BIPOLAR DISORDER (MANIC-DEPRESSIVE PSYCHOSIS)

MICHAEL A. HERMAN · 2026 · Case ID: A26036887

MIXED

Summary

The Veteran served in the Army from January 2003 to March 2004, with additional service in the Army National Guard. He appeals a May 2023 rating decision that granted service connection for allergic rhinitis but denied claims for bipolar I disorder, functional gastrointestinal disorder (claimed as irritable bowel syndrome), chronic fatigue syndrome, bilateral knee conditions, and chronic sinusitis. The Board granted service connection for bipolar I disorder, finding the evidence in approximate balance and resolving doubt in the Veteran's favor, noting the private opinion's link to service-connected PTSD and the inadequacy of the VA examiner's negative opinion. The Board also granted service connection for a functional gastrointestinal disorder, finding the Veteran had objective indications of diarrhea during service and that the evidence was in approximate balance, despite the VA examiner's negative opinion and the chiropractor's limited competence. The claim for chronic fatigue syndrome was denied, as the Veteran did not meet the diagnostic criteria and the private opinion was found unpersuasive due to lack of competence and diagnostic rigor. The Board granted service connection for bilateral knee conditions, finding the Veteran's competent testimony of ongoing pain since service, combined with a favorable private opinion (despite chiropractor limitations), tipped the balance in his favor. The claim for chronic sinusitis was denied due to lack of diagnosis and unpersuasive private opinion. The Board remanded claims for a bilateral leg neurological disorder, diabetes mellitus type II, and hypertension due to inadequate VA examinations and opinions, requiring further development and clarification on nexus and aggravation.

Rationale

Favorable private medical opinion linking bipolar disorder to military experiences; Inadequate VA examiner opinion; Evidence in approximate balance, resolved in Veteran's favor

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

231205-400954

Full Decision Text

Citation Nr: A26036887
Decision Date: 04/21/26 Archive Date: 04/21/26

DOCKET NO. 231205-400954
DATE: April 21, 2026

ORDER

Entitlement to service connection for bipolar I disorder is granted.

Entitlement to service connection for a functional gastrointestinal disorder is granted.

Entitlement to service connection for chronic fatigue syndrome is denied.

Entitlement to service connection for left knee joint arthritis and meniscal tear with chondromalacia is granted.

Entitlement to service connection for right knee joint osteoarthritis and derangement is granted.

Entitlement to service connection for chronic sinusitis is denied.

Entitlement to an initial rating in excess of 30 percent for allergic rhinitis is denied.

REMANDED

Entitlement to service connection for a bilateral leg neurological disorder is remanded.

Entitlement to service connection for diabetes mellitus, type II is remanded.

Entitlement to service connection for hypertension is remanded.

FINDINGS OF FACT

1. The Veteran's favor bipolar I disorder was caused by his active military service.

2. The Veteran's has a functional gastrointestinal disorder that is presumptively related to his participation in toxic exposure risk activities (TERAs) during his service in Southwest Asia during the Persian Gulf War.

3. The evidence persuasively weighs against finding that the Veteran has had a diagnosis of chronic fatigue syndrome at any time during or approximate to the pendency of the claim.

4. The Veteran's left knee joint arthritis and meniscal tear with chondromalacia began during or is causally related to his active service.

5. The Veteran's right knee joint osteoarthritis and derangement began during or is causally related to his active service.

6. The evidence persuasively weighs against finding that the Veteran has had a diagnosis of chronic sinusitis at any time during or approximate to the pendency of the claim.

7. Throughout the entire appeal period, the Veteran's allergic rhinitis has been assigned a 30 percent rating, which is the maximum evaluation authorized under Diagnostic Code 6522.

CONCLUSIONS OF LAW

1. The criteria for service connection for bipolar I disorder have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.125.

2. The criteria for service connection for a functional gastrointestinal disorder have been met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.303, 3.317.

3. The criteria for service connection for chronic fatigue syndrome have not been met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.303, 3.317, 4.88a.

4. The criteria for service connection for left knee joint arthritis and meniscal tear with chondromalacia have been met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.317.

5. The criteria for service connection for right knee joint osteoarthritis and derangement have been met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.317.

6. The criteria for service connection for chronic sinusitis have not been met. 38 U.S.C. §§ 1110, 1119, 1120, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.320.

7. The criteria for an initial rating in excess of 30 percent for allergic rhinitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.97, Diagnostic Code 6522.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active military service from January 2003 to March 2004 with additional service in the Army National Guard of Florida.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active military service from January 2003 to March 2004 with additional service in the Army National Guard of Florida.

This appeal comes to the Board of Veterans' Appeals (the Board) following a May 2023 rating decision. In this decision, the Agency of Original Jurisdiction (AOJ) granted service connection for allergic rhinitis and assigned a 30 percent rating from August 10, 2022. The AOJ denied entitlement to service connection for bipolar I disorder, irritable bowel syndrome, chronic fatigue syndrome, a left knee disorder, a right knee disorder, chronic sinusitis, left and right lower extremity restless leg syndrome, diabetes mellitus, type II, and hypertension. The Veteran appealed the May 2023 decision by filing a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) on December 5, 2023. He elected the Evidence Submission docket.

Therefore, the Board may only consider the evidence of record at the time of the May 2023 AOJ decision on appeal, as well as any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the VA Form 10182 (i.e., March 4, 2024). 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182 or (2) more than 90 days following the date the Board received the VA Form 10182 (i.e., after March 4, 2024), the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801.

Evidence of record specifically identified by the Veteran within 90 days from receipt of the VA Form 10182 is likewise considered "submitted" during the evidence submission window. See Cash v. Collins, 2026 U.S. App. LEXIS 3596, 2026 LX 94368, 166 F.4th 1046 (Fed. Cir., Feb. 5, 2026).

If the Veteran would like the Department of Veterans Affairs (VA) to consider any evidence that was submitted that the Board could not consider, he may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. 38 C.F.R. § 3.2501. Specific instructions for filing a Supplemental Claim are included with this decision.

However, because the Board is remanding the claims for entitlement to service connection for a bilateral leg neurological disorder, diabetes mellitus, type II, and hypertension, any evidence that the Board could not consider will be considered by the AOJ in the adjudication of that claim. 38 C.F.R. § 3.103(c)(2)(ii).

Service Connection

Eligibility for VA benefits, such as service connection, is governed by statutory and regulatory law which defines an individual's legal status as a veteran of active military, naval, or air service. 38 U.S.C. §§ 101(2), 101(24); 38 C.F.R. §§ 3.1, 3.6.

Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury in the line of duty. 38 U.S.C. § 101(24); 38 C.F.R. § 3.6(a). ACDUTRA is full-time duty in the Armed Forces performed by Reserves for training purposes or by members of the National Guard of any state. 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(c).

Active military, naval, or air service also includes any period of inactive duty for training (INACDUTRA) during which the individual concerned was disabled or died from injury incurred or aggravated in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebral vascular accident occurring during such training. 38 U.S.C. § 101(24); 38 C.F.R. § 3.6(d).
(a). ACDUTRA is full-time duty in the Armed Forces performed by Reserves for training purposes or by members of the National Guard of any state. 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(c).

