Citation Nr: 20021922 Decision Date: 03/27/20 Archive Date: 03/27/20 DOCKET NO. 17-48 447 DATE: March 27, 2020 ORDER Entitlement to service connection for cerebrovascular disease is denied. Entitlement to service connection for acute stroke with paralysis is denied. Entitlement to service connection for loss of mobility as secondary to acute stroke with paralysis is denied. Entitlement to service connection for loss of sight, right eye, as secondary to acute stroke with paralysis is denied. Entitlement to service connection for loss of speech as secondary to acute stroke with paralysis is denied. Entitlement to service connection for atrial fibrillation is denied. Entitlement to service connection for diabetes mellitus, type II, is denied. Entitlement to special monthly compensation (SMC) based on the housebound criteria for the period prior to August 11, 2011, and from December 1, 2011, is denied. Entitlement to SMC based on the need for aid and attendance for the entire appellate time period is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that cerebrovascular disease began during active service or is otherwise caused by an in-service injury or disease, to include herbicide exposure. 2. The preponderance of the evidence is against finding that acute stroke with paralysis began during active service or is otherwise caused by an in-service injury or disease, to include herbicide exposure. 3. The preponderance of the evidence is against finding that loss of mobility began during active service, is otherwise caused by an in-service injury or disease (to include herbicide exposure), or was caused or aggravated by a service-connected disability. 4. The preponderance of the evidence is against finding that loss of sight, right eye, began during active service, is otherwise caused by an in-service injury or disease (to include herbicide exposure), or was caused or aggravated by a service-connected disability. 5. The preponderance of the evidence is against finding that loss of speech began during active service, is otherwise caused by an in-service injury or disease (to include herbicide exposure), or was caused or aggravated by a service-connected disability. 6. The preponderance of the evidence is against finding that atrial fibrillation began during active service or is otherwise caused by an in-service injury or disease, to include herbicide exposure. 7. The preponderance of the evidence of record is against finding that the Veteran had diabetes mellitus, type II, at any time during or approximate to the pendency of the claim. 8. Prior to August 11, 2011, and from December 1, 2011, the Veteran did not have a service-connected disability rated as total and an additional service-connected disability or disabilities independently ratable at 60 percent or more and was not permanently housebound by reason of his service-connected disabilities. 9. The Veteran was not blind, was not in a nursing home, had not lost the use of both feet, permanently bedridden, and was not in need of regular aid and attendance as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for cerebrovascular disease are not met. 38 U.S.C. §§ 1110, 1131, 5107(2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 2. The criteria for service connection for acute stroke with paralysis are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for loss of mobility are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 4. The criteria for service connection for loss of sight, right eye, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 5. The criteria for service connection for loss of speech are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 6. The criteria for service connection for atrial fibrillation are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for service connection for diabetes mellitus, type II, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 8. Prior to August 11, 2011, and from December 1, 2011, the criteria for the award of SMC based on the housebound criteria have not been not met. 38 U.S.C. §§ 1114, 5107 (2012); 38 C.F.R. §§ 3.102, 3.350, 3.351, 3.352 (2019). 9. The criteria for the award of SMC based on the need for regular aid and attendance have not been not met. 38 U.S.C. §§ 1114, 5107, 38 C.F.R. §§ 3.102, 3.350, 3.351, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty as a postal clerk in the United States Navy from February 1963 to November 1966 and from May 1981 to April 1983. He died in September 2016. The appellant is his surviving spouse and has been substituted for the Veteran for the purpose of the current claims. As to the SMC claim, in a January 2020 rating decision the RO granted entitlement to SMC based on the housebound criteria being met from August 11, 2011, to December 1, 2011. As such, the Board will limit its consideration to whether SMC based on the housebound criteria was met for the period other than what was granted above and whether the need for aid and attendance was warranted for the entire period prior to the Veteran’s death. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). A veteran who served in Vietnam between January 9, 1962 and May 7, 1975, is presumed to have been exposed to herbicides, such as Agent Orange, during such service. Certain specified diseases will be presumed service-connected due to herbicide exposure during service, if they manifest to a compensable degree at any time after service. 38 C.F.R. §§ 3.307(a) (6), 3.309(e). For purposes of establishing service connection for a disability resulting from exposure to certain herbicide agents, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during service. 38 U.S.C. § 1116(f). The last date on which a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975. 