INTERVERTEBRAL DISC SYNDROME

A. S. CARACCIOLO · 2026 · Case ID: A26038781

MIXED

Summary

The Veteran, an Air Force Veteran who served from December 2001 to November 2002 and August 2005 to September 2006, including service in Southwest Asia during the Persian Gulf War, appeals the denial of service connection for hypertension and chronic urticaria, and seeks increased ratings for his low back disability and radiculopathy. The Board granted service connection for a gastrointestinal disorder, presumed due to Gulf War exposures, and for a left ear hearing loss disability, finding the VA examiner's opinion inadequate and resolving doubt in the Veteran's favor. The Board also granted service connection for a headache disorder, finding the private examiner's opinion persuasive and the VA examiner's opinion inadequate for failing to address lay evidence and continuity of symptoms. The claim for an increased rating for chronic urticaria was denied as the evidence did not support a rating higher than 30 percent. The claim for hypertension was denied, with the Board finding the Veteran's condition was most likely caused by post-service chemotherapy for non-service-connected lymphoma, as supported by a persuasive VA examiner's opinion. The Board remanded claims for increased ratings for low back disability and radiculopathy, as well as for allergic rhinitis, respiratory insufficiency, fibromyalgia, and chronic fatigue syndrome, due to inadequate VA examinations that failed to properly consider medication effects, continuity of symptoms, or provide adequate rationales.

Rationale

Grant of increased 40% rating based on limitation of forward flexion to 30 degrees or less; VA C&P exam inadequate for failing to consider medication effects; Private examiner's findings supported 40% rating

Service Branch

AIR FORCE

Special Benefit

NO SPECIAL BENEFIT

Diagnostic Code

5242

Docket No.

250623-557425

Full Decision Text

Citation Nr: A26038781
Decision Date: 04/27/26 Archive Date: 04/27/26

DOCKET NO. 250623-557425
DATE: April 27, 2026

ORDER

Entitlement to an increased 40 percent disability rating for thoracolumbar spine degenerative disc disease (DDD) and degenerative joint disease (DJD), status post surgical treatment with scar (hereinafter "low back disability"), is granted.

Entitlement to an initial rating in excess of 30 percent for chronic urticaria is denied.

Entitlement to service connection for a gastrointestinal disorder, claimed as functional abdominal pain syndrome and irritable bowel syndrome (IBS), is granted.

Entitlement to service connection for hypertension is denied.

Entitlement to service connection for a left ear hearing loss disability is granted.

Entitlement to service connection for a headache disorder is granted.

REMANDED

Entitlement to a rating in excess of 40 percent for a low back disability is remanded.

Entitlement to an initial rating in excess of 10 percent for left lower extremity radiculopathy is remanded.

Entitlement to an initial rating in excess of 10 percent for right lower extremity radiculopathy is remanded.

Entitlement to an initial compensable rating for allergic rhinitis is remanded.

Entitlement to an initial compensable rating for a bilateral hearing loss disability is remanded.

Entitlement to service connection for respiratory insufficiency (also claimed as dyspnea and chronic sinusitis) is remanded.

Entitlement to service connection for fibromyalgia is remanded.

Entitlement to service connection for chronic fatigue syndrome is remanded.

FINDINGS OF FACT

1. Resolving any reasonable doubt in the Veteran's favor, his low back disability was manifested by limitation of forward flexion of the thoracolumbar spine to 30 degrees or less for the entire appeal period.

2. The Veteran's chronic urticaria required second-line treatment but did not require third-line of treatment for control.

3. The Veteran has a gastrointestinal disorder, claimed as functional abdominal pain syndrome and IBS, that was causally related to his service in the Southwest Asia theater of operations.

4. The Veteran's hypertension was not incurred in active service or within one year of separation from active service, nor was it otherwise related to active service.

5. Resolving any reasonable doubt in the Veteran's favor, his left ear hearing loss disability was related to hazardous noise exposure sustained in active service.

6. The Veteran's headache disorder was incurred in active service.

CONCLUSIONS OF LAW

1. The criteria for an increased rating of 40 percent for a low back disability were met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5242 (2022).

2. The criteria for an initial rating in excess of 30 percent for chronic urticaria were not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.118, DC 7825 (2022).

3. The criteria for service connection for a gastrointestinal disorder, claimed as functional abdominal pain syndrome and IBS, were met. 38 U.S.C. §§ 1101, 1110, 1117, 1118, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2022).

4. The criteria for service connection for hypertension were not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2022).

5. The criteria for service connection for a left ear hearing loss disability were met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.385.

6. The criteria for service connection for a headache disorder were met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2022).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Air Force from December 2001 to November 2002,
a left ear hearing loss disability were met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.385.

6. The criteria for service connection for a headache disorder were met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2022).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Air Force from December 2001 to November 2002, and from August 2005 to September 2006. He was awarded the Kosovo Campaign Medal and the Air Force Longevity Service Award, among other decorations and medals.

These matters come before the Board of Veterans' Appeals (Board) on appeal from March 2025 and April 2025 rating decisions issued by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). In June 2025, the Veteran filed a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) (NOD), electing the Evidence Submission docket. Accordingly, the Board may only consider the evidence of record at the time of the March 2025 and April 2025 AOJ decisions on appeal, as well as evidence submitted by the Veteran within 90 days following receipt of the NOD. See 38 C.F.R. § 20.303.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran 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 claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a supplemental claim are included with this decision.

Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159.

Regarding the claims denied herein, there is no indication of any error on VA's part in notifying or assisting the Veteran that reasonably affects the fairness of the adjudications. See 38 C.F.R. § 3.159. The Veteran has not raised any specific issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument).

The Board notes that there is a documented toxic exposure risk activity (TERA) pertaining to the Veteran given his deployment to Southwest Asia during the Persian Gulf War. A March 2025 TERA memorandum acknowledged the Veteran's presumed toxic exposure under 38 U.S.C. § 1119 based on deployment in the Southwest Asia theater of operations. See 38 U.S.C. § 1710(e)(1).

Increased Ratings

Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1.

In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the claimant, as well as the entire history of the claimant's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991).

If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified;
severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the claimant, as well as the entire history of the claimant's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991).

If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21.

In deciding these appeals, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119 (1999).

1. Low back disability

The Veteran seeks an increased rating for his low back disability. For the following reasons, the Board finds that at least a 40 percent rating is warranted at this time.

The Veteran symptoms are currently rated as 20 percent disabling, under DC 5242. See 38 C.F.R. § 4.71a. Disabilities of the spine are evaluated under either a General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) or under DC 5243, which governs intervertebral disc syndrome (IVDS).

Under the General Rating Formula, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. Id.

A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id.

A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. Id.

Alternatively, DC 5243 provides that a 20 percent rating is assigned for incapacitating episodes of IVDS having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is assigned for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is assigned in the event of incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243.

Note (1) under DC 5243 defines an incapacitating episode as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Id.

The Board notes that, effective February 7, 2021, the spine regulations were amended to state that DC 5243 should only be assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root; and that DC 5242 should apply to all other disc diagnoses (the criteria under the General Rating Formula remained unchanged). See 85 Fed. Reg. 76462 (Nov. 30, 2020) (effective February 7, 2021).

The Board emphasizes that, when assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must, in addition to applying schedular criteria, also consider evidence of pain, weakened movement, excess fat
The Board notes that, effective February 7, 2021, the spine regulations were amended to state that DC 5243 should only be assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root; and that DC 5242 should apply to all other disc diagnoses (the criteria under the General Rating Formula remained unchanged). See 85 Fed. Reg. 76462 (Nov. 30, 2020) (effective February 7, 2021).

The Board emphasizes that, when assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must, in addition to applying schedular criteria, also consider evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-207 (1995).

In Correia v. McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the Court's holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. The Court has also held that flare-ups must be factored into an examiner's assessment of functional loss. Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017).

The instant appeal period dates from the Veteran's January 2025 claim for increase. After careful review of the relevant evidence, the Board will resolve reasonable doubt in the Veteran's favor by finding that the criteria for an increased 40 percent rating were met throughout the appeal period. The AOJ's grant of a 20 percent rating was based on a VA Compensation and Pension (C&P) examination report from March 2025, which reflects forward flexion of the thoracolumbar spine exceeding 30 degrees. However, that examination report notes that the Veteran took medication to manage his symptoms, and it does not appear that the examiner estimated the severity of the Veteran's symptoms without considering the ameliorative effects of medication. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012) (holding that "the Board may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria"); Ingram v. Collins, 38 Vet. App. 130, 132 (2025) (holding that, with regard to the DCs for rating musculoskeletal conditions and other DCs that do not reference medication, "the Board must discount beneficial medication effects when assigning an evaluation"). Accordingly, the C&P examination report is inadequate, and the Board must presume that the Veteran's limitation of motion was more severe than the assigned 20 percent rating reflects.

The Board further notes that, in February 2025, the Veteran submitted a November 2024 report from a private examiner which includes findings which support an increased 40 percent rating. More specifically, the report notes that the Veteran's forward flexion was limited to 30 degrees. The examiner further noted that the Veteran was in constant pain, in varying degrees, intensified with standing, sitting, and walking.

Given the inadequacy of the VA C&P examination of record, the Board finds that it is appropriate to essentially adopt the private examiner's findings as to range of motion, which support the award of an increased 40 percent rating for the entire appeal period.

In sum, although the March 2025 VA C&P examination report appeared to show limitation of motion consistent with no more than a 20 percent rating, those findings are inadequate as they did not take into account the ameliorative effect of medications. See Jones, supra; Ingram, supra. Furthermore, the November 2024 report from the private examiner notes that the Veteran's forward flexion was limited to 30 degrees on examination, which is consistent with a 40 percent rating under the General Rating Formula.

Accordingly, the Board finds that the competent and credible evidence reasonably shows that the Veteran's symptoms more nearly approximated limitation of forward flexion to 30 degrees or less throughout the appeal period. See 38 C.F.R. § 4.71a. Entitlement to an increased 40 percent rating is therefore warranted. Given the pre-decisional error discussed above, the Board further finds that the issue of entitlement to a rating in excess of 40 percent must be remanded for evidentiary development.

2. Chronic urticaria

The Veteran seeks an initial rating in excess of 30 percent for chronic urticaria. For the following reasons, the Board finds that this claim must be denied.

