Citation Nr: 22062240 Decision Date: 11/07/22 Archive Date: 11/07/22 DOCKET NO. 18-26 302 DATE: November 7, 2022 ORDER The appeal for entitlement to an initial evaluation in excess of 10 percent for gastroesophageal reflux disease (GERD) is dismissed. New and material evidence has been received, the claim for service connection for chronic fatigue syndrome, to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) or due to exposure to particulate matter as a result of Persian Gulf War Service, is reopened. New and material evidence has been received, the claim for service connection for digestive system disorder (other than GERD), claimed as stomach problems to include IBS, to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) or due to exposure to particulate matter as a result of Persian Gulf War Service, is reopened. New and material evidence has been received, the claim for service connection for a respiratory disorder, claimed as breathing problems, to include rhinitis and sarcoidosis, to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) or due to exposure to particulate matter as a result of Persian Gulf War Service, is reopened. New and material evidence have been received, the claim for service connection for joint and muscle pain, to include hand and wrist pain, to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) or due to exposure to particulate matter as a result of Persian Gulf War Service, is reopened. Service connection for rhinitis due to exposure to particulate matter as a result of Persian Gulf War Service is granted. An initial 10 percent disability rating for service-connected hypertension is granted. REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for headaches, to include migraines, to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) or due to exposure to particulate matter as a result of Persian Gulf War Service, or secondary to service-connected PTSD, is remanded. Entitlement to service connection for joint and muscle pain, to include hand and wrist pain, to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) or due to exposure to particulate matter as a result of Persian Gulf War Service, is remanded. Entitlement to service connection for chronic fatigue syndrome (CFS), to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) or due to exposure to particulate matter as a result of Persian Gulf War Service, or secondary to service-connected PTSD, is remanded. Entitlement to service connection for a digestive disorder (other than GERD), to include irritable bowel syndrome (IBS), to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) or due to exposure to particulate matter as a result of Persian Gulf War Service, or as secondary to service-connected PTSD, is remanded. Entitlement to service connection for a respiratory condition (other than rhinitis), claimed as lung and coughing condition, to include sarcoidosis, to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) or due to exposure to particulate matter as a result of Persian Gulf War Service is remanded. Entitlement to an initial rating higher than 10 percent for left ankle strain is remanded. FINDINGS OF FACT 1. At his June 2022 hearing, prior to the promulgation of a decision in the appeal, the Veteran explicitly and unambiguously withdrew his appeal of the issue of entitlement to an initial evaluation in excess of 10 percent for GERD. 2. The January 1994 rating decision denying service connection for chronic fatigue syndrome is final. The Veteran did not submit a notice of disagreement, and new and material evidence was not received within one year of notice of the decision. 3. Evidence added to the claims file since the January 1994 rating decision is not cumulative or redundant and relates to an unestablished fact necessary to substantiate the claim for CFS. 4. The January 1994 rating decision denying service connection for a digestive system disorder, claimed as stomach problems, to include IBS, is final. The Veteran did not submit a notice of disagreement, and new and material evidence was not received within one year of notice of the decision. 5. Evidence added to the claims file since the January 1994 rating decision is not cumulative or redundant and relates to an unestablished fact necessary to substantiate the digestive system disorder claim. 6. The January 1994 rating decision denying service connection for a respiratory disorder, claimed as breathing problems, to include rhinitis and sarcoidosis, is final. The Veteran did not submit a notice of disagreement, and new and material evidence was not received within one year of notice of the decision. 7. Evidence added to the claims file since the January 1994 rating decision is not cumulative or redundant and relates to an unestablished fact necessary to substantiate the respirator disorder claim. 8. The January 1994 rating decision denying service connection for joint and muscle pain, to include hand and wrist pain, as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) or due to exposure to particulate matter as a result of Persian Gulf War Service is final. The Veteran did not submit a notice of disagreement, and new and material evidence was not received within one year of notice of the decision. 9. Evidence added to the claims file since the January 1994 rating decision is not cumulative or redundant and relates to an unestablished fact necessary to substantiate the joint and muscle claim. 