Citation Nr: 0002204 Decision Date: 01/28/00 Archive Date: 02/02/00 DOCKET NO. 96-32 144 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim concerning service connection for skin symptoms as a chronic disability resulting from an undiagnosed illness. 2. Entitlement to service connection for leishmaniasis. 3. Entitlement to service connection for fatigue as a chronic disability resulting from an undiagnosed illness. 4. Entitlement to service connection for headaches as a chronic disability resulting from an undiagnosed illness, to include the issue of whether a substantive appeal was timely filed. 5. Whether new and material evidence has been submitted to reopen a claim concerning service connection for joint pain as a chronic disability resulting from an undiagnosed illness, to include the issue of whether a substantive appeal was timely filed. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. A. Saadat, Associate Counsel INTRODUCTION The veteran had active military service from September 1990 to May 1992, and he received, in part, the Kuwait Liberation Medal. By February 1994 rating decision, the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky, denied service connection for a skin symptoms and joint pain as chronic disabilities resulting from an undiagnosed illness. The veteran was notified of these adverse determinations but did not appeal. By a November 1995 rating decision, the RO in Philadelphia, Pennsylvania, denied service connection for skin symptoms, joint pain, fatigue, and headaches, all as chronic disabilities resulting from an undiagnosed illness. By the same rating decision, the RO also denied entitlement to service connection for leishmaniasis. The veteran testified, with a female companion, before a local hearing officer in May 1996. At the local hearing, the veteran appeared to raise a claim concerning service connection for chest pain as a chronic disability resulting from an undiagnosed illness. Since this matter has not been developed or certified for appeal, and inasmuch as it is not inextricably intertwined with the issues now before the Board of Veterans' Appeals (Board) on appeal, it is referred to the RO for initial consideration. The veteran's claims concerning service connection for skin symptoms and fatigue, as chronic disabilities resulting from an undiagnosed illness, and for leishmaniasis, are discussed in the decision section. The claims concerning service connection for headaches as a chronic disability resulting from an undiagnosed illness, to include the issue of whether a substantive appeal was timely filed, and whether new and material evidence has been submitted to reopen a claim concerning service connection for joint pain as a chronic disability resulting from an undiagnosed illness, to include the issue of whether a substantive appeal was timely filed, are discussed in the Remand section below. By rating action dated in January 1997, the RO granted eligibility for dental treatment for tooth number 9. Accordingly, this issue will not be discussed in this decision. FINDINGS OF FACT 1. Service connection for skin symptoms as a chronic disability resulting from an undiagnosed illness was last denied by decision of the RO in February 1994; the additional evidence reviewed in connection with this claim to reopen is more than merely cumulative and is so significant that it must be considered in order to decide the merits of the claim. 2. The veteran has submitted some evidence that he currently has skin symptoms as a chronic disability which is related to an undiagnosed illness; the claim is plausible. 3. The veteran's allegation that his leishmaniasis is related to service is not supported by any medical evidence that would render the claim plausible. 4. The veteran has submitted some evidence that he currently has fatigue as a chronic disability which is related to an undiagnosed illness; the claim is plausible. CONCLUSIONS OF LAW 1. The February 1994 rating decision denying service connection for skin symptoms as a chronic disability resulting from an undiagnosed illness is final. 38 U.S.C.A. § 7105 (c) (West 1991); 38 C.F.R. § 20.302 (1999). 2. Evidence submitted since the February 1994 rating decision is new and material and the veteran's claim concerning service connection for skin symptoms as a chronic disability resulting from an undiagnosed illness is reopened. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156 (1999). 3. The veteran has submitted evidence of a well-grounded claim concerning service connection for skin symptoms as a chronic disability resulting from an undiagnosed illness. 38 U.S.C.A. § 1117 (West 1991 and Supp. 1999); 38 C.F.R. § 3.317 (1999); VAOPGCPREC 4-99 (May 3, 1999). 4. The veteran has not submitted evidence of a well-grounded claim concerning service connection for leishmaniasis. 38 U.S.C.A. § 5107 (West 1991). 5. The veteran has submitted evidence of a well-grounded claim concerning service connection for fatigue as a chronic disability resulting from an undiagnosed illness. 38 U.S.C.A. § 1117 (West 1991 and Supp. 1999); 38 C.F.R. § 3.317 (1999); VAOPGCPREC 4-99 (May 3, 1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background Service medical records reflect, in pertinent part, that prior to his entrance examination in May 1989, the veteran denied any history of skin diseases. Upon examination, the veteran's skin was normal, although scars on the veteran's left finger, left arm, and right leg were noted. The veteran was examined for separation purposes in April 1992. Prior to the examination, the veteran denied any history of skin diseases. Upon examination, the veteran's skin was normal. In June 1992, additional service medical records were associated with the claims file. These records do not reflect any additional complaints of or treatment for any skin symptoms or symptoms of fatigue. The veteran underwent a VA joints examination in December 1992. He complained only of chronic pain and instability in his right knee. In a June 1993 written statement, the veteran sought service connection for, in pertinent part, "spots" all over his body which had not been diagnosed (but which he felt were the result of his tour in Saudi Arabia). In September 1993, medical records from the Harrisburg Hospital in Harrisburg, Pennsylvania, were associated with the claims file. These records reflect treatment of the veteran in June 1993 for conditions unrelated to his claims for service connection. In September 1993, the veteran underwent a skin examination for VA purposes. The veteran reported that he had had no basic skin problems while on active duty, except for a lymphangitis in June 1991 while at Fort Riley, Kansas. An infection of the right thumb, ascending the forearm to the axilla, was "quieted down" without sequelae on antibiotic medicines over a 10 to 14 day period. The veteran was discharged in May 1992. He started to go to vocational school and only became employed in July 1993 as a forklift operator. Around mid-June 1993, at home, he first noted some "tiny welts," vesicopapules, sparsely scattered over the forearms, anterior aspects of the cheeks, upper interscapular area, anterior chest wall, front of legs, and a few on the facial area. These were mostly 3+ mm. in size, but a few reached 6+ mm. in size. There was no associated itching or burning. The vesicles contained a clear, "yellowish" fluid. They spontaneously resolved over a two to three week period, leaving no scarring (with the possible exception of a faint macular scar of outer aspect of the left orbit). At the Harrisburg Hospital and at the Camp Hill VA outpatient clinic, he was told "it was not chicken pox." He was told the same at the Camp Hill VA Outpatient