INACDUTRA means duty other than full-time duty prescribed for Reserves or the National Guard of any state. 38 U.S.C. § 101(23); 38 C.F.R. § 3.6(d).

National Guard duty is different from other Reserve service in that a member of the National Guard may be called to duty by the Governor of their state. Members of the National Guard only serve the Federal military when they are formally called into the military service of the United States. At all other times, National Guard members serve solely as members of the State militia under the command of a state governor. Allen v. Nicholson, 21 Vet. App. 54, 57 (2007). Therefore, to have basic eligibility for Veterans' benefits based on a period of duty as a member of a state National Guard, a National Guard servicemember must have: (1) been ordered into Federal service by the President of the United States; (2) performed "full-time duty" under the provisions of 32 U.S.C. §§ 316, 502, 503, 504, or 505; or (3) ordered to ACDUTRA under 10 U.S.C. § 12301(d). See 10 U.S.C. § 12401.

Put differently, when a claim is based on a period of Reserve or National Guard service, it must be shown that the individual concerned became disabled as a result of disease or injury incurred or aggravated in the line of duty on ACDUTRA, became disabled as a result of injury incurred or aggravated in the line of duty on INACDUTRA, or became disabled as a result of injury or disease incurred or aggravated during Federalized National Guard service. In the absence of such evidence, the period would not qualify as "active military, naval, or air service," and the claimant would not achieve veteran status for purposes of that claim. See 38 U.S.C. § 101(2)-(24).

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge when the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d).

Applicable law holds that presumptions pertaining to chronic diseases, soundness, and aggravation do not attach to periods of ACDUTRA and INACDUTRA when veteran status has not previously been established for the same period. See Smith v. Shinseki, 24 Vet. App. 40, 47 (2010) (holding that "a claimant whose claim is based on a period of active duty for training can never be entitled to the presumption of service connection"); see also Paulson v. Brown, 7 Vet. App. 466, 470-71 (1995) (noting that the Board did not err in not applying the presumptions of soundness and aggravation to a veteran's claim where he served only on ACDUTRA and had not established any service-connected disabilities from that period).

Certain chronic diseases are subject to presumptive service connection if they manifest to a compensable degree within one year of separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3
. Brown, 7 Vet. App. 466, 470-71 (1995) (noting that the Board did not err in not applying the presumptions of soundness and aggravation to a veteran's claim where he served only on ACDUTRA and had not established any service-connected disabilities from that period).

Certain chronic diseases are subject to presumptive service connection if they manifest to a compensable degree within one year of separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden elements is through a demonstration of continuity of symptomatology if the claimed disability qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 780 F.3d 1331, 1336 (Fed. Cir. 2013).

Service connection may be granted for a Persian Gulf Veteran with objective indications of a qualifying chronic disability that manifested either during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). A qualifying chronic disability is one that results from an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI) such as chronic fatigue syndrome, fibromyalgia, or a functional gastrointestinal disorder (excluding structural gastrointestinal diseases). 38 C.F.R. § 3.317(a)(2)(i). The term "chronic" means that the disability has existed for 6 months or more, to include intermittent episodes of improving or worsening over that period. 38 C.F.R. § 3.317(a)(4).

An undiagnosed illness requires that the illness, by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(4). There is no burden on a veteran to demonstrate that a medical professional has eliminated all possible diagnoses before the veteran can be compensated for a disability stemming from an undiagnosed illness. Joyner v. McDonald, 766 F.3d 1393, 1395 (Fed. Cir. 2014).

MUCMI has been defined as 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." 38 C.F.R. § 3.317(a)(2)(ii). "Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained." 38 C.F.R. § 3.317(a)(2)(ii). Along with the three examples of a MUCMI provided by 38 U.S.C. § 1117(a)(2)(B), Congress has provided a list of signs or symptoms that may be a manifestation of a MUCMI that includes: skin symptoms, headaches, muscle pain, joint pain, neurologic symptoms, neuropsychological symptoms, respiratory system symptoms, sleep disturbances, gastrointestinal symptoms, cardiovascular symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C. § 1117(g); 38 C.F.R. § 3.317(b).

Objective indications of a qualifying chronic disability include both signs and symptoms, in the medical sense of objective evidence perceptible to an examining physician, and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Non-medical indicators include evidence such as time lost from work, the veteran having sought treatment for his symptoms, and change in the veteran's appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995).

Chronic fatigue syndrome and a functional gastrointestinal disorder qualify per se as medically unexplained chronic multi-symptom illnesses, or MUCMIs. Atencio v. O'Rourke, 30 Vet. App. 74, 81 (2018). The disability must manifest either during active service in Southwest Asia during the Persian Gulf War or to a degree of 10 percent or more before December 21, 2021. 38
indicators include evidence such as time lost from work, the veteran having sought treatment for his symptoms, and change in the veteran's appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995).

A Persian Gulf veteran is defined as a veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War on or after August 2, 1990. 38 U.S.C. § 1117(f); 38 C.F.R. § 3.317(e)(1). The Southwest Asia theater of operations refers to 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 U.S.C. § 1117(f); 38 C.F.R. § 3.317(e)(2). The Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxins Act of 2022 (PACT Act), which was signed into law by the President of the United States on August 10, 2022, extends the definition of "Persian Gulf veteran" to veterans who served in Afghanistan, Turkey, Israel, Syria, Egypt, and Jordan on or after August 2, 1990. 38 U.S.C. § 1117(f); 38 C.F.R. § 3.317(e)(2).

VA is responsible for determining whether the evidence persuasively favors one side or another. 38 C.F.R. § 4.3. When there is an approximate or nearly equal balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the Veteran and the claim will be granted on the merits. 38 U.S.C. § 5107(b). When the evidence persuasively favors against the claims of the Veteran, the benefit of the doubt doctrine is inapplicable, and the claim will be denied on its merits. 38 U.S.C. § 5107; Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).

1. Entitlement to Service Connection for Bipolar I Disorder

The Veteran has been service connected for posttraumatic stress disorder (PTSD) from August 9, 2017. He contends that he has bipolar I disorder in addition to his service-connected PTSD and that this bipolar I disorder is also related to service. A veteran may be service-connected and compensated for a separate psychiatric disorder if it results in distinguishable functional impairment. Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009). Thus, the Board will consider whether the Veteran's bipolar I disorder is also service connected. The issue of whether it is entitled to a separate rating (which the Board does not concede at this time) will be determined by the AOJ at a later date if service connection is granted.

In addition to the general requirements for service connection, diagnoses of mental disorders must conform to the DSM-V criteria. 38 C.F.R. § 4.125 (incorporating by reference VA's adoption of the American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fifth Edition (DSM-V) for rating purposes).

The May 2023 rating decision on appeal favorably found that the Veteran has a diagnosis of bipolar I disorder. This favorable finding is binding on the Board. 38 C.F.R. § 3.104(c). The first element of service connection-a current diagnosis-is met. Shedden, 381 F.3d at 1166-67.

As for the second element of service connection-an in-service injury, event, or disease-the Board again notes that the Veteran is service connected for PTSD as due to his
incorporating by reference VA's adoption of the American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fifth Edition (DSM-V) for rating purposes).

