Citation Nr: 20074188 Decision Date: 11/18/20 Archive Date: 11/18/20 DOCKET NO. 16-07 599 DATE: November 18, 2020 ORDER The claim for service connection for essential tremors of the bilateral upper extremities as secondary to the service-connected traumatic brain injury (TBI) is granted. The claim for symptoms of dizziness, memory loss, and fatigue as the result of service-connected residuals of TBI is granted. The claim for service connection for an ear disease to include Meniere’s disease including as secondary to the service-connected disabilities is denied. REMANDED The claim for service connection for a low back disability to include degenerative joint disease (DJD) is remanded. The claim for service connection for a neck condition to include DJD is remanded. The claim for service connection for a left thigh condition is remanded. The claim for service connection for a right thigh condition is remanded. The claim for an effective date earlier than March 6, 2013 for the grant of total disability evaluation based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Essential tremors of the bilateral upper extremities are the result of active are the result of the service-connected TBI. 2. Dizziness, memory loss, and fatigue are the result of the service-connected TBI. 3. The Veteran is not diagnosed with an ear condition to include Meniere’s Disease. CONCLUSIONS OF LAW 1. The criteria for service connection for essential tremors of the bilateral upper extremities as a result of the service-connected TBI are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). 2. The criteria for service connection for dizziness, memory loss, and fatigue as a result of the service-connected TBI are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 3. The criteria for service connection for an ear condition to include Meniere’s Disease are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Marine Corps on active duty from October 1978 to February 1979, and March 1980 to April 1982. This appeal comes before the Board of Veterans Appeals (Board) from April 2014 and July 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The April 2014 rating decision denied service connection for back, neck, bilateral thighs, a hand condition, depression, memory loss and fatigue. The July 2017 rating decision granted entitlement to TDIU, effective May 24, 2017. The Veteran disagreed with the effective date assigned. In a March 2019 rating decision, an effective date of March 6, 2013 for the TDIU was awarded. The Veteran has not withdrawn his claim; hence it remains before the Board. See AB v. Brown, 6 Vet. App. 35, 38 (1993). This case was previously before the Board in October 2018, when the above issues were remanded. The directed development having been completed; the claims are now again before the Board. Unfortunately, the claims for service connection for back, neck, and bilateral thigh disabilities must again be returned for additional examination. This is the subject of a remand immediately following the decision below. In addition, the claim for an effective date earlier than March 6, 2013 for entitlement to TDIU is inextricably intertwined with the remanded claims, and is therefore also remanded. The Board has re-characterized the issues on appeal for reasons explained below. First, the issue of service-connection for a psychiatric disorder to include depression has already been service-connected as posttraumatic stress disorder (PTSD) and is no longer on appeal as a claim for service connection. In a May 2020 rating decision, the RO granted service connection for PTSD and, in a July 2020 notification letter, explained the grant of PTSD was a full grant of all benefits sought on appeal for the issue of service-connection for an acquired psychiatric disorder to include depression. Hence, the issue of service connection for a psychiatric disorder to include depression is no longer before the Board. Second, the Veteran claimed service-connection for hand tremors, dizziness, memory loss and fatigue on his 2013 claim, and has consistently argued that these symptoms have been present since active service to the present. It was not until VA examinations could be completed that it became clear that the Veteran was diagnosed with TBI. Although the Veteran has since been service-connected for TBI, the Veteran’s claim for these disabilities have remained denied. As the Veteran perfected his appeal to these claims, they remain before the Board. Third, in its October 2018 remand, the Board added the claim for an ear condition to include Meniere’s Disease. This is because the medical evidence at the time revealed an apparent conflict in that a 2017 VA examination for TBI showed a finding of Meniere’s Disease as a residual of TBI, but a 2017 VA examination for ears shows vertigo but no nystagmus and no diagnosis of Meniere’s Disease. As the October 2018 remand added the claim, it remains before the Board. Finally, in service connecting PTSD, the RO evaluated the disability with the already service-connected TBI as 70 percent disabling, effective March 6, 2013. The RO explained in its May 2020 rating decision that symptoms of the service-connected residuals of TBI and PTSD overlapped, and VA examiners were unable to separate them for the purpose of determining which disability caused which functional disability. Hence the RO combined the disabilities under diagnostic code 9411-8045, evaluating the TBI and PTSD as 70 percent disabling under the criteria for TBI. See 38 C.F.R. § 4.27. However, the Board notes that the residuals of TBI were evaluated as 70 percent disabling in the 2017 rating decision, when TBI residuals were initially