two days later. No treatment was recommended. The veteran stated that he had had childhood chicken pox, and had also received an immunizing shot against chicken pox upon entering service. Starting at about the same time as his skin symptom outbreak, the veteran also complained of other symptoms, including low back pain. "Blood work" done in July 1993 was reportedly normal. In September 1993, the veteran noted a diffuse, red, slightly scaly rash over his forearms and anterior abdomen, considered clinically a contact allergy. The process abated, with slight residual patchy dermatitis still noted over a three week period. Over his back and shoulders, the veteran had a number of scattered acneiform-like lesions which had "been there all along" and seemed unrelated to the rash. Following the examination, the examiner concluded that the veteran had dermatitis, seemingly of two differing etiologies, neither of which was determinable at that time. The examiner indicated that he could not conclude these symptoms were related to the veteran's Army service except by their closeness to the date of discharge. The examiner further recommended that if and when further trouble arose, the veteran should be given the benefit of any doubt for the pursuit of further studies and evaluation. The veteran also underwent a joints examination for VA purposes in September 1993. He did not make any specific complaints concerning his skin or any symptoms of fatigue. In October 1993, the veteran underwent a general examination for VA purposes. The veteran reported that he had been in the Gulf War from January 1991 to July 1991 and that he had been asymptomatic during this period. The veteran reported, in pertinent part, a brief period of rash and fever for three to four weeks in 1993, although he did not have these symptoms at present. Upon examination, the veteran's skin did not have any symptoms, although the veteran did describe his rash as being a red, erythematous, non-itchy, "prickly heat" over the abdomen and upper arms, apparently beginning in September 1993. Following the examination, the veteran was diagnosed as having, in pertinent part, a history of rash. By a February 1994 rating decision, the RO, in pertinent part, denied service connection for a skin condition secondary to exposure to environmental hazards while serving in Southwest Asia. The basis of this denial was that there was no evidence of skin condition related to exposure to environmental hazards. The veteran was provided notice of this rating decision in an February 1994 letter, but he did not initiate a timely appeal. Accordingly, the February 1994 rating decision denying service connection for skin symptoms as a chronic disability resulting from an undiagnosed illness became final. 38 U.S.C.A. § 7105(c) (West 1991). In February 1994, the veteran filed a written statement seeking service connection for, in pertinent part, "desert storm syndrome." Subsequently in February 1994, the veteran submitted a written statement, referencing the February 1994 rating decision. He indicated, in part, that the condition of chronic fatigue (to include chronic fatigue syndrome) had not been addressed and he requested a statement of the case. In March 1994, the veteran filed a written statement in which he sought service connection for leishmaniasis. The veteran attached to his statement a private clinical laboratory report dated in January 1994, which indicates that he had tested positive for leishmaniasis. The veteran also attached two medical journal articles which discussed leishmaniasis and referenced cases in which U.S. military personnel acquired leishmaniasis during Operation Desert Storm. One article was entitled "Leishmaniasis in Americans," and was published in "Infectious Disease Alert" in January 1994. The other article was entitled "Infectious Diseases Associated with Operation Desert Storm," and was published in the "Clinical Microbiology Newsletter" in November 1993. In April 1995, a large number of VA medical records were associated with the claims file. These records reflect that the veteran underwent a Gulf War Registry examination in July 1993. Prior to the examination, he reported that he had served in the Gulf War from January 1991 to July 1991. He indicated that he had been possibly exposed to heavy smoke from oil well fires for about one month. The veteran was also concerned about immunization pills he took, as well as his exposure to diesel fuel. The veteran reported that he would awaken and feel tired and worn out, and would get spells of being completely worn out. Examination revealed normal skin, although the veteran was diagnosed as having, in part, history of exanthem, exact etiology not clear. On another record dated in July 1993 and apparently completed in conjunction with the veteran's Gulf War examination, it was noted that his primary complaint was easy fatigability and decreased physical tolerance. It was also noted that the veteran's resolving exanthem of unknown etiology had resolved with treatment. These records also reflect that the veteran sought outpatient treatment for, in part, easy fatigability in November 1993. In January 1994, the veteran was hospitalized at the VA Medical Center (VAMC) in Washington, D.C., in January 1994. It was noted that the veteran presented for work up of a seven month history of subacute progression of, in part, fatigue. The veteran noted that this was worse in the morning with cold. Upon examination, the veteran was thin and in no acute distress. Skin was normal turgor. Head and neck were normocephalic and atraumatic. There was poor detention but no lesions. Extremities showed no clubbing, cyanosis, or edema. The veteran complained of point tenderness in the T8 - T9 region. There was no abnormal curvature of the back. Neurologically, the veteran was alert and oriented to person, place, and time. Strength was 5/5 in all groups. There was normal tone and bulk. There was no drift. Sensation was intact to pinprick, light touch, vibration, and position. There was a slight feeling of subjective numbness in the lower extremities in the medial malleolar region. Reflexes were 1+ symmetric and bilateral in the upper extremities, 2+ at the knees, 1+ at the ankles. Coordination was intact to rapid alternating movements finger-to-nose and heel-to-shin. Station and gait as well as tandem gait were within normal limits. The veteran was admitted with the diagnosis of chronic fatigue syndrome. He underwent numerous tests including EMG, which was normal, and electronystagmogram, which was also within normal limits. He had an EKG, which showed sinus bradycardia. He underwent colonoscopy with colonic biopsies which showed chronic inflammation throughout. A bone scan was negative, a MRI of the brain was normal, and an upper GI with small bowel follow-through was normal, as was a chest X- ray. The veteran underwent numerous blood tests including CBC which was normal, a full chemistry, and a serum electrolyte screen which was normal with the exception of mildly elevated serum glucose. He had numerous serologies drawn. Q fever, Brucellosis, and sandfly fever were negative. Leishmaniasis donovani, braziliensis, mexicana, and tropicalis were all low titer positive. There were no malarial forms seen on blood smear. Serum protein and urine protein electrophoresis were within normal limits. RPR was nonreactive. Erythrocyte sedimentation rate was 2. The veteran also underwent a lumbar puncture which was essentially within normal limits. Upon discharge following over two weeks of hospitalization, the diagnoses included chronic fatigue syndrome. A dermatology consultation conducted during the veteran's hospitalization in January 1994 noted that