The Veteran's symptoms are rated under DC 7825. Under that DC, chronic urticaria is defined as continuous urticaria at least twice per week, off treatment, for a period of six weeks or more. 38 C.F.R. § 4.118, DC 7825. A 10 percent rating is warranted for chronic urticaria that requires first-line treatment (antihistamines) for control. A 30 percent rating is warranted for chronic urticaria that requires second-line treatment (e.g., corticosteroids, sympathomimetics, leukotriene inhibitors, neutrophil inhibitors, thyroid hormones) for control. A 60 percent rating is warranted for chronic refractory urticaria that requires third-line treatment for control (e.g., plasmapheresis, immunotherapy, immunosuppressives) due to ineffectiveness with the first- and second-line treatments. Id.

This appeal dates from the Veteran's January 2025 claim for service connection. Relevant evidence of record includes a November 2024 report from a private examiner, a March 2025 VA C&P examination report, VA treatment records, and the Veteran's lay statements regarding his symptoms.

The November 2024 private examiner's report reflects that the Veteran took daily Claritin for chronic urticaria "which controls the condition." However, the examiner noted that if the Veteran misses a dose, the condition "flares up." At such times, it affects the entire body presenting as itchy red welts.

The March 2025 VA C&P examination report reflects the Veteran's report that his skin symptoms were well controlled on H2 blockers with occasional flare-ups resulting in itching prior to lesion appearance with occasional lesions on the skin. He was diagnosed with chronic urticaria. The examiner noted that the Veteran took antihistamines (Loratadine) orally, constantly or near-constantly. He also reported using topical corticosteroid cream 1% for less than 6 weeks over the past 12 months. No other treatments or medications were noted. The examiner noted that the Veteran's skin condition was without any visible characteristic lesions at the time of the examination, but that when present, lesions typically appeared on the arms, upper legs, chest, and back and were diffuse in coverage. The examiner indicated that the Veteran used first-line treatment (antihistamine) and second-line treatment (corticosteroids) but there was no indication that he required any third-line treatments. No functional impact was noted.

The Veteran's treatment records during the appeal period do not show that he required third-line treatments for chronic urticaria. Likewise, his lay statements of record do not reflect his reports of such treatment.

Based on the relevant evidence, the Board finds that the Veteran's impairment during the appeal period most closely approximates the criteria associated with a 30 percent rating. In this case, the Veteran reported using first- and second-line treatments for his chronic urticaria. This was confirmed by the March 2025 VA examiner. (The November 2024 private examiner's report identifies only first-line antihistamine treatment for chronic urticaria.) The relevant evidence does not show that the Veteran's chronic urticaria was refractory, requiring the use of third-line treatments for control, such as plasmapheresis, immunotherapy, or immunosuppressives, due to ineffectiveness with first- and second-line treatments. Rather, the medical and lay evidence of record shows that the Veteran
period most closely approximates the criteria associated with a 30 percent rating. In this case, the Veteran reported using first- and second-line treatments for his chronic urticaria. This was confirmed by the March 2025 VA examiner. (The November 2024 private examiner's report identifies only first-line antihistamine treatment for chronic urticaria.) The relevant evidence does not show that the Veteran's chronic urticaria was refractory, requiring the use of third-line treatments for control, such as plasmapheresis, immunotherapy, or immunosuppressives, due to ineffectiveness with first- and second-line treatments. Rather, the medical and lay evidence of record shows that the Veteran was largely able to control his symptoms with first- and second-line treatments. Accordingly, the criteria for an initial rating in excess of 30 percent for chronic urticaria were not met.

Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the record). The claim for an increased initial rating for chronic urticaria is denied.

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013).

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

For veterans who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for certain chronic diseases if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309.

For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic as per 38 C.F.R. § 3.309(a)).

Under 38 U.S.C. § 1168, a disability examination and medical opinion may be requested for certain non-presumptive conditions involving TERA. More specifically, the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act) requires the completion of a TERA examination "when there is evidence of a disability" and evidence of participation in a TERA. 38 U.S.C. § 1168(a). A TERA memorandum is also required in such cases. When a medical opinion involving a TERA is requested, the examiner must consider the total potential exposure through all applicable deployments and the synergistic, combined effect of all toxic exposure risk activities of the veteran.

3. Gastrointestinal disorder (claimed as functional abdominal pain syndrome and IBS)

The Veteran seeks entitlement to service connection for a gastrointestinal disorder, which he contends first developed during active service as a result of Gulf War exposures.

In addition to the statutes and regulations pertaining to service connection, for veterans who served in the Southwest Asia theater of operations during the Persian Gulf War, service connection may also be established for chronic disability that cannot be attributed to a known clinical diagnosis (undiagnosed illness) or for a medically unexplained multi-symptom illness (MUCMI), such as chronic fatigue syndrome, fibromyalgia, or "functional gastrointestinal disorders."

Under 38 U.S.C. §
of all toxic exposure risk activities of the veteran.

3. Gastrointestinal disorder (claimed as functional abdominal pain syndrome and IBS)

The Veteran seeks entitlement to service connection for a gastrointestinal disorder, which he contends first developed during active service as a result of Gulf War exposures.

