FACIAL NERVE (VII CRANIAL NERVE) PARALYSIS

JENNIFER WHITE · 2025 · Case ID: A25107837

MIXED

Summary

The Veteran served in the Army from February 1998 to October 2003, with service at Fort McClellan and deployments to Kuwait and Uzbekistan. The Veteran appeals the denial of service connection for pulmonary nodules and obstructive sleep apnea, and seeks an increased rating for irritable bowel syndrome (IBS) and allergic rhinitis. Service connection for facial numbness was granted. The Board found the evidence weighed against a diagnosis of obstructive sleep apnea and that the criteria for an increased rating for IBS and an initial rating for sinusitis were not met. The Veteran is a Persian Gulf Veteran, and the Board found the evidence in approximate balance regarding pulmonary nodules as a medically unexplained chronic multisymptom illness, granting service connection. Several issues, including PTSD, right arm disability, left eye optic neuritis, heart disability, alopecia/hair loss, anemia, Gulf War Syndrome, hypogammaglobulinemia, liver disability, psoriasis, vertigo, hemorrhoids, and left/right upper extremity paresthesia, were either not properly before the Board or remanded for further development. The remand instructions specifically address the Veteran's claims of toxic risk exposure activity (TERA) at Fort McClellan and other locations, noting the AOJ's failure to research or consider these claims and the Veteran's specific statements about chemical spills and other exposures. The Board also noted a failure to consider whether alopecia began during service and to address specific TERA exposures.

Rationale

Criteria for service connection met; Facial numbness granted

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

240916-473430

Full Decision Text

Citation Nr: A25107837
Decision Date: 12/15/25 Archive Date: 12/15/25

DOCKET NO. 240916-473430
DATE: December 15, 2025

ORDER

Entitlement to service connection for facial numbness is granted.

Entitlement to service connection for pulmonary nodules is granted.

Entitlement to service connection for obstructive sleep apnea is denied.

Entitlement to a rating in excess of 30 percent for irritable bowel syndrome (IBS) is denied.

Entitlement to an initial compensable rating for chronic sinusitis is denied.

REMANDED

Entitlement to service connection for alopecia/hair loss is remanded.

Entitlement to service connection for anemia is remanded.

Entitlement to service connection for Gulf War Syndrome is remanded.

Entitlement to service connection for hypogammaglobulinemia is remanded.

Entitlement to service connection for a liver disability is remanded.

Entitlement to service connection for psoriasis is remanded.

Entitlement to service connection for vertigo (claimed as dizziness) remanded.

Entitlement to an increased rating for hemorrhoids is remanded.

Entitlement to an increased rating for left upper extremity paresthesia is remanded.

Entitlement to an increased rating for right upper extremity paresthesia is remanded.

Entitlement to an increased rating for allergic rhinitis is remanded.

FINDINGS OF FACT

1. The Board adopts the favorable findings in the November 2024 and August 2025 rating decisions which granted entitlement to service connection for facial numbness.

2. The Veteran is a Persian Gulf Veteran, and the evidence is at least in approximate balance that her left lung pulmonary nodules are a medically unexplained chronic multisymptom illness.

3. The evidence of record during the relevant period weighs persuasively against a fining that the Veteran has a diagnosis of obstructive sleep apnea.

4. The Veteran is in receipt of the highest schedular rating for IBS during the entire period on appeal.

5. The evidence of record during the relevant weighs persuasively against a finding that the Veteran's sinusitis is manifested by one or more incapacitating episodes (as defined by VA regulation) of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment; three or more non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting; radical surgery with chronic osteomyelitis; or near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries.

CONCLUSIONS OF LAW

1. The criteria for the establishment of service connection for facial numbness are met. 38?U.S.C. §§ 1110, 5107; 38 C.F.R. §§?3.102, 3.303.

2. The criteria for the establishment of service connection for pulmonary nodules have been met. 38?U.S.C. §§ 1110, 5107; 38 C.F.R. §§?3.102, 3.303, 3.317.

3. The criteria for the establishment of service connection for obstructive sleep apnea have not been met. 38?U.S.C. §§ 1110, 5107; 38 C.F.R. §§?3.102, 3.303.

4. The criteria for the establishment of an initial rating in excess of 30 percent for irritable bowel syndrome have not been met. 38?U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7319.

5. The criteria for the establishment of an initial compensable rating for sinusitis have not been met. 38?U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.97, Diagnostic Code 6513.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had confirmed service from February 1998 to October 2003.

This case comes before the Board of Veterans' Appeals (Board) on appeal from March 2024 (service connection for vertigo), April 2024 (an increased rating for IBS), and two separate September 2024 (remaining claims on appeal) rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO).

In the September 2024, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the direct review docket. Therefore, the Board
, 4.97, Diagnostic Code 6513.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had confirmed service from February 1998 to October 2003.

In the September 2024, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the direct review docket. Therefore, the Board may only consider the evidence of record at the time of the March 2024, April 2024, and September 2024 Agency of Original Jurisdiction (AOJ) decisions on appeal with respect to the issues decided in those decisions. 38 C.F.R. § 20.301. If evidence was submitted after the AOJ issued the decision on appeal, the Board did not consider it in its decision. Id.

Initially, the Board notes that it is acknowledging the Veteran's Appeals Modernization Act (AMA) elections in the Veteran's September 2024 VA Form 10182. Here, there are several claims and rating decisions the Veteran has identified which are not valid, and therefore, as outlined below, are not before the Board.

