which would require specialized knowledge or training, as would be required to diagnose a complex condition such as dermatosis. See Layno v. Brown, 6 Vet. App. at 469 - 470; Kahana v. Shinseki, 24 Vet. App. at 435. The Board notes that although the Veteran's statements are competent to describe his symptomology, as the cause of such symptomology involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, he is not competent to render such a complex medical opinion regarding etiology. As such, the question of diagnosis and etiology in this case may not be competently addressed by lay evidence. See Davidson v. Shinseki, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d at 1372; see also Clyburn v. West, 12 Vet. App. at 301; Savage v. Gober, 10 Vet. App. at 496-97.

Further, the private chiropractor's opinion is not based on any analysis of the Veteran's medical history, current presentation, or clinical testing results. The chiropractor just determined that he had chronic dermatitis because he said he had it. The Board may reject a medical opinion that is conclusory, lacks supporting analysis, and is not based on the veteran's relevant medical history. See Stefl v. Nicholson, 21 Vet. App. at 124-25; D'Aries v. Peake, 22 Vet. App. at 104. The chiropractor did not review the STRs or post-service treatment records, did not perform any clinical testing, and provided zero medical analysis to make her diagnosis. Therefore, the Board finds that the opinion holds no probative value.

The Board finds the contemporaneous medical treatment records during service and post-service which are silent for any dermatosis symptomology to be highly probative. With no competent or credible evidence of dermatosis or adequate medical opinion attributing such to service, the claim must be denied.

5. Respiratory Insufficiency

The Veteran has contended that he has respiratory insufficiency that is due to active service, to include his verified Southwest Asia service.

A May 2011 service enlistment examination reflected normal lungs. On a report of medical history, the Veteran denied shortness of breath, bronchitis, wheezing or problems with wheezing, chronic cough, or chronic or frequent colds.

An October 2018 STR noted that the Veteran's respiration rhythm and depth were normal. In January 2019, clinicians stated that he had no difficulty breathing. STRs were silent for any respiratory complaints.

At a December 2018 separation examination, the Veteran's lungs were normal. On an accompanying report of medical history, he denied shortness of breath, bronchitis, wheezing or problems with wheezing, chronic cough, or chronic or frequent colds.

Just prior to separation, a February 2019 VA general medical examination indicated that the Veteran had no respiratory history.

As noted above, the Veteran's MOS was petroleum supply specialist. He had service in Afghanistan and no combat service.

Post-service, a March 2022 VA treatment record noted that the Veteran did not have shortness of breath, cough, or wheezing.

A private opinion from a chiropractor was completed in November 2022. She stated that the Veteran reported to her that he suffered with respiratory deficiency to include dyspnea with compromised volume of air on expiratory effort. She diagnosed respiratory insufficiency (dyspnea) and determined it was as likely as not that the condition was directly and causally related to Gulf War syndrome and the Veteran's service.

A. Entitlement to service connection for respiratory insufficiency is denied.

Based on the foregoing, the Board finds that service connection for respiratory insufficiency is not warranted.

At the outset, the Board notes that the Veteran has not undergone a VA examination in connection with his claim. For the reasons outlined below, an examination was needed to establish entitlement to the benefit sought.
. She stated that the Veteran reported to her that he suffered with respiratory deficiency to include dyspnea with compromised volume of air on expiratory effort. She diagnosed respiratory insufficiency (dyspnea) and determined it was as likely as not that the condition was directly and causally related to Gulf War syndrome and the Veteran's service.

A. Entitlement to service connection for respiratory insufficiency is denied.

Based on the foregoing, the Board finds that service connection for respiratory insufficiency is not warranted.

Following his service connection claim, the AOJ scheduled a VA examination for respiratory insufficiency. Multiple attempts (four telephone calls, one couriered letter, and two emails) were made to inform the Veteran of the scheduled examination in January 2023. His correct telephone number, physical address, and email address were used for each communication, as identified on his December 2022 claim. The couriered letter was successfully delivered and there are no indications that the emails were not successful. Therefore, it is clear that the Veteran was informed of the upcoming examination appointment.

