Citation Nr: 19170682 Decision Date: 09/12/19 Archive Date: 09/11/19 DOCKET NO. 16-27 565A DATE: September 12, 2019 ORDER New and material evidence not having been received, the petition to reopen the claim for service connection for a dental disorder is denied. REMANDED Entitlement to service connection for a traumatic brain injury (TBI) is remanded. Entitlement to service connection for sinusitis is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for an eye disorder is remanded. Entitlement to service connection for a stomach disability is remanded. Entitlement to service connection for typhoid vaccination residuals is remanded. Entitlement to service connection for a respiratory disorder is remanded. Entitlement to service connection for diabetes mellitus, type II, is remanded. Entitlement to service connection for a kidney disability is remanded. Entitlement to service connection for body pains is remanded. Entitlement to an initial compensable rating for a bilateral foot disability is remanded. FINDINGS OF FACT 1. In an April 1995 decision, the RO denied the claim for service connection for a dental disorder. The Veteran did not file a timely notice of disagreement, and no new and material evidence was received within a year of the rating decision’s issuance. 2. Evidence received since the April 1995 rating decision is not new and material as it is cumulative, and does not relate to an unestablished fact necessary to substantiate the claim of service connection for a dental disorder. CONCLUSIONS OF LAW 1. The April 1995 rating decision that denied service connection for a dental disorder is final. 38 U.S.C. § 7105; 38 C.F.R. § § 3.156(b), 20.1103. 2. New and material evidence has not been received to reopen the claim of entitlement to service connection for a dental disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Navy from July 1988 to January 1994. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a June 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Travel Board hearing in Indianapolis, Indiana in March 2019. A transcript is of record. New and Material Evidence Where a claim has been finally adjudicated, new and material evidence is required in order to reopen the previously denied claim. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); see also, Wakeford v. Brown, 8 Vet. App. 239, 239–40 (1995). New evidence is that which was not previously submitted to agency decision makers. Material evidence is that which by itself, or when considered with previous evidence of record, relates to an unestablished fact that is necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial, and it must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). Where new and material evidence is received within one year after the initial denial, the denial is not final, and the claim remains pending. 38 C.F.R. § 3.156(b). For the purpose of reopening, evidence received is generally presumed credible. Justus v. Principi, 3 Vet. App. 510, 513 (1992). There is a low threshold for finding new evidence raises a reasonable possibility of substantiating a claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). VA should consider whether the newly received evidence could reasonably substantiate the claim were the claim to be reopened, including whether VA’s duty to provide a VA examination is triggered. Id. 1. Whether new and material evidence has been submitted to reopen the petition for service connection for a dental disorder. The Veteran has submitted additional evidence in support of his claim for service connection for a dental disorder. In April 1995, the RO denied the claim for a dental disorder, to include residuals of gingival grafting. The RO found that there was not a permanent residual or chronic disability that was subject to service connection, and that compensable evaluations are not assigned for periodontal disease. The evidence at the time of this rating decision included: treatment records, service medical records, and a 1994 VA examination report. The Veteran did not appeal this denial, and no new and material evidence was received within one year of the rating decision. Therefore, the decision became final 38 U.S.C. § 7105; 38 C.F.R. § 3.156(b). Service connection may be awarded for missing teeth due to dental trauma or bone loss in service. The law and regulations also provide that treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are considered non-disabling conditions and may be considered service-connected solely for the purpose of determining entitlement to VA dental examination or outpatient dental treatment. See 38 U.S.C. § 1712 38 C.F.R. § § 3.381, 17.161; see also Woodson v. Brown, 8 Vet. App. 352, 354 (1995). In order establish entitlement to service connection for loss of a tooth, the Veteran must have sustained a combat wound or other in-service trauma. 38 C.F.R. § 3.381(b). The Board notes that the term “service trauma” does not include the intended effects of therapy or restorative dental care and treatment provided during a veteran’s active service. See 38 C.F.R. § 3.306(b)(1); VAOGCPREC 5-97. Further, the Federal Circuit defined “service trauma” as “an injury or wound produced by an external force during the service member’s performance of military duties.” Nielson v. Shinseki, 607 F.3d 802, 808 (Fed. Cir. 2010). Dental disabilities which may be awarded compensable disability ratings are set forth under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. Since the April 1995 decision, the Veteran submitted testimony regarding his reported dental disorder. He testified at the Board hearing that he receives treatment for gingivitis. The Board acknowledges this evidence is new to the extent it was not previously of record. However, a thorough review of the evidence still does not reflect the Veteran has a dental condition for which compensation may be paid pursuant to 38 C.F.R. § 4.150. The gum and peridental disease are not considered a dental disorder for which VA compensation benefits are payable. As the Veteran’s evidence is redundant (showing no diagnosis of a dental disorder for which VA compensation benefits are payable) and not material, the Board finds that VA’s duty to provide an examination is not triggered. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). In sum, new and material evidence has not been received because the evidence continues to fail to indicate that the Veteran has a dental disorder diagnosis for which VA benefits are payable. The Board has considered the evidence in light of the low threshold for finding new and material evidence as articulated in Shade, but it finds that the evidence pertaining to the issue of service connection for a dental disorder is not material. The submitted evidence does not go to the previously unestablished fact— here, a diagnosis of compensable dental disorder for VA purposes. Without new and material evidence, the claim of service connection for a dental disorder cannot be reopened at this time. 38 C.F.R. § 3.156(a). REASONS FOR REMAND 2. Entitlement to service connection for a traumatic brain injury (TBI) is remanded. The Veteran asserts service connection for a head injury. He testified at a Board hearing that he injured his head in service where a wrench hit his head. He reported that he was dazed and that he had temporary imbalance. His service treatment records document a head injury while in service in December 1990. The Board notes that while the Veteran has received examinations (March 2013), he has not been afforded a VA TBI examination. As such, the Board finds that a VA TBI examination is warranted as such would be useful for a full and fair adjudication of this issue. Indeed, VA has not obtained a medical opinion as to whether the Veteran has a diagnosis of TBI and whether it was incurred in or is otherwise related to or aggravated by service to include his documented head injury, and the Board finds such would be useful to adjudicate the issue. 3. Entitlement to service connection for sinusitis is remanded. The Veteran asserts service connection for sinusitis. He has a diagnosis of allergic rhinitis and sinusitis. As such, the first element of service connection is met. Sinus problems were documented during service. He underwent a VA examination in March 2013. The examiner noted that his examination and x-rays were normal with no signs of a chronic condition and did not opine on the nexus. Additionally, he has testified at a Board hearing that he believes he was exposed to spray chemicals (he may have ingested them), exposed to diesel fumes, paint, and possibly asbestos. Additionally, with respect to claims involving asbestos exposure, the Secretary of VA has not promulgated any specific regulations. However, in 1988, VA issued a circular on asbestos-related diseases that provided guidelines for considering asbestos compensation claims. See Department of Veterans Benefits, Veterans Administration, DVB Circular 21-88-8, asbestos-related diseases (May 11, 1988). The information and instructions contained in the DVB Circular are included in VBA’s Adjudication Procedures Manual, M21-1, IV.ii.2.C.2. In addition, an opinion by VA’s Office of General Counsel discussed the development of asbestos claims. See VAOPGCPREC 4-2000. The M21-1 is not binding on the Board. However, the Board must address relevant provisions of the M21-1 and conduct an independent analysis before determining whether the provisions may be relied upon as a factor to support its decision. Overton v. Wilkie, 30 Vet. App. 257 (2018). VA has acknowledged that a relationship exists between asbestos exposure and the development of certain diseases, which may occur 10 to 45 years after exposure. See M21-1, IV.ii.2.C.2.f. When considering VA compensation claims, rating boards have the responsibility of ascertaining whether or not military records demonstrate evidence of asbestos exposure in service and of ensuring that development is accomplished to ascertain whether or not there was pre-service and/or post-service evidence of occupational or other asbestos exposure. Accordingly, a determination must then be made as to the relationship between asbestos exposure and the claimed diseases, keeping in mind the latency and exposure information noted above. M21-1, IV.ii.2.C.2.h. [In this regard, the Board notes that the VA Manual M21-1 reflects the policy of the Veterans Benefit Administration (VBA), and not the policy of the VA Secretary, given that VBA and the Secretary are separate entities within VA and that M21 provisions do not go through the regular rulemaking procedures. Unlike a regulation, the VA Secretary does not have input into what goes into the Manual.] The Board finds that a new VA examination is warranted to opine on the documented rhinitis and sinusitis, and the relationship between the Veteran’s reported sinus problems in service. The examination should include appropriate rationale for any opinion regarding the Veteran’s current disabilities and potential asbestos/other chemical exposure so that all raised theories of entitlement may be considered. 4. Entitlement to service connection for headaches is remanded. The Veteran asserts service connection for headaches. He has a current diagnosis of headaches, to include sinus headaches as noted at the March 2013 VA examination. His service treatment records document headaches. He underwent a VA examination in March 2013. The examiner did not provide a further opinion as the examiner found that his headaches were caused by his sinusitis. Since that examination, he has testified at a Board hearing, that he believes that he has two different types of headaches, only one of which is related to his sinuses. Moreover, the Board cannot issue a decision on the issue of service connection for headaches because it is inextricably intertwined with the remanded issue of service connection for sinusitis/rhinitis. See Harris v. Derwinksi, 1 Vet. App. 180, 183 (1991) (noting that two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). As such, this issue is deferred pending the receipt of additional evidence, as directed below. Therefore, the Board finds that a new VA examination is warranted to opine on the documented headaches, and the relationship between the Veteran’s reported headaches in service. 