he had minimal acne vulgaris on the chest and face (the veteran reported that he had a rash which had almost cleared up). The assessment was no acute dermatitis. The veteran again sought outpatient treatment for, in part, fatigue for January 1994 through March 1994. Additionally in March 1994, it was noted that the veteran had tested positive for leishmaniasis; specifically that his titers were positive between 1:16 and 1:20. The veteran also sought outpatient treatment for a rash on his abdomen in April 1994. These records reflect that in April 1994, a consultation examination was requested to confirm whether the veteran had leishmaniasis. In May 1994, the veteran was examined by a VA physician who noted that he presented with a variety of complaints including chronic fatigue. Examination revealed a few acneform lesions on the chest. The physician assessed the veteran as having "no clinical evidence of leishmaniasis." These records also reflect that additionally in May 1994, the veteran underwent a systemic conditions examination for VA purposes. It was noted that the veteran had been discharged from a VAMC with a diagnosis of, in part, chronic fatigue. Most of his complaints were related to easy fatigability and an inability to do anything. He was fine whenever he was not doing anything. Upon examination, the veteran appeared alert and oriented and in no acute distress. A rash was noted on his extremities and his stomach. The veteran was diagnosed, in pertinent part, as having "Persian Gulf Syndrome," and chronic fatigue. The veteran continued to seek outpatient treatment for fatigue and feeling "like I've been run over by a truck" between May 1994 and December 1994. A biopsy of the veteran's skin lesions was set for March 1995, but immediately prior to this procedure, the veteran's spouse called and reported that his lesions had disappeared. There was nothing left to biopsy. In May 1995, the veteran underwent a general medical examination for VA purposes. He reported that he was currently unemployed. The veteran also reported, in pertinent part, that since his departure from the Gulf in July 1991, he had experienced chronic fatigue. The veteran reported that he had been diagnosed as having leishmaniasis at the Washington VAMC by serum titre only. There was no liver biopsy or bone marrow done at that time. He was seen by the infectious disease specialist at Hershey Medical Center and clinically was told that there was no evidence of clinical leishmaniasis. Nevertheless, according to the VA examiner, the veteran continued to be symptomatic on review of most of his organ systems. At present, the veteran complained of, in pertinent part, joint pain particularly in his elbows, hips, back, hands, and right knee with morning stiffness. He also complained of diffuse acne and comedones on his upper body and arms. Examination of the skin revealed some acne lesions on the back, but otherwise it was unremarkable. Although the veteran complained of multiple aches and pains, the examination was normal. The veteran was diagnosed as having, in pertinent part, leishmaniasis based on antibody titer only, and chronic fatigue syndrome. The veteran also underwent a skin examination for VA purposes in May 1995. It was noted that at the time of induction, the veteran had teen-age "zits" of the facial area. This facial acne began to abate after induction. About March 1992, he experienced a lymphangitis and adenitis of the right hand and arm, starting with an infected nailbed of the right thumb. The process promptly responded to appropriate oral antibiotic therapy in a week's time. In June 1993, the veteran was treated in the emergency room of Harrisburg Hospital for fever, sweats, and chills, and an outbreak of lesions scattered over the face, chest, and arms at that were said to resemble chicken pox. The onset was in a 12 to 24 hour period. The veteran recalled having had chicken pox in childhood. The diagnosis was not clear to the physicians who treated him. This was his only "attack," but the veteran said that he had continued to have an acneform-like skin reaction over his shoulders and back. In March 1995, the veteran had an outbreak of seeming "poison ivy," which was limited to less than a week after a "shot of cortisone" from his family physician. The veteran reminded the examiner of his almost complete loss of appetite in the Gulf War, when he dropped to about 135 lbs. from about 168 lbs. Examination of the skin, hair, and mucous membranes revealed no significant findings, except a suggestion of occasional acneform lesions over the back of the shoulders. The veteran also underwent a systemic conditions examination for VA purposes in May 1995. It was noted that the veteran had been diagnosed as having leishmaniasis based on an antibody titre, and that he had continued to have chronic fatigue since he was in the Gulf, as well as polyarthralgias in most joints. Examination of the veteran was basically unremarkable except for the acne lesions on his back. He was diagnosed as having polyarthralgias and diagnosis of leishmaniasis based only on antibody titre. The examiner noted that there was no bone marrow or liver biopsy to substantiate this. In June 1995, service personnel records were associated with the claims file. These records reflect, in pertinent part, that the veteran served in Saudi Arabia from January 10, 1991, to July 6, 1991. In October 1995, a large number of medical records were associated with the claims file, some of which are duplicative of those summarized above. These records reflect, in pertinent part, that in September 1994, the veteran sought outpatient treatment after making "multiple somatic complaints." The examination was entirely normal. There were no motor weaknesses or local skin changes. The veteran advised that his symptoms were probably non-cardiac in origin and was probably musculoskeletal versus somatization of mental and psychiatric problems. In December 1994, the veteran sought treatment for extreme fatigue and skin rashes. Following an examination, the veteran was noted to have increased fatigue. These records also reflect that the veteran sought VA outpatient treatment in January 1995, during which comedones of the skin were noted. The impressions included "Gulf - intestinal - skin - CNS Illness (?Leish)." By a November 1995 rating decision, the RO, in pertinent part, denied service connection for skin symptoms as a chronic disability resulting from an undiagnosed illness undiagnosed, for leishmaniasis, and for fatigue as a chronic disability resulting from an undiagnosed illness. In December 1995, the veteran filed a written statement, in which he argued that even if his skin condition existed prior to service, it was aggravated by service. The veteran did not have the proper facilities to bathe daily and take care of his skin condition. As for leishmaniasis, the veteran stated that this condition "comes and goes," and suggested that the titer reading of 1.16 was sufficient evidence of this diagnosis. The veteran also asserted that due to his fatigue, the veteran was also unable to hold a steady job. The veteran testified with a female companion at a May 1996 local hearing. He stated that he had been experiencing symptoms of leishmaniasis for approximately four and a half years. He started getting diarrhea and constipation. He eventually was treated for this condition in Washington, although the veteran was uncertain whether he had actually been diagnosed as having leishmaniasis. He was told by his current physician that he had tested positive for this condition. The veteran's rash condition also began in June 1992. It looked like chicken pox but he was not aware of any clinical diagnosis. He