Citation Nr: 19184792 Decision Date: 11/08/19 Archive Date: 11/08/19 DOCKET NO. 16-53 587 DATE: November 8, 2019 ISSUE 1. Entitlement to service connection for a bilateral hearing loss disability. 2. Entitlement to service connection for a right cholesteatoma disability. 3. Entitlement to service connection for a chronic otitis media disability. 4. Entitlement to service connection for an actinic keratosis disability (also claimed as photo damage). 5. Entitlement to service connection for tinea a pedis disability (also claimed as onychomycosis). ORDER Entitlement to service connection for a right ear hearing loss disability is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to service connection for a left ear hearing loss disability is denied. REMANDED Entitlement to service connection for right cholesteatoma disability is remanded. Entitlement to service connection for a chronic otitis media disability is remanded. Entitlement to service connection for an actinic keratosis disability is remanded. Entitlement to service connection for a tinea pedis disability, to include onychomycosis, is remanded. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran's right ear hearing loss disability is related to his in-service noise exposure. 2. The evidence does not show that three of the Veteran's left ear auditory thresholds in the 500 Hertz, 1000 Hertz, 2000 Hertz, 3000 Hertz, or 4000 Hertz frequencies exceeded 26 decibels, or that one auditory threshold exceeded 40 decibels, or that his speech recognition score was less than 94 percent. CONCLUSIONS OF LAW 1. . Resolving reasonable doubt in the Veteran's favor, service connection for a right ear hearing loss disability is warranted. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.385 (2018). 2. A left ear hearing loss disability for VA compensation purposes has not been shown. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.385 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION This matter is before the Board of Veterans' Appeals (Board) on appeal from a June 2015 Rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), Columbia, SC. In September 2019, the Veteran was afforded a Video Conference Board Hearing with the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is in the record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900 (c) (2018). 38 U.S.C. § 7107 (a)(2) (2012). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81(Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). The Veteran’s claim of entitlement to service connection for right cholesteatoma, chronic otitis media, actinic keratosis and tinea pedis, to include onychomycosis, is remanded and be addressed in the remand portion of this decision. Entitlement to service connection for a bilateral hearing loss disability. The Veteran asserts that he is entitled to service connection for a bilateral hearing loss disability. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection for impaired hearing shall only be established when hearing status, as determined by audiometric testing, meets specified pure tone and speech recognition criteria. Audiometric testing measures threshold hearing levels (in decibels), over a range of frequencies (in Hertz). See Hensley v. Brown, 5 Vet. App. 155, 158 (1993). For purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels (dB) or greater; or when the auditory thresholds for at least three of the frequencies of 500, 1000, 2000, 3000, or 4000 Hz are 26 dB or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d). The Court of Appeals for Veterans Claims held that "when audiometric test results at a veteran's separation from service do not meet the regulatory requirements for establishing a 'disability' at that time, he or she may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service." Hensley v. Brown, 5 Vet. App. 155, 160 (1993). To make this determination, the Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases, to include organic diseases of the nervous system, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). For organic diseases of the nervous system, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307 (a)(3). Service connection for a recognized chronic disease can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303 (b), 3.309. For chronic diseases shown as such in service or within the applicable presumptive period, subsequent manifestations of the same chronic disease at any later date are service-connected unless attributable to an intercurrent cause. 38 C.F.R. § 3.303 (b). For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including sensorineural hearing loss and tinnitus, are presumed to have been incurred in service if manifest to a compensable degree within one year after discharge from service. 38 U.S.C. §§ 1101, 1112, 1137 (West 2012); 38 C.F.R. §§ 3.307, 3.309 (2017); see Fountain v. McDonald, 27 Vet. App. 258, 264, 271 (2015) (specifying that sensorineural hearing loss and tinnitus are considered organic diseases of the nervous system subject to § 3.309(a)). For a chronic disease to be considered to have been "shown in service," there must be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Id. When the condition noted in service or within the presumptive period is not a chronic disease, a showing of continuity of symptomatology after discharge is required. Id. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C. § 7104 (a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail."). See Wise v. Shinseki, 26 Vet. App. 517, 531 (2014). To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. As will be discussed below in this decision, an August 2019 VA audiological examination confirms that the Veteran has sensorineural hearing loss that is considered disabling for VA purposes in his right ear. 38 C.F.R. § 3.385. Thus, for purposes of establishing a service connection claim, the requirement for a current disability for the Veteran’s right ear has been met. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). With regards to the second element of service connection, an in-service incurrence or aggravation of a disease or injury, the Veteran asserts that as a Navy Seaman he was exposed to loud noise using machinery such as gunners & drills etc., without the use of hearing protection. In addition, the Veteran asserts that as part of the Weapons Department, he was exposed to the rapport of the inch guns on numerous occasions. Further, the Veteran asserts that as Sonar Technician he was exposed to sonar systems that generated ambient white noise. The Veteran asserts that he was exposed to this ambient white noise daily. See April 2019 Notice of Disagreement (NOD); See also DD-214 (MOS). The Board concedes exposure to acoustic trauma in this case and finds that the second element of service connection has been met, an in-service incurrence or aggravation of a disease or injury. Id. Turning to the third prong of service connection, a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement. Id. As discussed above in this decision, the Veteran was afforded a VA audiological examination in August 2019 to determine the nature and etiology of his bilateral hearing loss disability. The August 2019 audiology examination produced the following results: Right Ear Hertz 500 1000 2000 3000 4000 6000 8000 Av. Hz. 30 35 30 55 85 80 75 51 Left Ear Hertz 500 1000 2000 3000 4000 6000 8000 Av. Hz. 15 15 15 15 20 65 55 16 Speech audiometry results using the Maryland CNC were 94 percent for the right ear and 94 percent for the left ear. Based on the above findings, the Veteran has a right ear hearing loss disability for VA purposes, but not a left ear hearing loss disability. None of the thresholds at 500 through 4000 Hz were 40 decibels or higher, and none of the thresholds (at 500 Hz and 4000 Hz) were 26 decibels or higher. Likewise, speech recognition scores were above 94 percent bilaterally. Thus, he has not been shown to have a left ear hearing loss disability for VA compensation purposes. 38 C.F.R. § 3.385 (2018). Accordingly, service connection for a left ear hearing loss disability is not warranted. While the findings from the VA examination show some degree of left ear hearing loss, and this is consistent with the private audiologist’s finding of "bilateral hearing loss," the degree of hearing loss in the left ear is not shown to be of such severity as to meet the specific criteria under 38 C.F.R. § 3.385 , which is a prerequisite to awarding service connection for a hearing loss disability. The preponderance of the evidence is thus against a finding that the Veteran has a left ear hearing loss for VA purposes. 38 C.F.R. § 3.385. As the Veteran does not have a current diagnosis of a left ear hearing loss for VA purposes, service connection for a left ear hearing loss is not warranted at this time. In the right ear, however, the Veteran had two auditory thresholds of 40 decibels (at 4000 Hz) and three auditory thresholds at 26 decibels or higher (500 Hz, 3000 Hz and 4000 Hz.) Thus, the criteria for a hearing loss disability in the right ear are met. While the August 2019 examiner provided a negative nexus opinion with regards to the Veteran’s right ear hearing loss, the Board observes that the examiner provided a positive rationale indicative of a nexus for service connection. The examiner reported that although the Veteran had no significant change in hearing from entrance to exit exams, he does have documented history of chronic ear infections while in the service. He has experienced chronic ear infections ever since which has affected his right ear hearing more significantly. See August VA 2019 Hearing examination. Thus, the Board finds that evidence is at least in equipoise as to whether the Veteran's right ear hearing loss disability is related to his in-service noise exposure. Resolving doubt in the Veteran's favor, the claim for entitlement to service connection for right ear hearing loss is granted. 38 U.S.C. § 5107 (2012). To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. REASONS FOR REMAND Entitlement to service connection for right cholesteatoma disability is remanded. The Veteran contends that his right cholesteatoma disability is related to service. The Veteran testified in his Board Hearing that he was discouraged to see a doctor during his service because it was frowned upon. The Veteran testified about an incident during service where he had blood coming from his ear and it felt as though he was being stabbed me in the ear. He was treated for an ear infection for about a month (from March 24 – April 11, 1986). The Veteran also testified that he has had chronic ear infections ever since. See Video Conference Board Hearing transcript, pg. 9. See also April 2019 Notice of Disagreement (NOD). The Veteran was diagnosed with cholesteatoma in April 1998. See April 1998 Clinic Note, and June 1998 operative report. The Veteran’s March 1986 service treatment records confirm that the Veteran experienced bleeding in his ear with complaints of a foreign object being in his ear. The Veteran was treated for an ear infection and referred to ENT. See March 1986 STR’s. The Veteran was afforded a June 2015 VA examination for his ear disability. The examiner noted the Veteran’s in-service occurrence of an ear ache and bleeding from the right ear. The examiner also noted that the Veteran was evaluated by ENT post service and had a tympanomastoidectomy with cartilage graft in June 1998. The examiner reported that the Veteran had no improvement with hearing. The examiner noted that Veteran asymptomatic for ear pain. The examiner also indicated that the Veteran did not have any signs or symptoms attributable to chronic ear infections, inflammation, cholesteatoma. The examiner did not provide an opinion regarding the etiology of the Veteran’s ear condition, in the absence of a current finding of cholesteatoma. Treatment records in June 2016 indicate that the Veteran’s right ear cholesteatoma was clear on examination. See June 2016 