As for the second element of service connection-an in-service injury, event, or disease-the Board again notes that the Veteran is service connected for PTSD as due to his military service. He is thereby conceded to have experienced military-related stressors. The second element of service connection is therefore met as well. Shedden, 381 F.3d at 1166-67.

The remaining question is whether his bipolar I disorder is at least as likely as not incurred in or caused by his active service. On this question, there is evidence both in favor of and against the claim.

In favor of his claim, the Veteran submitted a November 2022 Disability Benefits Questionnaire (DBQ) and private medical opinion from Dr. M.H., a licensed psychologist. Dr. M.H. determined that the Veteran had a diagnosis of bipolar disorder in addition to PTSD. She opined that it is at least as likely as not that the Veteran's bipolar disorder is related to his military experiences. She explained, among other things, that testing suggested that the Veteran was experiencing a major depressive episode and that his military experiences included witnessing and experiencing multiple traumas. She noted that the Veteran had been treated by VA for bipolar disorder for four years. Dr. M.H.'s medical opinion considered the Veteran's medical history and linked his bipolar disorder to active service.

The record also contains a VA examination and medical opinion from March 2023. The VA examiner opined that the Veteran's bipolar I disorder is less likely than not incurred in or caused by his military service. She explained,

The [V]eteran did not receive mental health treatment while [sic] active duty. There is nothing in his records available for review that mentions Bipolar I Disorder until 2017, after he was discharged. It is less likely than not, at least 50% or less, that the [V]eteran's Bipolar I Disorder with anxious distress, most recent episode depressed was incurred in or caused by Bipolar Disorder during service. In an article from Beta Healthy, 3/25/2023, entitled, "What's Bipolar Disorder? How do I know if I have it? Symptoms, causes, diagnosis, types, treatment," it is noted that, "Certain environmental factors can also contribute to the development of bipolar disorder including drug abuse, alcohol abuse, sleep disturbance, and stress."

The Board affords the March 2023 VA medical opinion little probative value. The fact that bipolar disorder was not diagnosed until 2017 does not mean that it was not present before that time. It also fails to address whether bipolar disorder is related to active service. Indeed, the VA examiner cited medical literature stating that stress can contribute to the development of bipolar disorder. The Veteran is conceded to have PTSD related to stressful events during active service. The examiner did not sufficiently explain why it is less likely than not that the Veteran's military stress contributed to the development of bipolar disorder. Thus, the March 2023 negative nexus opinion is not persuasive in this case.

In light of the foregoing, the Board concludes that the evidence is in at least approximate balance. Given this, the Board will resolve reasonable doubt in the Veteran's favor and conclude that service connection for bipolar I disorder is warranted.

2. Entitlement to Service Connection for a Functional Gastrointestinal Disorder

The Veteran seeks service connection for a gastrointestinal disorder, claimed as irritable bowel syndrome. He reports that he has symptoms of bloating and functional abdominal pain related to his participation in a TERA during his service in Southwest Asia.

The Note to 38 C.F.R. § 3.317(a)(2)(i)(B)(3) specifies that functional gastrointestinal disorders are a group of conditions characterized by chronic or recurrent symptoms that are unexplained by any structural, endoscopic, laboratory, or other objective signs of injury or disease and may be related to any part of the gastrointestinal tract. Specific functional gastrointestinal disorders include, but are not limited to, irritable bowel syndrome, functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, and functional dysphagia. These disorders are commonly characterized by symptoms including abdominal pain, substernal burning or pain, nausea, vomiting, altered bowel habits (including diarrhea, constipation), indigestion, bloating, postpr
§ 3.317(a)(2)(i)(B)(3) specifies that functional gastrointestinal disorders are a group of conditions characterized by chronic or recurrent symptoms that are unexplained by any structural, endoscopic, laboratory, or other objective signs of injury or disease and may be related to any part of the gastrointestinal tract. Specific functional gastrointestinal disorders include, but are not limited to, irritable bowel syndrome, functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, and functional dysphagia. These disorders are commonly characterized by symptoms including abdominal pain, substernal burning or pain, nausea, vomiting, altered bowel habits (including diarrhea, constipation), indigestion, bloating, postprandial fullness, and painful or difficult swallowing. Diagnosis of specific functional gastrointestinal disorders is made in accordance with established medical principles, which generally require symptom onset at least six months prior to diagnosis and the presence of symptoms sufficient to diagnose the specific disorder at least three months prior to diagnosis.

In the May 2023 rating decision on appeal, the AOJ favorably found that the Veteran served in Iraq and Kuwait and was exposed to a TERA. These favorable findings are binding on the Board. 38 C.F.R. § 3.104(c). The Board notes that the Veteran's service in Southwest Asia occurred during a period of active service from January 2003 to March 2004, so presumptive service connection is available for this period of service. See Smith, 24 Vet. App. at 47; see also Paulson, 7 Vet. App. at 470-71.

The remaining questions are whether there is a current disability and a nexus between such disability and the Veteran's active service, to include whether the disability is subject to presumptive service connection under 38 C.F.R. § 3.317.

Service treatment records (STRs) show that the Veteran reported diarrhea occurring during active service. A post-deployment questionnaire from January 2004 shows that the Veteran responded "yes" when asked whether he had diarrhea during his deployment. No diagnosis of a gastrointestinal disorder was made at that time. The clinician did not elaborate on the nature or cause of the Veteran's reported diarrhea.

The Veteran had a VA gastroenterology consultation in February 2020. He reported having alternating diarrhea and constipation for the past several years that he believed to be from metformin use. The clinician indeed noted that the Veteran is diabetic and on metformin. The Veteran was scheduled for a colonoscopy, but the procedure was apparently cancelled due to the COVID-19 pandemic. It does not appear that the procedure was rescheduled prior to the rating decision on appeal.

According to the Mayo Clinic, metformin is a medication taken to treat diabetes mellitus, type II. Abdominal or stomach discomfort, diarrhea, acid or sour stomach, belching, bloating, excess air and gas in the stomach or intestines, full feeling, heartburn, indigestion, loss of appetite, metallic taste in the mouth, passing of gas, stomachache, stomach upset or pain, vomiting, and weight loss are among the more common side effects of metformin. See Mayo Clinic, "Metformin (Oral Route)", https://www.mayoclinic.org/drugs-supplements/metformin-oral-route/description/drg-20067074 (last visited April 13, 2026).

The Veteran underwent a VA examination in March 2023. At that time, he reported that his symptoms began in 2004, and that sometimes he must immediately use the restroom after eating and suffers from diarrhea. He complained of abdominal cramping, bloating, and abdominal pain, but denied constipation at any time. The VA examiner concluded that no diagnosis of an intestinal condition is warranted. She explained that the Veteran does not have a diagnosis of irritable bowel syndrome in his records or on the present exam and that his reported symptoms are subjective only. She noted that the gastroenterology consult note confirmed no diagnosis.

