Citation Nr: 1333888 Decision Date: 10/25/13 Archive Date: 11/06/13 DOCKET NO. 08-01 706 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARINGS ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD L. Kirscher Strauss, Counsel INTRODUCTION The Veteran served on active military duty from February 1979 to April 1982. The appeal comes before the Board of Veterans' Appeals (Board) from an April 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In the course of appeal, the Veteran testified at a decision review officer (DRO) hearing in January 2009 and at a Board Central Office hearing in March 2010. Transcripts of both these hearings are contained within the claims file. In a July 2010 decision, in pertinent part, the Board denied service connection for PTSD and remanded the TDIU claim because it was inextricably intertwined with other issues then on appeal. By a Joint Motion for Partial Remand (Joint Motion) approved by a March 2011 Order of the United States Court of Appeals for Veterans Claims (Court), the Secretary and the appellant agreed to vacate that portion of the Board's July 2010 decision that denied service connection for PTSD, in part based on a need to address an additional potential stressor to support the PTSD claim, and in part based on new Court precedent regarding the scope of a PTSD claim. In a recent decision, the Court held that claims for service connection for PTSD include claims for service connection for all psychiatric disabilities reasonably raised by the Veteran or the evidentiary record, based on the inherent unreasonableness of imputing self-knowledge of mental conditions from which the Veteran may be suffering. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Similarly, in this case the Veteran's claim of PTSD requires broadening based on evidence of diagnosed depression. The psychiatric disorder claim on appeal has accordingly been recharacterized as one for service connection for a psychiatric disorder, to include PTSD and depression. In January 2012 and April 2013, the Board remanded the issues of entitlement to service connection for a psychiatric disorder to include PTSD and depression and entitlement to TDIU. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran has a right to substantial compliance with the Board's remand orders. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Moreover, if the Board proceeds with final disposition of an appeal, and the remand orders have not been complied with, the Board itself errs in failing to ensure compliance. Stegall, 11 Vet. App. at 271. Thus, while the Board regrets the additional delay in this case, for the reasons discussed below, the case must be returned to the RO/AMC. In January 2012 and April 2013, the Board remanded the claims remaining on appeal, in part, to afford the Veteran an examination by a qualified psychiatrist or psychologist to determine whether he had a current psychiatric disorder, to include PTSD and depression, related to events during military service and to determine whether any current depression was "part and parcel" of any PTSD or was a separate psychiatric disorder. Unfortunately, the March 2012 VA examination report prepared by a clinical psychologist contained internally inconsistent conclusions regarding whether the Veteran had PTSD as a result of military service and did not offer the requested medical opinions regarding depression. In a March 2013 addendum, the same clinical psychologist again made inconsistent statements regarding PTSD. The psychologist opined that PTSD was less likely than not a result of military service. However, he also opined that although the Veteran's reported military stressors were rather vague even when explored in depth, his medical records and the Veteran's complaints supported the possibility that the Veteran may have developed symptoms of PTSD as a possible result of active duty experiences. In the April 2013 remand, the Board requested further clarification from the March 2012 VA examiner due to the contradictory statements with regard to the likelihood that the Veteran's psychiatric disorder is related to incidents during active duty. In a May 2013 addendum, the March 2012 VA examining clinical psychologist indicated that he reviewed the Veteran's claims file again and "in light of findings and to provide the highest support for our veterans, it is determined that the Veteran's PTSD is possibly at least as likely as not caused by or a result of military service." In a June 2013 deferred rating, a VA decision review officer recognized that clarification remained needed because the May 2013 opinion was speculative, was unsupported by a complete rationale, and because an opinion was not provided regarding depression. In August 2013, a VA Medical Officer from the AMC, who appears to be a podiatrist, indicated that she reviewed the Veteran's claims file and provided medical opinions. First, the Medical Officer opined that it is less likely than not that the Veteran's "claimed depression is 'part or parcel' or nexus of his claimed PTSD" and less likely than not incurred, caused by or aggravated by his time in military service. She based this opinion on the findings of an August 2010 VA psychiatric examination, which "was silent on a diagnosis of depression" and on the March 2013 addendum opinion, which "is silent on the Veteran's claimed depression." Therefore, the Medical Officer opined that "it is less likely than not that the Veteran's claimed depression is a nexus of his claimed PTSD or a separate diagnosis