Under 38 U.S.C. § 3.317, "functional gastrointestinal disorders" are defined as 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. Listed under "specific functional gastrointestinal disorders" are IBS and other functional symptoms such as dyspepsia, vomiting, and dysphagia. 38 C.F.R. § 3.317(a).

In this case, as noted above, the AOJ has acknowledged the Veteran's deployment to Southwest Asia. By law, he is considered a Persian Gulf War Veteran under 38 C.F.R. § 3.317(e)(2). Furthermore, the Veteran's VA treatment records show that he has been regularly seen for gastrointestinal issues, which have been diagnosed at times as IBS. A November 2024 evaluation from a private examiner notes a diagnosis of IBS and functional abdominal pain syndrome with episodes of bloating. Finally, a March 2025 VA Gulf War examination report is positive for a functional gastrointestinal disorder (although examinations of the stomach and intestines were negative for a specific diagnosis).

The lay and medical evidence of record shows the Veteran experienced symptoms, for example abdominal pain and bloating, that are commensurate with a compensable rating for IBS. See 38 C.F.R. § 4.114, DC 7319. As noted, symptoms commonly attributed to IBS are listed under the "functional gastrointestinal disorders" category in 38 C.F.R. § 3.317(a).

Under 38 C.F.R. § 3.317(a)(2)(i)(B)(3), "irritable bowel syndrome" is specifically listed as an example of a medically unexplained chronic multisymptom illness, or MUCMI. In light of the evidence and regulations discussed above, and the VA's examiner's findings of a "functional" gastrointestinal disorder with recurrent symptoms over the course of the appeal period, the Board finds that the Veteran's claimed gastrointestinal disorder is presumed to be causally related to his service in the Southwest Asia theater of operations. Under these specific circumstances, service connection is granted.

4. Hypertension

The Veteran seeks service connection for hypertension, which he contends developed due to Gulf War exposures.

As to the "current disability" element, post-service private treatment records reflect that the Veteran was diagnosed with hypertension in 2008. A report from a March 2025 VA C&P examination confirms a diagnosis of hypertension. Accordingly, the Board finds that the "current disability" element has been met with respect to this claim. See 38 C.F.R. § 3.303(a). Additionally, hypertension is considered a chronic disease under 38 C.F.R. § 3.309(a).

The crucial question relates to the "in-service incurrence" and "nexus" elements-i.e., whether the Veteran's hypertension was incurred in or is otherwise related to service. At the outset, the Veteran has not asserted that he was diagnosed with hypertension during his period of active service. The Veteran's service treatment records do not reflect instances of elevated blood pressure. An August 2006 Report of Medical Assessment one month prior to his separation revealed no significant medical problems.

Post-service medical records show that the Veteran was diagnosed with hypertension in 2008 while he was being treated for (non-service-connected) non-Hodgkin's lymphoma. In the years afterward, his blood pressure results appeared to normalize. More recent (October 2022 and January 2023) VA treatment notes reflect that he was seen for symptomatic hypotension (low blood pressure), which resolved with medication adjustments.

A November 2024 report from a private examiner notes the examiner's opinion that the Veteran's hypertension was "as likely as not" "directly and causally related to Gulf War Syndrome" and "directly and causally related" to his military service. The examiner further stated (citing no evidence) that the Veteran's hypertension had its onset during his deployment to Southwest Asia. On review, however, this opinion is not persuasive as the examiner did not appear to review the Veteran's service treatment records or address specific pieces of evidence, to include the significance of the Veteran's history of cancer treatment as a possible cause of his hypertension. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (stating that a medical opinion must support its conclusion with an analysis that the Board can weigh, and a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (stating that "[t]he Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion").

The Veteran was afforded a VA C&P examination in March 2025. The report reflects that he was diagnosed with hypertension in 2008 during chemotherapy treatment for lymphoma. He also developed cardiomegaly and had continued treatment since that time. The examiner opined that the Veteran's hypertension had a known etiology of being chemotherapy-induced (the chemotherapy also led to the development of cardiomegaly and reduced ejection fraction). The examiner noted that the Veteran denied having elevated blood pressure since 2008, and primary care provider records starting in 2013 were negative for hypertension; antihypertensive medications were noted to be related to reduced ejection fraction and not elevated blood pressure. The examiner explained that hypertension has been reported to be the most common comorbidity encountered in patients with malignancy. Additionally, cancer therapy-induced hypertension is often dose limiting, increasing cardiovascular mortality in cancer survivors, and is usually reversible after interruption or discontinuation of treatment. The examiner reasoned that such a picture was consistent with the Veteran's medical records "that show normal blood pressure results or mild hypotension post-completion of chemotherapy treatment in 2008." Accordingly, the examiner opined that the Veteran's hypertension was less likely than not caused by the indicated TERA(s), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERAs of the Veteran.

The Veteran has not challenged the VA examiner's findings. In September 2025, his representative submitted an Informal Hearing Presentation with no substantive arguments or evidence.

After careful review, the Board finds that the March 2025 VA examiner's opinion is the most persuasive evidence regarding the etiology of the Veteran's claimed hypertension. The opinion establishes that the Veteran's hypertension was most likely caused by post-service treatment for non-service-connected lymphoma, and was not related to any service-related cause, to include the Veteran's documented TERAs.