The examiner further opined that:

The [V]eteran has claimed IBS. The [claims] file was reviewed in its entirety. The [V]eteran had complaints of diarrhea initially in 2006. There were numerous visits with gastroenterology for screenings with no diagnosis of IBS or treatment of such. C file shows occasional visit notes with symptoms of diarrhea but with upper respiratory illness or other virus. There is no ongoing documentation or treatment of IBS as well as the Veteran denying these symptoms on multiple occasions and referencing it to be due to Metformin. Metformin [sic] main side effect is diarrhea.

The Veteran submitted a favorable nexus opinion from Dr. M.T., a chiropractor, dated November 2022. Dr. M.T. wrote as follows:

[
an has claimed IBS. The [claims] file was reviewed in its entirety. The [V]eteran had complaints of diarrhea initially in 2006. There were numerous visits with gastroenterology for screenings with no diagnosis of IBS or treatment of such. C file shows occasional visit notes with symptoms of diarrhea but with upper respiratory illness or other virus. There is no ongoing documentation or treatment of IBS as well as the Veteran denying these symptoms on multiple occasions and referencing it to be due to Metformin. Metformin [sic] main side effect is diarrhea.

The Veteran submitted a favorable nexus opinion from Dr. M.T., a chiropractor, dated November 2022. Dr. M.T. wrote as follows:

[The Veteran] states he suffers with [irritable bowel syndrome] condition via intermittent constipation and diarrhea which has been present since Gulf War service. It is as likely as not that the aforementioned is directly and causally related to Gulf War Syndrome per the presumptions (undiagnosed illness) published in Gulf War. Winter 2016. www.publichealth.va.gov. It is as likely as not that same is directly and causally related to [the Veteran's] military service. This is a permanent condition which had its' [sic] onset during deployment to The Southwest Asia Theater of Military Operations and has persisted to the present.

The Board emphasizes that the November 2022 private medical opinion was provided by a chiropractor. A chiropractor is a healthcare professional who performs adjustments (manipulations) to the spine or other parts of the body with the goal of correcting alignment problems, easing pain, and supporting the body's natural ability to heal itself. See National Library of Medicine, "Chiropractic", https://medlineplus.gov/chiropractic.html (last visited April 13, 2026). In general, a chiropractor is qualified to testify as an expert in relation to injuries that are within the ambit of chiropractic discipline. Horowitz v. American Motorist Ins. Co., 343 So.2nd. 1305, 1308 (1997). The Horowitz Court commented that the educational and training requirements for chiropractors may have been less uniform than those in traditional schools, and a trial judge must look carefully into the backgrounds, education, and experience of the actual witness before determining that a chiropractor is qualified to testify as to matters within the ambit of his or her permitted practice and professional expertise. See, e.g., Yagodinski v. Sutton, 309 Neb. 179 (2021) (holding that a chiropractor was not competent to testify to a traumatic brain injury which was outside the scope of chiropractic practice); Totton v. Bukofchan, 80 N.E. 891 (2017) (holding that a non-physician healthcare provider such as a chiropractor was not competent to testify to a medical-causation issue which was complex in nature); Carlson v. Bioremedi Therapeutic Sys., 822 F.3d 194, 200 (5th Cir. 2016) (holding that a chiropractor was not competent to speak in fields of medicine such as podiatry, endocrinology, or nephrology but may be well qualified to provide expert testimony about the musculoskeletal system).

Here, the Board finds that the question of the nature and etiology of the Veteran's claimed gastrointestinal disorder is outside of the competence of Dr. M.T. as a chiropractor, as disabilities of the gastrointestinal system are outside of the scope of chiropractic practice.

Nevertheless, the Board finds that the evidence is at least in approximate balance as to whether the Veteran has a qualifying functional gastrointestinal disorder. The Veteran's medical records confirm that he reported diarrhea occurring during his deployment to Southwest Asia. He has competently reported that his symptoms have continued to the present date. The VA gastroenterology consult did not result in a definitive diagnosis for his symptoms. This is sufficient meet the criteria for a functional gastrointestinal disorder under 38 C.F.R. § 3.317.

The Board has considered the March 2023 VA medical opinion in which the examiner claimed that the Veteran's symptoms were subjective only. However, objective medical evidence is not required to establish a MUCMI. Regulations only require competent evidence with "signs in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification." See Gutierrez v. Principi, 19 Vet. App. 1, 9 (2004). The symptom of diarrhea is competent evidence that is capable of independent verification. Additionally, although the VA examiner attributed the Veteran's diarrhea and constipation to metformin use, she failed to discuss STRs showing that the onset of the Veteran's diarrhea was during deployment in 2003 to 2004. The Veteran was not diagnosed with diabetes
Veteran's symptoms were subjective only. However, objective medical evidence is not required to establish a MUCMI. Regulations only require competent evidence with "signs in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification." See Gutierrez v. Principi, 19 Vet. App. 1, 9 (2004). The symptom of diarrhea is competent evidence that is capable of independent verification. Additionally, although the VA examiner attributed the Veteran's diarrhea and constipation to metformin use, she failed to discuss STRs showing that the onset of the Veteran's diarrhea was during deployment in 2003 to 2004. The Veteran was not diagnosed with diabetes mellitus type II and placed on metformin until 2017. Therefore, his diarrhea predated his metformin use by about 13 years.

Thus, resolving reasonable doubt in the Veteran's favor, the Board concludes that the Veteran has a diagnosis of a functional gastrointestinal disorder that is considered chronic under the regulatory criteria. As there is no affirmative evidence to the contrary, see 38 C.F.R. § 3.317(a)(7)(i)-(iii), the Veteran's functional gastrointestinal disorder is considered a MUCMI, and presumptive service connection is warranted.

3. Entitlement to Service Connection for Chronic Fatigue Syndrome

The Veteran seeks service connection for chronic fatigue syndrome. He asserts that he has chronic fatigue syndrome related to his participation in a TERA during his service in Southwest Asia.

For VA disability compensation and pension purposes, a diagnosis of chronic fatigue syndrome requires: (A) new onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least six months; and (B) the exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms; and (C) six or more of the following: (1) acute onset of the condition, (2) low grade fever, (3) non-exudative pharyngitis, (4) palpable or tender cervical or axillary lymph nodes, (5) generalized muscle aches or weakness, (6) fatigue lasting 24 hours or longer after exercise, (7) headaches (of a type, severity or pattern that is different from headaches in the pre-morbid state), (8) migratory joint pains, (9) neuropsychological symptoms, or (10) sleep disturbance. 38 C.F.R. § 4.88a.

VA medical records do not show a diagnosis of chronic fatigue syndrome or another qualifying separate chronic fatigue disorder. The March 2023 VA examiner did not diagnose chronic fatigue syndrome or a related disorder. During this examination, the Veteran reported difficulty sleeping due to nightmares with fatigue during the day regardless of the amount of sleep he got the previous night. These symptoms have progressively worsened over the years.

