Citation Nr: 1601915 Decision Date: 01/15/16 Archive Date: 01/21/16 DOCKET NO. 09-39 309 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for degenerative disc disease and cervical spondylosis ("neck condition"). 2. Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder and chronic depressive/anxiety disorder. 3. Entitlement to service connection for a headache disorder. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD R. Kipper, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1970 to July 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2008 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In August 2014, the Veteran testified at a hearing before the undersigned Veterans Law Judge, a transcript of which has been prepared and associated with the claims file. In November 2014, the Board remanded this case for additional development, to include providing the Veteran with VA examinations in order to obtain etiology opinions regarding his claimed conditions and obtaining outstanding treatment records. Regarding the characterization of the issues on appeal, the Board notes that the Veteran's initial claim was for entitlement to service connection for residuals of a cervical injury and residuals from fever. Pursuant to relevant case law, a veteran may identify the scope of a claim by reference "to a body part or system that is disabled or by describing symptoms of the disability." The factors for the adjudicator to consider, in determining the scope of a claim, are a veteran's descriptions of the claim and symptoms as well as the information submitted, or obtained by VA, in support of the claim. See Clemons v. Shinseki, 23 Vet. App. 1 (2009); Brokowski v. Shinseki, 23 Vet. App. 79, 86-87 (2009). In the present case, the evidence developed during the processing of this claim reflects the Veteran's contention that in addition to a neck condition, he has chronic headaches and an acquired psychiatric disorder as a result of a fever and/or a neck/head injury he suffered in service. Under these circumstances, the Board has recharacterized the issues for consideration as reflected on the title page to more accurately reflect the distinct disorders for which the Veteran seeks service connection. See Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008) (claims based on distinctly diagnosed diseases must be considered as separate and distinct claims). This appeal was processed using the Veterans Benefits Management System (VBMS) and Virtual VA paperless claims processing systems. Therefore any future consideration of the Veteran's claim should take into account the existence of the electronic record. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND After a careful review of the Veteran's claims file the Board finds that further development is required prior to adjudicating the issues on appeal. Neck Condition The Veteran contends that service connection is warranted for a neck condition. He asserts that he originally injured his neck during training when he landed on his head. See, e.g. November 2014 VA Treatment Record. He contends that he has had recurrent neck pain since his injury. See September 2014 Hearing Transcript; October 2009 VA 9. Service treatment records show that the Veteran reported headaches after a head injury on April 2, 1971. On April 9, 1971, the Veteran reported that he fell on his cervical spine the day before. X-rays were negative. During an April 29, 1971, examination for airborne school, the Veteran reported a neck injury while in training. He indicated that he had occasional stiffness. During a March 1972 discharge examination, the Veteran reported a history of head injury. On the corresponding examination report, the Veteran's neck and spine were evaluated as clinically normal. Post-service, an August 2006 private treatment record shows complaints of neck pain since a fall a month earlier. X-rays of the cervical spine showed "significant C5-C6 degenerative disc disease" and less severe degenerative disc disease at C4-C5. The Veteran was diagnosed with degenerative cervical disc disease. Subsequent VA treatment records show continuing complaints of chronic neck pain. A March 2007 VA treatment record shows that the Veteran reported chronic pain in his knees, ankles, neck, and back. A February 2008 VA treatment record shows that the Veteran reported chronic pain in his neck. He reported intermittent, severe muscle spasms in his neck since an injury in 1970 when he was "body slammed." An August 2008 VA treatment record shows that the Veteran reported a long history of intermittent neck pain since an injury in active service in 1971. An October 2009 VA treatment record shows that the Veteran reported chronic neck pain since he was slammed head first into the ground in 1970. A July 2010 VA treatment record shows diagnoses of degenerative disc disease and cervical spondylosis. A November 2014 VA treatment record shows that the Veteran reported neck pain since an injury in 1970 while on active duty. He reported that during a training exercise he was slammed head first into the ground and that he was carried off in a stretcher. In November 2014, the Board remanded this case in order to afford the Veteran a VA examination with opinion regarding the etiology of his current neck condition. The Veteran was examined in September 2015. The Veteran reported that he suffered a neck injury in early 1971 during training and that he was treated with pain pills. He indicated that x-rays were normal, so he resumed normal duty after a couple of days of light duty. He reported that after discharge, he saw several civilian doctors for neck pain and that the pain got progressively worse between 2006 and 2008 when he started VA medical treatment. He indicated that the pain was