Citation Nr: 20021350 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 19-05 127 DATE: March 25, 2020 ORDER Entitlement to service connection for nerve damage including numbness in face and lower extremities is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for bipolar disorder is denied. Entitlement to service connection for chronic fatigue syndrome as due to an undiagnosed illness is denied. Entitlement to service connection for a right knee disability as due to an undiagnosed illness is denied. Entitlement to service connection for carpal tunnel syndrome right hand is denied. Entitlement to service connection for gastritis (also claimed as gastroesophageal reflux disease (GERD)) as due to an undiagnosed illness, medically unexplained chronic multi-symptom illness, or chronic illness under 38 C.F.R. § 3.317 is denied. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for fibromyalgia as due to an undiagnosed illness is denied. Entitlement to service connection for cirrhosis is denied. Entitlement to an effective date prior to June 14, 2016 for an increased rating for migraine headaches (formerly evaluated as tension headaches) is granted. REMANDED Entitlement to service connection for sleep apnea to include as secondary to service-connected posttraumatic stress disorder with unspecified depressive disorder, service-connected migraine headaches, and service-connected allergic rhinitis is remanded. Entitlement to service connection for degenerative arthritis of the lumbar spine is remanded. Entitlement to service connection for eczema (claimed as skin condition) to include as due to an undiagnosed illness is remanded. Entitlement to a rating in excess of 50 percent for migraine headaches is remanded. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder with unspecified depressive disorder is remanded. Entitlement to a rating in excess of 10 percent for allergic rhinitis is remanded. Entitlement to a total disability rating for individual unemployability (TDIU) is remanded. Entitlement to an effective date prior to June 14, 2016 for an increased rating for migraine headaches (formerly evaluated as tension headaches) is dismissed. FINDINGS OF FACT 1. The Veteran does not have a current diagnosis of a nerve condition to include numbness in face and lower extremities that is related to service. 2. The Veteran’s tinnitus did not have its onset during active service, was not caused by active service, and did not manifest within one year of separation from active service. 3. The Veteran does not have a current diagnosis of bipolar disorder. 4. The Veteran does not have chronic fatigue syndrome, and his fatigue symptoms are not due to an undiagnosed illness or medically unexplained chronic multisymptom illness. 5. The Veteran does not have a current diagnosis of a right knee disability and his right knee pain is not due to an undiagnosed illness or medically unexplained chronic multisymptom illness. 6. The Veteran’s carpal tunnel syndrome right hand did not have its onset during active service, was not caused by active service, and did not manifest within one year of separation from active service. 7. The Veteran’s current diagnosis of GERD did not have its onset during active service, was not caused by active service, did not manifest within one year of separation from active service, and is not due to an undiagnosed illness, medically unexplained chronic multisymptom illness, or chronic illness as defined under pertinent regulations. 8. The evidence is against a finding that the Veteran has a bilateral hearing loss disability for VA purposes. 9. The Veteran does not have fibromyalgia, and his fatigue and pain symptoms are not an undiagnosed illness or medically unexplained chronic multisymptom illness. 10. The Veteran’s current cirrhosis did not have its onset during active service, was not caused by active service, and did not manifest within one year of separation from active service. 11. In a February 18, 2020, rating decision, entitlement to an effective date of September 23, 2015, for an increased rating for migraine headaches (formerly evaluated as tension headaches) was granted, which was a full grant of the benefits sought on appeal. 12. There is currently no justiciable case or controversy for active consideration by the Board on the issue of entitlement to an earlier effective date for the grant of an increased rating for migraine headaches (formerly evaluated as tension headaches). CONCLUSIONS OF LAW 1. The criteria for service connection for nerve damage have not been met. 38 U.S.C. § 1110, 5107; 38 C.F.R. § 3.303. 2. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.310. 3. The criteria for service connection for bipolar disorder have not been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. 4. The criteria for service connection for chronic fatigue syndrome as due to an undiagnosed illness or medically unexplained chronic multisymptom illness have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317(b). 5. The criteria for service connection for a right knee disability as due to an undiagnosed illness or medically unexplained chronic multisymptom illness have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for carpal tunnel syndrome right hand have not been met. 38 U.S.C. §§ 1101, 1110; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for service connection for gastritis (also claimed as gastroesophageal reflux disease) as due to an undiagnosed illness, medically unexplained chronic multi-symptom illness, or chronic illness under 38 C.F.R. § 3.31 have not been met. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. 8. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304, 3.309. 9. The criteria for service connection for fibromyalgia as due to an undiagnosed illness or medically unexplained chronic multisymptom illness have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317(b). 10. The criteria for service connection for cirrhosis have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 11. The criteria for dismissal of the appeal for entitlement to an earlier effective date for an increased rating for migraine headaches (formerly evaluated as tension headaches) have been met. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 20.101, 20.200. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1987 to November 1987, November 1989 to August 1993, and from May 2002 to October 2002. In January 2019, the RO granted an earlier effective date of September 23, 2015 for an increased rating for posttraumatic stress disorder with unspecified depressive disorder; that date is the same as the recognized date of service connection for the psychiatric disorder, and the Veteran never timely challenged the September 2016 rating action which assigned the effective for service connection. Consequently, the effective date matter for the award of an increased rating is no longer before the Board (particularly as the Board’s further grant of an increased rating is also effective September 23, 2015). In a January 2019 rating action, the AOJ granted an increased rating for allergic rhinitis, effective June 14, 2016. Although on his February 2019 VA Form 9 he indicated that he wished appellate review of the assigned effective date, he is required to submit his disagreement on a designated form, which he has not done. The effective date matter is not before the Board. In May 2019, the RO granted service connection for irritable bowel syndrome also claimed as Gulf War undiagnosed illness/unexplained chronic multi-symptom illness. As this represents a full grant of the benefit sought, the issue is no longer before the Board. Service Connection 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; 38 C.F.R. § § 3.303(a). To establish a right to compensation for a present disability, 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. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War to a degree of 10 percent or more. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. For purposes of section 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2). An undiagnosed illness is defined as a condition that by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Further, lay persons are competent to report objective signs of illness. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). A medically unexplained chronic multisymptom illness is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. A medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2). There are currently no diagnosed illnesses that have been determined by the Secretary to warrant a presumption of service connection under 38 C.F.R. § 3.317(a)(2)(C). Objective indications of chronic disability include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of an undiagnosed illness or a medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 3.317(b). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 32.317(a)(4). 1. Entitlement to service connection for nerve damage including numbness in face and lower extremities The Veteran contends that he has nerve damage in his face and hands that is related to his active duty service. Service connection may only be granted for a current disability. When a claimed condition is not shown, there may be no grant of service connection. Congress specifically limited entitlement for service-connected disease or injury to cases where the incident resulted in a disability. In the absence of proof of a present disability there can be no valid claim. 38 U.S.C. § 1110 (2012); Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Veteran’s service treatment records (STRs) show that the Veteran complained of numbness in the face and lower extremities. No diagnosis was made, and no abnormalities were found. VA treatment records do not show any treatment for or diagnosis of a facial or lower extremity nerve condition. A June 2016 VA cranial nerve examination reflects that the Veteran does not have, nor has he ever had a diagnosis of a cranial nerve condition. Muscle strength testing and sensory examinations were normal and none of the cranial nerves were affected. A June 2016 VA peripheral nerve examination also reflects that the Veteran had no symptoms attributable to any peripheral nerve conditions of the lower extremities. Muscle strength, reflex, and sensation testing were all normal. Lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (sometimes the layperson will be competent to identify the condition where the condition is simple, for example, a broken leg, and sometimes not, for example, a form of cancer), (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 (Fed. Cir. 2007). In the present case, while a lay person may be competent to report symptoms of numbness, they are not competent to diagnose a nerve disability. The diagnosis of a nerve disability requires greater medical knowledge and testing to determine a diagnosis, which the Veteran has not shown he possesses. Accordingly, the Veteran is not competent to establish diagnosis for his claimed nerve disability. 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). The requirement that a current disability be present is satisfied when a claimant has a disability at any time during the pendency of a claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). The record does not demonstrate that the Veteran has a current nerve disability. The threshold element of a service connection claim (a current disability) has not been met; therefore, service connection for a nerve disability must be denied. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Accordingly, the preponderance of the evidence is against the claim for service connection for a nerve disability, the benefit of the doubt doctrine enunciated in 38 U.S.C. § 5107 (b) is not applicable, as there is no approximate balance of evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). 2. Entitlement to service connection for tinnitus A September 2015 VA audiology examination reflects that the Veteran failed to endorse symptoms of tinnitus. VA treatment records show that the Veteran reported symptoms of tinnitus in conjunction with an ear infection. Additional audiograms in September 2017 and 2018 do not show a diagnosis of tinnitus that is related to military service. 