had been told at Harrisburg Hospital that it was not acne, but rather an "unknown explainable rash." The skin symptoms had remained and the veteran testified about them during the hearing. Concerning his fatigue, the veteran stated that it started in July 1992, two weeks after his rash had begun. During July 4th celebrations, he noticed that people were able to walk faster than himself. The symptoms continued and the veteran was also taking medication for this. The veteran's female companion asserted that a VA physician had stated that the veteran's fatigue was related to the Persian Gulf, possibly something to do with the sand there. She described the veteran's current symptoms of fatigue in detail. The veteran testified that he first began missing formations during service, due to oversleeping. The veteran further stated that following service, he worked for a construction company as a forklift operator, until December 1993. He missed about one week from work during this period. In December 1993, he contracted pneumonia and had to stop working. From that time on, the veteran had not worked. In May 1996, a handwritten letter written by Ms. [redacted] [redacted] was associated with the claims file. Ms. [redacted] noted that the veteran had been a member of her family for about two years. In that time, Ms. [redacted] had witnessed more than one incident relating to his medical condition. The veteran seemed to have periods of weakness and pain that were not related to any special activity. He could be sitting quietly and without warning, his heart would race so fast that she could see his chest moving. His color would be bad, and it would appear that he was having a heart attack. The veteran once went to an emergency room because of an episode in which he was numb and could not walk. The veteran had always tried to join in with grocery shopping and cleaning, but Ms. [redacted] could see the energy "just draining of him." Damp weather seemed to bring extra discomfort and the smell of diesel seemed to make the veteran sick to his stomach. It was obvious to Ms. [redacted] that something physical was wrong with the veteran. Additionally in May 1996, a letter written by a VA physician, dated in October 1995, was associated with the claims file. The physician included the following text in the letter: This is to verify that [the veteran] has been disabled [and] unable to work since December 1993. . . . I am unable to determine a date or time that [the veteran] will be able to return to work, but at this time he is still disabled with . . . skin . . . problems, possibly or likely related to his work in the Persian Gulf. On a May 1996 Form 9, the veteran indicated, in pertinent part, that he was perfecting his appeal regarding his skin and fatigue claims. In August 1996, the RO wrote to the veteran and advised him concerning the types of medical and nonmedical evidence he could submit in support of his claims. In September 1996, the veteran underwent a general examination for VA purposes. It was noted that the veteran was working as a fork lift operator. He had been employed there beginning in June 1992, and had lost approximately 30 days from work due to fatigue and loss of energy. The veteran also complained of skin discoloration, i.e., white blotches on the palms of both hands. Upon examination, the veteran appeared to be well nourished and well developed. He had tattoos on both deltoids. The veteran walked with a slight limp. There was no skin discoloration on his trunk and torso. He had multiple erythematous raised lesions on his posterior aspect of his trunk. Scars were noted on the left knee and left index finger. The veteran also underwent a skin examination for VA purposes in September 1996. The veteran reported that he had been seen by a dermatologist in Harrisburg and diagnosed as having "chicken pox." At that time, there was no skin biopsy performed and he had received no treatment for his skin disorder. Since that time, the veteran continued to have complaints relating to his skin, predominantly of the torso. He described the skin rash as beginning with "large, painful sores" on the torso. These subsequently decreased in size and he reported that they sometimes bled. The veteran also reported itching and burning. Upon examination, the veteran was found to have numerous follicle-based papules and pustules on the torso. There were no cysts present. A course of oral antibiotic and topical therapy was recommended for the resolution of this problem. The veteran was diagnosed as having folliculitis. In October 1996, medical records from the Lebanon VAMC were associated with the claims file. These records include a March 1995 letter in which the veteran's Gulf War Registry findings were summarized. The veteran's history of diffuse acne and comedones were noted, as were the Leishmania titers. It was noted that it was unclear if his health conditions were related to his Persian Gulf service. These records reflect, in pertinent part, that the veteran sought outpatient treatment in March 1996 for increased weakness and tremors at rest and on intention. Examination revealed, in part, eight to ten acne pimples on the veteran's face, back and arms. II. Analysis A. New and material evidence to reopen the claim for service connection for skin symptoms as a chronic disability resulting from an undiagnosed illness The Board reiterates that while the RO considered the veteran's claim for service connection for skin symptoms as a chronic disability resulting from an undiagnosed illness on a de novo basis, the Board is not bound by that determination and is, in fact, required to conduct an independent new and material evidence analysis in claims involving final rating decisions. See Barnett v. Brown, 8 Vet. App. 1 (1995), aff'd No. 95-7058 (U.S. Ct. App. Fed.Cir. May 6, 1996). In order to reopen this claim, the appellant must present or secure new and material evidence with respect to the claim which has been disallowed. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). Section 5108 of title 38 of the United States Code provides that, "[i]f new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim." The regulations provide that new and material evidence means evidence not previously submitted to agency decisionmakers which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a) (1999). Current caselaw provides for a three-step analysis when a claimant seeks to reopen a final decision based on new and material evidence. First, it must be determined whether new and material evidence has been presented under 38 C.F.R. § 3.156(a); second, if new and material evidence has been presented, it must be determined immediately upon reopening whether, based upon all the evidence and presuming its credibility, the claim as reopened is well grounded pursuant to 38 U.S.C.A. § 5107(A); and third, if the claim is well grounded, the merits of the claim must be evaluated after ensuring the duty to assist under 38 U.S.C.A. § 5107(b) has been fulfilled. See Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998) and Winters v. West, 12 Vet App 203 (1999) (en banc). The Board notes that, until recently, caselaw of the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (hereinafter "the Court") mandated that an additional question had to be addressed; that is, whether in light of all the evidence of record, there was a "reasonable possibility that the new evidence, when viewed in the context of all the evidence, both new and old, would change the outcome" in the prior determination. See Colvin v. Derwinski, 1 Vet. App. 171, 174 (1991). This additional test was overruled in the Hodge case cited above. Therefore, in the present case, the Board