The Veteran's statements suggest that his fatigue is caused by sleep impairment from his service-connected acquired psychiatric disorder. He is already compensated for chronic sleep impairment related to his PTSD, as chronic sleep impairment is listed as one of the symptoms contributing to the 70 percent evaluation assigned for PTSD. Moreover, the only symptoms noted during the March 2023 VA examination were generalized muscle aches or weakness and sleep disturbance. He therefore does not meet the diagnostic criteria for a diagnosis of chronic fatigue syndrome for VA compensation purposes, as he only demonstrates two of the 10 symptoms listed in 38 C.F.R. § 4.88a(a)(3). As noted above, at least six of the 10 symptoms listed in 38 C.F.R. § 4.88a(a)(3) are required to establish a diagnosis of chronic fatigue syndrome for VA purposes. His available treatment records do not show otherwise. Thus, the evidence persuasively weighs against finding that the Veteran has a diagnosis of chronic fatigue syndrome or a related disability.

The Veteran submitted a favorable nexus opinion from Dr. M.T., dated November 2022. Dr. M.T. wrote as follows:

[The Veteran] states he has suffered with chronic fatigue syndrome since active duty. Diagnosis: Chronic fatigue syndrome. It is as likely as not that the aforementioned is directly and causally related to Gulf War Syndrome per the provisions published in Gulf War. Winter 2016. www.publichealth.va.gov. It is as likely as not that same is directly and causally related to [the Veteran's] military service. This is a permanent condition which had its' onset during deployment to the Southwest Asia Theater of Military Operations and has persisted to the present.

The opinion is not persuasive. As explained above, a diagnosis of chronic fatigue syndrome for VA disability purposes requires certain medical criteria to be established. Dr. M.T. merely cited the Veteran's lay reports that he had chronic fatigue syndrome, which he is not competent to provide, and used this as the basis for a favorable opinion. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995) (holding that transcriptions of lay history unenhanced by any medical comment by a clinician are not transformed into "competent medical evidence" merely because the transcriber happens to be a medical professional). Dr. M.T. did not appear to conduct relevant diagnostic testing or exclude other potential causes for the Veteran's fatigue. Notably, she did not address the role of the Veteran's chronic sleep impairment in his condition. Further, the question of the nature and etiology of the Veteran's claimed chronic fatigue syndrome is outside of the competence of Dr. M.T. as a chiropractor, as such disabilities are outside of the scope of chiropractic practice. The findings contained in the November 2022 private medical opinion are therefore entitled to no probative weight.

The Board has also considered the application of Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), in which the United States Court of Appeals for the Federal Circuit held that "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability" if it "reaches the level of functional impairment of earning capacity." 886 F.3d at 1367-39. Here, however, the fatigue and generalized muscle aches or weakness noted by the Veteran have not been shown to impact his ability to work. The March 2023 VA examiner specifically found that the Veteran's claimed chronic fatigue syndrome does not affect his ability to work, and the Veteran has not reported otherwise.

While the Veteran believes that he has a diagnosis of chronic fatigue syndrome, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized diagnostic testing. The record does not show that the Veteran in this case has the knowledge or training required to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Board therefore gives more probative weight to the medical evidence of record showing the absence of a diagnosis of chronic fatigue syndrome or a related disability.

In sum, the evidence of record persuasively weighs against finding that the Veteran has had a diagnosis of chronic fatigue syndrome at the time he filed his claim or during the pendency of his claim. The factors of the Veteran's appeal are distinguishable from Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), and McClain v. Nicholson, 21 Vet. App. 319 (2007). In those cases, the veterans had current disabilities when they filed their claims for entitlement to service connection, which had resolved during the pendency of the appeal. Romanowsky, 26 Vet. App. at 293-94; McClain, 21 Vet. App. at 323.

Because the Veteran is not shown to have a diagnosis of chronic fatigue syndrome, nor has he had such a diagnosis at any time during the pendency of the claim, the first element of service connection is not met. Without probative evidence of a diagnosed chronic fatigue syndrome disability, the elements of service connection cannot be established. The Board need not engage in any further analysis on either a presumptive or a direct basis. 38 C.F.R. §§ 3.303(a), 3.307(a); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (holding that where the evidence does not support a finding of a current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit).

Thus, for the reasons and bases discussed, the evidence for the claim for service connection for chronic fatigue syndrome versus the evidence against the claim is not in "approximate" balance (i.e., nearly equal). Instead, the most probative and, therefore, most persuasive evidence is against this claim
analysis on either a presumptive or a direct basis. 38 C.F.R. §§ 3.303(a), 3.307(a); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (holding that where the evidence does not support a finding of a current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit).

Thus, for the reasons and bases discussed, the evidence for the claim for service connection for chronic fatigue syndrome versus the evidence against the claim is not in "approximate" balance (i.e., nearly equal). Instead, the most probative and, therefore, most persuasive evidence is against this claim. See Lynch, 21 F.4th at 781-82; see also Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). The claim for entitlement to service connection for chronic fatigue syndrome is denied.

4. Entitlement to Service Connection for Left Knee Joint Arthritis and Meniscal Tear with Chondromalacia and Right Knee Joint Osteoarthritis and Derangement

The Veteran seeks service connection for bilateral knee disorders that he contends are related to his active military service.

In the May 2023 rating decision on appeal, the AOJ favorably found that the Veteran had diagnoses of left knee joint arthritis and meniscal tear with chondromalacia, as well as right knee osteoarthritis and derangement. The AOJ also favorably found that a qualifying event, injury, or disease relevant to the Veteran's claimed bilateral knee disorder had its onset during his active service. It was noted that the Veteran's STRs showed reports of knee pain/strain in February 2004. These favorable findings are binding on the Board, and the first two elements of direct service connection are met. 38 C.F.R. § 3.104(c); Shedden, 381 F.3d at 1166-67.

The remaining question is whether the Veteran's current left and right knee disorders were incurred in or caused by the Veteran's active service, to include via continuity of symptomatology for arthritis as a chronic disease. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a); Walker, 780 F.3d at 1336.

The Veteran's February 2004 separation examination showed normal lower extremities and specifically noted a normal knee examination. However, the clinician also wrote "chronic knee pain" in the section for recommendations for further specialist examination. It is unclear whether such examination occurred. The Veteran's February 2004 separation report of medical history shows that he endorsed ankle and knee pain, and the clinician clarified that the Veteran reported onset of pain in both knees beginning approximately one year ago during physical training. He denied receiving any profiles for this bilateral knee pain. Likewise, on a report of medical assessment dated February 2004, the Veteran responded "yes" when asked if he had suffered from any injury or illness while on active duty for which he did not seek medical care. He specified that this untreated condition involved sprains of the knees and ankles.

In the November 2022 private medical opinion, Dr. M.T. linked the Veteran's present bilateral knee pain to his active service. She also opined that the Veteran's joint pain of the bilateral knees represents a form of Gulf War syndrome subject to presumptive service connection. While Dr. M.T. is a chiropractor, she possesses some degree of competence to offer an opinion as to the nature and etiology of the Veteran's bilateral knee disorders, as musculoskeletal disorders are within the scope of chiropractic practice. See Carlson, 822 F.3d at 200. Whether she is competent to attribute the Veteran knee problems to Gulf War syndrome is questionable, however.