5. Entitlement to service connection for an eye disorder is remanded. The Veteran asserts service connection for an eye disability. He has current diagnoses of dry eye syndrome, glaucoma, astigmatism, and presbyopia. The Board notes that at the March 2013 VA examination, he did not have an eye disorder, and as such, the examiner did not provide an opinion. Since that time, he has testified at a Board hearing, that he has eye sensitivity that he believes is due to his headaches. The Board finds that a new VA examination is warranted to opine on the documented disabilities, and the relationship between the Veteran’s disabilities and his service. Moreover, the Board cannot issue a decision on the issue of service connection for headaches because it is inextricably intertwined with the above remanded issues. As such, this issue is deferred pending the receipt of additional evidence, as directed below.   6. Entitlement to service connection for a stomach disability is remanded. The Veteran asserts service connection for a stomach disability. He has a current diagnosis of gastroesophageal reflex disorder as shown in the March 2013 VA examination. However, the examiner stated that it was most likely due to his diet habits. At the Board hearing, he asserted that his disability may be to chemical exposures (fuel, asbestos, paint) he encountered in service. Additionally, he explained that he had stomach problems noted in service. The Board finds that a new VA examination is warranted to opine on the documented disability, and the relationship between the Veteran’s disabilities and his service, to include chemical exposures. 7. Entitlement to service connection for typhoid vaccination residuals is remanded. The Veteran asserts service connection for typhoid vaccination residuals, to include headaches, stomach pain, nausea, and vomiting. He testified at the Board hearing that he believes that his symptoms are residuals from his vaccination. Additionally, his service treatment records document that he had some residuals during service to include nausea, dizziness, weakness, and fever. The Board finds that a new VA examination is warranted to opine on whether his symptoms are due to his typhoid vaccination rather than separate and distinct disabilities. Moreover, the Board cannot issue a decision on the issue of service connection for typhoid residuals because it is inextricably intertwined with other remanded issues. As such, this issue is deferred pending the receipt of additional evidence, as directed below.   8. Entitlement to service connection for a respiratory disorder is remanded. The Veteran asserts service connection for a respiratory disorder. He has a diagnosis of asthma and an upper respiratory infection. However, at the March 2013 VA examination, the examiner stated that the Veteran did not have a respiratory disorder. Additionally, he testified at the Board hearing that he believed that he was exposed to asbestos, diesel fumes, paint, and other chemicals. The Board finds that a new VA examination is warranted to opine on the documented asthma and upper respiratory infections, and the relationship between the Veteran’s service. Additionally, appropriate rationale is needed for any opinion regarding the Veteran’s current asthma and upper respiratory infections and the relationship to potential exposure to asbestos, chemicals, fuel, and paint so that all raised theories of entitlement are considered. 9. Entitlement to service connection for diabetes mellitus, type II is remanded. The Veteran asserts service connection for diabetes mellitus, type II, to include as secondary to his service-connected disabilities. The Veteran has a current diagnosis of diabetes mellitus, type II, as shown at the March 2013 VA examination. However, while the examiner noted that it was not an undiagnosed condition associated with the Gulf War, the examiner did not otherwise opine on the relationship with service. Additionally, the examiner reported that the Veteran’s weight was 300 pounds. He testified at the Board hearing that he believed his diabetes mellitus was caused by his increased weight because he is unable to exercise because of his service-connected bilateral great toe disability. In light of the Veteran’s testimony regarding his service-connected disabilities, his weight, and his belief that his weight gain caused his diabetes, a new VA examination is warranted. The Board notes that the medical evidence of record, including the March 2013 VA examination lists the Veteran’s current weight in the diabetes mellitus disability benefits questionnaire (DBQ) section of the examination. Additionally, the Board further acknowledges the VA’s General Counsel (GC) has issued a precedential opinion on how the issue of obesity is to be assessed. One of the primary holdings of the opinion is that obesity is not a disability for purposes of VA benefits; hence, it cannot be the subject of service connection. VAOPGCPREC No. 1-2017 (Jan. 6, 2017); see also Marcelino v. Shulkin, 29 Vet. App. 155 (2018). The GC recognized further, however, that obesity may act as an “intermediate step” between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38 C.F.R. § 3.310(a). Hence, the Board will remand for additional medical assessment, to include under the criteria noted by the GC. 10. Entitlement to service connection