will review the veteran's claim to reopen solely in accordance with the criteria found in 38 C.F.R. § 3.156. The Court has stated that in determining whether the evidence is new and material, the credibility of the newly presented evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510 (1992). In this case, the Board is required to consider all the evidence received since the last disallowance of the claim concerning service connection for skin symptoms as a chronic disability resulting from an undiagnosed illness. As noted above, when this claim was denied by the RO in February 1994, the basis was that there was no evidence that the veteran had a skin condition related to his exposure to environmental hazards in the Gulf War. Subsequent to this final denial, the evidence the veteran has submitted to reopen his claim include the veteran's own written and oral statements and medical treatment records, including the October 1995 letter from a VA physician. The submission of the October 1995 letter, alone, is sufficient to reopen the veteran's claim. This document includes a medical opinion that the veteran's skin symptoms are "likely related" to his Gulf War service. This record was not considered by the RO in its final rating decision. Using the guidelines noted above, the Board finds that new and material evidence has been presented; hence, the claim concerning service connection for skin symptoms as a chronic disability resulting from an undiagnosed illness may be reopened. As the first step has been met regarding this claim, it must next be determined whether, based upon all the evidence and presuming its credibility, the claim as reopened is well grounded. In Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 118 S. Ct. 2348 (1998), the United States Court of Appeals for the Federal Circuit held that, under 38 U.S.C. § 5107(a), VA has a duty to assist only those claimants who have established well grounded (i.e., plausible) claims. More recently, the United States Court of Appeals for Veterans Claims issued a decision holding that VA cannot assist a claimant in developing a claim which is not well grounded. Morton v. West, 12 Vet. App. 477 (July 14, 1999), req. for en banc consideration by a judge denied, No. 96-1517 (U.S. Vet. App. July 28, 1999) (per curiam). Once a claimant has submitted evidence sufficient to justify a belief by a fair and impartial individual that a claim is well grounded, the claimant's initial burden has been met, and VA is obligated under 38 U.S.C. § 5107(a) to assist the claimant in developing the facts pertinent to the claim. On November 2, 1994, Congress enacted the "Persian Gulf War Veterans' Act, " Title I of the "Veterans' Benefits Improvements Act of 1994," Public Law 103-446. That statute added a new section 1117 to Title 38, United States Code, authorizing VA to compensate any Persian Gulf veteran suffering from a chronic disability resulting from an undiagnosed illness or combination of undiagnosed illnesses which became manifest either during active duty in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more within a presumptive period following service in the Southwest Asian theater of operations during the Persian Gulf War. To implement the Persian Gulf War Veterans' Act, VA added the following regulation: (Note: As originally constituted, the regulation established the presumptive period as not later than two years after the date on which the veteran last performed active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. Effective November 2, 1994, the period within which such disabilities must become manifest to a compensable degree in order for entitlement for compensation to be established was expanded.) The revised regulations are as follows: (a)(1) Except as provided in paragraph (c) of this section, VA shall pay compensation in accordance with chapter 11 of title 38, United States Code, to a Persian Gulf veteran who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of this section, provided that such disability: (i) became manifest either during active military, naval, or air 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, 2001; and (ii) by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. (2) For purposes of this section, "objective indications of 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. (3) For purposes of this section, disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-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. (4) A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. (5) A disability referred to in this section shall be considered service- connected for purposes of all laws of the United States. (b) For the purposes of paragraph (a)(1) of this section, signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: (1) fatigue (2) signs or symptoms involving skin (3) headache (4) muscle pain (5) joint pain (6) neurologic signs or symptoms (7) neuropsychological signs or symptoms (8) signs or symptoms involving the respiratory system (upper or lower) (9) sleep disturbances (10) gastrointestinal signs or symptoms (11) cardiovascular signs or symptoms (12) abnormal weight loss (13) menstrual disorders. (c) Compensation shall not be paid under this section: (1) if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or (2) if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or (3) if there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. (d) For purposes of this section: (1) 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. (2) 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 (1999). A well grounded claim for compensation under 38 U.S.C. § 1117(a) and 38 C.F.R. § 3.317 for disability due to undiagnosed illness generally requires the submission of some evidence of: (1) active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) the manifestation of one or more signs or symptoms of undiagnosed illness; (3) objective indications of chronic disability during the relevant period of service or to a degree of disability of 10 percent or more within the specified presumptive period; and (4) a nexus between the chronic disability and the undiagnosed illness. VAOPGCPREC 4-99. With respect to the second and fourth elements, evidence that the illness is "undiagnosed" may consist of evidence that the illness cannot be attributed to any known diagnosis or, at minimum, evidence that the illness has not been attributed to a known diagnosis by physicians providing treatment or examination. The type of evidence necessary to establish a well grounded claim as to each of these elements may depend upon the nature and circumstances of the particular claim. Medical evidence would ordinarily be required to satisfy the fourth element, although lay evidence may be sufficient in cases where the nexus between the chronic disability and the undiagnosed illness is capable of lay observation. For purposes of the second and third elements, the manifestation of one or more signs or symptoms of undiagnosed illness or objective indications of chronic disability may be established by lay evidence if the claimed signs or symptoms, or the claimed indications, respectively, are of a type which would ordinarily be susceptible to identification by lay persons. If the claimed signs or symptoms of undiagnosed illness or the claimed indications of chronic disability are of a type which would ordinarily require the exercise of medical expertise for their identification, then medical evidence would be required to establish a well grounded claim. With respect to the third element, a veteran's own testimony may be considered sufficient evidence of objective indications of chronic disability, for purposes of a well grounded claim, if the