First, in her September 2024 VA Form 10182, the Veteran disagreed with the decisions for the claims for posttraumatic stress disorder (PTSD) and a right arm disability and identified the November 2022 rating decision as the decision on appeal. These issues were last denied by the AOJ in November 2022. In May 2024, CAVC issued its decision in Ferko v. McDonough, 137 Vet. App. 262, holding that the one-year deadline to file an NOD is not a jurisdictional bar to Board review, but a mandatory claims-processing rule. In this case, the Veteran has failed to follow the claims processing rules with regard to the issues of service connection for PTSD and a right arm disability, specifically the general timeliness requirement of 38 U.S.C. § 7105(b); and has failed to provide any basis upon which this requirement should be waived, to include good cause for an extension of the time limit under 38 C.F.R. § 3.109(b). Further, the Board finds that the claims processing rules were not waived in this case. Although the Veteran was sent a letter docketing the appeal generally in the AMA, the Board's mere administrative docketing of a claim does not demonstrate acceptance of said claim or specific issues identified therein or waiver of a claims processing rule. Thus, the Board will not adjudicate the issues of entitlement to service connection for PTSD and a right arm disability herein.

Next, in her September 2024 VA Form 10182, the Veteran identified claims for left eye optic neuritis and a heart disability (pulmonic mitral tricuspid valve regurgitation) and identified the April 2024 rating decision as the decision on appeal. Here, however, the Veteran filed an April 2024 Higher Level Review with that rating decision, a subsequent April 2024 rating decision identified duty to assist errors (but did not adjudicate these claims), and they were readjudicated in a November 12, 2024, rating decision (left optic neuritis), and a November 27, 2024, rating decision (heart disability). As the Veteran's claims for higher-level review were pending at the time she filed the VA Form 10182, these claims are not properly before the Board.

Additionally, in the September 2024 VA Form 10182, the Veteran identified the issues of an earlier effective date for the grant of service connection for urticaria and an increased rating for urticaria and identified the March 2024 rating decision. At the time VA received the September 2024 VA Form 10182, the Veteran had already filed an April 2024 VA Form 10182 (which also elected the direct docket), and therefore, since there was already a valid VA Form 10182 pending, the September 2024 VA Form 10182 is invalid with respect to these issues. Of note, the Board decided these issues in a May 2025 decision.

The Board notes that the AOJ requested the Veteran submit any relevant private treatment records or submit information with which VA can assist the Veteran in obtaining private treatment records. Required notice and information were provided in the claim form which the Veteran signed, certifying to the fact that such notice was received and further that they have included or identified relevant evidence. VA requested records for which the Veteran submitted a proper release and/or adequately identified. The duty to assist is not a one-way street. If a Veteran desires help, she cannot passively wait for it in those circumstances where she may or should have information that is essential in obtaining evidence. Wood v. Derwinski, 1 Vet. App. 190 (1991). Thus, the Board finds that VA has satisfied the duty to assist. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002).

The standard set forth in 38 C.F.R. § 3.103(c)(2)(iii) only permits constructive receipt of Veterans Health Administration (VHA) records that not only existed prior to the issuance of the AOJ decision on appeal, but also for which the claimant furnished sufficient information to make the Veterans Benefits Administration (VBA) aware of the existence of those records. Thus, the Board's consideration of VHA records is limited to the same. Here, the Board finds that VA treatment records were obtained and reviewed consistent with 38 C.F.R. § 3.103(c)(2)(iii) and the AMA framework.

38 C.F.R. § 3.103 provides that a Veteran, upon request, is entitled to a hearing prior to VA's adjudication of an initial or supplemental claim. The Board observes that notice regarding the opportunity for a hearing at the AOJ was not provided in this case. In Bowen, the Court found that there was no due process violation in the denial of the Veteran's requested hearing before the AOJ because the Veteran had subsequently been offered the opportunity to have a hearing before the Board. Bowen v. Shinseki, 25 Vet. App. 250, 253 (2012). Here, the Veteran was offered a choice of three dockets in the AMA framework to include the Board hearing docket. Although the issue in Bowen was not one of notice, the Board cannot discern a basis to find that the underlying holding and logic of Bowen would not lead to the same finding of a lack of prejudicial error under the procedure and facts of this case.

Service Connection Claims

Service connection may be established for disability due to a disease or injury that was incurred in or aggravated by active military service.? 38?U.S.C. §§?1110, 1131; 38?C.F.R. §?3.303.? Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.? 38?C.F.R. §?3.303(d).??????

In general, in order to prevail on the issue of service connection the evidence 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.? Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

In the absence of proof of a current disability, there can be no valid claim for service connection.? Brammer?v. Derwinski,?3?Vet. App.?223, 225?(1992).? The requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim... even though the disability resolves prior to the Secretary's adjudication of the claim."? McClain?v. Nicholson,?21?Vet. App.?319, 321?(2007).

Facial Numbness

In a June 2022
3, 1167 (Fed. Cir. 2004).

Facial Numbness

In a June 2022 Fully Developed Claim (FDC), the Veteran claimed service connection for, in pertinent part, numbness of the head.

In November 2024 and August 2025 rating decisions, the AOJ found the criteria for the establishment of service connection for paresthesia of the face were met and granted the claims.? Thus, the Board grants the instant claim, acknowledging any favorable findings in the November 2024 and August 2025 rating decisions which are binding on the Board in the absence of clear and unmistakable error.

Pulmonary Nodules

In her December 2023 FDC, the Veteran is claiming service connection for a lung nodule.

The record contains an August 2024 opinion indicating that a September 2022 chest CT scan shows the Veteran had a pleural based nodule in the left lung, and the examiner indicated that the etiology of this condition is not known.