During the March 2023 VA examination, the Veteran reported progressive bilateral knee pain since service. This knee pain is intermittent and occurs with walking. It is described as a sharp pain, and he also complained of popping of the knees and swelling after walking. The Veteran also indicated that he wears braces on both knees constantly. Although the examiner stated that the Veteran's bilateral knee disorder onset in 2008, the Veteran's STRs clearly document reports of knee pain prior to 2008. The March 2023 VA examiner also offered a negative nexus opinion. Among other things, she opined, "As evidenced above the [V]eteran had complaints of knee troubles on one report of medical history. The medical histories and medical care were silent for knee conditions until over ten years later due to injuries to the knee during civilian work." The March
pain is intermittent and occurs with walking. It is described as a sharp pain, and he also complained of popping of the knees and swelling after walking. The Veteran also indicated that he wears braces on both knees constantly. Although the examiner stated that the Veteran's bilateral knee disorder onset in 2008, the Veteran's STRs clearly document reports of knee pain prior to 2008. The March 2023 VA examiner also offered a negative nexus opinion. Among other things, she opined, "As evidenced above the [V]eteran had complaints of knee troubles on one report of medical history. The medical histories and medical care were silent for knee conditions until over ten years later due to injuries to the knee during civilian work." The March 2023 examiner did not discuss the Veteran's reports of continuing symptoms since active service or why she would expect him to have sought treatment for this condition (from a medical perspective). This omission renders the VA medical opinion insufficient. See Miller v. Wilkie, 32 Vet. App. 249, 262 (2020) (holding an examiner's failure to consider a veteran's lay statement when offering a medical opinion renders that opinion inadequate). Moreover, when deciding the question of a nexus, it is the continuation of symptoms, not treatment, that is the relevant consideration. Wilson v. McDonough, 2 Vet. App. 16, 19 (1991).

Rather, it is clear in this case that the Veteran reported an onset of chronic knee pain during a period of active service. The Veteran is competent to make such reports and to state that his symptoms have continued to the present. The Board finds that the evidence does not weigh against his credibility to the extent that the evidence of record persuasively weighs against finding a nexus in this case. Considering the Veteran's competent testimony about ongoing knee pain, combined with the favorable medical opinion from Dr. M.T., the Board will resolve reasonable doubt in the Veteran's favor and conclude that there is a nexus between the Veteran's service and his left knee joint arthritis and meniscal tear with chondromalacia and right knee joint osteoarthritis and derangement.

In summary, the evidence is at least in approximate balance as to the question of a nexus between the Veteran's bilateral knee disorders and a period of active service. Service connection for left knee joint arthritis and meniscal tear with chondromalacia and right knee joint osteoarthritis and derangement is granted.

5. Entitlement to Service Connection for Chronic Sinusitis

The Veteran seeks service connection for chronic sinusitis. He asserts that he has sinusitis related to his participation in TERAs during his service in Southwest Asia, to include exposure to burn pits.

The PACT Act expanded presumptions that certain veterans were exposed to fine particulate matter during service and that certain diseases, including asthma, rhinitis, and sinusitis, are presumptively linked to such exposure regardless of when such disability manifests after qualifying service. 38 U.S.C. § 1120; 38 C.F.R. § 3.320. This includes veterans who served in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.320(a)(5). Prior to the PACT Act, the law required that the qualifying condition manifest within ten years of discharge, but it still presumed that Persian Gulf War veterans were exposed to particulate matter.

As discussed above, the record establishes that the Veteran served in Iraq and Kuwait from April 2003 through February 2004. He is therefore presumed to have been exposed to burn pits and other toxins (BPOT) based on such service. 38 U.S.C. § 1119. The Board notes that the Veteran's service in Southwest Asia occurred during a period of active service from January 2003 to March 2004, so presumptive service connection is available for this period of service. See Smith, 24 Vet. App. at 47; see also Paulson, 7 Vet. App. at 470-71.

The remaining issue is whether the Veteran has a qualifying sinusitis diagnosis. During the March 2023 VA examination, the Veteran was not diagnosed with chronic sinusitis and was instead only diagnosed with allergic rhinitis. The examiner opined that the Veteran does not have a diagnosis of chronic sinusitis, as the medical record is silent for any complaints or treatment of sinusitis, the examination was negative for an assessment of sinusitis, and the Veteran denied any history or complaints related to a diagnosis of sinusitis. Indeed, VA treatment records do not show complaints, symptoms, treatment, or diagnosis of chronic sinusitis during or proximate to the appeal period beginning in July 2022.

While Dr. M.T. opined that the Veteran does have a current diagnosis of chronic sinusitis, the Board finds this opinion unpersu
2023 VA examination, the Veteran was not diagnosed with chronic sinusitis and was instead only diagnosed with allergic rhinitis. The examiner opined that the Veteran does not have a diagnosis of chronic sinusitis, as the medical record is silent for any complaints or treatment of sinusitis, the examination was negative for an assessment of sinusitis, and the Veteran denied any history or complaints related to a diagnosis of sinusitis. Indeed, VA treatment records do not show complaints, symptoms, treatment, or diagnosis of chronic sinusitis during or proximate to the appeal period beginning in July 2022.

While Dr. M.T. opined that the Veteran does have a current diagnosis of chronic sinusitis, the Board finds this opinion unpersuasive. Dr. M.T. explained,

[The Veteran] states he has suffered with respiratory deficiency to include congestion of the maxillary sinuses with difficulty breathing and facial pressure. Also coughing is noted. Diagnosis: Chronic sinusitis. It is at least as likely as not that the aforementioned is directly and causally related to Gulf War Syndrome per the presumptions (undiagnosed illness) published in Gulf War. Winter 2016. www.publichealth.va.gov. It is as likely as not that same is directly and causally related to [the Veteran's] military service. This is a permanent condition which had its' [sic] onset during deployment to The Southwest Asia Theater of Military Operations and has persisted to the present.

This opinion is insufficient because Dr. M.T. based her diagnostic findings and medical opinion solely on the Veteran's lay testimony. See LeShore, 8 Vet. App. at 409. The Veteran is not competent to state that his respiratory symptoms of congestion, difficulty breathing, facial pressure, and coughing are caused by chronic sinusitis as opposed to another condition (such as allergic rhinitis, for which service connection has already been granted in the May 2023 rating decision, or an acute respiratory infection). Dr. M.T. noted the presence of coughing, but she did not explain why coughing is diagnostically indicative of sinusitis rather than another respiratory condition. Moreover, the question of the nature and etiology of the Veteran's claimed chronic sinusitis is outside of the competence of Dr. M.T. as a chiropractor, as respiratory disabilities are outside of the scope of chiropractic practice. The findings contained in the November 2022 private medical opinion are therefore entitled to no probative weight.

The Board has also considered the application of Saunders, 886 F.3d at 1367-69. While the Veteran reported zero to one week of work lost in the last 12 months due to sinus congestion, difficulty functioning, and constant runny nose, the March 2023 VA examiner attributed these symptoms to the Veteran's allergic rhinitis. The Veteran is already being compensated for allergic rhinitis. The record does not show occupational impairment due to symptoms other than those contemplated by the rating assigned for his allergic rhinitis, and the Veteran does not assert otherwise.

Although the Veteran believes that he has a diagnosis of chronic sinusitis, he is not competent to provide a diagnosis. The issue is medically complex, as it requires specialized diagnostic testing. The record does not show that the Veteran here has the knowledge or training required to make such a determination. Jandreau, 492 F.3d at 1377, 1377 n.4. The Board therefore gives more probative weight to the medical evidence of record showing the absence of a diagnosis of chronic sinusitis or a related disability.