10. The Veteran had verified service in the Southwest Asia theater of operations during the Persian Gulf War. 11. The Veteran is presumed to have been exposed to fine, particulate matter during service in Southwest Asia during the Persian Gulf War. 12. The Veteran's currently diagnosed rhinitis manifested within 10 years from the date of separation from service that included the period of service in Southwest Asia. 13. Resolving doubt in favor of the Veteran, the service-connected hypertension is manifested by a history of diastolic pressure predominantly 100 or more that requires continuous medication for control. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal for entitlement to an initial evaluation in excess of 10 percent for GERD have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The January 1994 rating decision denying service connection for chronic fatigue syndrome is final. 38 U.S.C. § 7015 (c), 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 3. New and material evidence sufficient to reopen the claim of service connection for chronic fatigue syndrome has been received after the last final decision. 38 U.S.C. § 5018; 38 C.F.R. § 3.156(a), (c). 4. The January 1994 rating decision denying service connection for a digestive system disorder, claimed as stomach problems, to include IBS is final. 38 U.S.C. § 7015 (c), 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 5. New and material evidence sufficient to reopen the claim of service connection for a digestive system disorder, claimed as stomach problems, to include IBS, has been received after the last final decision. 38 U.S.C. § 5018; 38 C.F.R. § 3.156(a), (c). 6. The January 1994 rating decision denying service connection for a respiratory disorder, claimed as breathing problems, to include rhinitis and sarcoidosis is final. 38 U.S.C. § 7015 (c), 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 7. New and material evidence sufficient to reopen the claim of service connection for a respiratory disorder, claimed as breathing problems, to include rhinitis and sarcoidosis, has been received after the last final decision. 38 U.S.C. § 5018; 38 C.F.R. § 3.156(a), (c). 8. The January 1994 rating decision denying service connection for a joint and muscle pain, claimed as aching joints, to include hand and wrist pain, is final. 38 U.S.C. § 7015 (c), 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 9. New and material evidence sufficient to reopen the claim of service connection for joint and muscle pain, claimed as aching joints, to include hands and wrist pain (MUCMI) has been received after the last final decision. 38 U.S.C. § 5018; 38 C.F.R. § 3.156(a), (c). 10. The criteria for entitlement to service connection for rhinitis have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.320. 11. The criteria for a 10 percent disability rating for service-connected hypertension have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.7, 4.21, 4.31, 4.104, Diagnostic Code 7101. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from July 1989 to December 1989, from December 1990 to March 1991, from May 2006 to May 2007, and from April 2010 to April 2011, to include service in Saudi Arabia and Afghanistan. This matter comes before the Board of Veterans Appeals (Board) on appeal from October 2013, June 2015, and July 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The October 2013 rating decision, in part, denied service connection for sleep apnea. The June 2015 rating decision in part, denied an increased rating for GERD and service connection for chronic fatigue syndrome, joint and muscle pain and chronic cough/respiratory condition. The July 2016 rating decision denied service connection for a respiratory condition, tension headaches and diarrhea. In June 2022, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript has been associated with the electronic claims file. After reviewing the evidence of record, in light of the Veteran's reported symptoms and contentions and to encompass all disorders that are reasonably raised by the record, the Board has recharacterized the Veteran's claims for digestive system disorder and respiratory disorder as indicated on the title page of this document. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (in determining the scope of a claim, the Board must consider the claimant's description of the claim, the symptoms described, and the information submitted or developed in support of the claim). The October 2013 rating decision combined the sleep apnea and respiratory claims. The Board has bifurcated the claims to reflect the Veteran's contentions and the medical evidence. The Board has also bifurcated the claim for rhinitis. 1. Entitlement to an initial evaluation in excess of 10 percent for GERD is dismissed. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the Veteran or by his authorized representative. Id. An oral withdrawal of an appeal, such as one made at a hearing, must be (1) explicit, (2) unambiguous, and (3) done with a full understanding of the consequences of such action on the part of the claimant. Acree v. O'Rourke, 891 F.3d 1009, 1014 (Fed. Cir. 2018). During the June 2022 Board hearing, prior to the promulgation of a decision in the appeal, the Veteran explicitly and unambiguously withdrew the appeal of the issue of entitlement to an initial evaluation in excess of 10 percent for GERD. He did so in the company of his representative with a full understanding of the consequences of withdrawal. As to this issue, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review this claim and it is dismissed. 