testimony relates to non-medical indicators of disability within the veteran's competence and the indicators are capable of verification from independent sources. As an initial matter, the Board notes that the DD Form 214 reflects that the veteran received the Kuwait Liberation Medal, indicating that he served in the Southwest Asia theater of operations during the Gulf War. The veteran's claim concerning service connection for skin symptoms as a chronic disability resulting from an undiagnosed illness is well grounded. The veteran has submitted medical evidence of a nexus (the October 1995 letter from the VA physician) suggesting a "likely" relationship between his skin symptoms and his service in the Gulf War. This letter constitutes at least some evidence suggesting a nexus between the veteran's skin symptoms and an undiagnosed illness. Therefore, subject to the Remand section below, the veteran's claim concerning service connection for skin symptoms as a chronic disability resulting from an undiagnosed illness is well grounded. B. Service connection for leishmaniasis As noted above, the threshold question is whether the veteran has met his initial burden of presenting a well-grounded claim. If he has not, then the claim must fail and there is no further duty to assist in the development of the claim. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A well-grounded claim requires more than an allegation; the claimant must submit supporting medical evidence. Furthermore, the evidence must justify a belief by a fair and impartial individual that the claim is plausible. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). For a well-grounded claim of service connection, there must be competent evidence of a current disability (a medical diagnosis), of inservice incurrence or aggravation of a disease or injury (lay or medical evidence), and of a nexus between the inservice injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see also Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). Evidentiary assertions by the veteran must be accepted as true for the purposes of determining whether a claim is well grounded, except where the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the veteran. King v. Brown, 5 Vet. App. 19, 21 (1993). It is the Board's conclusion that the veteran has failed to submit evidence of a well-grounded claim for service connection for leishmaniasis. Although there is some confusion as to whether the veteran even has leishmaniasis, there is, in any case, no competent evidence linking this condition to service, to any applicable presumptive period or to a service-connected disability. Caluza, supra. While the veteran has opined that his current leishmaniasis was first manifested in active duty or shortly upon discharge, this evidence is insufficient to establish service connection. The Court has held that lay persons cannot provide testimony where an expert opinion is required. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Nothing in the claims file indicates that the appellant is a health care professional, and there is no indication that he is a physician or otherwise has any specialized training or knowledge in the science of determining etiologies of medical conditions. Therefore, the opinion he has offered is beyond his competence to make. Black v. Brown, 10 Vet. App. 279 (1997). In the absence of a well-grounded claim, there is no duty to assist the veteran further in the development of that claim. Grivois v. Brown, 6 Vet. App. 136 (1994). If a claim is not well grounded, the Board does not have jurisdiction to adjudicate it. Boeck v. Brown, 6 Vet. App. 14 (1993). Accordingly, as a claim that is not well-grounded does not present a question of fact or law over which the Board has jurisdiction, the claim concerning entitlement to service connection for leishmaniasis must be denied. C. Service connection for fatigue as a chronic disability resulting from an undiagnosed illness The veteran's claim concerning service connection for fatigue as a chronic disability resulting from an undiagnosed illness is well grounded. As noted above, the claims file indicates that the veteran served in the Southwest Asia theater of operations during the Gulf War. He has complained of symptoms of fatigue since his return from his active duty in the Southwest Asia theater during the Gulf War. Moreover, as noted above, the veteran has submitted medical evidence of a nexus (the May 1994 systemic conditions examination for VA purposes) suggesting that the veteran had chronic fatigue and "Persian Gulf Syndrome." This constitutes at least some evidence suggesting a nexus between the veteran's symptoms of fatigue and an undiagnosed illness. Therefore, subject to the Remand section below, the veteran's claim concerning service connection for fatigue as a chronic disability resulting from an undiagnosed illness is well grounded. ORDER The claim concerning service connection for skin symptoms as a chronic disability resulting from an undiagnosed illness is well grounded. The appeal is granted to this extent subject to the following remand directions of the Board. A well-grounded claim not having been submitted, service connection for leishmaniasis is denied. The claim concerning service connection for fatigue as a chronic disability resulting from an undiagnosed illness is well grounded. The appeal is granted to this extent subject to the following remand directions of the Board. REMAND Claims concerning skin symptoms and fatigue as chronic disabilities resulting from an undiagnosed illness As noted above, the veteran essentially contends that he is entitled to service connection for skin symptoms and fatigue as chronic disabilities resulting from an undiagnosed illness. The Board finds that new examinations are necessary in relation to these claims. With regard to fatigue, VA's criteria for diagnosing chronic fatigue syndrome appear in 38 C.F.R. § 4.88a, and were revised effective July 15, 1995. [A new Diagnostic Code 6354 was also established so that once service-connected, disability ratings might be uniformly effectuated]. Specifically, the pertinent VA regulation concerning the diagnosis of chronic fatigue syndrome reads as follows: (a) For VA purposes, the diagnosis of chronic fatigue syndrome requires: (1) new onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least six months; and (2) the exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms; and (3) six or more of the following: (i) acute onset of the condition, (ii) low grade fever, (iii) nonexudative pharyngitis, (iv) palpable or tender cervical or axillary lymph nodes, (v) generalized muscle aches or weakness, (vi) fatigue lasting 24 hours or longer after exercise, (vii) headaches (of a type, severity, or pattern that is different from headaches in the pre-morbid state), (viii) migratory joint pains, (ix) neuropsychologic symptoms, (x) sleep disturbance. 38 C.F.R. § 4.88a (1999). The claims file indicates that the veteran has been diagnosed as having "chronic fatigue syndrome" as well as simply "chronic fatigue." A new examination is necessary to determine whether or not the veteran has objective evidence of fatigue; whether he has chronic fatigue syndrome or whether he has chronic fatigue as a manifestation of an undiagnosed illness. As for the veteran's skin symptoms, the claims file indicates a great deal of disparity as to whether he has leishmaniasis or other such diagnosed condition. The Board therefore finds that a new skin examination for VA purposes (as detailed below) is also necessary to properly adjudicate the veteran's claim and fulfill the mandatory guidelines of M21-1, Part III, Change 74 (April 30, 1999). The Board further notes that in August 1996, the RO issued a letter to the veteran advising, in part, that he could submit evidence indicating that he had an undiagnosed illness which began either during active service in the Southwest Asia theater of operations or within two years thereafter. However, in April 1997, the VA published a new rule, effective retroactively to November 2, 1994, to expand the period within which disabilities resulting from undiagnosed illnesses suffered by Gulf War veterans must become manifest to a compensable degree in order for entitlement for compensation to be established. The presumptive period was expanded to December 31, 2001. 