There was no diagnosis of respiratory insufficiency nor any pertinent respiratory complaints during active service or anywhere in VA treatment records. The Veteran has not identified outstanding private treatment records establishing a diagnosis or containing relevant complaints. The only diagnosis was made by the chiropractor, based merely on the Veteran's report that he had the condition. No clinical testing was completed to make the diagnosis.

The Board notes that the Veteran has contended he has respiratory insufficiency. However, there is no current pathology supporting that contention. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that they observed and that are within the realm of their personal knowledge, such as difficulty breathing. But lay persons are not competent to establish that which would require specialized knowledge or training, as would be required to diagnose a complex condition such as respiratory insufficiency. See Layno v. Brown, 6 Vet. App. at 469 - 470; Kahana v. Shinseki, 24 Vet. App. at 435. The Board notes that although the Veteran's statements are competent to describe his symptomology, as the cause of such symptomology involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, he is not competent to render such a complex medical opinion regarding etiology. As such, the question of diagnosis and etiology in this case may not be competently addressed by lay evidence. See Davidson v. Shinseki, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d at 1372; see also Clyburn v. West, 12 Vet. App. at 301; Savage v. Gober, 10 Vet. App. at 496-97.

Further, the private chiropractor's opinion is not based on any analysis of the Veteran's medical history, current presentation, or clinical testing results. The chiropractor just determined that he had respiratory insufficiency because he said he had it. The Board may reject a medical opinion that is conclusory, lacks supporting analysis, and is not based on the veteran's relevant medical history. See Stefl v. Nicholson, 21 Vet. App. at 124-25; D'Aries v. Peake, 22 Vet. App. at 104. The chiropractor did not review the STRs or post-service treatment records, did not perform any clinical testing, and provided zero medical analysis to make her diagnosis. Therefore, the Board finds that the opinion holds no probative value.

The Board finds the contemporaneous medical treatment records during service and post-service which are silent for any respiratory complaints to be highly probative. With no competent or credible evidence of respiratory insufficiency or adequate medical opinion attributing such to service, the claim must be denied.

6. RLS

The Veteran has contended that he has bilateral RLS
21 Vet. App. at 124-25; D'Aries v. Peake, 22 Vet. App. at 104. The chiropractor did not review the STRs or post-service treatment records, did not perform any clinical testing, and provided zero medical analysis to make her diagnosis. Therefore, the Board finds that the opinion holds no probative value.

6. RLS

The Veteran has contended that he has bilateral RLS that is due to active service, to include his verified Southwest Asia service.

A May 2011 service enlistment examination reflected normal lower extremities and neurological system. On a report of medical history, the Veteran denied impaired use of legs and neurological symptoms.

The STRs were silent for RLS or any neurological complaints in the lower extremities.

At a December 2018 separation examination, the Veteran's lower extremities and neurological system were normal. On an accompanying report of medical history, he denied impaired use of legs and neurological symptoms.

Just prior to separation, a February 2019 VA general medical examination indicated that he had no neurological history.

As noted above, the Veteran's MOS was petroleum supply specialist. He had service in Afghanistan and no combat service.

Post-service, VA treatment records were silent for RLS or pertinent symptomology.

A private opinion from a chiropractor was completed in November 2022. She stated that the Veteran reported to her that he suffered with bilateral RLS that had been progressively symptomatic since Gulf War service. She diagnosed RLS of the bilateral legs and determined it was as likely as not that the condition was directly and causally related to Gulf War syndrome and the Veteran's service.

A VA peripheral nerves examination was conducted in January 2023 associated with a claim for bilateral lower extremity radiculopathy secondary to service-connected recurrent back strain. The examiner did not diagnose RLS or discuss the claimed condition.

A. Entitlement to service connection for LLE RLS is denied.

B. Entitlement to service connection for RLE RLS is denied.

Based on the foregoing, the Board finds that service connection for bilateral lower extremity RLS is not warranted.

At the outset, the Board notes that the Veteran has not undergone a VA examination specifically for RLS in connection with his claim. For the reasons outlined below, an examination was needed to establish entitlement to the benefit sought. 38 C.F.R. § 3.655(a).