The evidence of record persuasively weighs against finding that the Veteran has had a diagnosis of chronic sinusitis at the time he filed his claim or during the pendency of his claim. The factors of the Veteran's appeal are distinguishable from Romanowsky and McClain. In those cases, the veterans had current disabilities when they filed their claims for entitlement to service connection, which had resolved during the pendency of the appeal. Romanowsky, 26 Vet. App. at 293-94; McClain, 21 Vet. App. at 323.

Because the Veteran does not have a diagnosis of chronic sinusitis, nor has he had such a diagnosis at any time during the pendency of the claim, the first element of service connection is not met. Without probative evidence of a diagnosed chronic sinusitis disability, the elements of service connection cannot be established. The Board need not engage in any further analysis on either a presumptive or a direct basis. 38 C.F.R. §§ 3.303(a), 3.307(a); see also Brammer, 3 Vet. App. at 225.

Therefore, for the reasons and bases discussed, the evidence for the claim for service connection for chronic sinusitis versus the evidence against the claim is not in "approximate"
Because the Veteran does not have a diagnosis of chronic sinusitis, nor has he had such a diagnosis at any time during the pendency of the claim, the first element of service connection is not met. Without probative evidence of a diagnosed chronic sinusitis disability, the elements of service connection cannot be established. The Board need not engage in any further analysis on either a presumptive or a direct basis. 38 C.F.R. §§ 3.303(a), 3.307(a); see also Brammer, 3 Vet. App. at 225.

Therefore, for the reasons and bases discussed, the evidence for the claim for service connection for chronic sinusitis versus the evidence against the claim is not in "approximate" balance (i.e., nearly equal). Instead, the most probative and, therefore, most persuasive evidence is against this claim. See Lynch, 21 F.4th at 781-82; see also Ortiz, 274 F.3d at 1364. The claim for entitlement to service connection for chronic sinusitis is denied.

Increased Rating

1. Entitlement to an Initial Rating in Excess of 30 Percent for Allergic Rhinitis

The Veteran has been in receipt of a 30 percent rating for allergic rhinitis. He contends that his symptoms warrant a higher rating.

Disability ratings are determined in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability picture more closely approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3.

The Board will consider whether staged ratings should be assigned to compensate for times when the disability may have been more severe than at other times during the pendency of the claim. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999).

Allergic or vasomotor rhinitis is rated pursuant to 38 C.F.R. § 4.97, Diagnostic Code 6522. Under Diagnostic Code 6522, a 10 percent rating is assigned for allergic or vasomotor rhinitis without polyps, but with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side. A maximum 30 percent rating is assigned for allergic or vasomotor rhinitis with polyps.

The Veteran has been in receipt of a 30 percent rating for his service-connected allergic rhinitis since August 10, 2022. He has therefore been in receipt of the maximum schedular rating for allergic rhinitis for the duration of the period on appeal. There are no additional symptoms or manifestations of allergic rhinitis that are not already contemplated by the 30 percent rating currently assigned. The Veteran has not provided evidence or argument to support a higher rating other than the vague assertion that this disability warrants a 60 percent rating. There is therefore no basis to consider extraschedular consideration. 38 C.F.R. § 3.321(b). Accordingly, entitlement to an initial rating in excess of 30 percent for allergic rhinitis must be denied.

REASONS FOR REMAND

One of the effects of the Appeals Modernization Act (AMA) is to narrow the set of circumstances in which the Board must remand appeals to the AOJ for further development instead of immediately deciding them directly. However, the Board has the duty to remand issues when necessary to correct a pre-decisional duty to assist error where the issues cannot be granted in full. 38 U.S.C. § 5103A(f); 38 C.F.R. § 20.802(a).

1. Entitlement to Service Connection for a Bilateral Leg Neurological Disorder

The Veteran seeks service connection for a bilateral leg neurological disorder with symptoms of uncontrollable shaking and kicking (also claimed as restless leg syndrome). He asserts that it is related to participation in a TERA during active service. He is again noted to be a Persian Gulf veteran. 38 U.S.C. § 1117(f); 38 C.F.R. § 3.317(e)(2).

During the March 2023 VA examination, the Veteran reported that, in approximately 2004, he started to notice uncont
38 U.S.C. § 5103A(f); 38 C.F.R. § 20.802(a).

1. Entitlement to Service Connection for a Bilateral Leg Neurological Disorder

During the March 2023 VA examination, the Veteran reported that, in approximately 2004, he started to notice uncontrollable shaking or kicking of his legs when trying to rest or sleep. The Veteran did not know why these symptoms occurred, but he stated that he would kick his leg off the bed and shake it. The examiner did not diagnose the Veteran with restless leg syndrome or any other condition of the central nervous system. Rather, she stated that the Veteran's reported symptoms are subjective only.

The March 2023 VA examination is inadequate. The evidence clearly shows that the Veteran has objective indications of a qualifying disability, including neurological symptoms. 38 C.F.R. § 3.317(a)(3), (b). The Veteran has not been properly evaluated to determine whether there is a diagnosis for these symptoms. Though the March 2023 VA examiner stated that the Veteran's symptoms are subjective only, objective medical evidence is not required to establish a MUCMI. Regulations only require competent evidence with "signs in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification." See Gutierrez, 19 Vet. App. at 9. The symptoms of uncontrollable kicking and shaking legs are perceptible to an examining physician (in the event that a physician was there to witness them) or, at a minimum, are capable of independent verification. The Veteran's symptoms therefore constitute objective indications of a qualifying disability pursuant to 38 C.F.R. § 3.317(a)(3) and (b).

The failure to ensure that all appropriate diagnostic testing has been performed constitutes a pre-decisional duty to assist error. Thus, upon remand, the Veteran should be scheduled for an examination to determine the nature and etiology of his claimed condition.

The Board acknowledges that Dr. M.T. diagnosed the Veteran with restless leg syndrome. However, this opinion is insufficient to render a decision on the Veteran's claim at this time. The question of the nature and etiology of the Veteran's claimed bilateral leg neurological disorder is outside of the competence of Dr. M.T. as a chiropractor, as neurological disabilities are outside of the scope of chiropractic practice.

2. Entitlement to Service Connection for Diabetes Mellitus, Type II

The Veteran seeks service connection for diabetes mellitus, type II as related to his active military service. Alternatively, he suggests that his diabetes mellitus, type II is secondary to his service-connected PTSD.

In a March 2023 medical opinion, a VA examiner opined that it is less likely than not that the Veteran's diabetes mellitus, type II was proximately due to or the result of his service-connected PTSD. She rationalized that the Veteran's diabetes mellitus, type II is a separate entity from his PTSD and they are medically unrelated. She explained,

Type 2 Diabetes Mellitus, one of the most common metabolic disorders, is caused by a combination of two primary factors: defective insulin secretion by pancreatic ß-cells and the inability of insulin-sensitive tissues to respond appropriately to insulin. T2DM risk factors include a complex combination of genetic, metabolic and environmental factors that interact with one another contributing to its prevalence. Although individual predisposition to T2DM due to non-modifiable risk factors (ethnicity and family history/genetic predisposition) has a strong genetic basis, evidence from epidemiological studies suggests that many cases of T2DM can be prevented by improving the main modifiable risk factors (obesity, low physical activity and an unhealthy diet).