constant and that he used Tylenol as needed. The examiner indicated that the Veteran's diagnosed cervical conditions were spondylosis lower cervical spine and degenerative disc disease and cervical spondylosis. After examining the Veteran and reviewing the claims file, the examiner opined that the Veteran's current cervical condition was less likely than not related to the claimed in-service injury. The examiner's rationale was that "[t]here is NO objective evidence of claimed condition onset in military service or shortly after discharge from military service." (emphasis in original). The examiner also noted that "[m]any years after discharge from military service on 8/8/2008 [the Veteran] was diagnosed with spondylosis lower cervical spine; natural aging process at age 55, [and] this has progressed to current degenerative disc disease and cervical spondylosis confirmed by imaging 8/19/2009." When VA undertakes the effort to provide an examination, it must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion must support its conclusion with an analysis the Board can consider and weigh against the other evidence of record. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Furthermore, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Here, the September 2015 VA examiner based the negative nexus opinion exclusively on a lack of evidence of treatment for a neck condition while in service, or for many years after service, without considering the many lay statements alleging symptoms in service and continuity since. Relying on the absence of evidence in medical records to provide a negative opinion is contrary to established case law, and such opinions are therefore inadequate. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). In this regard, the Board highlights that the credibility of lay statements may not be refuted solely by the absence of corroborating medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (lay evidence concerning continuity of symptoms after service, if credible, may be competent, regardless of the lack of contemporaneous medical evidence). Additionally, the examiner's statements regarding the Veteran's post-service neck symptoms and treatment are inaccurate and reflect a less than thorough review of the evidence. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). In this regard, the examiner indicated that the Veteran's age-related spondylosis diagnosed in August 2008 progressed to cervical degenerative disc disease confirmed by imaging in August 2009. As noted above, the record reflects that the Veteran was diagnosed with significant cervical degenerative disc disease, confirmed by imaging, in August 2006. Moreover, the examiner's statement that there was no evidence of a neck problem in service is contrary to the evidence of record, which shows that the Veteran was treated for neck pain after a fall and that he continued to report neck pain on a later medical examination. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence...is essential for a proper appellate decision"); see also Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). Based on the foregoing, the Board finds that the September 2015 opinion is inadequate because the examiner does not appear to have considered all relevant facts, including competent lay evidence of symptoms ever since service and medical evidence of treatment for a neck condition. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (the probative value of a medical opinion is determined by whether the examiner was informed of sufficient facts upon which to base an opinion and whether the report contains data, conclusions, and a complete rationale in support thereof). As such, the Board finds that another medical opinion is needed to determine whether the Veteran's current neck condition is related to the injury sustained during his active military duty. Acquired Psychiatric Disorder The Veteran contends that he developed an acquired psychiatric disorder during service. He asserts that he was a good soldier when he entered service and that his personality "abrupt[ly]" changed after either the blow to the head when he injured his neck or a fever he contracted. See August 2014 Hearing Transcript; October 2009 VA-9. The Veteran contends that this personality change is evident because his reenlistment code on his DD-214 means character and behavior disorders. See October 2009 VA-9. Service treatment records do not document any mental health treatment; however, on an April 1971 report of medical history, the Veteran reported a positive response to the question of whether he ever had or had now "nervous trouble of any sort." In the physician's summary and elaboration it was noted, "generally nervous - hospitalized 1 week." The Veteran's service treatment records also show that he was treated for a fever caused by strep throat in May 1971. The Veteran's DD-214 indicates that the Veteran was discharged under honorable conditions. The separation authority and code was Army Regulation (AR) 635-200, SPN 264, which is unsuitability, character and behavioral disorders. Private treatment records show that the Veteran was treated for depression and anxiety in 2004 and 2005. VA treatment records show mental health treatment from March 2007 to the present and diagnoses of major depressive disorder and chronic depressive/anxiety disorder. During an April 2007 VA psychiatry initial assessment, the Veteran reported that he had been depressed "his whole adult life." An April 2008 VA treatment record shows that the Veteran "discussed history of chronic history of recurring irritability and anger and prior behavioral problem in the service (1 court marshall, 2 article 15) prior serious head injury from MVA with extended LOC and hospitalization x 2 weeks