Following his service connection claim, the AOJ scheduled a VA examination for RLS. Multiple attempts (four telephone calls, one couriered letter, and two emails) were made to inform the Veteran of the scheduled examination in January 2023. His correct telephone number, physical address, and email address were used for each communication, as identified on his December 2022 claim. The couriered letter was successfully delivered and there are no indications that the emails were not successful. Therefore, it is clear that the Veteran was informed of the upcoming examination appointment.

There was no diagnosis of RLS nor any pertinent complaints during active service or anywhere in VA treatment records. The Veteran has not identified outstanding private treatment records establishing a diagnosis or containing relevant complaints. The only diagnosis was made by the chiropractor, based merely on the Veteran's report that he had the condition. No clinical testing was completed to make the diagnosis.

The Board notes that the Veteran has contended he has RLS. However, there is no current pathology supporting that contention. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that they observed and that are within the realm of their personal knowledge, such as involuntary movement in the legs. But lay persons are not competent to establish that which would require specialized knowledge or training, as would be required to diagnose a complex condition such as RLS. See Layno v. Brown, 6 Vet. App. at 469 - 470; Kahana v. Shinseki, 24 Vet. App. at 435. The Board notes that although the Veteran's statements are competent to describe his symptomology, as the cause of such symptomology involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, he is not competent to render such a complex medical opinion regarding etiology. As such, the question of diagnosis and etiology in this case may not be competently addressed by lay evidence. See Davidson v. Shinseki, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d at 1372; see also Clyburn v. West, 12 Vet. App. at 301; Savage v. Gober, 10 Vet. App. at 496-97.

Further, the private chiropractor's opinion is not based on any analysis of the Veteran's medical history, current presentation, or clinical testing results. The chiropractor just determined that he had RLS because he said he had it. The Board may reject a medical opinion that is conclusory, lacks supporting analysis, and is not based on the veteran's relevant medical history. See Stefl v. Nicholson, 21 Vet. App. at 124-25; D'Aries v. Peake, 22 Vet. App. at 104. The chiropractor did not review the STRs or post-service treatment records, did not perform any clinical testing, and provided zero medical analysis to make her diagnosis. Therefore, the Board finds that the opinion holds no probative value.

The Board finds the contemporaneous medical treatment records during service and post-service which are silent for any RLS complaints to be highly probative. With no competent or credible evidence of LLE and RLE RLS or adequate medical opinion attributing such to service, the claims must be denied.

7. Tremors

The Veteran has contended that he has bilateral hand tremors that are due to active service, to include his verified Southwest Asia service.

A May 2011 service enlistment examination reflected normal upper extremities and neurological system. On a report of medical history, the Veteran denied impaired use of hands and neurological symptoms.

The STRs were silent for hand tremors or any neurological complaints in the upper extremities.

At a December 2018 separation examination, the Veteran's upper extremities and neurological system were normal. On an accompanying report of medical history, he denied impaired use of hands and neurological symptoms.

Just prior to separation, a February 2019 VA general medical examination indicated that the Veteran had no neurological history.

As noted above, the Veteran's MOS was petroleum supply specialist. He had service in Afghanistan and no combat service.

Post-service, VA treatment records were silent for hand tremors or pertinent symptomology.

A private opinion from a chiropractor was completed in November 2022. She stated that the Veteran reported to her that he suffered with tremors of the bilateral hands that had been progressively symptomatic since Gulf War service. She diagnosed tremors of the bilateral hands and determined it was as likely as not that the condition was directly and causally related to Gulf War syndrome and the Veteran's service.

A. Entitlement to service connection for left hand tremors is denied.

B. Entitlement to service connection for right hand tremors is denied.

Based on the foregoing, the Board finds that service connection for bilateral hand tremors is not warranted.

At the outset, the Board notes that the Veteran has not undergone a VA examination specifically for hand tremors in connection with his claims. For the reasons outlined below, an examination was needed to establish entitlement to the benefit sought. 38 C.F.R. § 3.655(a).

Following his service connection claim, the AOJ scheduled a VA examination for hand tremors. Multiple attempts (four telephone calls, one couriered letter, and two
the claimed condition.