incurred in, caused by or aggravated by his time in military service." The Medical Officer also concluded that depression was unrelated to the Veteran's military service because a clinical diagnosis was made approximately 20 years following his military service. Instead, she concluded that his depression was a "consequence of his civilian life long experiences and his desired behavioral choice." The Board finds that the Medical Officer's opinion, which is based on silence regarding depression in other VA examination reports and on the length of time between military service and a clinical diagnosis of depression, does not logically or sufficiently support the Officer's conclusion. Moreover, neither the clinical psychologist in the May 2013 addendum nor the podiatrist or Medical Officer in the August 2013 VA medical opinion clarified the opinion as to whether the Veteran has PTSD that meets the relevant diagnostic criteria related to claimed stressors in service, as directed again in the April 2013 Remand. Therefore, the claim for service connection for a psychiatric disorder, to include PTSD and depression, must be remanded to afford the Veteran a VA examination conducted by a psychiatrist to obtain the medical information and opinions necessary to decide the claim. Prior to arranging for a VA examination, ongoing treatment records from the Mountain Home VA Medical Center (VAMC) dated from July 2013 to the present should be obtained and associated with the claims file. For the benefit of the VA examining psychiatrist or psychologist, the Board summarizes the evidence pertinent to the claim for service connection. However, the examiner must thoroughly review the claims file in conjunction with the requested examination. The Veteran claimed entitlement to service connection for PTSD in June 2007. Throughout the course of his claim for VA benefits, he has reported several stressful events. Initially, he asserted in his claim that he had "been having problems since the 9/11 terrorist attack that ultimately came to a head on the day that Saddam Hussein was executed [on December 30, 2006]." He added that he "keeps a loaded gun by [his] side most of the time and [is] addicted to the news channels sometimes watching the same thing over and over." The Board observes that the Veteran's initial statement regarding the onset of psychiatric problems is consistent with the medical evidence of record and supported by lay statements from the Veteran's wife and mother-in-law. Second, in a July 2007 stressor statement and in subsequent statements, he asserted that he was assigned to guard duty aboard the USS Haleakala in December 1979 while the ship was docked in Manila, Republic of the Philippines during the time of the Iran hostage crisis or "Shah of Iran thing." He stated that "Muslims. . .were protesting" the presence of the ship while "burning stuff in effigy" and shouting. He reported that he was given a rifle without ammunition during the protest and told "not to worry about it," but he was "scared to death." He indicated that "nothing happened and soon the MPs came and ran the protestors off." (See August 2007 PTSD follow-up note; see also December 2006 VA urgent care psychiatry note). He elaborated that the "war and situation in the Mid-East have brought back these old memories and I feel afraid and that I must be prepared for something bad to happen on our homeland. . . ." VA provided this information regarding the December 1979 stressor to the United States Army and Joint Services Records Research Center (JSRRC) for verification. In October 2008, JSRRC responded that the USS Haleakala was in port in Manila, Republic of the Philippines from December 24, 1979 to December 28, 1979; however, the deck logs obtained from the Naval Historical Center did not document any incidents of protestors as related in the stressor provided by the Veteran. Third, during an August 2007 appointment with a VA readjustment counselor, noted to be a certified master social worker (CMSW), the Veteran related that he was involved in "picking up boat people from Vietnam or Cambodia" and that several of these boats were blown out of the water after passengers were unloaded. Fourth, during the January 2009 hearing, the Veteran testified about an event in October 1979 that resulted in a left shoulder injury, which is service-connected. He described a "real bad fight on the base at the bar" and everybody in Shore Patrol was sent to stop the fighting. He reported that "we came walking in the bar and a chair came right at me at the time" and he "hit the ground the same time that the chair hit" him, "but it stopped the fight" because he was "just flopping around like a wet rag" and "screaming and hollering." Asked whether he considered that as being a stressor, the Veteran replied, "Yeah, it is, it is, you know. Certain things, being on an ammunition ship is stress related, you know." However, during the March 2010 Board hearing when asked whether "the pain related to [his] shoulder [had] any impact on [his] psychological condition," he replied, "I think so. I think that is what is helping me be - by the use of narcotics, it probably helped me, it's probably added to emotions." Then, he confirmed that he was not sure. The Veteran did not describe the in-service event that caused his shoulder injury as traumatic or characterize it as a stressor causing PTSD. Fifth, in March 2010, he testified he was on an ammunition ship in the Persian Gulf that aborted a rescue mission during the Iran hostage crisis and