2. Whether new and material evidence has been received to reopen the claim for service connection for chronic fatigue syndrome. 3. Whether new and material evidence has been received to reopen the claim for service connection for a digestive system disorder, claimed as stomach problems, to include IBS. 4. Whether new and material evidence has been received to reopen the claim for service connection for respiratory disorder, claimed as breathing problems, to include rhinitis. 5. Whether new and material evidence has been received to reopen the claim for service connection for joint and muscle pain, claimed as aching joints, to include hand and wrist pain. Claims to reopen Generally, a claim which has been denied in a final unappealed rating decision, or a rating decision that was appealed but was not perfected, may not thereafter be reopened or allowed. 38 U.S.C. § 7105(c), (d)(3); 38 C.F.R. § 20.1103. If "new and material" evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). "New evidence" means evidence not previously submitted to agency decision makers which is neither cumulative nor redundant of the evidence of record at the time of the last prior denial. 38 C.F.R. § 3.156(a). Materiality has two components; first, that the new evidence pertains to the reason(s) for the prior denial, and second, that the new evidence, combined with VA assistance and considering the other evidence of record, raises a reasonable possibility of substantiating the claim. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. Additionally, the United States Court of Appeals for the Federal Circuit has noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a claimant's injury or disability, even where it would not be enough to convince the Board to grant a claim. Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998). Regardless of the RO's determination as to whether new and material evidence has been received, the Board has a jurisdictional responsibility to determine whether a claim previously denied by the RO has been properly reopened. See Jackson v. Principi, 265 F.2d 1366 (Fed. Cir. 2001) (citing 38 U.S.C. §§ 5108, 7105(c)). Here, the Veteran has requested that VA reopen his claims for service connection for chronic fatigue syndrome (CFS), a digestive system disorder; a respiratory disorder, claimed as breathing problems, to include rhinitis and sarcoidosis; and joint and muscle pain. The Veteran's claims were denied in January 1994. At that time, the RO considered evidence in the form of the Veteran's service records; medical treatment records; and the Veteran's personal statements made in support of his claim. The RO's denial was based on lack of evidence of a diagnosis of CFS, stomach problems, breathing problems, and aching joints in the Veteran's record, as well as no nexus for a stomach problem. The Veteran was notified of the January 1994 rating decision and of his appellate rights, but he did not submit a notice of disagreement (NOD), or new and material evidence, within one year of the notice of this rating decision. Therefore, the January 1994 rating decision became final. See Lang v. Wilkie, 971 F.3d 1348, 1354-55 (Fed. Cir. 2020); Beraud v. McDonald, 766 F.3d 1402, 1407 (Fed. Cir. 2014). Since the January 1994 rating decision became final, additional evidence has been received in the form of additional medical records, showing diagnoses of IBS, chronic rhinitis, sarcoidosis, and new statements provided by the Veteran, including his June 2022 Board hearing testimony. This evidence is new as it was not part of the record at the time the prior decision became final. It is material because relates to unestablished facts necessary to substantiate the claims for service connection for chronic fatigue syndrome (CFS), a digestive system disorder, a respiratory disorder, rhinitis, and joint and muscle pain, claimed as aching joints, to include hands and wrist pain. See Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998). As new and material evidence has been received, reopening the previously denied claims of entitlement to service connection for the Veteran's chronic fatigue syndrome (CFS), a digestive system disorder, claimed as stomach problems, to include IBS, a respiratory disorder, claimed as breathing problems, to include rhinitis and sarcoidosis, and joint and muscle pain, claimed as aching joints, to include hands and wrist pain, is warranted. To this limited extent, the petition to reopen is granted. Service Connection Generally, to establish service connection there must be competent evidence showing: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the in-service injury incurred or aggravated during service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. To establish secondary service connection the VA must find 1) that there is a current disability that is not service connected; and 2) that there is at least one service- connected disability; and 3) evidence that the non-service-connected disability is either, a) proximately due to or the result of a service-connected disability; or b) aggravated beyond its natural progress by a service-connected disability. 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). Service connection may also be established for a chronic disability resulting from an undiagnosed illness which manifests either during active service in the Southwest Asia Theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2026. 