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). The requirement that a current disability be present is satisfied when a claimant has a disability at any time during the pendency of a claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). The record does not demonstrate that the Veteran has been diagnosed with tinnitus etiologically related to his active duty service. The threshold element of a service connection claim (a current disability) has not been met; therefore, service connection for bilateral hearing loss must be denied. Brammer v. Derwinski, 3 Vet. App. 223 (1992). As the preponderance of the evidence is against the claim for service connection for tinnitus, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for bipolar disorder The Veteran contends that service connection is warranted for bipolar disorder. Service connection may only be granted for a current disability. When a claimed condition is not shown, there may be no grant of service connection. Congress specifically limited entitlement for service-connected disease or injury to cases where the incident resulted in a disability. In the absence of proof of a present disability there can be no valid claim. 38 U.S.C. § 1110 (2012); Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1992). A review of the Veteran’s service treatment records (STRs) shows no evidence of treatment for or a diagnosis of bipolar disorder. Post-service treatment records do not show a diagnosis of bipolar disorder. September 2016 and January 2020 VA PTSD examinations are absent any diagnosis for bipolar disorder, as is an August 2019 private psychiatric examination. Lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (sometimes the layperson will be competent to identify the condition where the condition is simple, for example, a broken leg, and sometimes not, for example, a form of cancer), (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 (Fed. Cir. 2007). In the present case, the diagnosis of a psychiatric disability requires greater medical knowledge and testing to determine a diagnosis, which the Veteran has not shown he possesses. Accordingly, the Veteran is not competent to establish a diagnosis for his claimed bipolar disorder. 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). The requirement that a current disability be present is satisfied when a claimant has a disability at any time during the pendency of a claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). The record does not demonstrate that the Veteran has been diagnosed with bipolar disorder. The threshold element of a service connection claim (a current disability) has not been met; therefore, service connection for bipolar disorder must be denied. Brammer v. Derwinski, 3 Vet. App. 223 (1992). As the preponderance of the evidence is against the claim for service connection for bipolar disorder, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 4. Entitlement to service connection for chronic fatigue syndrome as due to an undiagnosed illness The Veteran contends that service connection is warranted for chronic fatigue syndrome. Service connection may only be granted for a current disability. When a claimed condition is not shown, there may be no grant of service connection. Congress specifically limited entitlement for service-connected disease or injury to cases where the incident resulted in a disability. In the absence of proof of a present disability there can be no valid claim. 38 U.S.C. § 1110 (2012); Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1992). A review of the Veteran’s service treatment records (STRs) shows no evidence of treatment for or a diagnosis of chronic fatigue syndrome. Post-service treatment records do not show a diagnosis of chronic fatigue syndrome. An April 2017 VA chronic fatigue syndrome examination reflects that the Veteran reported daily fatigue that he associated with his PTSD disability. The examiner concluded that while the Veteran had complaints of fatigue, the Veteran does not have a diagnosis of chronic fatigue syndrome as he has no signs, symptoms, or findings of chronic fatigue syndrome. Additionally, an April 2017 Gulf War general medical examination states that the Veteran does not meet the criteria for chronic fatigue syndrome and has no diagnosis of chronic fatigue syndrome. The examiner also stated that the Veteran’s claimed disability is not an undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology or a diagnosable chronic multi-symptom illness with a partially explained etiology. As the examiner’s determined the Veteran does not have a current chronic fatigue syndrome disability, the examiner opined that it was less likely as not that such disability was related to service, to include as due to an undiagnosed illness. Lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (sometimes the layperson will be competent to identify the condition where the condition is simple, for example, a broken leg, and sometimes not, for example, a form of cancer), (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 (Fed. Cir. 2007). In the present case, while a lay person may be competent to report symptoms of fatigue, they are not competent to diagnose chronic fatigue syndrome. The diagnosis of chronic fatigue syndrome requires greater medical knowledge and testing to determine a diagnosis, which the Veteran has not shown he possesses. This is particularly true here, where the VA examiner noted that there are specific criteria to be met before a diagnosis of chronic fatigue syndrome is appropriate. Accordingly, the Veteran is not competent to establish a diagnosis for his claimed chronic fatigue syndrome. 