Thus, given that this is a diagnosed illness without a conclusive etiology, the Board finds it is a medically unexplained chronic multisymptom illness and, given that the Veteran is a Persian Gulf Veteran, service connection must be granted pursuant to 38 C.F.R. 3.317.

Obstructive Sleep Apnea

In her October 2024 FDC, the Veteran is claiming service connection for obstructive sleep apnea (OSA), which she believes is secondary to asthma.

In the September 2024 rating decision on appeal, the AOJ made a favorable finding that the Veteran had TERA participation during service. This favorable finding is binding on VA unless rebutted by evidence that identifies a clear and unmistakable error in the favorable finding. 38 C.F.R. 3.104(c).

An October 2023 VA War Related Illness and Injury Study Center (WRIISC) note reflects the Veteran indicated she was prescribed medication for sleep which worked temporarily then decreased effectiveness and stopped; she stated she now used Temazepam to assist with sleep. She reported inconsistent sleep, indicating that four to five out of seven nights she had decent sleep, for eight to nine hours at best, otherwise with two hours of bad sleep. The Veteran also reported breathing problems at that assessment. In documenting the Veteran's past medical history, the examiner documents: "OSA ? mild; no CPAP being used or prescribed at present," and indicates she should consider establishing service connection for, among other disabilities, OSA.

An active problem list from her local VA Medical Center printed in January 2024 contains an assessment of OSA syndrome and the diagnosing physician is the same one who conducted the October 2023 VA WRIISC evaluation.

A February 2024 examination report reveals that a review of the record did not reveal any objective evidence of a sleep condition. A February 2024 home sleep study was negative for any OSA.

Based on the foregoing, the Board finds the claim for OSA must be denied as the evidence of record during the relevant period weighs persuasively against a finding that the Veteran has a diagnosis of OSA. Significantly, the February 2024 sleep study revealed no diagnosis of OSA and the February 2024 examiner did not find any objective reports of sleep apnea symptoms in the record. Although an October 2023 examiner provided a questionable diagnosis of OSA, and OSA is listed as on the Veteran's active problem list in January 2024, there is no indication that any sleep study was performed to render such a diagnosis in either October 2023 or January 2024 (or any time prior to then). Rather, a February 2024 diagnostic test specifically designed to test for the presence or absence of OSA revealed no diagnosis, and the Board finds this official diagnostic testing to be more probative than the October 2023 assessment (also transcribed in the January 2024 problem list), which was not based on diagnostic testing.

Further, while the Veteran is competent to report problems with breathing or sleep, she has not been shown to have the experience, training, or education necessary to provide a medical diagnosis of OSA. Although lay persons are competent to provide opinions on
there is no indication that any sleep study was performed to render such a diagnosis in either October 2023 or January 2024 (or any time prior to then). Rather, a February 2024 diagnostic test specifically designed to test for the presence or absence of OSA revealed no diagnosis, and the Board finds this official diagnostic testing to be more probative than the October 2023 assessment (also transcribed in the January 2024 problem list), which was not based on diagnostic testing.

Further, while the Veteran is competent to report problems with breathing or sleep, she has not been shown to have the experience, training, or education necessary to provide a medical diagnosis of OSA. Although lay persons are competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative diagnosis as to the specific issue in this case in light of the education and training necessary to make a finding with regard to the complexities of the medical field in general, specifically as it pertains to sleep medicine, pulmonology, otolaryngology, and other associated specialty fields.

Moreover, to the extent the Veteran has claimed difficulty with sleep and breathing, the Board notes that her difficulty with sleep is already contemplated in the rating for her service-connected acquired psychiatric disorder, and difficulty breathing is already contemplated in the rating for her service-connected asthma.

Absent a current diagnosis of OSA or another sleep disorder not already encompassed by a service-connected disability, the claim must be denied.

Increased Rating Claims

Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule).? 38?C.F.R. Part 4.? The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service.? The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38?U.S.C. §?1155; 38?C.F.R. §?4.1.? Where there is a question as to which of two ratings shall be applied, the higher rating 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.? When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant.? 38?C.F.R. §?4.3.????

Irritable Bowel Syndrome (IBS)

The Veteran's IBS is rated as 30 percent disabling since July 27, 2020, under Diagnostic Code 7319. She has continuously pursued this claim, and therefore, the Board will consider whether an initial compensable rating is warranted beginning June 27, 2020.

At a January 2023 examination, the Veteran reported diarrhea (frequent loose stools), abdominal distention (frequent bloating), and frequent nausea. At a February 2024 examination, the Veteran reported alternating diarrhea and constipation, abdominal distention (bloating), and intermittent episodes of nausea. At both examinations, the examiners described the frequency of the Veteran's episodes of bowel disturbance with abdominal distress as more or less constant abdominal distress. Both examiners found the Veteran did not have weight loss attributable to an intestinal condition; did not have malnutrition, serious complications, or other general health effects attributable to the intestinal condition; and that the Veteran did not have a benign or malignant neoplasm or metastases related to her IBS. Both examiners also found the Veteran did not have any other pertinent physical findings, complications, conditions, signs or symptoms related to her IBS.

Diagnostic Code 7319, which specifically contemplates IBS, provides a maximum 30 percent rating for this disability. See 38 C.F.R. 4.114.

As the Veteran is already in receipt of the highest schedular rating for IBS, the claim must be denied.