38 U.S.C. § 1116; 38 C.F.R. § 3.307(a)(6). Moreover, it is provided that the diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, with an exception not applicable to this case. 38 U.S.C. § 1116; 38 C.F.R. § 3.307(a)(6)(ii). The Federal Circuit held in Procopio v. Wilkie, 913 F.3d 1371 (Fed. Cir. 2019) that “service in the Republic of Vietnam” in 38 U.S.C. § 1116 includes the territorial sea of the Republic of Vietnam and is not limited to the landmass or inland waterways of that nation.” Following the Board’s April 2019 remand, the RO determined that the Veteran served aboard the USS Kitty Hawk as it sailed within the territorial sea (within 12 nautical miles) of the coast of South Vietnam. As such, exposure to herbicides has been conceded. Based on the presumed exposure to herbicides, entitlement to service connection for ischemic heart disease (also claimed as coronary atherosclerosis and microvascular disease) was granted in a January 2020 rating decision. The remaining claims on appeal, are not among the disabilities for which presumed herbicide exposure may be granted (other than diabetes mellitus, type II, and, as discussed below, the Veteran was not diagnosed with diabetes mellitus during his life). However, even if a veteran is not entitled to presumptive service connection for a disease claimed as secondary to herbicide exposure, VA must also consider the claim on a direct service-connection basis. When a disease is first diagnosed after service but not within the applicable presumptive period, service connection may nonetheless be established by evidence demonstrating that the disease was in fact incurred in service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). 1. Entitlement to service connection for cerebrovascular disease 2. Entitlement to service connection for acute stroke with paralysis 3. Entitlement to service connection for loss of mobility as secondary to acute stroke with paralysis 4. Entitlement to service connection for loss of sight, right eye, as secondary to acute stroke with paralysis 5. Entitlement to service connection for loss of speech as secondary to acute stroke with paralysis The Veteran and now the appellant contend that his cerebrovascular disease and acute stroke with paralysis were due to herbicide exposure in service. In addition, they contend that the Veteran had loss of mobility, loss of sight in the right eye, and loss of speech secondary to the stroke. The Veteran’s service treatment records do not include any complaints, treatment, or diagnosis of cerebrovascular disease, stroke, or any residuals thereof. The Veteran and now appellant do not contend otherwise. In August 2011, the Veteran was evaluated for a possible cerebrovascular accident. An MRI showed no significant flow within the left vertebral artery, but there was no evidence of intracranial infarct or other significant intracranial abnormality. In July 2012, the Veteran was noted to have experienced a recent transient ischemic attack (TIA) with right-sided weakness, facial asymmetry, and dysphasia that lasted about 2 days. There was a notation of cerebrovascular accident (CVA) in June 2012 with no residual deficits. In February 2013, the Veteran was seen for recurrent TIAs. In May 2015, the Veteran was noted to have experienced an acute cerebrovascular accident with right-sided deficit / aphasia and a previous history of cerebrovascular accident in January 2015. His family felt that he also had small TIAs between that stroke and the current stroke. In June 2015, the Veteran reestablished care with VA. At that time, the appellant reported that the Veteran had experienced two strokes earlier that year, had lost the ability to communicate, and had right-side weakness. The Veteran was able to move his left arm and hand, but not to command. He was able to make noise, but his speech did not make sense. The Veteran also had a noted visual deficit. In August 2015, the appellant contacted VA and indicated that since the Veteran’s stroke he could not talk or communicate with anyone, even the appellant. She wondered if there was any kind of device that could help in clarifying the Veteran’s speech. In an October 2016 statement, the appellant alleged that Agent Orange exposure, “caused Cardiovascular Disease with Multiple Cerebral Vascular Infarctions, Cardiac Aneurysm and Ischemic Heart Condition. All of these particular medical conditions have a relationship or an association with agent orange exposure.” There is no medical evidence of record suggesting that the cerebrovascular disease and acute stroke with paralysis were the result of the Veteran’s active service, to include herbicide exposure. The sole evidence suggesting a link between the Veteran’s service and cerebrovascular disease and acute stroke with paralysis are the Veteran’s and appellant’s contentions. While the Veteran and now appellant believes his cerebrovascular disease and acute stroke with paralysis were the result of in-service herbicide exposure, the issue is medically complex, as it requires specialized medical education, the ability to interpret complicated diagnostic medical testing, and the complexity of linking herbicide exposure to symptom onset first experienced decades later. As such, the Board find the Veteran and appellant not to be competent to make such assertions and affords these lay contentions no probative weight. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions); see also Layno v. Brown, 6 Vet. App. 465 (1994). As to the loss of mobility, loss of speech, and loss of sight in the right eye, as there is no basis for granting entitlement to service connection for the Veteran’s stroke, service connection on a secondary basis is not warranted. See 38 C.F.R. § 3.310. There is no lay or medical evidence to suggest that such symptoms are the direct result of the Veteran’s active service. In summary, the most probative evidence of record is against finding that the Veteran’s cerebrovascular disease, stroke, loss of mobility, loss of speech, and loss of sight in the right eye had their onset in service, within one year of service, or were otherwise related to service. As service connection on a direct basis is not warranted for his stroke, service connection on a secondary basis for the loss of mobility, loss of speech, and loss of sight in the right eye. In light of the evidence, the Board concludes that the preponderance of the credible evidence is against the claims, and that service connection for these disabilities is not warranted. As the preponderance of the evidence is against the claims, the benefit-of-the-doubt rule does not apply, and the claim must be denied. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). 