treatment records (ENT private provider). The Board finds that in view of the totality of evidence, including a VA examination discussed earlier in this decision that referenced the Veteran having chronic ear infections since service, there is competent evidence to indicate that the Veteran has a current disability that may be related to service, sufficient to trigger VA's duty to obtain a VA examination, and a medical opinion, regarding the current nature and etiology of his ear disability. See Shade v. Shinseki, 24 Vet. App. 110; see also McLendon v. Nicholson, 20 Vet. App. 79. See also August 2019 VA Hearing examination, pg. 4.) Entitlement to service connection for chronic otitis disability is remanded. The Veteran asserts that his chronic otitis disability media is related to his active military service. The Veteran testified in his Board Hearing that that since having an ear infection during service, he has had ear infections ever since. See Video Conference Board Hearing transcript, pg. 10. See also April 2019 Notice of Disagreement (NOD). The Veteran was diagnosed with chronic nonsuppurative otitis media in April 1998. See April 1998 Clinic Note and June 1998 operative report. The Veteran’s March 1986 service treatment records report that the Veteran had complaints of right ear pain. The Veteran complained of a foreign body in his ear when he awoke. His right ear was bleeding. The Veteran had purulent drainage in his ear. He was referred to ENT for debridement and follow-up. See March 1986 STR. The Veteran’s March service treatment records also report that the Veteran complained of right ear pain for 4 days, fever, shaking, chills and tinnitus, with right ear yellow purulent discharge along auditory canal. His left ear was reported as normal. The Veteran was diagnosed with otitis media and extrema and consultations were ordered for follow-up (CWO). The Veteran was prescribed medications for treatment. See March 1986 STR. The Veteran was afforded a June 2015 VA examination to assess the etiology of his otitis media. The examiner noted that the Veteran’s STRs document seeking evaluation 3/1986 for ear ache and bleeding from right ear. Veteran does not recall this episode. Sought evaluation for hearing loss that began after military separation. Was evaluated by civilian ENT and had tympanomastoidectomy with cartilage graft 6/1998 soon after consult. No improvement with hearing. The Veteran was not found to have cholesteatoma or any of the diagnoses. The examiner opined that the conditions claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner provided the following rationale to support this opinion: The Veteran was “evaluated in March 1986 for complaint of fullness and hearing loss in his right ear. The Veteran stated that he did not recall the episode in service. Describes feeling fullness and hearing loss. He did not seek additional medical attention until 1998 when he went to civilian ENT for complaint of hearing loss. There is no evidence of chronicity of care for OM. Per today's exam, TMs were normal with postoperative findings at upper edge of TM without evidence of otitis media or externa.” The Board finds that in view of the totality of evidence in this case, the Board finds that further development is required on this claim to establish the current nature and etiology of the Veteran’s ear disability, to include whether the Veteran has a current disability. While the VA examiner found that the Veteran did not have a current disability, evidence before the Board indicates that the Veteran may have a chronic condition; therefore, the Board finds that further development is warranted to obtain a new VA examination with regards to the Veteran’s ear disability. See Video Conference transcript, pg. 10; see also August 2019 VA Hearing examination, pg. 4 Entitlement to service connection for actinic keratosis disability is remanded. The Veteran contends that his actinic keratosis is related to military service due to his sun exposure. The Veteran testified that didn't use any kind of protective wear for his sun exposure, i.e., sunscreen. The Veteran testified that he would be exposed to the sun as part of his duties as Seaman, including the performance of the duties as rover, security and maintenance on the ship’s topside (USS Joseph Hewes). See April 2019 Notice of Disagreement (NOD); See also Video Conference Board Hearing transcript, pg., 6-8. See also DD-214 (Sonar Technician). The Veteran has been diagnosed with actinic keratosis. See July 2011 treatment record. Therefore, the first element of service connection has been met, a current disability. The Board also finds that his testimony about sun exposure aboard ship to be credible and consistent with the duties and circumstances of his service, therefore the Board will concede that the Veteran has had an in-service injury or event with regards to sun exposure. See DD-214. Turning to the third element of service connection, a nexus between the current disability and service: The Veteran submitted an opinion by a dermatology clinician. In pertinent part, the dermatology clinician reported that the Veteran was evaluated for a lesion that developed on his scalp that had been present for several months with some itching and discomfort. A biopsy of the lesion revealed an actinic keratosis which is a pre-cancer for squamous cell carcinoma. The dermatology clinician opined that the Veteran’s time in service, with extended periods of time on a ship in areas close to the equator could have resulted in actinic damage that resulted in this type of lesion, therefore increasing the Veteran’s risk for skin cancer. See March 2019 Correspondence from dermatology professional. While the Board acknowledges that this opinion is credible in that it is from are from a medical professional, the opinions appear to be speculative at best and therefore have limited probative value. See Bloom v. West, 12 Vet. App. 185, 187(1999) (stating that medical opinions that are equivocal in nature, such