38 U.S.C. § 1117; 38 C.F.R. § 3.317; 86 Fed. Reg. 51,001 (September 14, 2021). The term "Persian Gulf Veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317 (d)(1). The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317 (d)(2). A 'qualifying chronic disability' means a chronic disability resulting from any of the following (or any combination of any of the following): an undiagnosed illness; a medically unexplained chronic multi-symptom illness (MUCMI) (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms; and any diagnosed illness that the Secretary determines. 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1)(i). Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A chronic disability resulting from an undiagnosed illness shall be rated using evaluation criteria from the VA's Schedule for Rating Disabilities for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. 38 C.F.R. § 3.317 (a) (2-5). Additionally, effective August 5, 2021, VA added 38 C.F.R. § 3.320 which, in relevant part, allows for a presumption of exposure to fine, particulate matter if a disease listed in paragraph (a)(2) becomes manifest to any degree (including non-compensable) within 10 years from the date of separation from service, that includes a qualifying period of service as defined in 38 C.F.R. § 3.320 (a)(4). The chronic diseases associated with exposure to particulate matter are: (i) Asthma, (ii) Rhinitis, (iii) Sinusitis, to include rhinosinusitis. 38 C.F.R. § 3.320. The presumption of exposure includes a Veteran who has a qualifying period of service as defined as any period of active military, naval, or air service in the Southwest Asia Theater of operations, as defined in § 3.317(e)(2), during the Persian Gulf War as defined in § 3.2(i). VA must consider all favorable lay evidence of record. 38 U.S.C. § 5107. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21. Vet. App. 303 (2007). The Secretary shall consider all information and lay and medical evidence of record in a case and make appropriate determinations as to competence, credibility, and weight. 38 U.S.C. § 5107; 38 C.F.R. § 3.303; Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience, if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. When there is an approximate balance between positive and negative evidence, equipoise, the benefit of the doubt doctrine must apply in favor of the Veteran. But when the evidence persuasively weighs against the claims of the Veteran the claim will be denied on its merits, and when the evidence weighs for the claims of the Veteran the claim will be granted on its merits. In those cases, the benefit of the doubt doctrine is inapplicable. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. Entitlement to service connection for rhinitis, to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) or due to exposure to particulate matter as a result of Persian Gulf War Service. The Veteran contends that his rhinitis is due to his service in the Southwest Asia. He specifically attributes his rhinitis to repeated exposure to burn pits while deployed in Saudi Arabia and Afghanistan. Here, the Veteran's personnel records and DD-214 show that he served in Saudi Arabia and Afghanistan in support of Operation Desert Shield and Storm from December 16, 1990 and March 15, 1991, Operation Noble Eagle and Enduring Iraqi Freedom from July 28, 2010 to February 26, 2011. The Veteran has also provided competent and credible testimony regarding the nature, circumstances, and frequency of his exposure to burn pits during multiple deployments in service, which is consistent with the places, types, and circumstances of the duties he performed during his period of active service. See 38 U.S.C. § 1154(a) and June 2022 Board hearing transcript. Accordingly, the Veteran is presumed to have been exposed to particulate matter during service. 38 C.F.R. § 3.320(a)(4). The claims file contains a competent, current diagnosis of chronic rhinitis and allergic rhinitis, and treatment in the form of medication for this condition. See April 2021 private treatment records. Accordingly, a current disability is established. The Board also notes that lay statements of record note that the symptoms of chronic rhinitis manifested during service and continued after separation. See August 2010 Service Treatment Records. Therefore, the Veteran's chronic rhinitis is shown to have been manifested and diagnosed within 10 years of his April 2011 separation from service. As the Veteran is presumed to have been exposed to particulate matter during service and rhinitis, which is one of the chronic diseases presumed to be associated with such exposure, is shown to have been manifested within 10 years of his qualifying period of service in Southwest Asia during the Persian Gulf War, service connection for rhinitis is granted. 