In this case, the positive evidence of record consists of the Veteran's stated belief that his hypertension was linked to Gulf War exposures, along with the November 2024 private examiner's opinion linking hypertension to such exposures. The Board explained above that the November 2024 private examiner's report is not persuasive evidence, as it lacks a substantive rationale. As for the Veteran's lay statements, the Board accepts that the Veteran is competent to report what he has personally observed. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he is not competent to offer opinions on complex medical questions requiring specialized knowledge, such as the physiological causes of his hypertension.

Moreover, the Veteran has not actually asserted that his hypertension had its onset in service or within one year of active service. As documented in the March 2025 C&P report, the Veteran indicated that his hypertension was diagnosed in 2008, more than one year after his discharge from service. The examiner explained that the Veteran's hypertension had a known etiology and that the weight of the evidence was against his claim. The Veteran has not challenged those findings,
au v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he is not competent to offer opinions on complex medical questions requiring specialized knowledge, such as the physiological causes of his hypertension.

Moreover, the Veteran has not actually asserted that his hypertension had its onset in service or within one year of active service. As documented in the March 2025 C&P report, the Veteran indicated that his hypertension was diagnosed in 2008, more than one year after his discharge from service. The examiner explained that the Veteran's hypertension had a known etiology and that the weight of the evidence was against his claim. The Veteran has not challenged those findings, notwithstanding his earlier assertions. The Veteran has not reported being told by any medical professional (other than the examiner who authored the November 2024 report) that his hypertension was incurred in service, within one year of separation from service, or was secondary to any service-connected disease or injury. See Jandreau, 492 F.3d at 1377.

Conversely, a VA medical professional has reviewed the record and opined that the Veteran's hypertension was less likely than not related to service, to include his documented TERAs. The March 2025 VA medical opinion reflects that the VA examiner provided the Veteran with an opportunity to describe his symptom history and, based on the relevant lay and medical evidence, determined that the Veteran's claimed hypertension had a known, post-service etiology and was therefore unlikely to have been linked to his period of active service. See, e.g., Nieves-Rodriguez, supra. Of note, the examiner acknowledged the Veteran's in-service TERAs but found that his hypertension was less likely than not caused by the indicated TERAs, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERAs of the Veteran. See 38 U.S.C. § 1168(a).

The Board emphasizes that the March 2025 VA medical opinion constitutes the most persuasive evidence of record on the question of nexus. See Flash v. Brown, 8 Vet. App. 332 (1995) (the Board is not free to reject medical evidence on the basis of its own unsubstantiated medical conclusions). Likewise, the Board finds that the March 2025 opinion persuasively weighs against a finding that the Veteran's hypertension developed to a compensable degree within one year of separation from active service. The Veteran has not credibly identified, and the record does not reflect, manifestations of any chronic disease process in service (such as instances of elevated blood pressure), nor has he provided competent evidence of continuity of symptomatology stemming from hypertension-related pathology since service. See 38 C.F.R. § 3.303(b); Walker, supra.

The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is not for application as to this claim. See Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). Entitlement to service connection for hypertension is denied.

5. Left ear hearing loss disability

The Veteran seeks service connection for a left ear hearing loss disability. He was previously service connected for a right ear hearing loss disability based on March 2025 VA examination findings; however, the same examiner determined that a causal nexus for the left ear had not been established.

As to the "current disability" element, the March 2025 VA examination report establishes a current left ear hearing loss disability for VA purposes under 38 C.F.R. § 3.385. The "in-service incurrence" element is also established, as the Veteran's military occupational specialty of flight engineer indicates a high probability of hazardous noise exposure during service.

Turning to the issue of "nexus," the Veteran's service treatment records include several audiograms completed during periods of Reserve service and active service. A March 2025 VA examination report reflects the Veteran's report of military noise exposure and in-service onset of hearing loss. The examiner noted that while there was a permanent threshold shift in the right ear, there was not a permanent shift in hearing from entrance to separation in the left ear. Consequently, the examiner opined that it was less likely than not that the Veteran's left ear hearing loss was due to service.

The Board finds that this opinion is inadequate for several reasons. First, the examiner characterized audiograms as "enlistment" and "separation" that were performed prior to and after periods of Reserve service, not active duty. Second, the examiner failed to address other audiograms completed during the Veteran's Reserve and active service periods. Third, the examiner failed to address the Veteran's competent lay reports of hearing loss (presumably in both ears) since service. Fourth, and most important, the examiner's rationale appears to hinge on a tiny difference in hearing shifts in each ear; the positive nexus for the right ear was based on a 15 decibel shift at 6000 Hz between April 1990 and September 2012 audiograms, while the negative finding for the left ear was based on a shift of only 10 decibels over the same period. The Board respects the examiner's expertise in these matters; however, such a small factual distinction introduces significant doubt when serving as the difference between a grant and a denial of service connection. The Board is obligated to resolve reasonable doubt in the Veteran's favor. See 38 U.S.C. § 5107(b).

Given the AOJ's decision to grant service connection for a right ear hearing loss disability; the marginal difference in threshold shifts in the right and left ears identified by the examiner; and the Veteran's competent and credible lay statements regarding the progression of his hearing loss, the Board finds that the evidence of record is sufficient to grant service connection for a left ear hearing loss disability. See 38 C.F.R. § 3.303(a).