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). The requirement that a current disability be present is satisfied when a claimant has a disability at any time during the pendency of a claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). Because the Veteran is a Persian Gulf Veteran, however, service connection may alternatively be established for a chronic disability resulting from an undiagnosed illness under the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. The Board notes that while the Veteran has reported symptoms of fatigue, it has not been confirmed as a chronic disability on physical examination. Furthermore, the Veteran associated his fatigue with his service-connected PTSD disability. Accordingly, as there are no objective indications of a qualifying chronic disability for which service connection may be granted, service connection for chronic fatigue syndrome cannot be granted under the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. The record does not demonstrate that the Veteran has been diagnosed with chronic fatigue syndrome. The threshold element of a service connection claim (a current disability) has not been met; therefore, service connection for chronic fatigue syndrome must be denied. Brammer v. Derwinski, 3 Vet. App. 223 (1992). As the preponderance of the evidence is against the claim for service connection for chronic fatigue syndrome, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 5. Entitlement to service connection for a right knee disability as due to an undiagnosed illness The Veteran’s STRs do not show complaints, treatment or diagnosis of a right knee condition during his period of service. The available post-service VA records show complaints of right knee pain with no diagnosis of a chronic disability. Based on a review of the record, the medical evidence does not show that the Veteran has a current right knee disability that had its onset in service or is otherwise related to service. Other than the filing of the claim, the Veteran has not submitted or alleged any evidence of an in-service injury to his right knee. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the etiology of a right knee disability falls outside the realm of common knowledge of a lay person. The Board acknowledges that the Veteran has not been afforded a VA examination for his claim for service connection for a right knee disability. VA’s duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A (d) (2012); 38 C.F.R. § 3.159 (c)(4). The RO did not provide the Veteran with an examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or symptoms of disability, (2) establishes that the veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, there is no evidence of an event, injury or disease in service, or of a presumptive disease during the pertinent presumptive period and the Veteran has not referenced any. Therefore, the second McLendon factor has not been met, and no VA examination is necessary. Currently, there is no medical evidence linking a current diagnosis of the claimed disability on appeal to the Veteran’s military service. Because the Veteran is a Persian Gulf Veteran, however, service connection may alternatively be established for a chronic disability resulting from an undiagnosed illness under the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. The Board notes that while the Veteran has reported symptoms of knee pain, it has not been confirmed as a chronic disability on physical examination or in the Veteran’s treatment records. Accordingly, as there are no objective indications of a qualifying chronic disability for which service connection may be granted, service connection for right knee pain cannot be granted under the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. In sum, there is no evidence of a right knee disability in service or within one year of separation from service and there is no basis for service connection under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107 (b) is not applicable, as there is no approximate balance of evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). 6. Entitlement to service connection for carpal tunnel syndrome right hand The Veteran’s STRs do not show complaints, treatment or diagnosis of carpal tunnel syndrome right hand or related symptoms during his period of service. The available post-service VA and private treatment records do not reflect diagnosis of cirrhosis until 2015, thirteen years after his discharge from service. Based on a review of the record, the medical evidence does not show that the Veteran has a current carpal tunnel syndrome disability that had its onset in service or is otherwise related to service. Other than the filing of the claim, the Veteran has not submitted or alleged any evidence of an in-service injury to his right hand or wrist. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the etiology of carpal tunnel syndrome falls outside the realm of common knowledge of a lay person. The Board acknowledges that the Veteran has not been afforded a VA examination for his claim for service connection for carpal tunnel syndrome. VA’s duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A (d) (2012); 38 C.F.R. § 3.159 (c)(4). The RO did not provide the Veteran with an examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or symptoms of disability, (2) establishes that the veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, there is no evidence of an event, injury or disease in service, or of a presumptive disease during the pertinent presumptive period and the Veteran has not referenced any. Therefore, the second McLendon factor has not been met, and no VA examination is necessary. Currently, there is no medical evidence linking a current diagnosis of the claimed disability on appeal to the Veteran’s military service. In sum, there is no evidence of carpal tunnel syndrome in service or within one year of separation from service. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107 (b) is not applicable, as there is no approximate balance of evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). 7. Entitlement to service connection for gastritis (also claimed as gastroesophageal reflux disease (GERD)) as due to an undiagnosed illness, medically unexplained chronic multi-symptom illness, or chronic illness under 38 C.F.R. § 3.317 The Veteran’s STRs do not show complaints, treatment or diagnosis of gastritis or related symptoms during his period of service. The available post-service VA and private treatment records do not reflect diagnosis of cirrhosis until 2015, thirteen years after his discharge from service. Based on a review of the record, the medical evidence does not show that the Veteran has a current gastritis disability that had its onset in service or is otherwise related to service. Other than the filing of the claim, the Veteran has not submitted or alleged any evidence of an in-service occurrence. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the etiology of gastritis falls outside the realm of common knowledge of a lay person. An April 2017 VA esophageal conditions examination reflects that the Veteran reported he was diagnosed with gastroesophageal reflux disease approximately three years prior but that he had symptoms while on active duty. He stated he could not recall if he sought treatment in service. The diagnosis of GERD was confirmed. The VA examiner opined that it was less likely than not the Veteran’s diagnosis of GERD was incurred in or caused by service. The rationale provided was that the STRs are silent for a diagnosis or complaint of GERD and he wasn’t diagnosed until April 2015. In sum, there is no evidence of GERD in service or within one year of separation from service. Currently, there is no medical evidence linking a current diagnosis of the claimed disability on appeal to the Veteran’s military service. For purposes of section 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2). Here, the Veteran’s GERD is not an undiagnosed illness or a medically unexplained chronic multi-symptom illness, and there are currently no diagnosed illnesses that have been determined by the Secretary to warrant a presumption of service connection under 38 C.F.R. § 3.317(a)(2)(C). Additionally, the April 2017 VA examiner stated the Veteran’s GERD has a clear and specific etiology and diagnosis. Therefore, service connection for GERD cannot be granted under the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107 (b) is not applicable, as there is no approximate balance of evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). 8. Entitlement to service connection for bilateral hearing loss Audio examinations during service show normal hearing bilaterally. In September 2015, the Veteran underwent VA audiological testing which showed the Veteran had normal hearing in both ears with 100 percent speech discrimination in both ears as well. A September 2017 audiology note shows that the Veteran complained of otalgia, tinnitus and muffled hearing. Audiometric testing revealed hearing within normal limits bilateral and speech discrimination of 100 percent in both ears. The Veteran was previously treated for ear infection in August 2017, but his hearing was noted to be grossly intact. An October 2017 ear, nose, and throat (ENT) consult note for ear pain reflects that recent audiometric testing showed normal hearing bilaterally. A September 2018 audiology note also shows the Veteran had normal hearing bilaterally and 100 percent speech discrimination in each ear. 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). The requirement that a current disability be present is satisfied when a claimant has a disability at any time during the pendency of a claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). The record does not demonstrate that the Veteran has been diagnosed with bilateral hearing loss. The threshold element of a service connection claim (a current disability) has not been met; therefore, service connection for bilateral hearing loss must be denied. Brammer v. Derwinski, 3 Vet. App. 223 (1992). As the preponderance of the evidence is against the claim for service connection for bilateral hearing loss, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 9. Entitlement to service connection for fibromyalgia as due to an undiagnosed illness The Veteran contends that service connection is warranted for fibromyalgia. Service connection may only be granted for a current disability. When a claimed condition is not shown, there may be no grant of service connection. Congress specifically limited entitlement for service-connected disease or injury to cases where the incident resulted in a disability. In the absence of proof of a present disability there can be no valid claim. 38 U.S.C. § 1110 (2012); Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1992). A review of the Veteran’s service treatment records (STRs) shows no evidence of treatment for or a diagnosis of fibromyalgia. Post-service treatment records do not show a diagnosis of fibromyalgia. An April 2017 VA fibromyalgia examination reflects that the Veteran reported chronic muscle pain all over his body due to jumping off trucks and handling heavy guns in service. The examiner concluded that while the Veteran endorsed chronic muscle pain, he does not have a diagnosis of fibromyalgia as he has no signs, symptoms, or findings of fibromyalgia. An April 2017 Gulf War general medical examination states that the Veteran does not meet the criteria for fibromyalgia and has no diagnosis of fibromyalgia. The examiner also stated that the Veteran’s claimed disability is not an undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology or a diagnosable chronic multi-symptom illness with a partially explained etiology. As the examiner’s determined the Veteran does not have a current fibromyalgia disability, the examiner opined that it was less likely as not that such disability was related to service, to include as due to an undiagnosed illness. Additionally, a February 2019 Gulf War general medical examination found that the Veteran did not have any diagnosed illness for which no etiology was established or any additional signs/symptoms that may represent an undiagnosed illness or diagnosed medically unexplained chronic multi-symptom illness. Lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (sometimes the layperson will be competent to identify the condition where the condition is simple, for example, a broken leg, and sometimes not, for example, a form of cancer), (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 (Fed. Cir. 2007). In the present case, while a lay person may be competent to report symptoms of fatigue and pain, they are not competent to diagnose fibromyalgia. The diagnosis of a fibromyalgia disability requires greater medical knowledge and testing to determine a diagnosis, which the Veteran has not shown he possesses. This is particularly true here, where the VA examiner noted that there are specific criteria to be met before a diagnosis of fibromyalgia is appropriate. Accordingly, the Veteran is not competent to establish a diagnosis for his claimed fibromyalgia. 