A. Entitlement to service connection for left hand tremors is denied.

B. Entitlement to service connection for right hand tremors is denied.

Based on the foregoing, the Board finds that service connection for bilateral hand tremors is not warranted.

Following his service connection claim, the AOJ scheduled a VA examination for hand tremors. Multiple attempts (four telephone calls, one couriered letter, and two emails) were made to inform the Veteran of the scheduled examination in January 2023. His correct telephone number, physical address, and email address were used for each communication, as identified on his December 2022 claim. The couriered letter was successfully delivered and there are no indications that the emails were not successful. Therefore, it is clear that the Veteran was informed of the upcoming examination appointment.

There was no diagnosis of hand tremors nor any pertinent complaints during active service or anywhere in VA treatment records. The Veteran has not identified outstanding private treatment records establishing a diagnosis or containing relevant complaints. The only diagnosis was made by the chiropractor, based merely on the Veteran's report that he had the condition. No clinical testing was completed to make the diagnosis.

The Board notes that the Veteran has contended he has hand tremors. However, there is no current pathology supporting that contention. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that they observed and that are within the realm of their personal knowledge, such as shaking in the hands. But lay persons are not competent to establish that which would require specialized knowledge or training, as would be required to diagnose a complex condition such as hand tremors. See Layno v. Brown, 6 Vet. App. at 469 - 470; Kahana v. Shinseki, 24 Vet. App. at 435. The Board notes that although the Veteran's statements are competent to describe his symptomology, as the cause of such symptomology involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, he is not competent to render such a complex medical opinion regarding etiology. As such, the question of diagnosis and etiology in this case may not be competently addressed by lay evidence. See Davidson v. Shinseki, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d at 1372; see also Clyburn v. West, 12 Vet. App. at 301; Savage v. Gober, 10 Vet. App. at 496-97.

Further, the private chiropractor's opinion is not based on any analysis of the Veteran's medical history, current presentation, or clinical testing results. The chiropractor just determined that he had hand tremors because he said he had them. The Board may reject a medical opinion that is conclusory, lacks supporting analysis, and is not based on the veteran's relevant medical history. See Stefl v. Nicholson, 21 Vet. App. at 124-25; D'Aries v. Peake, 22 Vet. App. at 104. The chiropractor did not review the STRs or post-service treatment records, did not perform any clinical testing, and provided zero medical analysis to make her diagnosis. Therefore, the Board finds that the opinion holds no probative value.

The Board finds the contemporaneous medical treatment records during service and post-service which are silent for any hand tremor complaints to be highly probative. With no competent or credible evidence of left hand and right hand tremors or adequate medical opinion attributing such to service, the claims must be denied.

REASONS FOR REMAND

1. Entitlement to a rating greater than 30 percent for adjustment disorder with depressed mood is remanded.

2. Entitlement to service connection for PTSD is remanded.

The Veteran has contended that a higher evaluation is warranted for his service-connected adjustment disorder with depressed
testing, and provided zero medical analysis to make her diagnosis. Therefore, the Board finds that the opinion holds no probative value.

REASONS FOR REMAND

1. Entitlement to a rating greater than 30 percent for adjustment disorder with depressed mood is remanded.

2. Entitlement to service connection for PTSD is remanded.

The Veteran has contended that a higher evaluation is warranted for his service-connected adjustment disorder with depressed mood and that service connection for PTSD is warranted. The Board finds that a pre-decisional duty to assist error has occurred which must be corrected before a decision may be rendered on the claims. See 38 C.F.R. § 20.802.

Accompanying his December 2022 claim, a private PTSD examination was submitted. The examiner focused on PTSD diagnostic criteria but listed all psychiatric symptomology, some of which appeared more severe than previously demonstrated in the claims file. Given this potential evidence of worsening in the service-connected adjustment disorder with depressed mood, a new VA psychiatric examination was scheduled for January 2023. No VA PTSD examination was scheduled.