service-connected and the claim for a psychiatric disorder including depression was still pending. By this rating decision, the Board is further granting service connection for hand tremors, dizziness, memory loss and fatigue as the result of the service-connected TBI. Accordingly, the Board highly recommends that the RO re-evaluate the service connected residuals of TBI and service-connected PTSD to ensure accurate and full compensation for those non-overlapping symptoms of TBI and PTSD, as well as those overlapping symptoms. Concerning the claims being decided in this appeal, the Board finds that the AOJ has fulfilled the duty to notify and assist the Veteran in substantiating his claim for VA benefits, as prescribed in 38 U.S.C. §§ 5100, 5102, 5103, 5109A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). All identified and relevant records have been obtained or appropriate efforts to secure them have been undertaken. Adequate examinations, considering the evidence of record and including appropriate findings and rationales for claimed conditions other than tremors were afforded the Veteran pursuant to the October 2018 remand, with the exception of the hand tremors. As the claim for hand tremors is resolved in the Veteran’s favor, there is no prejudice to adjudicating this claim. See 38 U.S.C. § 5103A(d), 38 C.F.R. § 3.159(c)(4), and McLendon v. Nicholson, 20 Vet. App. 79 (2006). There are no further arguments against a finding that the agency of original jurisdiction (AOJ) has not met its duty to assist. The Board thus finds that the AOJ has met its duty to assist and further remand is not required. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence 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. Shedden v. Principi, 391 F.3d 1163, 1166-67 (Fed. Cir. 2004). Generally, the Veteran may satisfy the requirement to identify the benefit sought by referring to a body part or system that is disabled or by describing the symptoms of the disability. See Browkowski v. Shinseki, 23 Vet. App. 79, 86-87 (2009). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) a current disability; (2) a service-connected disability; and (3) a nexus between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1988). The current disability may be either proximately caused by or proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In addition, certain listed chronic diseases, such as organic diseases of the nervous system such as essential tremor and Meniere’s Disease may be presumed to have been incurred during service if the disease becomes manifest to a compensable degree within one year of separation from qualifying military service. 38 U.S.C. §§ 1101, 1112; Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.307(a)(3), 3.309(a). However, essential tremor in the right hand and was diagnosed beyond the presumptive period provided in the regulations. Hence, this presumption does not apply here. Service connection may also be granted on a presumptive basis for certain diseases associated with exposure to contaminated water at Camp Lejeune if a Veteran, former reservist, or member of the National Guard shows: (1) that he or she served at Camp Lejeune for no less than 30 consecutive or nonconsecutive days between August 1, 1953 and December 31, 1987; (2) that he or she currently suffers from a disease associated with exposure to contaminants in the water supply at Camp Lejeune enumerated under 38 C.F.R. § 3.309 (f); and (3) that the current disease manifested to a degree of 10 percent or more at any time after service. 38 C.F.R. §§ 3.307(a)(7), 3.309(f). Service records indicate that he was stationed at Camp Lejeune from March 1980 to August 1981. The Veteran is thus presumed to have been exposed to water supply contaminants trichloroethylene (TCE), perchloroethylene (PCE), benzene and vinyl chloride. However, the Veteran’s claimed disorders are not among those associated with exposure to contaminants in the water supply at Camp Lejeune, North Carolina which are limited to (1) kidney cancer, (2) liver cancer, (3) non-Hodgkin’s lymphoma, (4) adult leukemia, (5) multiple myeloma, (6), Parkinson’s disease, (7) aplastic anemia and other myelodysplastic syndromes, and (8) bladder cancer. The Veteran has not been diagnosed with any of these conditions; thus, these regulations are not here for application. Notwithstanding, the Veteran is not precluded from establishing service connection with proof of direct causation. The Board will consider all relevant theories of service connection. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran’s representative reported, and VA examiners have observed, that the Veteran’s service treatment records, although present, are partly illegible. The Board concurs and finds that such illegibility frustrates full review of these records. Thus, the Board will treat this case as one in which there is a heightened obligation on the part of VA to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule. See O’Hare v. Derwinski, 1 Vet. App. 365 (1991). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. A. § 5107 (b); 38 C.F.R. § 3.102. 