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). The requirement that a current disability be present is satisfied when a claimant has a disability at any time during the pendency of a claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). Because the Veteran is a Persian Gulf Veteran, however, service connection may alternatively be established for a chronic disability resulting from an undiagnosed illness under the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. The Board notes that while the Veteran has reported symptoms of muscle aches, it has not been confirmed as a chronic disability on physical examination or in the Veteran’s treatment records. Accordingly, as there are no objective indications of a qualifying chronic disability for which service connection may be granted, service connection for fibromyalgia cannot be granted under the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. The record does not demonstrate that the Veteran has been diagnosed with fibromyalgia. The threshold element of a service connection claim (a current disability) has not been met; therefore, service connection for fibromyalgia must be denied. Brammer v. Derwinski, 3 Vet. App. 223 (1992). As the preponderance of the evidence is against the claim for service connection for fibromyalgia, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 10. Entitlement to service connection for cirrhosis The Veteran’s STRs do not show complaints, treatment or diagnosis of cirrhosis or related symptoms during his period of service. The available post-service VA and private treatment records do not reflect diagnosis of cirrhosis until 2017, fifteen years after his discharge from service. Based on a review of the record, the medical evidence does not show that the Veteran has a current cirrhosis disability that had its onset in service or is otherwise related to service. Other than the filing of the claim, the Veteran has not submitted or alleged any evidence of an in-service injury to his liver. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the etiology of cirrhosis falls outside the realm of common knowledge of a lay person. Additionally, presumptive service connection on the basis of a chronic condition is not available for cirrhosis because there is no evidence it manifested within one year after service. The Board acknowledges that the Veteran has not been afforded a VA examination for his claim for service connection for cirrhosis. VA’s duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A (d) (2012); 38 C.F.R. § 3.159 (c)(4). The RO did not provide the Veteran with an examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or symptoms of disability, (2) establishes that the veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, there is no evidence of an event, injury or disease in service, or of a presumptive disease during the pertinent presumptive period and the Veteran has not referenced any. Therefore, the second McLendon factor has not been met, and no VA examination is necessary. Currently, there is no medical evidence linking a current diagnosis of the claimed disability on appeal to the Veteran’s military service. In sum, there is no evidence of cirrhosis in service or within one year of separation from service. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107 (b) is not applicable, as there is no approximate balance of evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Effective Date Under governing law, the effective date for a grant of compensation will be the day following separation from active service, or the date entitlement arose if a claim is received within one year after separation from service. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (b)(2)(i). Otherwise, the effective date is the date of receipt of claim or date entitlement arose, whichever is later. Id. As relevant herein, a claim or application is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1 (p). Unless specifically provided, the effective date will be assigned on the basis of the facts as found. 38 C.F.R. § 3.400 (a). 11. Entitlement to an effective date prior to June 14, 2016 for the grant of an increased rating for migraine headaches (formerly evaluated as tension headaches) A review of the record shows that the Veteran filed an intent to file a claim September 23, 2015. A fully developed claim for service connection was filed within one year on January 24, 2016. An August 2016 rating decision granted service connection for migraine headaches and assigned a rating of 0 percent effective January 24, 2016. A September 23, 2016 rating decision assigned an earlier effective date for service connection of tension headaches of September 23, 2015, the date on intent to file a claim, based on clear and unmistakable error. In December 2016 the Veteran took issue with the noncompensable evaluation assigned and a May 2017 rating decision increased the rating for migraine headaches to 30 percent and assigned an effective date of June 14, 2016. The RO stated the effective date was based on a June 14, 2016 intent to file a claim. The Veteran filed a notice of disagreement on February 23, 2017 with the effective date assigned for the increased rating, stating it should be September 23, 2015. A February 18, 2020 rating decision granted an earlier effective date of September 23, 2015 for the grant of an increased rating for migraine headaches (formerly evaluated as tension headaches). Despite the Veteran receiving the full benefits sought, the issue has remained in appeal status. Based upon the foregoing, the Board finds that the Veteran no longer has