which occurred months after discharged from military and ongoing issue on deceased brother and chronic history of anxiety/depression." A September 2008 VA treatment record shows that the Veteran recounted an episode in service when he lost consciousness. He indicated that his father told him that he "was a different person after this, with more impulsive behaviors." An October 2012 VA treatment record shows that the Veteran reported he received a general discharge from the Army because he did not get along with authority, he hit a sergeant, he disobeyed direct orders, and he was disrespectful. The Veteran indicated he was diagnosed "as character and behavior disorder." In November 2014, the Board remanded this case in order to afford the Veteran a VA examination with opinion regarding the etiology of any currently diagnosed acquired psychiatric disorders. The Veteran underwent a VA Mental Disorders examination in September 2015. After examining the Veteran and reviewing the claims file, the examiner diagnosed the Veteran with unspecified depressive disorder and opined that "[i]t is less likely as not that this disorder is related to his prior military service or headaches as there is no objective evidence to create a nexus." The examiner also stated that "[t]his [V]eteran has experienced numerous intercurrent stressors including substance abuse that have likely impacted his symptoms." The Board finds that the opinion is inadequate as there was no adequate rationale given for the opinion. The mere statement by the examiner that there was "no objective evidence to create a nexus" is wholly conclusory and renders that opinion inadequate for adjudication purposes. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In light of these circumstances, and in light of the fact that the September 2015 VA examiner did not elicit any information from the Veteran regarding his symptoms in service, the Veteran should be afforded another VA examination to assess the nature and etiology of his acquired psychiatric disorders. 38 C.F.R. § 4.2 (noting that if the examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes). Headache Disorder The Veteran contends that he has chronic headaches as the result of a fever he contracted during service. During the August 2014 hearing, the Veteran testified that he was first diagnosed with migraine headaches in April 1971. The Veteran also asserted that the strep throat he suffered from in the military caused his migraine headaches, and that he has suffered from headaches since service. During the Veteran's November 1970 enlistment report of medical history, he did not report a history of frequent or severe headaches, and no headaches were noted on the corresponding examination report. A March 1971 service treatment record shows that the Veteran complained of a headache. On April 2, 1971, the Veteran reported a two week history of headaches. On April 19, 1971, the Veteran complained of a frontal headache. During an April 1971 airborne school examination report of medical history, the, the Veteran reported a positive response to the question of whether he ever had or had now "frequent or severe headaches." In the physician's summary and elaboration it was noted, "frequent headaches-takes no meds-also had headaches at 16 y.o.-tests neg." On a March 1972 discharge report of medical history, the Veteran indicated that he had frequent or severe headaches. In the physician's summary section, it was noted that the Veteran used to have headaches prior to service with no sequelae. Private treatment records from August 2004 show that the Veteran reported severe headaches for three days. An MRI of the brain showed evidence of an old ischemic stroke in the right frontal lobe. A September 2004 private treatment record shows that the Veteran reported frontal headaches. A December 2004 private treatment records shows that the Veteran reported occasional headaches. During a May 2007 VA initial psychiatric evaluation, the Veteran reported experiencing headaches. In November 2014, the Board remanded this case in order to afford the Veteran a VA examination with opinion regarding the etiology of any currently diagnosed headache disorder. The Board directed the examiner to opine as to the following three areas: (1) whether it is at least as likely as not that the Veteran currently suffers from residuals of fever, including a headache disorder; (2) whether it is at least as likely as not that any current headache disorder is etiologically related to headaches noted in service, including the likelihood that any current headaches are a continuing disease process of headaches noted in service; and (3) whether it is clear and unmistakable that the Veteran entered active military service with a pre-existing headache disorder, and, if so, whether it is clear and unmistakable that the Veteran's pre-existing headache disorder was not aggravated beyond the natural progress of the disorder by his active military service. The Veteran was afforded a VA examination in September 2015. The Veteran reported headaches for many years since he was "a kid." He reported that he hit his head several times; however, he reported no head injury or TBI in active duty with loss of consciousness. The Veteran also indicated that he no longer has the "blinding migraines" that he had as a teenager. He reported that for the past 5-10 years, his headaches have changed and that they are now more of a dull ache requiring no medication. After examining the Veteran and reviewing the claims file, the examiner diagnosed the Veteran with infrequent tension type headaches. The examiner opined that "there is no subjective/objective evidence that the Veteran currently suffers from residuals of fever to include the current headache disorder." The examiner also opined that the Veteran's current tension type headache disorder was less likely than not incurred in or caused by service and is not etiologically related to the headaches noted in service. Finally, the examiner opined that "[t]he pre-existing headache disorder has resolved without residuals...