Sinusitis

In an April 2024 rating decision, the AOJ granted service connection for chronic sinusitis and assigned a noncompensable rating effective December 4, 2022. The Veteran has continuously pursued this claim, and therefore, the Board will consider whether an initial compensable rating is warranted beginning December 4, 2022.

Sinusitis

Diagnostic Code 6513 contemplates chronic maxillary sinusitis and directs the adjudicator to rate this disability under the General Rating Formula for Sinusitis. 38 C.F.R. § 4.97. Under this diagnostic code, a noncompensable rating is warranted when sinusitis is detected by x-ray only. Id. A 10 percent rating is warranted when there are one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. Id. A 30 percent rating is warranted when there are three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. Id. The maximum 50 percent rating is warranted following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. Id. A note following this rating formula indicates that an incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. Id.

At a January 2024 examination, the Veteran reported nasal congestion, nasal drainage, and cough, and the examiner diagnosed allergic rhinitis and sinusitis. The Veteran did not report taking any antibiotics for his sinusitis. The examiner indicated the Veteran's findings, signs, and symptoms attributable to chronic sinusitis were episodes of sinusitis, headaches, pain of affected sinus, and tenderness of affected sinus. The examiner found the Veteran had two non-incapacitating episodes of sinusitis (characterized by headaches, pain, and purulent discharge or crusting) in the past twelve months and no incapacitating episodes of sinusitis requiring prolonged (four to six weeks) of antibiotic treatment in the past twelve months. The examiner indicated the Veteran had not had any sinus surgery.

Following a review of the evidence of record during the relevant period, the Board finds it weighs persuasively against a finding that the Veteran's is manifested by one or more incapacitating episodes (as defined by VA regulation) of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment; three or more non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting; radical surgery with chronic osteomyelitis; or near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries.

Based on the foregoing, an initial compensable rating for chronic sinusitis is not warranted, and the claim must be denied.

REASONS FOR REMAND

The matters are REMANDED for the following action:

BACKGROUND INFORMATION FOR REGIONAL OFFICE (RO) ADJUDICATOR:

" All Remanded Service Connection Claims: In a January 2019 statement and in her June 2022 FDCs, the Veteran states, in pertinent part, she had toxic risk exposure activity (TERA) participation while stationed at Fort McClellan from February 1998 to June 1998; she indicates there were "massive chemical spills and leaks" there and cites to internet sources which she states reference toxic spills. The Veteran's personnel records confirm her service at Fort McClellan from February 1998 to June 1998. The Board recognizes that VA has acknowledged that veterans who served at Fort McClellan had potential exposure to hazardous materials. In an October 2025 claim, the Veteran states she believes she was exposed to radiation, mustard gas, asbestos, yellow cake uranium, cyanide, arsenic, Agent Orange, Agent Blue, and jet fuel.

The record contains, in pertinent part, a November 2025 TERA memorandum which reflects the Veteran had TERA participation while stationed in Kuwait from April 2003 to July 2003. The record also contains, in pertinent part, a September 2025 Individualized Longitudinal Exposure Report (ILER) which indicates the Veteran had TERA participation in Kuwait and at "Stronghold Freedom," which the Board takes notice is another name for Karshi-Khanabad Air Base (a former base in Uzbek
. In an October 2025 claim, the Veteran states she believes she was exposed to radiation, mustard gas, asbestos, yellow cake uranium, cyanide, arsenic, Agent Orange, Agent Blue, and jet fuel.

The record contains, in pertinent part, a November 2025 TERA memorandum which reflects the Veteran had TERA participation while stationed in Kuwait from April 2003 to July 2003. The record also contains, in pertinent part, a September 2025 Individualized Longitudinal Exposure Report (ILER) which indicates the Veteran had TERA participation in Kuwait and at "Stronghold Freedom," which the Board takes notice is another name for Karshi-Khanabad Air Base (a former base in Uzbekistan), also known as "K-2." Of note, her Form DD-215 reflects she had service in Uzbekistan and Pakistan from October 2001 to May 2002, and a Form DD-215 (correcting the Form DD-214) reflects she had six months and fourteen days of foreign service.

There is no indication the AOJ has researched/considered the Veteran's statements and conducted any development to determine whether she had TERA participation at Fort McClellan. Moreover, while the above-referenced TERA development indicates that she had some of the exposures referenced in her October 2025 claim, as noted in the September 2025 ILER, there is no indication the AOJ has researched/considered her statements regarding additional claimed exposures. Of note, the Veteran's Form DD-214 shows her military occupational specialty was a Chemical Operations Specialist. This is both a remand to correct a pre-decisional duty to assist error and a remand to correct an error by the AOJ in satisfying a regulatory or statutory duty.

" Alopecia/Hair Loss: In her June 2022 FDC, the Veteran is claiming she has alopecia/hair loss due to exposure to chemicals and burn pits during service and is also claiming it is secondary to her service-connected urticaria. The record contains a July 2023 opinion which considers her TERA participation, yet this opinion does not consider whether her alopecia began during service, specifically failing to consider her June 2024 statement that she began to lose "a ton of hair" while stationed at Karshi-Khanabad Air Base. Further, while the record contains an April 2024 opinion finding the Veteran's alopecia is not caused by her service-connected urticaria, there is no opinion considering aggravation. This is a remand to correct pre-decisional duty to assist errors.

" Anemia: In her November 2021 FDC, the Veteran is claiming service connection for pernicious anemia. In March 2024, the Veteran claims her anemia is secondary to her intestinal disease (her service-connected IBS); while the record contains a May 2024 opinion finding it is not caused by IBS, and there is no opinion of record considering aggravation. This is a remand to correct a pre-decisional duty to assist error.