stated that he believes "we have to be so cautious in America of Muslims now." Finally, during an August 2010 VA psychiatric examination performed in connection with a previous claim for service connection for narcotic addition secondary to his service-connected left shoulder disability, which the Board denied in a January 2012 decision, the Veteran disclosed that while on active duty in Oakland, California at a place that another Veteran had previously taken him to obtain heroin, he was held up at gunpoint and feared for his life. The March 2011 Joint Remand directs the Board to "consider potentially favorable evidence concerning a potential in-service stressor" involving a 1979 incident during which the Veteran was hit with a chair and sustained a left shoulder dislocation. The parties to the Joint Remand noted that the "Board did not address whether the evidence reasonably raises a theory that [the Veteran's] stressor is due to an in-service assault." The Board is also directed to consider whether service connection is warranted for any other current psychiatric disability, to include diagnosed depression. The Veteran's service records reflect that he served during peacetime and did not engage in combat with the enemy. His service treatment records are silent for complaints, findings, diagnosis, or treatment related to psychiatric disorder. His service treatment records do reflect that in October 1979 he was observing a fight between Navy Seals and a shipmate when he was hit with a chair. One of the Seal Team members helped him place his dislocated shoulder back in place. He subsequently sought medical treatment many times for his left shoulder and underwent surgery in March 1981. Following a Medical Board review in June 1981, he was discharged in April 1982 due to physical disability of his left shoulder. Neither service treatment records nor post-service private or VA treatment records during multiple visits and examinations for his service-connected left shoulder disability reflects complaints or statements by the Veteran indicating that he experienced the October 1979 left shoulder injury as a traumatic event. Rather, prior to the March 2011 Joint Motion and with the exception of his January 2009 hearing testimony, he had described the injury to military, VA, and private treatment providers and to Veterans Benefits Administration (VBA) personnel without communicating that he experienced intense fear, helplessness, or horror in response to the event that caused physical injury to his shoulder. Accordingly, the Board finds that there is conflicting evidence as to whether the October 1979 event resulting in a left shoulder injury has been clinically significant regarding current psychiatric disability, and a VA examination and medical opinion is required to address this question. Post-service private treatment records dated from 1992 until shortly before receipt of the Veteran's claim for service connection for PTSD document ongoing treatment for a left shoulder disability and are silent for complaints, findings, diagnosis, or treatment for psychiatric disorder other than opiate dependence. In this regard, the Board notes that a September 1998 discharge summary from the Mountain Home VA Medical Center (VAMC) reflects that the Veteran was admitted for detoxification for chronic opiate dependence one week after the death of his father, to whom he had promised he would quit using drugs. The discharge diagnosis was drug dependence (opiates) and continuous drug withdrawal syndrome. In November 2001, he presented to East Tennessee Baptist Hospital with the chief complaint of needing to "quit taking narcotics." He described his drug use behavior and that he had been able to keep it a secret from his wife until the past few months. He did not describe traumatic military events or mention the events of 9/11, including any particular coping difficulty. The diagnosis was opiate dependence. A January 2004 private treatment record from L. Pannocchia, M.D., reflects that the Veteran was on Methadone treatment for his narcotic addition. A January 2006 history, physical, and admission document from Northwest Georgia Treatment Center documents the Veteran's history of drug use beginning with alcohol in 1964 and multiple other drugs beginning in 1969, approximately one decade before entering military service. The diagnosis was opioid dependence and the plan included Methadone maintenance. In December 2007, the Veteran claimed entitlement to service connection for narcotics addiction secondary to taking narcotic medications prescribed for his service-connected left shoulder disability and was afforded a VA psychiatric examination in August 2010. The report reflects that the Veteran gave the examining psychiatrist a "very detailed history" of legal or other problematic consequences of his substance use "as this was key to the question posed" as to whether the Veteran's opiate addiction was service connected as a result of his left shoulder surgical procedure. The psychiatrist concluded that the Veteran's opiate dependence and abuse began prior to entry into military service and was associated with an underlying antisocial personality disorder. The basis for the psychiatrist's conclusions was described in great detail in the examination report. As noted, the Board denied the claim for service connection for narcotics addiction in January 2012. Returning to the medical evidence of record, the earliest documented report of psychiatric problems, other an opiate dependence, is in July 