7. Entitlement to an initial compensable rating for hypertension. Increased rating Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. If there is a question as to which disability rating to apply to the Veteran's disability, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where the Veteran is appealing the initial assignment of a disability rating, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, in determining the present level of a disability for any increased rating claim, the application of staged ratings must be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is proper. The Veteran contends that he is entitled to a compensable disability rating for his service-connected hypertension. The Veteran's hypertension is rated under 38 C.F.R. § 4.104, Diagnostic Code 7101, which lists the criteria for rating hypertension. Under this diagnostic code provision, a 10 percent disability rating is warranted where diastolic blood pressure is predominantly 100 or more, or systolic blood pressure is predominantly 160 or more, or when an individual with a history of diastolic blood pressure predominantly 100 or more requires continuous medication for control. A 20 percent disability rating is warranted where diastolic blood pressure is predominantly 110 or more, or systolic blood pressure is predominantly 200 or more. A 40 percent disability rating is warranted where diastolic pressure is predominantly 120 or more, and a 60 percent disability rating is warranted where diastolic blood pressure is predominantly 130 or more. In Jones v. Shinseki, 26 Vet. App. 56 (2012), the Court held that, in the context of assigning disability ratings, the Board may not consider the ameliorative effects of medication where such effects are not explicitly contemplated by the rating criteria. However, Diagnostic Code 7101 explicitly contemplates the effects of medication; any ameliorative effects of blood pressure medication are not discounted in the evaluation. McCarroll v. McDonald, 28 Vet. App. 267 (2016). In a recent precedential decision, the Court held that under Diagnostic Code 7101, "a history of diastolic pressure predominantly 100 or more [that] requires continuous medication for control" refers to blood pressure readings taken before a Veteran began medication to control hypertension, and therefore may require analyzing blood pressure readings prior to the period on appeal. Wilson v. McDonough, No. 19-6020 (December 20, 2021). Private treatment records show that in May 2008, the Veteran had blood pressure readings of 151/120 and 147/110. In June 2008, he had blood pressure readings taken on 3 consecutive days. Starting on June 6, 2008, his blood pressure was 140/100, 130/88 and 141/83. In a September 2013 Gulf War examination, the VA examiner noted that the Veteran was diagnosed with hypertension while in Cuba on active duty and that he takes continuous medication. The examiner noted no history of a diastolic BP elevation to predominantly 100 or more. However, the examiner also noted that it was unknown if the initial diagnosis of hypertension was confirmed by BP readings taken 2 or more times on 3 different days. The September 2013 examination report noted blood pressure readings of 130/80, 132/82, 130/80. The Veteran submitted a July 2021 opinion from Dr. P. After reviewing the Veteran's records, he stated that "from 1994 to 2004, his systolic blood pressure ranged from 110 to 132, and his diastolic blood pressure ranged from 68 to 81. These blood pressures according to the latest ACC/AHA guidelines are acceptable as normal range. In 2006, while on active duty in Cuba, he had a BP reading of 140/76. Upcoming returning home in May 2008, he sought medical care due to the previous elevated blood pressure. Over a span of 1 week in May 2008, he had 3 separate BP readings of 158/104, 151/120 and 147/110. ... Due to high readings, he was placed on blood pressure medication. He started with lisinopril 10 mg, but over the next two years his medication was increased to lisinopril 40 mg and amlodipine 10 mg. The medications did help lower his blood pressure, which ultimately will help decrease his morbidity and mortality. Unfortunately for his service connection, due to his pressures improving with medications, it was not acknowledged that he would have had elevated systolic or diastolic blood pressures readings if he was not treated with antihypertensives." Notwithstanding that the September 2013 VA examiner indicated that the Veteran did not have a history of diastolic blood pressure elevation to predominantly 100 or more, the May 2008 and June 2008 treatment records clearly show that historically, he exhibited diastolic blood pressure elevation to predominantly 100 or more. The evidence also demonstrates that the Veteran's hypertension requires the continuous use of medication for control. Upon longitudinal review of the record and considering both the medical evidence of record and the recent holding in Wilson v. McDonough, the Board finds that the Veteran's hypertension warrants a 10 percent disability rating under Diagnostic Code 7101. A next higher 20 percent disability rating under Diagnostic Code 7101 is not warranted at any time during the appeal period. Although the record shows a few isolated readings of higher diastolic pressure, the record does not show that diastolic pressure was predominantly 110 or more during the period for consideration. The record also does not show any systolic pressures of 200 or higher. Accordingly, the schedular criteria for a 20 percent rating for hypertension are not met. Thus, based on the forgoing, and in resolving all reasonable doubt in the Veteran's favor, a 10 percent disability rating for service-connected hypertension is warranted. REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea is remanded. The Veteran contends that his sleep apnea is due to his service in the Persian Gulf theater of operations. In the alternative, he contends that his sleep apnea is related to his service-connected posttraumatic stress disorder (PTSD). See November 2013 NOD and June 2022 Hearing Transcript. In his November 2013 