Thus, the examiner concluded that review of the medical literature fails to show a causal relationship between diabetes mellitus, type II and PTSD.

The March 2023 VA medical opinion is inadequate. The examiner focused on whether the Veteran's service-connected PTSD caused his diabetes mellitus, type II. The examiner did not address whether the Veteran's diabetes mellitus, type II was aggravated by his service-connected PTSD. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013).

When VA provides an examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Because the March 202
diet).

Thus, the examiner concluded that review of the medical literature fails to show a causal relationship between diabetes mellitus, type II and PTSD.

When VA provides an examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Because the March 2023 VA medical opinion is inadequate, it was a pre-decisional duty to assist error for the AOJ to rely on this inadequate opinion in denying the claim for service connection for diabetes mellitus, type II. Remand is therefore required for the correction of this error.

Dr. M.T. offered a positive nexus opinion linking the Veteran's diabetes mellitus, type II to his active service and/or his service-connected PTSD. This opinion is insufficient to render a decision on the Veteran's claim at this time. Dr. M.T. did not provide any rationale or explanation for her positive opinion. Moreover, the question of the nature and etiology of the Veteran's claimed diabetes mellitus, type II is outside of the competence of Dr. M.T. as a chiropractor, as endocrine disabilities are outside of the scope of chiropractic practice. She simply lack the competence to provide an opinion on the etiology of diabetes mellitus.

3. Entitlement to Service Connection for Hypertension

The Veteran seeks service connection for hypertension as directly related to active military service. Alternatively, the evidence suggests that his hypertension may be secondary to his service-connected PTSD.

In a March 2023 medical opinion, a VA examiner opined that it is less likely than not that the Veteran's hypertension was proximately due to or the result of his service-connected PTSD. She rationalized that the Veteran's hypertension and PTSD are not medically related and that hypertension is a separate entity from PTSD. She added that a thorough review of the medical literature fails to demonstrate a causal relationship between hypertension and PTSD.

The March 2023 VA medical opinion is inadequate. First, the examiner's rationale is conclusory, as she merely stated that there is no causal relationship between hypertension and PTSD without explaining why. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Further, the examiner only offered an opinion as to whether the Veteran's service-connected PTSD caused his hypertension without offering an opinion as to whether his hypertension was aggravated by his PTSD. See El-Amin, 26 Vet. App. at 140.

Thus, because the March 2023 VA medical opinion is inadequate, it was a pre-decisional duty to assist error for the AOJ to rely on this inadequate opinion in denying the claim for service connection for hypertension. Remand is therefore required for the correction of this error. Barr, 21 Vet. App. at 311.

The Board acknowledges that Dr. M.T. offered a positive nexus opinion linking the Veteran's hypertension to his active service and/or his service-connected PTSD. This opinion is insufficient to render a decision on the Veteran's claim at this time. Dr. M.T. once again did not provide any rationale or explanation for her positive opinion. Moreover, she lacks the competence to enter an opinion as to the nature and etiology of the Veteran's claimed hypertension. Such is outside of the competence of Dr. M.T. as a chiropractor, because hypertension is a disability outside of the scope of chiropractic practice.

The matter is REMANDED for the following action:

1. Schedule the Veteran for an appropriate examination to determine the nature and etiology of his claimed bilateral leg neurological disorder. The examiner must review the entire claims file, including a copy of this remand.

The examiner should conduct all appropriate diagnostic testing. The examiner should then record all noted signs and reported symptoms, document all clinical findings, and provide diagnosis if possible.

The examiner is asked to provide responses to the following:

A) Identify the Veteran's objective indications of a disability.

"Objective indications" of a qualifying chronic disability include both objective evidence perceptible to an examining physician and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Non-medical indicators include evidence such as time lost from work, the veteran having sought treatment for the symptoms, and change in the veteran's appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995).

B) By history,
findings, and provide diagnosis if possible.

The examiner is asked to provide responses to the following:

A) Identify the Veteran's objective indications of a disability.

B) By history, physical examination, or laboratory testing, can the Veteran's objective indications of a disability be attributed to a known clinical diagnosis?

If the signs and symptoms are not characteristic of a known clinical diagnosis, the examiner should so indicate. There is no requirement that the examiner provide a diagnosis of undiagnosed illness.

C) If the Veteran's objective indications cannot be attributed to a known clinical diagnosis, is there affirmative evidence that the undiagnosed illness is not incurred during active service during the Persian Gulf War or that it was caused by a supervening condition or event that occurred since the Veteran's departure from service during the Persian Gulf War?

The examiner should note that a positive response to this question requires affirmative evidence. The mere absence of evidence is not sufficient.

D) If the Veteran's objective indications can be attributed to a known clinical diagnosis, is the etiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood?

This determination as to each 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.

E) If the Veteran's objective indications can be attributed to a known clinical diagnosis, is the pathophysiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood?

This determination as to each must be based on the Veteran's specific case and cannot be based on the pathophysiology of the disease or disability population as a whole.

F) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (a 50 percent or greater probability) that the Veteran's diagnosed condition was incurred in, or is otherwise related to, active service?

A complete rationale must be provided for all opinions expressed

2. Obtain an addendum opinion from an appropriate clinician to determine the etiology of the Veteran's diabetes mellitus, type II. The Veteran's claims file must be made available to the examiner. After reviewing the claims file, with any necessary examination and testing, the examiner should provide the following opinions:

Is it at least as likely as not (the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's diabetes mellitus, type II was caused by or underwent any incremental increase in disability, regardless of its permanence, due to his service-connected PTSD?

The term "incremental increase in disability" means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any "incremental increase in disability" need not be permanent.

The examiner is advised that proximate cause is not required for secondary service connection. Rather, the question is whether the Veteran's service-connected PTSD is a but for cause of his diabetes mellitus, type II, to include whether his diabetes mellitus, type II would have been less severe but for his service-connected PTSD.

3. Obtain an addendum opinion from an appropriate clinician to determine the etiology of the Veteran's hypertension. The Veteran's claims file must be made available to the examiner. After reviewing the claims file, with any necessary examination and testing, the examiner should provide the following opinions:

Is it at least as likely as not (the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's hypertension was caused by or underwent any incremental increase in disability, regardless of its permanence, due to his service-connected PTSD?

The examiner is advised that proximate cause is not required for secondary service connection. Rather, the question is whether the Veteran's service-connected PTSD is a but for cause of his hypertension, to include whether his hypertension would have been less severe but for his service-connected PTSD.

MICHAEL A. HERMAN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board
incremental increase in disability, regardless of its permanence, due to his service-connected PTSD?

The examiner is advised that proximate cause is not required for secondary service connection. Rather, the question is whether the Veteran's service-connected PTSD is a but for cause of his hypertension, to include whether his hypertension would have been less severe but for his service-connected PTSD.

MICHAEL A. HERMAN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board R.M. Sachs, 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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