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 his representative, 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). a) Right Hand Essential Tremor The Veteran reports he first experienced hand shaking during active service and that the symptom has been present continuously since then to the present. He and his representative argued that the diagnosed essential tremors of the bilateral upper extremities are the result of exposure to contaminated water at MCB Camp Lejeune or his service-connected TBI. The medical evidence shows that essential tremor of the bilateral upper extremities is the result of service-connected TBI. Private treatment records document hand tremors as early as in 2013, with the 2020 VA examiner diagnosing shaking in the hands as essential tremors. The Veteran’s exposure to contaminated waters at MCB Camp Lejeune is conceded. In addition, the Board also concedes the Veteran’s statements that he first observed his hands to shake during active service after his head injury and that the shaking has been present since then to the present. Finally, the Veteran is service-connected for residuals of TBI. He has therefore met the first and second requirements of Shedden and Wallin. However, there is dispute as to the third requirement of Shedden and Wallin, that of a causal nexus, or etiological link, between the diagnosed essential tremors of the hands and active service to include exposure to contaminated water or, in the alternative, service-connected disabilities. VA examinations were conducted in 2019 and 2020, after the 2018 Board remand. It is crucial here to again observe that the Veteran’s service records, while present, are largely illegible. Accordingly, the 2018 Board remand specifically advised the clinicians conducting VA examinations that the Veteran is competent to report his symptoms and history and directed the clinicians to acknowledge these reports and consider them in formulating any opinion. If the clinician rejected the Veteran’s lay statements, the clinician was directed to provide an explanation for the rejection. The clinician was further directed not to rely on an absence of medical evidence in the record as support for the clinician’s conclusion. Turning now to the evidence, the record presents two medical opinions, the 2019 VA medical opinion finding that hand tremors may be attributed to the service-connected TBI, and the 2020 VA medical opinion finding the hand tremors are not the result of active service or of service-connected disabilities. The Board will discuss each in turn. In the April 2019 VA examination for TBI, the Veteran reported upper extremity tremors. Although he stated he was unsure when they began, he reported he remembered having tremors during active duty because he was laughed at for them. The VA examiner found impairment of motor function due to tremor. In the December 2019 VA medical opinion, which was conducted to obtain an opinion as to whether the tremors and other conditions could be the result of exposure to contaminated water at MCB Camp Lejeune, the VA examiner instead concluded that the Veteran’s neurobehavioral effects, including upper extremity tremors, were the result of factors other than contaminated water, including the service-connected TBI and chronic pain syndrome. In explaining his rationale, the VA examiner explained the Veteran’s hand tremors were likely an essential tremor, which can occur with age or be familial and observed that mild TBI can produce symptoms that may be temporary or permanent. In arriving at these findings and opinion, the December 2019 VA examiner conducted a long and detailed review of the medical evidence, and of current medical literature, which is documented in four pages within the report. In pertinent part, the VA examiner noted private medical records finding tremor in both hands in 2013, a 2015 neurologic examination showing slight intention tremor in both upper extremities, and magnetic resonance imaging (MRI) of the Veteran’s brain showing minor defect in 2012, and normal MRI results in 2015. Although the VA examiner did not explicitly state the Veteran’s lay testimony had been considered, the VA examiner did not reject the Veteran’s assertions of inservice tremor and, rather, appeared to take that evidence into consideration when attributing the tremors to, in part, the service-connected TBI. A 2020 VA examination for central nervous disorders diagnosed essential tremors. The VA examiner opined the condition was less likely than not caused by active service to include the inservice head trauma; and less likely than not caused or aggravated by the service-connected TBI, migraines, or scars. In explaining her rationale, the VA examiner explained that there was no medical evidence showing the tremors began within the first six to twelve months after the inservice brain injury. Rather, the examiner stated the tremors were first observed to begin in 2014, after TBI, migraines and scars were diagnosed. The VA examiner further explained that TBI, migraines and scars do not cause tremors. In addition, the VA examiner noted that the Veteran had stated he had at last one family member with a tremor. The VA examiner concluded that the slow onset of the tremor, and increasing severity with age, made it at least as likely that the essential tremor was hereditary. The 2020 VA examiner stated the record had been reviewed, but the examiner’s review is clearly less complete than the 2019 VA examiner’s review. Moreover, the 2020 VA examiner incorrectly identified the medical observation of onset of the Veteran’s tremors in 2014. The 2020 examiner did not take note of the documentation of hand tremors in 2013, or of MRI findings including those in 2012 showing abnormality. In addition, the VA examiner did not discuss or appear to take into account the Veteran’s lay statements of inservice tremors and their continuity to the present. Rather, the VA examiner’s findings and opinions were explicitly based on the absence of tremors in service medical records and on the absence of tremors in post-service medical records until the VA examiner noted them in 2014. The VA examiner provided no explanation as to why the Veteran’s lay testimony was rejected. Finally, the VA examiner provided no references or other bases for stating the service-connected disabilities including TBI do not cause tremors. As the 2020 VA medical opinion is based on a less extensive and erroneous review of the record, and failed to comply with the directives of the 2018 Board remand, it cannot be probative here. This leaves the 2019 VA medical opinion. However, the 2019 VA opinion has its own defect in that the VA examiner attributed the diagnosed the upper extremity tremors to both service-connected TBI and nonservice-connected chronic pain syndrome. Ordinarily, the appropriate remedy would be to again remand the claims. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stegall v. West, 11 Vet. App. 268 271 (1998). However, in the present case, the Board finds it may resolve this issue without additional remand. The Board finds the Veteran’s lay testimony persuasive. The Veteran has consistently asserted he first noticed tremor during active service and that such has been present from active service to the present. The 2019 VA examiner appeared to recognize the Veteran’s assertions in concluding that the claimed neurobehavioral symptoms were the result of the service-connected TBI, even after acknowledging that mild TBI can cause both temporary and permanent symptoms and that essential tremor can be age-related and hereditary. In sum, the service treatment records are not completely legible; the Veteran’s report as to the onset and continuance of his claimed tremors is consistent and credible; service-connection has been awarded for TBI; and there is no other medical evidence or opinions finding the diagnosed essential tremors are not the result of the service-connected TBI. And, after discussing other possible causes of tremor, the 2019 VA examiner concluded the claimed essential tremors of the bilateral upper extremities were the result of the service-connected TBI and nonservice-connected chronic pain syndrome. This opinion is entitled to greater weight than the December 2020 for the reasons discussed above. Service connection for essential tremors of the upper extremities as secondary to the service-connected TBI is warranted. b) Dizziness, Memory Loss, and Fatigue The Veteran reports he first experienced dizziness, memory loss, and fatigue during active service and that these symptoms have been present continuously since then to the present. He and his representative also argue that these symptoms are the result of exposure to contaminated water at MCB Camp Lejeune or of service-connected disabilities. The medical evidence shows that dizziness, memory loss and fatigue had their onset during active service and are the result of the service-connected TBI. Dizziness, memory loss and fatigue are established by VA examinations in 2017, 2019 and 2020. In addition, the Board concedes the Veteran’s report of dizziness, memory loss, and fatigue during active service and continuously from then to the present. Finally, the Veteran is service-connected for residuals of TBI. He has therefore met the first and second requirements of Shedden and Wallin. As to the third requirement of Shedden and Wallin, that of a causal nexus, or etiological link, between the claimed dizziness, memory loss and fatigue and active service or service-connected disabilities, the 2019 VA examiner opined that these symptoms, described as neurocognitive symptoms, are the result of the service-connected TBI and nonservice-connected chronic pain disorder. As above observed, the December 2019 VA examiner’s opinion was informed by a long and detailed review of the medical evidence and current medical literature. Although the VA examiner did not explicitly state the Veteran’s lay testimony had been considered, the VA examiner did not reject the Veteran’s assertions of dizziness, memory loss and fatigue. Rather, he appeared to take that evidence into consideration in attributing dizziness, memory loss and fatigue to, in part, the service-connected TBI. In fact, the VA examiner specifically noted symptoms of dizziness and memory loss can be the result of TBI, with dizziness having appeared within weeks of the inservice head injury. Also as discussed above, the Board finds the Veteran’s lay testimony persuasive. The Veteran has consistently asserted he first noticed dizziness, memory loss and fatigue during active service and that such has been present from active service to the present. The 2019 VA examiner appeared to recognize the Veteran’s assertions in concluding that the claimed neurocognitive symptoms were the result of the service-connected TBI, even after acknowledging that mild TBI can cause both temporary and permanent symptoms. In sum, the service treatment records are not completely legible; the Veteran’s report as to the onset and continuance of his claimed dizziness, memory loss, and fatigue is consistent and credible; service-connection has been awarded for TBI; and there is no other medical evidence or opinions finding the claimed dizziness, memory loss, and fatigue are not the result of the service-connected TBI. And, after discussing other possible causes of the Veteran’s claimed neurocognitive disorders, the VA examiner concluded they were the result of the service-connected TBI and nonservice-connected chronic pain syndrome. Service connection for dizziness, memory loss, and fatigue as secondary to the service-connected TBI is warranted. c) Ear Condition to include Meniere’s Disease The Veteran and his representative assert service connection is warranted for an ear condition to include Meniere’s disease as the result of the inservice head injury or, in the alternative, water