" Gulf War Syndrome (GWS): In her December 2023 FDC, the Veteran is claiming service connection for GWS and states she was diagnosed by WRIISC (which is VA's War Related Illness & Injury Study Center). Private records dated February 2023 reflect the Veteran reported daily muscle spasms and cramps which were worse when sitting; the examiner noted she was mentioning Parkinsonian symptoms (tremor, decreased arm swing, bradykinesia) and that she did not have rigidity or tremor on examination but did have decreased right arm swing. An August 2023 private record reflects a diagnosis of "cramp and spasm" and indicates the Veteran was referred to WRIISC for, in pertinent part, weakness/muscle spasms/cramps. At an October 2023 VA WRIISC appointment, the Veteran reports several symptoms and indicates a private neurologist recommended she be seen by the WRIISC; in pertinent part, the examiner diagnosed GWS and an undiagnosed neuromuscular disorder. The Veteran attended an April 2024 Gulf War examination, and the examiner found no diagnosed illnesses for which no etiology was established. An August 2024 addendum opinion indicates there was no constellation of unexplained symptoms that led the examiner to believe the Veteran has GWS, elaborating that the Veteran's tension headaches, musculoskeletal conditions, and nerve conditions are not undiagnosed or of unknown etiology, the Veteran does not have any diagnosed autoimmune disease, and that facial numbness does not fit the criteria for GWS. These opinions do not reconcile the October 2023 diagnoses of GWS and an undiagnosed neuromuscular disorder
WS and an undiagnosed neuromuscular disorder. The Veteran attended an April 2024 Gulf War examination, and the examiner found no diagnosed illnesses for which no etiology was established. An August 2024 addendum opinion indicates there was no constellation of unexplained symptoms that led the examiner to believe the Veteran has GWS, elaborating that the Veteran's tension headaches, musculoskeletal conditions, and nerve conditions are not undiagnosed or of unknown etiology, the Veteran does not have any diagnosed autoimmune disease, and that facial numbness does not fit the criteria for GWS. These opinions do not reconcile the October 2023 diagnoses of GWS and an undiagnosed neuromuscular disorder and do not appear to consider the reported symptoms of muscle spasms/cramps and Parkinsonian symptoms. A remand is required to correct this pre-decisional duty to assist error.

" Psoriasis: At her August 2023 examination, the Veteran is claiming her psoriasis began in 2003, with dry scaly patches on her hands and feet which would turn into a plaque. While the record contains November 2023 and August 2023 opinions which consider the Veteran's TERA participation, these opinions fail to consider whether her psoriasis began during service. The Board notes that while the Veteran is not competent to diagnose a skin disability, either current or historical, her described symptomatology must be considered in determining any accurate skin diagnoses and the etiology of any skin diagnoses. A remand is required to correct this pre-decisional duty to assist error.

" Vertigo: At a January 2023 ear conditions examination, the Veteran reported that in 2000 she began to experience intermittent vertigo episodes lasting up to a couple minutes which coincided with particular head movements. Service treatment records dated August 2003 reflect that the Veteran complained of dizziness when standing. The record contains a July 2023 opinion finding the Veteran's vertigo was less likely than not related to service, to include TERA participation, yet this opinion does not consider the Veteran's reports of in-service vertigo and her documented August 2003 report of dizziness when standing. A remand is required to correct this pre-decisional duty to assist error.

" Hemorrhoids: In her September 2024 VA Form 10182, the Veteran is claiming an initial increased rating is warranted for her hemorrhoids. At her January 2023 examination, the Veteran reported she used "over the counter hemorrhoid products, laxatives" for her hemorrhoids. It is unclear if this examination report considers the ameliorative effects of medication on the Veteran's hemorrhoids, and therefore, additional opinions are required.? This is a remand to correct a pre-decisional duty to assist error.?

" Left and Right Upper Extremity Paresthesia: In her September 2024 VA Form 10182, the Veteran is claiming an initial increased ratings are warranted for her left and right upper extremity paresthesia. At her April 2024 examination, the Veteran reported she took Lyrica for her left and right upper extremity paresthesia. It is unclear if this examination report considers the ameliorative effects of medication on the Veteran's left and right upper extremity paresthesia, and therefore, additional opinions are required.? This is a remand to correct a pre-decisional duty to assist error.?

" Allergic Rhinitis: In her September 2024 VA Form 10182, the Veteran is claiming an initial increased rating is warranted for her allergic rhinitis. At her January 2024 examination, the Veteran reported she took Benadryl and Atarax for her allergic rhinitis. It is unclear if this examination report considers the ameliorative effects of medication on the Veteran's allergic rhinitis, and therefore, additional opinions are required.? This is a remand to correct a pre-decisional duty to assist error.?

THE REMAND DIRECTIVES FOLLOW.

1. Conduct the necessary development to consider the Veteran's claims regarding TERA participation during her service at Fort McClellan and additional claimed exposures during deployments.

The Board draws the RO's attention, but does not limit it, to the following evidence:

The AOJ's attention is drawn, but not limited to, the following evidence:?

" The Veteran's personnel records show she was stationed at Fort McClellan from February 1998 to June 1998.

" The Veteran's Form DD-214 shows her military occupational specialty was a Chemical Operations Specialist and also shows she had service in Uzbekistan and Pakistan from October 2001 to May 2002. A Form DD-215, correcting the Form DD-214, and
Conduct the necessary development to consider the Veteran's claims regarding TERA participation during her service at Fort McClellan and additional claimed exposures during deployments.