Multiple attempts (four telephone calls, one couriered letter, and two emails) were made to inform the Veteran of the scheduled examination. The Veteran's correct telephone number, physical address, and email address were used for each communication, as identified on his December 2022 claim for increase. The couriered letter was successfully delivered and there are no indications that the emails were not successful. It was unclear whether the telephone calls were answered. Therefore, it is clear that the Veteran was informed of the upcoming examination appointment.

The Veteran did not attend the examination and no good cause was given for the missed appointment.

Following the Veteran's submission of additional information regarding his PTSD claim, the AOJ scheduled both a VA PTSD examination and a VA psychiatric examination in March 2023. The AOJ later, without explanation, corrected the appointment to include only a PTSD examination. The examination was later cancelled due to a no show of the Veteran. Prior to the rating decision on appeal, no good cause for the missed examination was provided.

The Board finds that the failure to reschedule the VA PTSD and psychiatric examinations constitutes a pre-decisional duty to assist error which must be corrected upon remand.

It is clear that entitlement to the benefits sought cannot be established without new VA PTSD and psychiatric examinations. 38 C.F.R. § 3.655(a). The medical opinion of record establishing a diagnosis of PTSD was completed by a private psychologist. However, 38 C.F.R. § 3.304(f)(3) directs that the examination must be conducted by a VA psychiatrist or psychologist or a psychiatrist or psychologist with whom VA has contracted. As such, entitlement to service connection for PTSD cannot be established without a VA PTSD examination. Further, although the private opinion suggested a worsening in the service-connected psychiatric disability, the clinician attributed the symptomology to PTSD. As such, a new VA psychiatric examination is needed to determine whether the service-connected disability itself has worsened.

Although the Veteran's correct contact information was included on the examination scheduling request form, it is unclear from the claims file whether he was successfully contacted about the scheduled examinations. Further, given the service-connected disability and the claimed PTSD and the nature of psychiatric symptomology, it is unclear why the VA psychiatric examination was cancelled by the AOJ prior to the appointment. Given this lack of clarity, more information was needed prior to issuing the rating decision on appeal. The failure to obtain such information or to just reschedule the examinations constitutes a pre-decisional duty to assist error which should be corrected upon remand.

Accordingly, a VA PTSD examination and a new VA psychiatric examination should be scheduled upon remand.

The matters are REMANDED for the following action:

1. Schedule the Veteran for both VA PTSD and mental disorders examinations from an appropriate clinician(s). The Veteran should be advised of the importance of attending the examinations to support his claims - all attempts to contact him regarding the examinations should be documented in the claims file. The claims folder should be made available to and be reviewed by the examiner. All indicated tests and studies should be performed. Following a review of the record, the examiner is asked to:

(a.) Determine whether the Veteran currently has, or has had at any point during the appeal period, a diagnosis of PTSD meeting the DSM-V criteria.

(b.) Determine whether the Veteran's claimed PTSD is at least as likely as not (likelihood is at least approximately
following action:

(a.) Determine whether the Veteran currently has, or has had at any point during the appeal period, a diagnosis of PTSD meeting the DSM-V criteria.

(b.) Determine whether the Veteran's claimed PTSD is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) etiologically related to his active service, to include his identified stressors.

(c.) To the extent possible, differentiate which psychiatric symptomology is attributable to service-connected adjustment disorder with depressed mood and which is attributable to PTSD, if diagnosed. The examiner is also asked to fully describe the practical effects caused by service-connected adjustment disorder with depressed mood, including the effect of his disability on his occupational and daily functioning.

(d.) In considering any lay statements of record, the examiner should note that the Veteran is competent to attest to matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation.

(e.) If medical literature is relied upon, the examiner should identify and specifically cite each reference material used and discuss how it relates to the Veteran's particular medical history. The examiner should specifically discuss any contradictory evidence in the claims file and reconcile that evidence with their findings.

(f.) All opinions should be accompanied by supporting rationale explaining how the examiner arrived at the conclusions expressed.

(g.) If the examiner determines that s/he cannot provide an opinion without resorting to speculation, s/he should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion.

2. After the above development, and any additionally indicated development, has been completed, readjudicate the claims.

SHEREEN M. MARCUS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Rachel E. Jensen, 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.

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