NOD the Veteran stated he experienced sleep apnea symptoms during active-duty deployment and that they have continued without aid of machine and medication. He claimed that a sleep disorder was documented during demobilization screening following active duty and believes it to be related to "the varying work schedules and PTSD." At his Board hearing, the Veteran testified that at the sleep center he was told that his sleep apnea was worse than it should because of his weight, and he gained the weight because of the PTSD and the medications. The Veteran was afforded a VA examination in August 2013. The examiner explained that the sleep apnea is a disease with a clear and specific diagnosis and etiology. He opined that the Veteran's sleep apnea was not related to environmental hazards in the Persian Gulf because the medical literature does not correlate sleep apnea with Gulf War exposure. The Board finds this rationale to be inadequate. The examiner did not render an opinion on direct or secondary service connection, and did not consider relevant lay evidence or medical evidence in the Veteran's service treatment records. The August 2013 opinion does not address the question as to whether the Veteran's obesity served as an intermediary step between the service-connected disabilities, particularly PTSD. If the sleep apnea is due to obesity, the question remains as to whether his service-connected PTSD caused his obesity. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Thus, on remand medical nexus opinions are warranted to encompass all the Veteran's theories of entitlement. 2. Entitlement to service connection for headaches, to include migraines, to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) or due to exposure to particulate matter as a result of Persian Gulf War Service, is remanded. The Veteran contends that his headache disability, to include migraine, is due to his service in the Persian Gulf theater of operations. In the alternative, he claims that is related to his service-connected posttraumatic stress disorder (PTSD) or his tinnitus. See June 2022 Hearing Transcript. A July 2016 VA examination report show that the Veteran reported initial onset of headaches in 1992 and was told to stay well hydrated. The examiner assessed the Veteran with tension headaches. While the examiner explained that tension headache is a condition with a clear and specific etiology, the examiner also opined that it was not related to an exposure event during his service in Southwest Asia but failed to provide a rationale. In addition, the examiner did not consider the Veteran's lay contentions regarding exposures. Furthermore, no examiner has rendered an opinion on direct or secondary service connection. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Thus, on remand new medical nexus opinions are warranted to encompass all the Veteran's theories of entitlement. 3. Entitlement to service connection for joint and muscle pain to include hand condition and wrist condition, to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) or due to exposure to particulate matter as a result of Persian Gulf War Service, is remanded. The Veteran contends that his joint and muscle pain, to include hand and wrist condition, is due to his service in the Persian Gulf theater of operations. During his May 2017 DRO hearing, the Veteran testified that his hand and wrist issues started around when he left the Persian Gulf and, as with other conditions, he was told he was dehydrated. Since he was the lowest ranking member of his unit, he had to do all of the menial tasks in his unit such as burning feces and other grunt work that exposed him to Southwest Asia hazards. His hands swell and hurt. During his June 2022 Board hearing, the Veteran testified that his arms, wrist, forearms, and neck were aching all the time. The Veteran was provided a Gulf War examination in June 2015 for muscle injuries, hand and finger conditions and wrist. The Veteran reported pain in muscle group of upper arms and forearms in 2011 after Operation Enduring Freedom. He reported bilateral hand pain started in 2012, periodic edema from wrist to fingertips, and dull achiness in his joints. The wrist condition started about 2013 and 2014. The examiner noted no diagnosis of muscles, hands or wrist. The examiner noted that "Veteran has claimed a disability pattern related to muscle pain. Muscle pain is a condition with a clear and specific etiology and diagnosis." The examiner opined that the claimed conditions were less likely as not (less than 50% probability) related to a specific event experienced by Veteran during service in Southwest Asia. Muscle pain is most frequently related to tension, overuse, or injury from exercise or physically demanding work. In these situations, the pain tends to involve specific muscles and starts during or just after the activity. The examiner did not render any rationale for the negative nexus opinion or consider the Veteran's lay contentions. Accordingly, a remand is required for a medical addendum opinion. 