The Board draws the RO's attention, but does not limit it, to the following evidence:

The AOJ's attention is drawn, but not limited to, the following evidence:?

" The Veteran's personnel records show she was stationed at Fort McClellan from February 1998 to June 1998.

" The Veteran's Form DD-214 shows her military occupational specialty was a Chemical Operations Specialist and also shows she had service in Uzbekistan and Pakistan from October 2001 to May 2002. A Form DD-215, correcting the Form DD-214, and a record of proceedings from the Army Board for Correction of Military Records reflects she had six months and fourteen days of foreign service and that she was awarded two medals based on her service in Uzbekistan and Pakistan.

" In a January 2019 statement, the Veteran indicates there were "massive chemical spills and leaks" at Fort McClellan and that she was stationed there right before it closed. She also cites to internet articles which she states reference toxic spills there.

" A December 2022 VA treatment records documents that the Veteran informed her provider that while stationed in Fort McClellan in 1998 that a lawsuit was underway for ground contamination with Agent Orange and nerve agents and that there had been leakage into the soil and water along with PCPs and asbestos.

" A September 2025 ILER indicates the Veteran had TERA participation in Kuwait and at "Stronghold Freedom," which the Board takes notice is another name for Karshi-Khanabad Air Base (a former base in Uzbekistan), also known as "K-2."

" In an October 2025 claim, the Veteran states she believes she was exposed to radiation, mustard gas, yellow cake uranium, cyanide, arsenic, Agent Orange, Agent Blue, jet fuel, and "more" during service.

" A November 2025 TERA memorandum which reflects the Veteran had TERA participation while stationed in Kuwait from April 2003 to July 2003.

2. Following completion of step 1, ensure the Veteran is scheduled for an examination to consider her claim for alopecia/hair loss.

Following an examination and review of the record, provide the following:

(a) Opine as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's alopecia areata (diagnosed at the January 2023 examination) had its onset in, or is otherwise etiologically related to active service to include as due to the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all the Veteran's TERAs during her active service. Why or why not?

The examiner must not only consider the Veteran's TERA participation but must also consider her June 2024 statement that she began to lose "a ton of hair" while stationed at Karshi-Khanabad Air Base.

(b) If not, is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's alopecia areata (diagnosed at the January 2023 examination) is aggravated by her service-connected urticaria. Why or why not?

(c) If aggravation is found, the examiner must describe the baseline level of severity for the alopecia based on medical evidence available prior to aggravation or the earliest medical evidence following aggravation. The examiner should address whether the current severity of the alopecia is greater than the baseline. If the examiner cannot provide a baseline level of severity, the examiner must explain why this is the case.

The examiner must review the entire record in conjunction with rendering the requested opinions.? The examiner's attention is drawn, but not limited to, the following evidence:???

" In her June 2022 FDC, the Veteran suggests she has alopecia/hair which is secondary to her service-connected urticaria. She states the urticaria occurs on her scalp frequently and burns horribly and itches severely, which causes scarring and moderate hair loss.

" At a January 2023 examination, the Veteran reported that around 2000 she started to notice hair loss/thinning. The examiner diagnosed alopecia areata.

" In a June 2024 statement, the Veteran indicated that she started losing "a ton of hair" while stationed at Karshi-Khanabad Air Base.

The Board notes that the claims folder must be provided to and reviewed by the examiner for all post-remand cases per AOJ policy. See VBA Manual M21-1, Part IV.i.2.A.8.b. Thus, the examiner must specifically note that the claims folder
on her scalp frequently and burns horribly and itches severely, which causes scarring and moderate hair loss.

" At a January 2023 examination, the Veteran reported that around 2000 she started to notice hair loss/thinning. The examiner diagnosed alopecia areata.

" In a June 2024 statement, the Veteran indicated that she started losing "a ton of hair" while stationed at Karshi-Khanabad Air Base.

The Board notes that the claims folder must be provided to and reviewed by the examiner for all post-remand cases per AOJ policy. See VBA Manual M21-1, Part IV.i.2.A.8.b. Thus, the examiner must specifically note that the claims folder was received and reviewed in the body of the examination report.

The examiner is informed by the Board that chronicity is not required to find a nexus to service or for service connection to be granted.

The examiner is informed that a positive opinion indicating a nexus to service (or to a service-connected disability) does not require certainty. Rather, if the weight of the evidence is in approximate balance for and against a nexus to service (or a service-connected disability), the examiner should make a determination favorable to the Veteran.

All requested opinions must be supported with a rationale based on generally accepted medical principles and the examiner's medical training and expertise.

3. Following completion of step 1, ensure the Veteran is scheduled for an examination to consider her claim for anemia.

Following an examination and review of the record, provide the following:

(a) Is the Veteran's anemia at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) aggravated by the Veteran's service-connected IBS? Why or why not?

(b) If aggravation is found, the examiner must describe the baseline level of severity for the anemia based on medical evidence available prior to aggravation or the earliest medical evidence following aggravation. The examiner should address whether the current severity of the anemia is greater than the baseline. If the examiner cannot provide a baseline level of severity, the examiner must explain why this is the case.

The examiner must review the entire record in conjunction with rendering the requested opinions.? The examiner's attention is drawn, but not limited to, the following evidence:???

" In her November 2021 FDC, the Veteran is claiming service connection for pernicious anemia, which she states was diagnosed in 2020 or 2021. She states she treats this disability with B-12 injections biweekly and that it has caused nerve damage, facial numbness, dizziness, blurred vision, chronic nausea, and severe chronic pain in both arms.