any issue on appeal, as the benefit sought has been granted. Accordingly, there is no justiciable case or controversy regarding such issue currently before the Board as contemplated by 38 U.S.C. § 7104. Consequently, in the absence of any justiciable questions, the appeal of entitlement to an earlier effective date for the grant of an increased rating for migraine headaches (formerly evaluated as tension headaches), must be dismissed. REASONS FOR REMAND 12. Entitlement to service connection for sleep apnea A review of the record shows that the Veteran was diagnosed with obstructive sleep apnea in March 2017. In September 2019, the Veteran submitted research articles and medical evidence in support of a claim of entitlement to service connection for sleep apnea. A private September 2019 sleep apnea opinion reflects that the examiner opined the Veteran’s sleep apnea is caused and permanently aggravated by his service-connected PTSD, psychotropic medications, and allergic rhinitis. The Board will remand the case for the AOJ to consider the new evidence and readjudicate the claim, to include on a secondary basis. 13. Entitlement to service connection for arthritis of the lumbar spine The Veteran contends that his currently diagnosed degenerative arthritis of the lumbar spine had its onset in service. Specifically, the Veteran asserts that he hurt his back in service as he always had to carry heavy items and he has had continued back pain since service. The STRs reflect in January 1993, the Veteran reported he had experienced recent back pain. There were no prior or subsequent treatment notes showing complaints of, or treatment for, a back condition. VA treatment records show complaints of back pain in 2015, the earliest records associated with the claims file. An April 2015 treatment note shows the Veteran reported having a history of chronic low back pain that was constant. VA treatment notes since then continue to show a history of chronic back pain. An October 2015 VA back examination reflects that the Veteran did not have a current diagnosis of a thoracolumbar spine condition. The examiner opined that the Veteran’s complaints of back pain were less likely than not incurred in or caused by service. The rationale provided was that the STRs revealed no objective clinical evidence to support a diagnosis of a lumbar spine condition or chronic residuals of a back condition. A March 2017 VA examination and x-rays showed a diagnosis of degenerative arthritis of the lumbar spine. The Veteran reported that the onset of his back pain was in 1991, during service. No opinion was provided on the etiology of the Veteran’s degenerative arthritis of the thoracolumbar spine. Therefore, on remand, a VA opinion should be obtained to determine whether the Veteran’s diagnosed degenerative arthritis of the lumbar spine was caused by or related to service. 14. Entitlement to service connection for eczema (claimed as skin condition) to include as due to an undiagnosed illness The Veteran contends that his eczema is causally related to his active duty service. At an October 2015 VA skin disease examination, the Veteran stated that after the Gulf War he began having dryness, cracking, and irritation of the skin. He reported that he sought treatment and was given a topical corticosteroid cream to apply to the skin at least three times a day. On physical examination, eczema was noted to be less than 5 percent of total body area and less than 5 percent of exposed area. Eczema was specifically noted as dryness, itching, and flaking of skin on the bilateral hands as well as some irritation and cracking. An October 2015 Gulf War general examination reflects that the Veteran had no diagnosed illnesses for which no etiology was established. The examiner stated that the claimed condition of eczema is a condition with a clear and specific diagnosis and therefore eczema is less likely than not related to his deployment in Southwest Asia or an undiagnosed illness. An April 2017 VA skin diseases examination reflects the Veteran reported his eczema began while he was on active duty in 1991. He stated he went to sick call and was prescribed a steroid cream. Since separating from service his eczema has been treated by his primary care physician and prescribed medication. The Veteran has been treated with topical corticosteroids for six weeks or more but not constant and other topical medications on a constant/near constant basis. On physical examination the Veteran’s eczema covered <5% of total body area and involved the radial and ulnar aspect of his bilateral wrist and the dorsal aspect of his thumb and all fingers bilaterally. No percentage was provided for total exposed area. Unfortunately, while the Gulf War examiner determined that eczema is a condition with a clear and specific diagnosis and therefore less likely than not an undiagnosed illness, the examiner also stated it was therefore not related to his deployment in Southwest Asia. The determination that it is not an undiagnosed illness does not imply that eczema did not originate during the Veteran’s service in Southwest Asia. A separate opinion and rationale must be provided as to etiology prior to adjudication. On remand, a new VA examination and opinion should be obtained to address whether the Veteran’s eczema is etiologically related to his active duty service during the Gulf War. 15. Entitlement to a rating in excess of 50 percent for migraine headaches With respect to the headache matter, the record reflects that the Veteran submitted a timely notice of disagreement with a May 2017 rating action which awarded a 30 percent rating for the headache disorder effective June 14, 2016. In a January 2019 rating action, the AOJ awarded a 50 percent rating for the headache disorder and indicated that this constituted a complete grant of the benefit sought on appeal. To this date the AOJ has not issued a statement of the case (SOC) addressing the matter of entitlement to a rating in excess of 50 percent for the headache disorder. In a February 2019 VA Form 9, the Veteran indicated that he was still seeking a higher rating for his headache disorder. In a May 2019 deferred rating decision, the AOJ determined that the increased rating matter was no longer on appeal, given that the disorder was assigned the highest schedular rating. Neither the Veteran nor his representative has indicated at any point that they would be satisfied with any particular rating for the headache disorder. The Board notes that it is possible they may argue that an extraschedular evaluation in excess of 50 percent is warranted. The AOJ consequently was incorrect to close out the appeal on the basis that no higher rating was available. The Board will remand the matter for the AOJ to issue a statement of the case to allow the Veteran the opportunity to appeal the matter. 16. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder with unspecified depressive disorder Evidence has been associated with the record after the issuance of the last supplemental statement of the case (SSOC) in May 2019. In addition to an August 2019 private opinion provided by the Veteran, it appears that the RO independently developed evidence that is relevant to the Veteran’s claim in the form of a January 2020 VA PTSD examination that discusses the current severity of the Veteran’s PTSD disability. Additionally, VA treatment records have also been associated with the claims file. The appellate scheme set forth in 38 U.S.C. § 7104 (a) contemplates that all evidence will first be reviewed at the RO so as not to deprive the claimant of an opportunity to prevail with his claim at that level. See generally Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). When the agency of original jurisdiction (AOJ) receives evidence relevant to a claim properly before it that is not duplicative of evidence already discussed in the statement of the case or a supplemental statement of the case, it must prepare a SSOC reviewing that evidence. 38 C.F.R. § 19.31 (b)(1). In order to afford the Veteran his full procedural rights, on remand, the AOJ must consider and address all of the evidence of record since the May 2019 SSOC including the January 2020 VA PTSD examination report, August 2019 private physician report, and VA treatment records dated through January 2020 in an SSOC. See 38 C.F.R. § 19.31. 17. Entitlement to a rating in excess of 10 percent for allergic rhinitis Evidence has been associated with the record after the issuance of the last supplemental statement of the case (SSOC) in May 2019. It appears that the RO independently developed evidence that is relevant to the Veteran’s claim in the form of a January 2020 VA examination that discusses the current severity of the Veteran’s allergic rhinitis disability. Additionally, VA treatment records have also been associated with the claims file. The appellate scheme set forth in 38 U.S.C. § 7104 (a) contemplates that all evidence will first be reviewed at the RO so as not to deprive the claimant of an opportunity to prevail with his claim at that level. See generally Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). When the agency of original jurisdiction (AOJ) receives evidence relevant to a claim properly before it that is not duplicative of evidence already discussed in the statement of the case or a supplemental statement of the case, it must prepare a SSOC reviewing that evidence. 38 C.F.R. § 19.31 (b)(1). In order to afford the Veteran his full procedural rights, on remand, the AOJ must consider and address all of the evidence of record since the May 2019 SSOC including the January 2020 VA allergic rhinitis examination report and VA treatment records dated through January 2020 in an SSOC. See 38 C.F.R. § 19.31. 18. Entitlement to TDIU As there are unresolved issues that bear on entitlement to TDIU, the Board finds that the Veteran’s claim of entitlement to TDIU is inextricably intertwined with the issues being remanded. Therefore, the Board finds that remanding the claim for TDIU for contemporaneous consideration is also warranted. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1.The AOJ shall issue a statement of the case addressing the issue of entitlement to a rating in excess of 50 percent for migraine headaches. The AOJ must inform the Veteran and his representative of the time limits in which to perfect an appeal of that matter.\ 2. The AOJ should schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of the Veteran’s skin disorder. The examiner should provide an opinion as to whether it is at least as likely as not that the Veteran’s skin disorder is etiologically related to service. 3. The AOJ should schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of the Veteran’s lower back disorder. The examiner should provide an opinion as to whether it is at least as likely as not that the Veteran’s low back disorder is etiologically related to service. 4. The AOJ should schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of the Veteran’s sleep apnea. The examiner should provide an opinion as to whether it is at least as likely as not that the Veteran’s sleep apnea is etiologically related to service. The examiner should also provide an opinion as to whether it is at least as likely as not that the Veteran’s sleep apnea was caused by a service-connected disorder, and whether it is at least as likely as not that the sleep apnea was aggravated by a service-connected disorder. 5. Readjudicate the Veteran’s claim for a rating in excess of 50 percent for PTSD in a new SSOC that includes all evidence associated with the claims file since the May 2019 SSOC including the January 2020 VA PTSD examination, the August 2019 private physician report, and VA treatment records through January 2020. 6. Readjudicate the Veteran’s claim for a rating in excess of 10 percent for allergic rhinitis in a new SSOC that includes all evidence associated with the claims file since the May 2019 SSOC including the January 2020 VA examination and VA treatment records through January 2020. 7. Thereafter, complete any additional development necessary to adjudicate the issue of TDIU. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Mitchell, 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.