6. Headache disorder

The Veteran seeks service connection for a headache disorder, which he contends developed due to Gulf War exposures.

As to the "current disability" element, a March 2025 VA C&P examination report shows that the Veteran was diagnosed with tension headaches. A November 2024 report from a private examiner also shows a diagnosis of cephalgia, or chronic headaches. The Board finds that the current disability element is satisfied with respect to this issue. See 38 C.F.R. § 3.303(a).

As to the "in-service incurrence" and "nexus" elements, the Board acknowledges that the Veteran's service treatment records are silent for any headache-related diagnoses. Notwithstanding, the November 2024 private examiner's report notes that the Veteran stated that he suffered from headaches that he believed were related to Gulf War exposures. The examiner opined that it was at least as likely as not that the Veteran's headache disorder was "directly and causally related to [the Veteran's] military service." This reflects a medical professional's assessment based on competent lay evidence of in-service incurrence with continuous symptoms thereafter. See Monzingo v. Shinseki, 26 Vet. App. 97 (2012) (examination reports are adequate when they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion).

The March 2025 VA C&P examination report reiterates the Veteran's complaints of headaches with onset in 2006, during his period of active service, and that he struggled with recurrent headaches thereafter. He was diagnosed with tension headaches. However, the examiner offered a negative nexus opinion based on the absence of medical or scientific evidence of a causal relationship between the Veteran's headaches and his documented in-service TERAs.

After careful review, the Board finds that, when resolving any reasonable doubt in the Veteran's favor, there is sufficient lay and medical evidence to support a finding that the Veteran's current headache disorder was incurred in service, with continuity of symptomatology thereafter. See 38 C.F.R. § 3.303(b); Walker, supra. As to the negative VA opinion, the Board finds that the VA examiner's rationale is unpersuasive because it does not adequately address the Veteran's competent lay reports of in-service incurrence with continuous symptoms and treatment thereafter. Conversely, the positive November 2024 private examiner's report takes these statements into account. The Board recognizes that further inquiry into the matter could lead to a prohibited remand for negative evidence. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003).

Based on the above evidence, the Board finds that all three
service, with continuity of symptomatology thereafter. See 38 C.F.R. § 3.303(b); Walker, supra. As to the negative VA opinion, the Board finds that the VA examiner's rationale is unpersuasive because it does not adequately address the Veteran's competent lay reports of in-service incurrence with continuous symptoms and treatment thereafter. Conversely, the positive November 2024 private examiner's report takes these statements into account. The Board recognizes that further inquiry into the matter could lead to a prohibited remand for negative evidence. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003).

Based on the above evidence, the Board finds that all three elements of service connection are satisfied. See 38 C.F.R. § 3.303(a). A medical professional has indicated a sufficient likelihood that the Veteran's current headache disorder was incurred in active service. His competent lay statements support this finding, and the positive opinion has not been persuasively rebutted.

Accordingly, for the reasons discussed above, the Board concludes that the evidence of record supports a finding that the Veteran's headache disorder was incurred in service. See 38 C.F.R. § 3.303(a). His claim for service connection is granted.

REASONS FOR REMAND

7. Entitlement to a rating in excess of 40 percent for a low back disability

8. Entitlement to an initial rating in excess of 10 percent for left lower extremity radiculopathy

9. Entitlement to an initial rating in excess of 10 percent for right lower extremity radiculopathy

The Veteran seeks an increased rating for his low back disability and associated lower extremity radiculopathy. These disabilities are rated under DCs 5242 and 8520, respectively. Under DC 5242 (the General Rating Formula for Diseases and Injuries of the Spine), a rating in excess of 40 percent is warranted for unfavorable ankylosis of the entire thoracolumbar spine. See 38 C.F.R. § 4.71a; see also Chavis v. McDonough, 34 Vet. App. 1 (2021) (holding that ankylosis of the spine can be demonstrated by its functional equivalent-i.e., functional loss consistent with that contemplated by ankylosis). Under DC 8520, a rating in excess of 10 percent are warranted for incomplete paralysis of the sciatic nerve that is at least "moderate." See 38 C.F.R. § 4.124a. Neither DC references medication or the effects thereof.

The Veteran received a VA C&P back examination in March 2025, during which he reported using corticosteroid injections and NSAIDs to treat his symptoms. His VA treatment records note the use of aspirin. The extent of the relief such treatment provided is unclear.

In Jones v. Shinseki, the Court held that "the Board may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria." 26 Vet. App. at 63. In a recent decision, Ingram v. Collins, the Court extended that holding, stating that, with regard to the DCs for rating musculoskeletal conditions and other DCs that do not reference medication, "the Board must discount beneficial medication effects when assigning an evaluation." 38 Vet. App. at 132.

Pursuant to Jones and Ingram, the Board finds that the C&P examination of record was inadequate, as the provider who completed the examination did not discuss the beneficial effects of medication used to treat the Veteran's symptoms. Remand is required to correct this pre-decisional duty to assist error. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate).