2006. The Veteran reported to Dr. Pannocchia that he was having episodes of "being on an ammo ship while he was in the Navy[;] he had no problems at that point[,] but now he is having flashbacks where he is getting nervous and anxious." He stated that he "wakes up scared," but was "not having nightmares." The assessment was PTSD. On December 31, 2006, he presented to the Mountain Home VAMC emergency department with the chief complaint of "This Saddam execution got to me." He related serving in the Navy on a ship in the Philippines when protestors were pointing toward the ship and he was asked to stay in front of them and protect the ship with an empty MP3 for four hours. Although "nothing happened on that day," he "always get[s] a bad feeling around Christmas time and especially after September 11, 2001 he became more protective of his house" and family. On mental status examination, his mood was dysphoric. The assessment was PTSD and depression not otherwise specified (NOS). A January 2007 history and physical examination report from Dr. Pannocchia reflects the Veteran's report that he was in the Persian Gulf while in the Navy and that "since the war has started, he has been having more flashbacks," getting angry and upset when he hears about war. He stated that he "never served in Iraq, but served in the Navy in that area for approximately a week and [was] having intermittent nightmares." He described being "angry, nervous, and depressed" with some crying episodes. The impression included PTSD, and Dr. Pannocchia opined that "due to the chronic [left shoulder] pain, injuries and his experience in the Navy, [the Veteran] has developed PTSD." In June 2008, he told Dr. Pannocchia that "since the terrorist attack on 9/11, he has had recurrent flashbacks, nightmares and difficulty sleeping, anxiety and symptoms of agoraphobia. The assessment included PTSD, and the physician opined that it was "secondary to service in the U.S. Navy." Other lay statements from the Veteran's wife (from whom he was divorced in 2011), mother-in-law, and the Veteran himself identify an onset of observable psychiatric symptoms contemporaneous with the 9/11 attacks, war in Iraq, and execution of Saddam Hussein. In September 2008, the Veteran's wife stated that after the execution of Saddam Hussein, the Veteran "seemed to suffer some kind of mental breakdown. He watched the execution over and over on all the news channels and was obsessed with it." Finally, she took him to the VA emergency department. Of possible relevance, private treatment records dated in October 2007 also document that the Veteran was involved in a single-vehicle motor vehicle collision with a tree and transported by helicopter to a hospital for evaluation and treatment of multiple injuries. The air transport report noted that the Veteran was initially combative with possibly some alcohol on board. Subsequent VA and private treatment records reflect evaluation and treatment for PTSD, depression, and substance abuse and overdose. Regarding the question of PTSD related to military service, service connection for PTSD requires medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304(f) (2013). In this case, PTSD was not diagnosed during military service, the Veteran did not engage in combat with the enemy, and he was not a prisoner-of-war. Therefore, the provisions of 38 C.F.R. § 3.304(f)(1), (2), and (4) are inapplicable to this appeal. Pursuant to 38 C.F.R. § 3.304(f)(3), if a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of posttraumatic stress disorder and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. The Board notes that while written statements and testimony in support of the claim and statements made to medical professionals appear to reflect a general fear, distrust, and "hat[red]" (see January 2009 hearing transcript, page 10) of Muslims as an entire group, the Veteran has not identified the December 1979 protestors as members of a "hostile military" or as "terrorists." His January 2009 hearing testimony described the protestors as "students." Moreover, he has reported that while he was "scared to death," nothing happened. Similarly, the JSRRC response regarding this claimed stressor did not identify or reflect any documented "hostile military or terrorist activity" directed against the USS Haleakala in December 1979 or protestors as reported by the Veteran. Nevertheless, the examining VA psychiatrist or psychologist should consider whether the Veteran's claimed stressor regarding being on guard watch during a protest by Muslim students in Manila in December 1979 is related to a fear of hostile military or terrorist activity as defined by 38 C.F.R. § 3.304(f)(3). In addition, as noted above, the Board is directed to consider the theory that the Veteran has PTSD due to the verified October 1979 incident in which he was struck by a chair and injured his left shoulder. While the Veteran has not described the incident in a clinical setting as traumatic and was unsure whether the residual pain in his left shoulder affected his psychological condition during the March 2010 hearing, he seemed to testify in January 2009 that the event was a stressor along with the general experience of being on an ammunition ship. Therefore, on VA examination, the examiner must consider whether the October 1979 was experienced by the Veteran as traumatic, sufficient to support a diagnosis of PTSD. Finally, during the March 2010 hearing, the Veteran testified that he was not sure whether his service-connected left shoulder