for kidney stones is remanded. The Veteran asserts service connection for kidney stones. At the March 2013 VA examination, the VA examiner stated that the Veteran did not have a current diagnosis of kidney stones, and noted that he did not have any other kidney disability. Since the examination, the Veteran’s medical records document the removal of a nephrolithiasis stone during the period on appeal. Additionally, the Veteran testified at the Board hearing, and asserted that diesel fuel can damage kidneys, and submitted an article in support. He also raised the contention that it was related to his diabetes mellitus. As such, the Board finds that a new VA examination is warranted to opine on the documented kidney stones, and the relationship between the Veteran’s disability and his service, to include diesel fuel exposure. Moreover, the Board cannot issue a decision on the issue of service connection for the disability because it is inextricably intertwined with the above remanded issues, specifically diabetes mellitus. As such, this issue is deferred pending the receipt of additional evidence, as directed below. 11. Entitlement to service connection for body pains is remanded. The Veteran asserts service connection for body pains. He has current diagnoses of upper and lower neuropathy. The Board notes that the March 2013 VA examination did not address the Veteran’s body pains. As such, the Board finds that new VA examination(s) are warranted to address the Veteran’s claim, and to ascertain whether he has body pains that are separate from his diagnosed neuropathy. 12. Entitlement to an initial compensable rating for a bilateral foot disability. The Veteran bilateral foot disorder, to include ingrown toenails, is rated noncompensable under DC 7899-7813. DC 7813 directs the rater to evaluate under the General Rating Formula for the Skin. The diagnostic code includes intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. He testified at a Board hearing in March 2019. He explained that he does not use any type of steroid at the time, but that he was frequently concerned about stubbing his toes as he does not have nails. He also testified that 20 percent of his toes were affected (two of ten), and that he has extreme pain from stubbing his toes, as well as objects falling on them. He further asserted that he has to be careful to avoid contact with his toes to avoid pain. Additionally, the amputation rule was raised at the hearing to compare his current condition to great toe amputation under 38 C.F.R. § 4.71a. Since the Veteran’s last VA examination, the competent evidence shows that his bilateral toe disability may have worsened. VA’s General Counsel has indicated that a new examination is appropriate when there is an assertion of an increase in severity since the last examination. VAOPGCPREC 11-95 (1995). 38 C.F.R. § 3.327(a). As such, a new VA examination is warranted to assess the current severity of the Veteran’s disabilities, to include discussion of systemic therapy, and the applicability of 38 C.F.R. § 4.71a. The matters are REMANDED for the following actions: 1. Obtain any outstanding VA treatment records. All requests and responses for the records must be documented. If any identified records cannot be obtained, notify the Veteran of the missing records, the efforts taken, and any further efforts that will be made by VA to obtain such evidence, and allow him an opportunity to provide the missing records. 2. Take any and all required efforts, to include following development procedures outlined in the M21-1, to determine whether the Veteran was exposed to asbestos in service. All efforts should be documented. 3. After associating any treatment records with the claims file, schedule the Veteran for a TBI examination to be conducted by one of the four designated specialists (physiatrist, psychiatrist, neurologist, or neurosurgeon), to determine the nature and etiology of any TBI. 4. After reviewing the record and examining the Veteran, the examiner is to respond to the following: Does the Veteran have a current TBI diagnosis? The examiner must provide a diagnosis for any conditions found. In doing so, the examiner must conduct all necessary diagnostic testing, unless it can be explained why such testing is not medically necessary. (a.) If diagnosed, is it at least as likely as not 50 percent or greater probability) related to an in-service injury, event, or disease, including a head injury. ** Please review and acknowledge the Veteran’s service treatment records that document a head injury in service. See 3/28/2019 – Medical Treatment Record – Government Facility, at 2; 03/17/1995 STR – Medical, at 9.** The Veteran has also credibly testified that he had imbalance and that he was dazed around the time of his head injury. See 3/28/2019 Hearing Transcript.** 5. After associating any treatment records with the claims file, the Veteran for a VA examination/addendum for his sinusitis/rhinitis disability and address: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s disability was caused by a disease or injury in service, to include as due to asbestos exposure? In answering this question, the examiner should address the Veteran’s assertions that a combination of exposure to asbestos, diesel smoke fumes, and other chemical exposure caused his disability. 6. After associating any treatment records with the claims file, for the scheduled VA examination for the Veteran’s headaches, respond to the following: --Identify any headache-related disorders, separate from any possible TBI.   Then, (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s disability was caused by a disease or injury in service, to include documented headaches in service? See 3/28/2019 – Medical Treatment Record – Government Facility, at 2.