[t]he claimed current headache disorder, tension type headache, was not present in active military." The examiner's rationale for all of the opinions was that "[t]here is NO objective evidence of the current tension type headache onset in military service or shortly after discharge from military service." (emphasis in original). The examiner noted that the Veteran reported that his headaches have changed in the past 5-10 years and opined that the Veteran's current headache disorder is "not [the] same seen in his STR." The Board finds that the opinion is inadequate. The examiner provided no rationale for the opinion that the Veteran's headaches preexisted service. Additionally, the examiner provided no rationale for the opinion that the Veteran's current headache disorder is not the same seen in the Veteran's STRs. Moreover, the opinion is inadequate because the examiner only noted that the Veteran's headaches "changed in the past 5-10 years" without providing an etiology opinion regarding the Veteran's headache condition in the past. The Court has held that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at any time during the pendency of his claim, even if the disability resolves prior to adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321(2007). The Board notes that the Veteran's claim has been pending since April 2007. Therefore, given the evidence of a headache disorder during the appeal period and the lack of a nexus opinion by the September 2015 examiner, the Board finds that the examination is inadequate. A remand for a new VA examination is necessary. See Barr, supra. Outstanding Records The Board notes that there may be pertinent service treatment records not associated with the claims file. In this regard, an April 1971 report of medical history indicates that the Veteran was "generally nervous - hospitalized 1 week." The Board notes that in-service hospitalization records and mental health records are sometimes stored at the National Personnel Records Center (NPRC) separately from a Veteran's other service treatment records. A remand is required for the purpose of obtaining any such separately stored records which may exist. Although the AOJ attempted to obtain in-service hospitalization and mental health records from Fort Benning, Georgia for the period of January 1971 to April 1971, the Veteran's service treatment records suggest that he was stationed at Fort Jackson, South Carolina until at least April 19, 1971. Accordingly, on remand, the AOJ should request in-service hospitalization and mental health records from Fort Jackson, South Carolina. Additionally, the Veteran asserts that his personality change and subsequent discharge for character and behavior disorders provide evidence that he developed an acquired psychiatric disorder in service. To date, the Veteran's personnel records have not been associated with the claims file. As such records may document behavior changes, the Veteran's complete service personnel records are relevant to his claim for an acquired psychiatric disorder and should be obtain on remand. Lastly, as the record reflects that the Veteran receives ongoing VA treatment, any outstanding VA treatment records should be obtained on remand. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the Veteran's claims file all outstanding VA treatment records documenting treatment for the issues on appeal dated from January 2015 to the present. The Veteran should also be afforded the opportunity to identify and submit any outstanding private treatment records. 2. Obtain and associate with the claims file the Veteran's complete service personnel records. All efforts should be made to obtain such records. If any records cannot be obtained after efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(e). 3. Attempt to obtain the Veteran's records from the National Personnel Records Center for any in-service hospitalizations and/or mental health treatment at Fort Jackson, South Carolina from November 1970 to April 1971. The Board again notes that service hospitalization records and mental health records are sometimes stored separately from other service medical records, and a specific request should be made for such separately stored records. All efforts should be made to obtain such records. If any records cannot be obtained after efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 4. After all available records have been associated with the claims file, return the claims file to the September 2015 VA examiner for an addendum opinion as to the etiology of the Veteran's neck condition. If the previous examiner is no longer available, then the requested opinion with rationale should be rendered by another qualified examiner. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The entire claims file and a copy of this Remand must be made available to the reviewing examiner and the examiner shall indicate in the report that the claims file was reviewed. After reviewing the record and, if necessary, examining the Veteran, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that any currently diagnosed neck condition, to include degenerative disc disease and cervical spondylosis, had its onset in service or is related to any in-service disease, event, or injury, to include the Veteran's reports of landing on his head during a training accident. In so opining, the examiner should address the likelihood that injury such as those described by the Veteran could have caused the Veteran's documented neck conditions. The examiner's report must reflect consideration of the Veteran's entire documented medical history and assertions and all lay evidence, particularly the service treatment records documenting a cervical spine injury in April 1971, VA and private treatment records documenting complaints of neck pain, and the Veteran's lay statements regarding his symptoms. 