10. Entitlement to an initial compensable rating for allergic rhinitis

The Veteran seeks a compensable rating for his allergic rhinitis, which is rated under 38 C.F.R. § 4.97, DC 6522. Notably, DC 6522 does not reference medication or the effects thereof. Id. The Veteran received a VA C&P examination in March 2025, during which he reported taking Loratadine for this condition. It is unclear whether the ameliorative effects of this medication were considered in the examiner's assessment. In light of Jones, supra, the Board finds that the March 2025 C&P examination of record was inadequate, as the examiner did not discuss the beneficial effects of
initial compensable rating for allergic rhinitis

11. Entitlement to an initial compensable rating for a bilateral hearing loss disability

The Board's grant of service connection for a left ear hearing loss disability changes the way the Veteran's condition is rated, pursuant to 38 C.F.R. §§ 4.85 and 4.86. Accordingly, a remand is required for the AOJ to adjudicate the rating for bilateral hearing loss disability during the appeal period. See 38 C.F.R. § 20.802(a).

12. Entitlement to service connection for respiratory insufficiency (also claimed as dyspnea and chronic sinusitis)

The Veteran seeks service connection for respiratory insufficiency. The initial question with this issue is whether the "current disability" element was satisfied. See 38 C.F.R. § 3.303(a).

The Veteran submitted a November 2024 report from a private examiner which notes the Veteran's history of respiratory insufficiency. The examiner noted that the Veteran had a very poor aerobic capacity, which began with his Gulf War service following his exposure to toxic burn pits. The examiner also linked the Veteran's respiratory symptoms to chronic sinusitis. The examiner opined that it was "as likely as not" that these conditions were "directly and causally related to Gulf War Syndrome." However, these findings are not supported by a substantive rationale; they do not reflect that the examiner undertook a clinical examination of the Veteran, nor that the examiner reviewed the Veteran's service treatment records or post-service medical history.

In March 2025, the Veteran received a VA C&P respiratory conditions examination, during which he was not diagnosed with any respiratory condition. The Veteran reported that he experienced intermittent shortness of breath when rising from a seated position or when rising from lying down. Notably, he stated that these symptoms began following chemotherapy treatment for non-Hodgkin's lymphoma. Additionally, a VA C&P sinusitis examination was negative for a sinusitis diagnosis.

The Board finds that the March 2025 VA examination report on this issue is inadequate. The VA examiner did not opine as to the etiology of the Veteran's respiratory symptoms. Also, the examiner's negative findings as to a current diagnosis are belied by the Veteran's reported symptoms; the examiner did not explain this discrepancy. See Stefl, 21 Vet. App. at 124-25 (stating that a medical opinion must support its conclusion with an analysis that the Board can weigh, and a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision); Nieves-Rodriguez, 22 Vet. App. at 304 (stating that "[t]he Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion").

Finally, the March 2025 C&P sinusitis examination report does not adequately explain why a sinusitis diagnosis was ruled out, particularly given the November 2024 private examiner's findings and the Veteran's reported symptoms of sinus pressure, congestion, nasal drainage, and history of sinus treatments with antibiotics. The Board notes that VA issued a final rule, effective August 5, 2021, that established service connection based on presumed exposure to fine particulate matter for specific rare cancers and certain chronic diseases including asthma, rhinitis, and sinusitis. See 38 C.F.R. § 3.320. As the Veteran was presumed to have had such harmful exposure, a valid diagnosis of sinusitis would likely be service connected.

Accordingly, this matter must be remanded for an updated examination to correct these pre-decisional duty to assist errors. Barr, supra.

13. Entitlement to service connection for fibromyalgia

14. Entitlement to service connection for chronic fatigue syndrome

The Veteran seeks service connection for fibromyalgia and chronic fatigue syndrome.
effective August 5, 2021, that established service connection based on presumed exposure to fine particulate matter for specific rare cancers and certain chronic diseases including asthma, rhinitis, and sinusitis. See 38 C.F.R. § 3.320. As the Veteran was presumed to have had such harmful exposure, a valid diagnosis of sinusitis would likely be service connected.

Accordingly, this matter must be remanded for an updated examination to correct these pre-decisional duty to assist errors. Barr, supra.

13. Entitlement to service connection for fibromyalgia

14. Entitlement to service connection for chronic fatigue syndrome

The Veteran seeks service connection for fibromyalgia and chronic fatigue syndrome. The initial question with these issues is whether the "current disability" element was satisfied. See 38 C.F.R. § 3.303(a). Given the Veteran's service in the Southwest Asia theater of operations, if indeed he has a current diagnosis of fibromyalgia and/or chronic fatigue syndrome, service connection on a presumptive basis would be warranted. See 38 C.F.R. § 3.317(a).

Relevant evidence includes a November 2024 report from a private examiner which notes diagnoses of both fibromyalgia and chronic fatigue syndrome. The examiner noted that the Veteran "reports symptoms of" fibromyalgia and chronic fatigue syndrome, and that it was "as likely as not" that the conditions were "directly and causally related to Gulf War Syndrome." On review, however, the report does not appear to be based on a clinical examination or review of relevant medical evidence. Likewise, the examiner does not explain whether the Veteran's symptoms were attributable to other, diagnosable conditions.