62 Fed. Reg. 23,139 (April 29, 1997). The RO should issue a new development letter to the veteran, reflecting this change in the presumptive period. The most recent treatment records concerning the veteran were associated with the claims file in October 1996. To ensure that the veteran's claims will receive a fully informed evaluation, clinical data relating to the veteran obtained since October 1996 should also be acquired and reviewed. Claims concerning service connection for joint pain and, headache. By its February 1994 rating decision, the RO also denied, in pertinent part, service connection for joint pain as a chronic disability resulting from an undiagnosed illness. The veteran did not file a notice of disagreement within one year of this adverse determination. By its November 1995 rating decision, the RO denied, in pertinent part, service connection for joint pain and headaches as chronic disabilities resulting from an undiagnosed illness. The RO advised the veteran of these adverse determinations by a letter dated November 30, 1995. The veteran indicated his disagreement with these determinations on a written statement filed in March 1996. A statement of the case was issued in April 1996, but these three issues were not referenced therein. In a July 1997 supplemental statement of the case, the RO did reference these three issues. The cover letter of this supplemental statement of the case included the following language: The enclosed Supplemental Statement of the Case . . . contains changes or additions to the original Statement of the Case sent to you on April 3, 1996. This is not a final decision on the appeal you have initiated. We are giving you a period of 60 days to make any comment you wish concerning the additional information before preparing your case for Board of Veterans' Appeals consideration. Before a case can be prepared for Board of Veterans' Appeals consideration, a substantive appeal (VA Form 9) or its equivalent in correspondence must be received from you. If you have filed a substantive appeal with respect to all issues contained in the Statement(s) of the Case, a response at this time is optional. If you feel that you have stated your case completely, you should let us know so that we may continue your appeal without waiting for the 60-day period to expire. If this Supplemental Statement of the Case contains an issue which was not included in substantive appeal, you must respond within 60 days to perfect your appeal of the new issue. If you do not timely file a substantive appeal as to the new issue(s) we will place your records on the docket of the Board of Veterans' Appeals for review of the prior issues, if any, and the Board of Veterans' Appeals will provide you with a copy of its decision. In June 1998, the veteran's representative submitted a VA Form 646, on which these three claims were referenced. The Board is raising the issue of the timeliness of the veteran's substantive appeal with regard to these claims for service connection. The Board will address this issue pursuant to authority which provides that it has the authority to determine, in the first instance, questions as to the timeliness of the response to a statement of the case. See 38 U.S.C.A. § 7105(d) (West 1991); VAOGCPREC 9-99 (August 18, 1999). An application for review on appeal shall not be entertained unless it is in conformity with Chapter 71, Title 38, United States Code. 38 U.S.C.A § 7108 (West 1991). Federal regulations provide as follows: (b) Substantive Appeal. Except in the case of simultaneously contested claims, a Substantive Appeal must be filed within 60 days from the date that the agency of original jurisdiction mails the Statement of the Case to the appellant, or within the remainder of the 1-year period from the date of mailing of the notification of the determination being appealed, whichever period ends later. The date of mailing of the Statement of the Case will be presumed to be the same as the date of the Statement of the Case and the date of mailing the letter of notification of the determination will be presumed to be the same as the date of that letter for purposes of determining whether an appeal has been timely filed. (c) Response to Supplemental Statement of the Case. Where a Supplemental Statement of the Case is furnished, a period of 60 days from the date of mailing of the Supplemental Statement of the Case will be allowed for response. The date of mailing of the Supplemental Statement of the Case will be presumed to be the same as the date of the Supplemental Statement of the Case for purposes of determining whether a response has been timely filed. Provided a Substantive Appeal has been timely filed in accordance with paragraph (b) of this section, the response to a Supplemental Statement of the Case is optional and is not required for the perfection of an appeal, unless the Supplemental Statement of the Case covers issues that were not included in the original Statement of the Case. If a Supplemental Statement of the Case covers issues that were not included in the original Statement of the Case, a Substantive Appeal must be filed with respect to those issues within 60 days in order to perfect an appeal with respect to the additional issues. 38 C.F.R. § 20.302 (b), (c) (1999). An extension of the 60-day period for filing a Substantive Appeal, or the 60- day period for responding to a Supplemental Statement of the Case when such a response is required, may be granted for good cause. A request for such an extension must be in writing and must be made prior to expiration of the time limit for filing the Substantive Appeal or the response to the Supplemental Statement of the Case. The request for extension must be filed with the Department of Veterans Affairs office from which the claimant received notice of the determination being appealed, unless notice has been received that the applicable records have been transferred to another Department of Veterans Affairs office. A denial of a request for extension may be appealed to the Board. 38 C.F.R. § 20.303 (1999). The filing of additional evidence after receipt of notice of an adverse determination does not extend the time limit for initiating or completing an appeal from that determination. 38 C.F.R. § 20.304 (1999). (a) Acceptance of postmark date. When these Rules require that any written document be filed within a specified period of time, a response postmarked prior to expiration of the applicable time limit will be accepted as having been timely filed. In the event that the postmark is not of record, the postmark date will be presumed to be five days prior to the date of receipt of the document by the Department of Veterans Affairs. In calculating this 5-day period, Saturdays, Sundays and legal holidays will be excluded. (b) Computation of time limit. In computing the time limit for filing a written document, the first day of the specified period will be excluded and the last day included. Where the time limit would expire on a Saturday, Sunday, or legal holiday, the next succeeding workday will be included in the computation. 