" In March 2024, the Veteran claims her anemia is secondary to her service-connected intestinal disease (IBS).

The Board notes that the claims folder must be provided to and reviewed by the examiner for all post-remand cases per AOJ policy. See VBA Manual M21-1, Part IV.i.2.A.8.b. Thus, the examiner must specifically note that the claims folder was received and reviewed in the body of the examination report.

The examiner is informed by the Board that chronicity is not required to find a nexus to service or for service connection to be granted.

The examiner is informed that a positive opinion indicating a nexus to service (or to service-connected disability) does not require certainty. Rather, if the weight of the evidence is in approximate balance for and against a nexus to service (or to a service-connected disability), the examiner should make a determination favorable to the Veteran.

All requested opinions must be supported with a rationale based on generally accepted medical principles and the examiner's medical training and expertise.

4. Following completion of step 1, ensure the Veteran is scheduled for an examination to consider her claim for Gulf War Syndrome.

Following an examination and review of the record, provide the following:

(a) Identify any symptomatology that constitutes Gulf War Syndrome in this Veteran. In other words, does the Veteran have an "undiagnosed illness" or, alternatively, a diagnosed illness but the result of a medically unexplained chronic multi-symptom illness (MUCMI) responsible for any symptoms claimed? Why or why not?

" NOTE: an "undiagnosed illness" is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis whereas the term "MUCMI" refers to an illness where either the etiology or the pathophysiology of the illness is inconclusive.

" These determinations must be based on the Veteran's specific case and cannot be based on the etiology of the disease or disability population as a whole.

In providing a response to the above, the examiner must consider, discuss, and (if necessary) reconcile the October 2023 diagnoses of GWS and
unexplained chronic multi-symptom illness (MUCMI) responsible for any symptoms claimed? Why or why not?

" These determinations must be based on the Veteran's specific case and cannot be based on the etiology of the disease or disability population as a whole.

In providing a response to the above, the examiner must consider, discuss, and (if necessary) reconcile the October 2023 diagnoses of GWS and an undiagnosed neuromuscular disorder as well as the Veteran's complaints of muscle spasms/cramps and Parkinsonian symptoms, noted at private February 2023 and August 2023 appointments.

(b) If the Veteran does not have an undiagnosed illness or a diagnosed MUCMI, then with respect to each of the claimed disabilities/set of symptoms the examiner should determine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that such disability/disabilities had its onset in, or is otherwise related to active service, to include as due to the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all the Veteran's TERAs during her active service.? Why or why not?

The examiner must review the entire record in conjunction with rendering the requested opinions.? The examiner's attention is drawn, but not limited to, the following evidence:???

" Private records dated February 2023 reflect the Veteran reported daily muscle spasms and cramps and indicated they were worse when sitting; the examiner noted she was mentioning Parkinsonian symptoms (tremor, decreased arm swing, bradykinesia) and that she did not have rigidity or tremor on examination but did have decreased right arm swing.

" An August 2023 private record reflects a diagnosis of "cramp and spasm" and indicates the Veteran was referred to the War Related Illness and Injury Study Center (WRIISC) for, among other things, weakness/muscle spasms/cramps.

" At an October 2023 VA WRIISC appointment, the Veteran reported several symptoms and indicated a private neurologist recommended she be seen by the WRIISC. The examiner diagnosed, in pertinent part, GWS and an undiagnosed neuromuscular disorder.

The Board notes that the claims folder must be provided to and reviewed by the examiner for all post-remand cases per AOJ policy. See VBA Manual M21-1, Part IV.i.2.A.8.b. Thus, the examiner must specifically note that the claims folder was received and reviewed in the body of the examination report.

The examiner is informed by the Board that chronicity is not required to find a nexus to service or for service connection to be granted.

The examiner is informed that a positive opinion indicating a nexus to service does not require certainty. Rather, if the weight of the evidence is in approximate balance for and against a nexus to service, the examiner should make a determination favorable to the Veteran.

All requested opinions must be supported with a rationale based on generally accepted medical principles and the examiner's medical training and expertise.

5. Following completion of step 1, ensure the Veteran is scheduled for an examination to consider her claim for psoriasis.

Following an examination and review of the record, provide the following:

Opine as to whether is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's psoriasis had its onset in, or is otherwise related to active service, to include as due to the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all the Veteran's TERAs during her active service. Why or why not?

The examiner must consider the Veteran's August 2023 claim that her psoriasis began in 2003.

In doing so, the Board notes that while the Veteran is not competent to diagnose a skin disability, either current or historical, the examiner should take into account the symptomatology described by the Veteran in determining any accurate diagnoses and the etiology of any diagnoses.

The examiner must review the entire record in conjunction with rendering the requested opinions.? The examiner's attention is drawn, but not limited to, the following evidence:???

" In her June 2022 FDC, the Veteran claims her psoriasis began in 2003; she states this disease affects fifty percent of her hands and toenails and that she develops nail psoriasis, which sometimes results in the nails falling off.

" At an August 2023
began in 2003.

The examiner must review the entire record in conjunction with rendering the requested opinions.? The examiner's attention is drawn, but not limited to, the following evidence:???

" At an August 2023 skin examination, the Veteran reported psoriasis since 2003 and stated she started getting dry and scaly patches on her hands and feet which would turn into a plaque. The examiner diagnosed, in pertinent part, psoriasis.

The Board notes that the claims folder must be provided to and reviewed by the examiner for all post-remand cases per AOJ policy. See VBA Manual M21-1, Part IV.i.2.A.8.b. Thus, the examiner must specifically note that the claims folder was received and reviewed in the body of the examination report.