In March 2025, the Veteran received VA C&P examinations for fibromyalgia and chronic fatigue syndrome. The reports reflect negative findings as to current diagnoses. Notable symptoms included fatigue, generalized pain, headaches, and bowel disturbances; however, the examiner explained that these symptoms were attributable to other, diagnosed conditions such as sleep apnea, residuals from chemotherapy for non-Hodgkin's lymphoma, and arthritis. Notably, both examination reports reflect the examiner's admission that the Veteran had not received a full workup for either fibromyalgia or chronic fatigue syndrome.

The Board finds that the existing medical evidence of record is inadequate. Neither the private examiner nor the VA examiners provided a sufficient rationale upon which to establish a diagnosis for either claimed condition. See Stefl, supra; Nieves-Rodriguez, supra. Moreover, the VA examination reports reflect that the Veteran did not receive full workups to rule out either diagnosis. Accordingly, these matters must be remanded for updated examinations to correct these pre-decisional duty to assist errors.

The matters are REMANDED for the following action:

1. Schedule the Veteran for an examination with an appropriate clinician to determine the nature and severity of the Veteran's low back disability, to include bilateral lower extremity radiculopathy and any other associated neurological impairment. To the extent possible, the clinician should respond to the following:

(a) Test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing.

(b) Elicit information regarding the severity, frequency, and duration of any flare-ups (if indicated), and the degree of functional loss during flare-ups. The clinician is asked to describe whether pain significantly limits functional ability during flares, and if so, the clinician must estimate range of motion during flares. IF THE EXAMINATION DOES NOT TAKE PLACE DURING A FLARE, THE CLINICIAN MUST GLEAN INFORMATION REGARDING THE FLARES' SEVERITY, FREQUENCY, DURATION, AND FUNCTIONAL LOSS MANIFESTATIONS FROM THE VETERAN, MEDICAL RECORDS, AND OTHER AVAILABLE SOURCES. EFFORTS TO OBTAIN SUCH INFORMATION MUST BE DOCUMENTED. If there is no pain and/or no limitation of function, such facts must be noted in the report.

(c) Estimate range of motion of the spine (including in the circumstances outlined above) when discounting the beneficial effects of treatment and medication (including the use of corticosteroid injections and NSAIDs) used to treat the Veteran's disability.

(d) Opine as to whether the Veteran's low back disability results in functional loss consistent with ankylosis, particularly during flare-ups.

(e) To the extent possible, identify any symptoms and functional impairments due to the Veteran's low back disability and discuss the effects of such on any occupational functioning and activities of daily living.

(f) Opine as to the overall severity of the Veteran's bilateral lower extremity radiculopathy.

The clinician is advised that the Veteran is competent to report symptoms, treatment, events
motion of the spine (including in the circumstances outlined above) when discounting the beneficial effects of treatment and medication (including the use of corticosteroid injections and NSAIDs) used to treat the Veteran's disability.

(d) Opine as to whether the Veteran's low back disability results in functional loss consistent with ankylosis, particularly during flare-ups.

(f) Opine as to the overall severity of the Veteran's bilateral lower extremity radiculopathy.

The clinician is advised that the Veteran is competent to report symptoms, treatment, events, and injuries, and that his assertions must be taken into account, along with the other evidence of record, in formulating the requested medical opinions.

Detailed rationales should be included in support of all opinions provided.

2. Schedule the Veteran for a VA examination by an appropriate clinician to determine the nature and severity of the Veteran's allergic rhinitis. The clinician should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria.

The clinician should specifically address:

(a) Whether the Veteran's use of medication (including Loratadine) affected the level of severity of his allergic rhinitis.

(b) Identify the likely level of severity of the Veteran's allergic rhinitis in the absence of medication.

Detailed rationales should be included in support of all opinions provided.

3. Assign a rating in the first instance for service-connected bilateral hearing loss (in light of the grant of service connection for a left ear hearing loss disability herein).

4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran's claimed respiratory insufficiency (also claimed as dyspnea and chronic sinusitis). The clinician must review the record and respond to the following:

(a) Clarify any relevant diagnoses pertaining to the Veteran's respiratory symptoms.

(b) Opine as to whether any indicated diagnosis had its onset in active service or is otherwise related to active service.

(c) Opine as to whether the Veteran's reported symptoms were caused by or otherwise related to participation in toxic exposure risk activities as a result of his service in Southwest Asia during the Persian Gulf War. The clinician must consider (i) the total potential exposure through all applicable deployments; and (ii) the synergistic, combined effect of all toxic exposure risk activities of the Veteran.

The clinician is advised that the Veteran is competent to report symptoms, treatment, events, and injuries, including those that occurred in service, and that his assertions must be taken into account, along with the other evidence of record, in formulating the requested medical opinions.

Detailed rationales should be included in support of all opinions provided.

5. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran's claimed fibromyalgia. The clinician must review the record and clarify whether the Veteran has a current diagnosis of fibromyalgia. If the Veteran does not meet the criteria for a diagnosis, please explain why.

Detailed rationales should be included in support of all opinions provided.

6. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran's claimed chronic fatigue syndrome. The clinician must review the record and clarify whether the Veteran has a current diagnosis of chronic fatigue syndrome. If the Veteran does not meet the criteria for a diagnosis, please explain why.

Detailed rationales should be included in support of all opinions provided.

A. S. CARACCIOLO

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board T. Minot, 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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