38 C.F.R. § 20.305 (1999). For the purpose of Rule 305 (§ 20.305 of this part), the legal holidays, in addition to any other day appointed as a holiday by the President or the Congress of the United States, are as follows: New Year's Day--January 1; Inauguration Day-- January 20 of every fourth year or, if the 20th falls on a Sunday, the next succeeding day selected for public observance of the inauguration; Birthday of Martin Luther King, Jr.--Third Monday in January; Washington's Birthday--Third Monday in February; Memorial Day--Last Monday in May; Independence Day--July 4; Labor Day--First Monday in September; Columbus Day--Second Monday in October; Veterans Day--November 11; Thanksgiving Day--Fourth Thursday in November; and Christmas Day--December 25. When a holiday occurs on a Saturday, the Friday immediately before is the legal public holiday. When a holiday occurs on a Sunday, the Monday immediately after is the legal public holiday. 38 C.F.R. § 20.306 (1999). This remand is the veteran's notice of the Board's intent to consider the timeliness of his substantive appeal as to the issue of whether new and material evidence has been submitted to reopen a claim concerning joint pain as a chronic disability resulting from an undiagnosed illness and the issue of service connection for headaches as a chronic disability resulting from an undiagnosed illness. The RO should forward a letter to the veteran (at his last known address) and to his representative, and advise them that that they have 60 days from the date of the letter to present evidence, written argument, and/or a request for a hearing to present oral argument on the question of timeliness of the veteran's substantive appeal relating to these claims. If so requested, the RO should schedule a hearing and advise the veteran and his representative as to the time and place of the hearing. Accordingly, the case is REMANDED to the RO for the following: 1. The RO should issue the veteran a new development letter, in accordance with M21-1, Part III, Change 74 (April 30, 1999). Specifically, the veteran should be asked to submit postservice medical and nonmedical indications of such manifestations that can be independently observed or verified. The nonmedical evidence may include, but is not limited to, proof of time lost from work and evidence affirming changes in the veteran's appearance, physical abilities, and mental or emotional attitude. A copy of this letter, which should be forwarded to the veteran's last known address, should be associated with the claims file. 2. With regard to the veteran's claims that have been determined to be well grounded, the RO should specifically request the names and addresses of all medical care providers, if any, who have treated the veteran since October 1996. After securing the necessary releases, the RO should obtain these records and permanently associate them with the claims file. Any pertinent VA medical records documenting treatment of the veteran since October 1996 which have not already been associated with the claims file, should also be obtained and made of record. These should include any such records from the Lebanon VAMC. 3. The RO should also forward a letter to the veteran (at his last known address) and to his representative, and advise them that they have 60 days from the date of the letter to present evidence, written argument, and/or a request for a hearing to present oral argument on the question of timeliness of the appeal concerning the issue of whether new and material evidence has been submitted to reopen a claim concerning joint pain as a chronic disability resulting from an undiagnosed illness and the issue of service connection for headaches as a chronic disability resulting from an undiagnosed illness. If so requested, the RO should schedule a hearing and advise the veteran and his representative as to the time and place of the hearing. 4. Following completion of the above development, the veteran should be afforded appropriate specialty examinations with regard to his claim concerning skin symptoms and fatigue, as chronic disabilities resulting from an undiagnosed illness. The RO should provide the examiners a list of the symptoms the veteran is claiming are manifestations of an undiagnosed illness. The claims folder and a copy of this REMAND must be made available to and be reviewed by the examiners prior to the examinations. (a) Each examiner should note and detail the veteran's reported symptoms relevant to the appropriate specialty. (b) Each examiner should determine if there are any objective medical indications that the veteran is suffering from the reported symptoms. (c) Skin examination: The examiner should determine whether the veteran has objective evidence of a skin disability. If so, the examiner should note whether it is at least as likely as not that the manifestations are attributable to a known diagnostic disability or disabilities. If the manifestations cannot be attributed to a diagnosed illness, the examiner should be asked to determine if there is affirmative evidence that the undiagnosed illness was not incurred during active service during the Gulf War, or that the undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from service during the Gulf War or that the illness was the result of the veteran's abuse of alcohol or drugs. (d) Fatigue examination: The examiner should specifically determine whether there are objective indications of fatigue. The examiner should also determine if it is at least as likely as not that the veteran has chronic fatigue syndrome (see criteria listed above) or another known diagnostic entity. If the symptoms cannot be attributed to an diagnosed illness, the examiner should be asked to determine if there is affirmative evidence that the undiagnosed illness was not incurred during active service during the Gulf War, or that the undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from service during the Gulf War or that the illness was the result of the veteran's abuse of alcohol or drugs. (e) All opinions expressed should be supported by reference to pertinent evidence. If the examiner disagrees with any opinions contained in the claims file which contradict his or hers, the reasons for the disagreement should be set forth in detail. 5. Upon receipt of the examination reports, the RO should review them to ensure that they are adequate for rating purposes. If an examination is inadequate for any reason, the RO should return the examination report to the examining physician and request that all questions be answered. 6. Upon completion of the development requested by the Board and any other development deemed appropriate by the RO, the RO should again consider the veteran's claims. If any action taken remains adverse to the veteran, he and his representative (if any) should be furnished a supplemental statement of the case concerning all evidence added to the record since the July 1997 statement of the case. The veteran and any representative should be given an opportunity to respond. Thereafter, the case should be returned to the Board, if in order. The appellant need take no action until otherwise notified, but he may furnish additional evidence and argument while the case is in remand status. Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992); Booth v. Brown, 8 Vet. App. 109 (1995). The purpose of this remand is to ensure due process and obtain additional medical information. No inference should be drawn regarding the final disposition of the veteran's claims as a result of this action. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. Iris S. Sherman Member, Board of Veterans' Appeals