contamination at MCB Camp Lejeune or as secondary to the service-connected TBI. The medical evidence does not support his claim. As will be explained, the Veteran does not have an ear condition, to include Meniere’s Disease. Initially, the 2017 VA examination for TBI noted Meniere’s Disease as a residual of TBI. But, the 2017 VA examination for ear conditions did not show that a diagnosis of Meniere’s disease was warranted. Rather, the 2017 VA ear examiner diagnosed dizziness due to vestibular dysfunction, noting the presence of vertigo but no nystagmus. Given the conflict in medical findings and diagnoses, the October 2018 Board remand directed additional VA examination to clarify whether the diagnosis of Meniere’s Disease, or any other ear or vestibular disorder, was appropriate. The resulting 2020 VA examination for ear conditions showed no findings, signs or symptoms of Meniere’s Disease or any other ear or vestibular disorder. Physical examination of the ears was found to be normal. The 2020 VA examination for ear conditions was conducted with review of the claims file and examination of the Veteran. The Board therefore finds the VA examination is probative as to the issue of whether the Veteran has an ear condition, to include Meniere’s Disease. In the absence of proof of a current disability, there is no valid claim of service connection. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). There are no other medical findings, statements or opinions establishing the Veteran is diagnosed with an ear condition to include Meniere’s Disease. Absent a diagnosis of an ear condition to include Meniere’s Disease, service connection for an ear condition to include Meniere’s Disease is not warranted. The Board notes that the symptom of dizziness has been service-connected, above, separate from any ear condition. REASONS FOR REMAND These claims were previously remanded in October 2018. Unfortunately, further remand is required. Stegall v. West, 11 Vet. App. 268 (1998). Lower Back, Neck, and Bilateral Thigh Disabilities First, the 2020 the VA examiner’s rationale for finding that the diagnosed thoracolumbar and cervical spine disorders not the result of active service was based on a finding that there were no reports of trauma or injuries in service to the back or neck. However, this is not correct. Service records, while in large part illegible, do document treatment for back pain, head injury with subsequent neck stiffness during active service, and right leg pain. The Veteran is service-connected for TBI based on the head injury, and the Veteran’s representative has argued that the type of injury the Veteran sustained during active service would have involved a whiplash-like injury to the neck. Second, the 2020 VA examiner did not comply with the Board’s 2018 remand instructions. The October 2018 remand directives specifically noted that the Veteran was competent to report his symptoms and history, and directed the VA examiner to acknowledge and consider the Veteran’s lay statements in the formulation of any opinion. If the VA examiner rejected the Veteran’s lay statements, the VA examiner was to explain why. Finally, the VA examiner was instructed not to rely on an absence of medical evidence in the record to support her or his conclusions. Yet, the 2020 VA examiner does not appear to have considered the Veteran’s report of onset of back, neck, and bilateral leg pain during active service, and persisting thereafter which would have preceded the 1986 occupational back injury. Rather, the VA examiner stated the onset of back pain was with the occupational injury in 1986, and of neck pain, in 1996. In essence, the VA examiner rejected the Veteran’s lay statement as to his symptoms but provided no reason for doing so. As such, the VA examination is not only inadequate because its conclusions are based on errors of fact, but also because the VA examiner failed to comply with the October 2018 Board directives. Accordingly, further examination is required. In addition, the claim for an effective date earlier than March 6, 2013 for TDIU is dependent on the outcome of the claim for service connection for the claimed back, neck, and bilateral thigh disabilities. It is therefore inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Return the 2020 VA examinations to the examiner who conducted them or, if that examiner is not available, another equally qualified medical professional; a new physical examination is at the discretion of the reviewer. In any case, the claims folder must be reviewed in its entirety. The reviewer must identify all current neck, back, and lower extremity disabilities. The examiner must opine as to whether any such are as likely as not caused or aggravated by active service. The VA examiner must consider the documented head injury, and documented treatment for back pain, head injury with subsequent neck stiffness during active service, and right leg pain among the legible portions of the Veteran’s service records. The VA examiner must also acknowledge and consider the Veteran’s report of back, head, and bilateral leg pain beginning during active service and persisting post-service, thus preceding his 1986 occupational injury. If the VA examiner determines the Veteran’s lay statements should be rejected, he or she must provide a reason for doing so. A full and complete rationale for any opinion expressed is required. 2. Readjudicate the claim. If any matter remains denied, issue a supplemental statement of the case and return the appeal to the Board for further consideration. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L.J. Bakke, 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.