The examiner is informed by the Board that chronicity is not required to find a nexus to service or for service connection to be granted.

All requested opinions must be supported with a rationale based on generally accepted medical principles and the examiner's medical training and expertise.

6. Following completion of step 1, ensure the Veteran is scheduled for an examination to consider her claim for vertigo.

Following an examination and review of the record, provide the following:

(a) Identify any disability manifested by dizziness/vertigo.

The examiner must consider, at minimum, benign paroxysmal positional vertigo, diagnosed at the January 2023 examination.

(b) For all disabilities found, as defined in (a) above, opine as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that such disability/disabilities had its onset in, or is otherwise etiologically related to active service to include as due to the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all the Veteran's TERAs during her active service.? Why or why not?

The examiner must consider and discuss the Veteran's report that in 2000 she began to intermittent vertigo episodes lasting a couple minutes which coincided with particular head movements and the August 2003 in-service complaint of dizziness when standing.

In doing so, the Board notes that while the Veteran is not competent to diagnose vertigo, either current or historical, the examiner should take into account the symptomatology described by the Veteran in determining any accurate diagnoses and the etiology of any diagnoses.

The examiner must review the entire record in conjunction with rendering the requested opinions.? The examiner's attention is drawn, but not limited to, the following evidence:???

" An August 2003 service treatment record documents the Veteran reported dizziness when standing.

" A December 2020 private medical report reflects the Veteran informed her provider she experienced dizziness and difficulty with balance when walking.

" In her November 2021 FDC, the Veteran reported that she experienced dizziness.

" At a January 2023 examination, the Veteran reported she began to notice intermittent vertigo episodes lasting a couple minutes which coincided with particular head movements in 2000. The examiner diagnosed benign paroxysmal positional vertigo.

The Board notes that the claims folder must be provided to and reviewed by the examiner for all post-remand cases per AOJ policy. See VBA Manual M21-1, Part IV.i.2.A.8.b. Thus, the examiner must specifically note that the claims folder was received and reviewed in the body of the examination report.

The examiner is informed by the Board that chronicity is not required to find a nexus to service or for service connection to be granted.

All requested opinions must be supported with a rationale based on generally accepted medical principles and the examiner's medical training and expertise.

7. Obtain an opinion regarding the following from an appropriate examiner for the Veteran's claim for an increased rating for hemorrhoids.

a) Clear
examiner must specifically note that the claims folder was received and reviewed in the body of the examination report.

The examiner is informed by the Board that chronicity is not required to find a nexus to service or for service connection to be granted.

All requested opinions must be supported with a rationale based on generally accepted medical principles and the examiner's medical training and expertise.

7. Obtain an opinion regarding the following from an appropriate examiner for the Veteran's claim for an increased rating for hemorrhoids.

a) Clearly indicate whether any medications (over the counter or prescription) the Veteran used affected the level of severity of her hemorrhoids as of the January 2023 examination.

b) If any such medication was productive of ameliorative effects, clearly identify such effects and opine as to the severity of the hemorrhoids absent such medication as of the January 2023 examination.

The examiner must review the entire record in conjunction with rendering the requested opinions.? The examiner's attention is drawn, but not limited to, the following evidence:???

At her January 2023 examination, the Veteran reported she used "over the counter hemorrhoid products, laxatives" for her hemorrhoids.

The Board notes that the claims folder must be provided to and reviewed by the examiner for all post-remand cases per AOJ policy. See VBA Manual M21-1, Part IV.i.2.A.8.b. Thus, the examiner must specifically note that the claims folder was received and reviewed in the body of the examination report.

8. Obtain an opinion regarding the following from an appropriate examiner for the Veteran's claim for an increased rating for left and right upper extremity paresthesia.

a) Clearly indicate whether any medications (over the counter or prescription) the Veteran used affected the level of severity of her left and right upper extremity paresthesia as of the April 2024 examination.

b) If any such medication was productive of ameliorative effects, clearly identify such effects and opine as to the severity of the left and right upper extremity paresthesia absent such medication as of the April 2024 examination.

The examiner must review the entire record in conjunction with rendering the requested opinions.? The examiner's attention is drawn, but not limited to, the following evidence:???

At her April 2024 peripheral nerves examination, the Veteran reported she took Lyrica for her left and right upper extremity paresthesia.

The Board notes that the claims folder must be provided to and reviewed by the examiner for all post-remand cases per AOJ policy. See VBA Manual M21-1, Part IV.i.2.A.8.b. Thus, the examiner must specifically note that the claims folder was received and reviewed in the body of the examination report.

9. Obtain an opinion regarding the following from an appropriate examiner for the Veteran's claim for an increased rating for allergic rhinitis.

a) Clearly indicate whether any medications (over the counter or prescription) the Veteran used affected the level of severity of her allergic rhinitis as of the January 2024 examination.

b) If any such medication was productive of ameliorative effects, clearly identify such effects and opine as to the severity of the allergic rhinitis absent such medication as of the January 2024 examination.

The examiner must review the entire record in conjunction with rendering the requested opinions.? The examiner's attention is drawn, but not limited to, the following evidence:???

At her January 2024 examination, the Veteran reported she took Benadryl and Atarax for her allergic rhinitis.

The Board notes that the claims folder must be provided to and reviewed by the examiner for all post-remand cases per AOJ policy. See VBA Manual M21-1, Part IV.i.2.A.8.b. Thus, the examiner must specifically note that the claims folder was received and reviewed in the body of the examination report.

10. Readjudicate.

Jennifer White

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board J. O'Connell

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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