as those expressed in speculative language (e.g., "could have caused", etc.), do not provide the degree of certainty required for medical nexus evidence); Black v. Brown, 5 Vet. App. 177, 180 (1993); Reonal v. Brown, 5 Vet. App. 458, 460 (1993). The Board however finds that this opinion, coupled with the Veteran’s credible testimony about sun exposure during service triggers the VA’s duty to provide an examination to assess the current nature and etiology of the Veteran’s s actinic keratosis disability. See McLendon v. Nicholson, 20 Vet. App. 79. Entitlement to service connection for tinea pedis disability is remanded. The Veteran asserts that his tinea pedis was incurred in service. The Veteran testified during his Board Hearing that it started out as athlete's foot and that this condition began when he started taking community showers during his military service. The Veteran testified that this condition has remained ever since, manifest by foot fungus spreading to his toenail. See Video Conference Board hearing transcript, pgs. 11-13; See also April 2019 Notice of Disagreement (NOD). The Veteran has been diagnosed with tinea pedis and onychomycosis. See July 2011 treatment record. Therefore, the first element of service connection has been met. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Turning to the third prong of service connection, a link between the current disability and service, the Veteran submitted a letter from a dermatology clinician in support of this claim. The dermatology clinician indicated that the Veteran has been treated for tinea pedis and onychomycosis. The clinician reported that both conditions were treated with anti-fungal cream and an oral medication that has required routine lab tests for liver enzyme monitoring due to the medication’s risk to cause elevated liver enzymes. The clinician opined that the Veteran’s time in service on the ship, having to shower in a community shower could have resulted in these two fungal infections. See March 2019 Correspondence from dermatology professional. Once again, the Board finds that this medical opinion has limited probative value because it is speculative and even falls short of providing a nexus medical opinion. See generally Obert v. Brown, 5 Vet. App. 30 (1993) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus); see also Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992) (holding that there was a plausible basis for the Board's decision that a disability was not incurred in service where even the medical evidence favorable to the appellant's claim did little more than suggest the possibility that the Veteran's illness might have been caused by an in-service event or injury). The Board however finds that this opinion, coupled with the Veteran’s testimony about his use of community showers during service, triggers the VA’s duty to provide an examination to assess the current nature and etiology of the Veteran’s tinea pedis and onychomycosis disability as there is an indication that the Veteran’s disability may be related to service. See McLendon v. Nicholson, 20 Vet. App. 79. The matters are REMANDED for the following action: 1. Obtain updated copies of any private treatment and VA treatment records and associate them with the Veteran's claims folder. 2. Then, schedule Veteran for a VA examination with a medical professional of sufficient expertise to determine the nature and etiology of any of the Veteran's current ear disabilities, to include right cholesteatoma and chronic otitis media. The entire claims file, to include a complete copy of this REMAND, should be made available to and reviewed by the examiner and a notation that it was reviewed should be included in the report. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran's active military service. See March 1986 Service Treatment Records. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Next, please schedule the Veteran for a VA examination to determine the current nature and etiology of the current nature and etiology of his actinic keratosis. The entire claims file, to include a complete copy of this REMAND, should be made available to the VA examiner designated to provide an opinion. The examiner should specifically provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that his actinic keratosis is otherwise etiologically related to the Veteran's military service, to include sun exposure while serving aboard a Navy Ship. See also Video Conference Board Hearing transcript, pg., 6-8. The examiner is invited to review the opinion of a Dermatology clinician. (See March 2019 Correspondence from Dermatologist Group.) The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 4. Then, please schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his tinea pedis disability and onychomycosis. The entire claims file, to include a complete copy of this REMAND, should be made available to the VA examiner designated to provide an opinion. The examiner must opine as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that his tinea pedis disability and onychomycosis. began during or is otherwise related to his military service, to include his use of community showers during service. See Video Conference Board hearing transcript, pgs. 11-13. The examiner is invited to review the opinion of a Dermatology clinician. (See March 2019 Correspondence from Dermatologist Group.) Any opinion expressed by the VA examiner should be accompanied by a complete rationale. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 5. After completing the above, and any other development deemed necessary, the claims remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. If any benefits sought are not granted, issue the Veteran and his attorney an appropriate supplemental statement of the case (SSOC). Provide the Veteran and his attorney a reasonable opportunity to respond before returning the appeal to the Board for further appellate review. Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.