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. The examiner must provide a rationale for each opinion given. 5. After all available records have been associated with the claims file, afford the Veteran an appropriate VA examination to determine the nature, onset, and likely etiology of any acquired psychiatric conditions. The entire claims file and a copy of this Remand must be made available to the examiner and the examiner shall indicate in the report that the claims file was reviewed. Any tests or studies deemed necessary should be conducted, and the results should be reported in detail. After examining the Veteran and reviewing the claims file, the examiner should render an opinion as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that any currently diagnosed acquired psychiatric disorder, to include major depressive disorder and chronic depressive/anxiety disorder, was incurred in, caused by, or is otherwise related to, the Veteran's military service. In offering these opinions, the examiner must acknowledge and discuss the Veteran's reports of personality and behavioral changes after suffering a neck/head injury in April 1971 and/or contracting a fever in May 1971. The examiner's report must reflect consideration of the Veteran's entire documented medical history and assertions and all lay evidence, particularly the service treatment records documenting a history of nervousness, VA and private treatment records documenting treatment for depression and anxiety, and the Veteran's lay statements regarding his symptoms. 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. The examiner must provide a rationale for each opinion given. 6. After all available records have been associated with the claims file, afford the Veteran an appropriate VA examination to determine the nature, onset, and likely etiology of any and all headache disorders diagnosed proximate to, or during the pendency of, this appeal. The entire claims file and a copy of this Remand must be made available to the examiner and the examiner shall indicate in the report that the claims file was reviewed. Any tests or studies deemed necessary should be conducted, and the results should be reported in detail. After examining the Veteran and reviewing the claims file, the examiner is requested to provide an opinion as to whether any headache disorder found to be present and/or diagnosed proximate to or during the pendency of the appeal clearly and unmistakably (i.e., highest degree of medical certainty) pre-existed the Veteran's entry onto active duty in November 1970. (a) If pre-existence is demonstrated clearly and unmistakably, the examiner should then opine whether any preexisting headache disorder was clearly and unmistakably not aggravated (i.e., not permanently worsened beyond the natural progression of the disease) during military service. If it is found that there is clear and unmistakable evidence that the Veteran's headache disorder existed prior to service and that there is clear and unmistakable evidence that the condition was not aggravated by service, the examiner should clearly indicate the clear and unmistakable evidence supporting his/her conclusions. (b) If, however, the examiner cannot clearly and unmistakably determine that the Veteran's headache disorder pre-existed military service, or that any preexisting condition was not aggravated in service, the examiner must take as conclusive fact that the Veteran's was sound on entrance into the military in November 1970. After presuming such, the examiner should then opine as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that any headache disorder found to be present and/or diagnosed proximate to or during the pendency of the appeal is related to the Veteran's military service, to include as a residual of a fever or as a residual of a neck injury. When providing these opinions, the examiner should consider and discuss the Veteran's service records, VA and private treatment records, and any other relevant information. The examiner's attention is directed to the November 1970 entrance examination showing no relevant abnormalities, service treatment records from March and April of 1971 showing complaints of headaches, an April 1971 Report of Medical History wherein the Veteran reported a history of frequent headaches, a March 1972 Report of Medical History wherein the Veteran reported frequent headaches, and the lay statements of the Veteran regarding his headache symptoms before, during, and after service. 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. The examiner must provide a rationale for each opinion given. 7. Thereafter, the RO/AMC must review the claims file to ensure that the foregoing requested development has been completed. In particular, review the requested examination reports to ensure that they are responsive to and in compliance with the directives of this remand and if not, implement corrective procedures. See Stegall v. West, 11 Vet. App. 268 (1998). 8. Following the completion of the foregoing, and any other development deemed necessary, the RO/AMC should readjudicate the Veteran's claims. If the claims are denied, supply the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). 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 2014). _________________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2015).