disability had any impact on his psychological condition. His wife testified that she believed that his condition, which she believed was a combination of anxiety and depression, was "more related to pain and that kind of thing." Therefore, the VA examining psychiatrist or psychologist should also provide a medical opinion as to whether any current psychiatric disorder, including depression, was caused or is aggravated by a service-connected left shoulder or right wrist disability. See 38 C.F.R. § 3.310 (2013); Allen v. Brown, 7 Vet. App. 439 (1995). The AMC/RO should provide VCAA notice to the Veteran regarding establishing service connection for disability on a secondary basis. The Veteran's TDIU claim remains intertwined with the service connection claim that is the subject of the present appeal and remand. Accordingly, adjudication of the TDIU claim must await development and readjudication of this claim. The Court has held that a claim that is inextricably intertwined with another claim that remains undecided and pending before VA must be adjudicated prior to a final order on the pending claim, so as to avoid piecemeal adjudication. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Provide VCAA notice to the Veteran regarding the information and evidence necessary to establish service connection for a psychiatric disorder on a secondary basis. 2. Obtain ongoing treatment records from the Mountain Home VAMC dated from July 2013 to the present and associate them with the claims file. 3. After completion of the above development, the Veteran should be afforded a VA examination conducted by a psychiatrist or clinical psychologist (other than the psychologist who conducted the March 2012 examination and provided addendum opinions in March 2013 and May 2013) to determine whether the diagnostic criteria for PTSD are met. The Veteran's claims file, to include a complete copy of this REMAND, must be provided to the psychiatrist or psychologist designated to examine the Veteran and the report of examination should note review of the claims file. All necessary special studies or tests, to include psychological testing and evaluation, should be accomplished. The examiner should consider the Veteran's contentions and evidence of record that he has PTSD from (1) the 9/11 terrorist attacks, war in Iraq, and execution of Saddam Hussein; (2) witnessing protests by Muslim students while docked and on guard duty in Manila, Republic of the Philippines without ammunition in his rifle; (3) picking up "boat people" from Vietnam or Cambodia and seeing boats blown out of the water after passengers were unloaded; (4) the October 1979 event, which is documented in service treatment records, that resulted in a left shoulder injury; (5) being on an ammunition ship in the Persian Gulf that aborted a rescue mission during the Iran hostage crisis; (6) being held up at gunpoint while buying heroin on active duty; or (7) his involvement in an October 2007 single-vehicle motor vehicle collision with a tree resulting in multiple injuries. Following a review of the claims file and examination of the Veteran, the examiner should clearly indicate whether the Veteran meets the diagnostic criteria for PTSD. If so, the examiner should clearly identify which claimed stressor(s) support the diagnosis of PTSD. With regard to the December 1979 event involving protestors, the examiner should determine whether the veteran currently suffers from PTSD related to his fear of hostile military or terrorist activity while on active duty and whether it is adequate to support a diagnosis of PTSD. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Regarding the claimed depression disability, and any other psychiatric disorder found on examination (other than opiate dependence or a personality disorder), the psychiatrist or psychologist should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any current psychiatric disability, including depression, began in service or is otherwise medically related to military service. If a psychiatric disorder, including depression, did not begin in service and is not medically related to military service, the examiner should indicate whether any psychiatric disorder, including depression, is at least as likely as not (a 50 percent or greater probability) caused or aggravated by the Veteran's service-connected left shoulder or right wrist disability. If aggravated, specify to the extent possible the baseline of psychiatric disorder or depression prior to aggravation, and the permanent, measurable increase in psychiatric impairment resulting from the aggravation. The examination report should include the complete rationale for all opinions expressed. The examiner should provide a rationale for the opinions. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. 4. After undertaking any other development deemed appropriate and ensuring that the requested actions are completed, the RO or AMC should readjudicate the claims of service connection for a psychiatric disorder to include PTSD and depression and for entitlement to TDIU. If any benefit is not granted in full, the Veteran and his representative should be furnished with a supplemental statement of the case and afforded an appropriate period of time for response. Thereafter, the case should be returned to the Board, if in order. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON NEXT PAGE) This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). _________________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2013).