4. Entitlement to service connection for chronic fatigue syndrome (CFS), to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) or due to exposure to particulate matter as a result of Persian Gulf War Service, or secondary to service-connected PTSD, is remanded. The Veteran contends that his CFS is due to his service in the Persian Gulf theater of operations. In the alternative, he claims that is related to his service-connected posttraumatic stress disorder (PTSD). See June 2022 Hearing Transcript. The June 2015 examiner noted that the Veteran does not have a current diagnosis of chronic fatigue syndrome and that the Veteran's fatigue is likely due to his service-connected PTSD and his OSA, and less likely to a specific exposure event during Gulf War service. The rationale given was that the Veteran does not meet the diagnostic criteria for CFS, the medical record is silent for CFS , labs were normal and the record documents depression, PTSD and OSA. In an August 2017 letter, Dr. J.A.S. stated that the Veteran is unable to work due to fatigue and decreased concentration. He added that the fatigue and decreased concentration are secondary to medications, PTSD and OSA. There is no opinion of record that addresses whether the Veteran's fatigue is a symptom of his service-connected PTSD or is the result of a different identifiable pathology. Accordingly, on remand, the Agency of Original Jurisdiction should obtain an opinion that addresses this question. 5. Entitlement to service connection for a digestive disorder, to include irritable bowel syndrome (IBS), to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) or due to exposure to particulate matter as a result of Persian Gulf War Service, or as secondary to service-connected PTSD, is remanded. The Veteran contends that his digestive disorder, to include irritable bowel syndrome (IBS) is due to his service in the Persian Gulf theater of operations. During the May 2017 DRO hearing, the Veteran testified that he feels like he either has to go to the bathroom really badly or throw up and that his symptoms started after Desert Storm and have continued to this day. During his June 2022 Board hearing, the Veteran testified that since he returned from Desert Storm, he has been having severe abdominal pains, bad enough as to having to go to the ER on several occasions. The June 2016 examiner noted that the Veteran does not have a current diagnosis for an intestinal condition. The examiner noted that the Veteran has claimed a chronic disability pattern related to irritable bowel syndrome and that the Veteran does not meet the diagnostic criteria for a diagnosis of irritable bowel syndrome. The examiner did not render an opinion. The Veteran submitted a February 2021 letter from his gastroenterologist. Dr. B.W. stated that the Veteran reported symptoms that began while he was in service, that he has been treated for symptoms of irritable bowel syndrome which are constipation predominant and diarrhea. Dr. B.W., opined that "IBS can certainly be associated with high stress condition such as PTSD. As such, if indeed his PTSD condition is attributed to his military service, then it would follow that IBS is linked as well." This opinion does not have a supporting rationale. Without a medical rationale for the opinion provided, the opinion is inadequate. Accordingly, a remand is required to afford the Veteran a medical opinion. 6. Entitlement to service connection for a respiratory condition (claimed as lung and coughing condition), other than rhinitis, to include sarcoidosis, to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) or due to exposure to particulate matter as a result of Persian Gulf War Service is remanded. The Veteran contends that his respiratory condition (claimed as lung and coughing condition), to include sarcoidosis, is due to his service in the Persian Gulf theater of operations. The August 1993 VA examiner did not find a throat, sinus or pulmonary condition. The Veteran was afforded VA examination in August 2013 and June 2015. The August 2013 and June 2015 VA examiners noted the Veteran's reports of dry cough. Both examiners opined that the Veteran's cough is less likely as not (less than 50% probability) related to a specific exposure event experienced by the veteran during service in Southwest Asia. The June 2015 examiner added that cough is likely secondary to GERD and or sleep apnea symptoms. These opinions do not have a supporting rationale. Without a medical rationale, the opinions are inadequate. Accordingly, a remand is required to afford the Veteran a medical opinion. Further, the evidence indicates that there may be outstanding relevant VA treatment records. The most recent VA treatment records in the claims file are from 2018. The Veteran provided a June 2021 VA problem list that reflects a diagnosis of sarcoidosis in April 2021. While a VA Problem List, last updated in June 2021, is of record, the Veteran's VA treatment records have otherwise not been associated with the claims file. Any VA treatment records are within VA's constructive possession and must be obtained regardless of their relevance as long as they are sufficiently identified. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (VA has a duty to assist in obtaining sufficiently identified VA medical records regardless of their relevance). A remand is required to allow VA to obtain them. The Presumptive Benefits for War Fighters Exposed to Burn Pits and Other Toxins Act of 2022 (PACT Act), was passed in August 2022 potentially impacting countless veterans who served in the Southwest Asia theatre of operations. Pact Act, Pub. L. 117-168 (2022). Effective August 10, 2022, VA has established presumptive service connection for pulmonary sarcoidosis for veterans with service in the Southwest Asia theater of operations during the Persian Gulf War. See Honoring Our PACT Act of 2022, Pub. L. 117-168 (2022). Specifically, VA will presume exposure to fine particulate matter for Gulf War veterans deployed in the Southwest Asia theater of operations regardless of length of deployment. 