** (b.) If no, is it at least as likely as not (50 percent or greater probability) that the Veteran’s disability was either 1) proximately due to OR 2) aggravated by any service-connected disability, to include any disability that has now been found to be related to service? 7. After associating any treatment records with the claims file, schedule the Veteran for a VA examination for his eye disabilities, and respond to the following: --Identify any eye disorder, then: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s disability was caused by a disease or injury in service? (b.) If no, is it at least as likely as not (50 percent or greater probability) that the Veteran’s disability was either 1) proximately due to OR 2) aggravated by any service-connected disability, to include any disability that has now been found to be related to service?   8. After associating any treatment records with the claims file, schedule the Veteran for a VA examination for his stomach disability and address: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s disability was caused by a disease or injury in service? In answering this question, the examiner should address the Veteran’s assertions that a combination of exposure to asbestos, diesel smoke fumes, and other chemical exposure caused his disability. 9. After associating any treatment records with the claims file, schedule the Veteran for a VA examination for his reported typhoid vaccinations residuals, and respond to the following: --Identify any residuals of the typhoid vaccination (separate and distinct from the remanded claims), then: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s residuals were caused by a disease or injury in service? See 3/28/2019, Medical Treatment Record – Government Facility. ** Please review and acknowledge the Veteran’s submitted articles regarding typhoid vaccination residuals.** See 3/28/2019, Correspondence – Vaccination & Fuel.   10. After associating any treatment records with the claims file,, the examiner for diabetes mellitus is to respond to the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s disability was caused by a disease or injury in service? (b.) If no, whether the service-connected disabilities caused the Veteran to become obese/gain weight; (c.) If so, whether the obesity/weight gain as a result of the service-connected disabilities was a substantial factor in causing diabetes mellitus; (d.) Whether diabetes mellitus would not have occurred but for the obesity/weight gain caused by the service-connected disabilities. (e.) If no to the above questions (b)-(d), is it at least as likely as not (50 percent or greater probability) that any disability was either 1) proximately due to OR 2) aggravated by any service-connected disability? In arriving at the opinion on diabetes mellitus and weight gain/obesity, inform the examiner that all lay evidence must be considered, including any articles submitted by the Veteran and his statements. Inform the examiner further that, under applicable legislation and VA requirements, obesity is not a disease or disability, but it may act as an “intermediate step” between a service-connected disability and a current disability that may be service-connected on a secondary basis. To determine whether any weight gain or obesity is an “intermediate step” between either any or all of the Veteran’s service-connected disabilities and diabetes mellitus, the examiner should fully answer the above questions. 11. After associating any treatment records with the claims file, schedule the Veteran for a VA examination for his kidney disability, and respond to the following: --Identify any kidney disability during the period on appeal (March 22, 2011 and later) disorder, then: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s disability was caused by a disease or injury in service, to include exposure to diesel fumes? See 3/28/2019, Correspondence – Vaccination & Fuel. (b.) If no, is it at least as likely as not (50 percent or greater probability) that the Veteran’s disability was either 1) proximately due to OR 2) aggravated by any service-connected disability, to include any disability that has now been found to be related to service? 12. After associating any treatment records with the claims file, schedule the Veteran for a VA examination for his body pains, and respond to the following: --Identify any disability during the period on appeal (March 22, 2011 and later) to include upper and lower extremity neuropathy,   then: (a.) Is it at least as likely as not (50 percent or greater) that the Veteran’s disability was caused by a disease or injury in service? (b.) If no, is it at least as likely as not (50 percent or greater probability) that the Veteran’s disability was either 1) proximately due to OR 2) aggravated by any service-connected disability, to include any disability that has now been found to be related to service? The term “aggravated” refers to a worsening of the underlying condition beyond the natural progression of the disease, as opposed to temporary or intermittent flare-ups or symptoms that resolve with return to the baseline level of disability. If aggravation is found, please state, to the extent possible, the baseline level of disability prior to aggravation. 13. After associating any treatment records with the claims file, schedule the Veteran for a VA examination to assess the current nature and severity of his service-connected bilateral toe disability, to include discussion of systemic therapy, and the applicability of whether his disability is equivalent to great toe amputation under 38 C.F.R. § 4.71a. 14. Inform EACH examiner that a comprehensive rationale for all opinions must be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be provided without resorting to speculation, the examiner must explain why this is so and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Morales, Associate Counsel 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.