38 C.F.R. § 3.320(a)(3), (a)(4). Here, the Veteran's personnel records and DD-214 show that he served in Saudi Arabia and Afghanistan in support of Operation Desert Shield and Storm from December 16, 1990 and March 15, 1991, Operation Noble Eagle and Enduring Iraqi Freedom from July 28, 2010 to February 26, 2011. However, the diagnosis of sarcoidosis is unclear from the available VA treatment records. 7. Entitlement to an initial rating higher than 10 percent for left ankle strain is remanded. The record reflects that the Veteran was most recently provided a VA medical examination to assess the severity of his left ankle strain in June 2016. During his June 2022 Board hearing, the Veteran testified that since that time his left ankle strain has continued to worsen. He described his current symptoms as unable to wear flip-flops or walk barefooted; "it's excruciating pain, where I it's hard to describe, but it's almost like walking on needles all the time with your heel." The Veteran testified that he walks on the sides of feet due to ankle pain, has trouble standing and walking, wears prescribed braces at night, and has swollen ankles. In light of this evidence of worsening, the Board finds that a remand is required to afford the Veteran a new VA medical examination to determine the current severity of this disability. Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The matters are REMANDED for the following action: 1. Associate with the claims file any outstanding VA treatment records. 2. Then, schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of the Veteran's sleep apnea. The claims file must be reviewed by the examiner. The examiner should offer the following opinions: (a.) Whether it is as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that his sleep apnea had its onset in service or is otherwise related to service, to include presumptive exposure to particulate matter during Persian Gulf service. (b.) Whether it is as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that his sleep apnea is caused by his PTSD, to include weight gain caused by symptoms or medications; (c.) Whether it is as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that his sleep apnea was aggravated (worsened) by his PTSD, to include weight gain caused by symptoms or medication. 3. Then, schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of any headaches, joint and muscle pain, fatigue, respiratory system disorder, and/or digestive system disorder (other than GERD). The claims file must be reviewed by the examiner. The examiner should offer the following opinions: (a.) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's headaches, joint and muscle pain, fatigue, respiratory system disorder, and/or digestive system disorder (other than GERD) are part of a medically unexplained chronic multi-symptom illness or an otherwise undiagnosed illness? (b.) If a chronic disorder(s) is/are found, can such disorder(s) be attributed to a known clinical diagnosis(es), or is there otherwise a medical explanation for the Veteran's headaches, joint and muscle pain, fatigue, respiratory system disorder, and/or digestive system disorder (other than GERD)? If so, state the diagnosis; if not, so state specifically. (c.) For any diagnosed disorder is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that such disorder(s) is/are etiologically related to the Veteran's periods of active duty service, including presumed exposure to particulate matter during service in Southwest Asia during the Persian Gulf War? (d.) Whether it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that his headaches, to include migraines, are caused by his PTSD. (e.) Whether it is as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that his headaches, to include migraines, are aggravated (worsened) by his PTSD. In rendering the opinions, the examiner(s) must comment on the indications of sarcoidosis in the Veteran's active problems lists; as well as the Veteran's reports of headaches, cough, joint and muscle pain, constipation, diarrhea, abdominal pain, and fatigue. The examiner should also determine whether the Veteran's fatigue ss is separate from any other diagnosis, to include sleep apnea and PTSD. The examiner must specifically address the June 2015 VA CFS examination and the August 2017 opinion from Dr. J.A.S. The examiner must specifically address the June 2016 VA intestinal conditions examination and the February 2021 opinion from Dr. B.W. The examiner must specifically address the June 2015 VA respiratory conditions examination. The examiner must provide the rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. Schedule the Veteran for a VA examination to assess the current severity of his left ankle strain. The claims folder must be reviewed by the examiner in conjunction with the examination. The examiner 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, to include heel pain. Moreover, the examiner must provide an opinion as to whether his heel pain is related to the service-connected left ankle disability. The examiner should also specifically consider the Veteran's June 2022 testimony. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. Rebecca N. Poulson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Romero 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.