6. Entitlement to service connection for atrial fibrillation The Veteran and now appellant contend that he had atrial fibrillation due to herbicide exposure in service. The Veteran’s service treatment records do not include complaints, treatment, or diagnosis of atrial fibrillation. The February 1983 Report of Medical Examination included a normal heart examination. In a contemporaneous Report of Medical History, the Veteran denied a history of palpitation or pounding heart. The Veteran and appellant do not contend that he had in-service onset of such problems. The first reports of heart problems in the claims file is from a January 2001 VA general medical examination. At that time, the Veteran reported episodic chest pain in the lower left anterior chest and upper left anterior chest. The symptoms were relieved with aspirin. The symptoms began a couple of years previously. An August 2011 echocardiogram did not include a finding of atrial fibrillation. In February 2013 and June 2015, the Veteran had a normal heart rate with a regular rhythm and normal heart sounds. No murmur was heard. Although somewhat unclear from the record, the RO has accepted that the Veteran had atrial fibrillation. Even presuming such a diagnostic finding, there is no competent evidence linking such a finding to the Veteran’s active service, to include exposure to herbicides. In that regard and as noted above, atrial fibrillation is not among the disabilities presumed to be the result of herbicide exposure for VA compensation purposes. There is no medical evidence of record suggesting that any atrial fibrillation was the result of the Veteran’s active service, to include herbicide exposure. The sole evidence suggesting a link between the Veteran’s service and any atrial fibrillation are the Veteran’s and appellant’s contentions. While the Veteran and now appellant believes he had a diagnosis of atrial fibrillation that was the result of in-service herbicide exposure, the issue is medically complex, as it requires specialized medical education, the ability to interpret complicated diagnostic medical testing, and the complexity of linking herbicide exposure to symptom onset first experienced decades later. As such, the Board find the Veteran and appellant not to be competent to make such assertions and affords these lay contentions no probative weight. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). 7. Entitlement to service connection for diabetes mellitus, type II The Veteran and now appellant contend that he had diabetes mellitus, type II, due to exposure to Agent Orange during service. As noted above, exposure to herbicides during service is conceded. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease, to include as due to in-service herbicide exposure. The Board concludes that the Veteran does not have a current diagnosis of diabetes mellitus, type II, and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The Veteran’s service treatment records do not include complaints, treatment, or diagnosis of diabetes mellitus. A February 1983 Report of Medical Examination included urinalysis results that were negative for albumin and sugar. In a contemporaneous Report of Medical History, the Veteran denied a history of sugar or albumin in the urine. The Veteran and appellant do not contend in-service onset of diabetes. In July 2011, the Veteran denied any past diagnoses of diabetes mellitus. A September 2012 VA general medical examination also indicated that the Veteran did not have diabetes mellitus. Thus, there is no VA or private treatment record documenting a diagnosis of diabetes mellitus, type II, prior or during the appellate time period. While the Veteran and now appellant believes he had a diagnosis of diabetes mellitus, type II, they are not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. 8. Entitlement to SMC based on the housebound criteria prior to August 11, 2011, and from December 1, 2011 9. Entitlement to SMC based on the need for aid and attendance The Veteran and now appellant contend that the Veteran was eligible for SMC based on his claimed need for aid and attendance and/or housebound status (other than for the period prior to August 11, 2011, and from December 1, 2011, for which SMC based on housebound status has been awarded). SMC as provided by 38 U.S.C. § 1114(l) is payable if as a result of a service-connected disability has suffered anatomical loss or loss of use of both feet, one hand and one foot, blindness in both eyes with visual acuity of 5/200 or less or being permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). The following will be accorded consideration in determining the need for regular aid and attendance: inability of claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352(a). It is not required that all of the disabling conditions enumerated in 38 C.F.R. § 3.352(a) be found to exist before a favorable rating may be made. The particular personal functions which the Veteran is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that the Veteran is so helpless as to need regular aid and attendance, not that there is a constant need. 38 C.F.R. § 3.352(a); see also Turco v. Brown, 9 Vet. App. 222, 224 (1996) (noting that at least one factor listed in § 3.352(a) must be present for a grant of special monthly pension based on need for aid and attendance). For the purposes of 38 C.F.R. § 3.352(a), “bedridden” will be a proper basis for the determination of whether the Veteran is in need of regular aid and attendance of another person. “Bedridden” will be that condition which, through its essential character, actually requires that the Veteran remain in bed. The fact that the Veteran has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. 38 C.F.R. § 3.352(a). SMC at the housebound rate may be paid if a Veteran has a single service-connected disability rated 100 percent and either: (1) has an additional service-connected disability or disabilities ratable at 60 percent, separate and distinct from the 100 percent service-connected disability, and involving different anatomical segments or bodily systems; or (2) is permanently housebound by reason of a service-connected disability or disabilities. Permanently housebound means the Veteran is substantially confined, as a direct result of a service-connected disability or disabilities, to his dwelling or the immediate premises (or, if institutionalized, to the ward or clinical areas), and it is reasonably certain that the service-connected disability or disabilities and resultant confinement will continue throughout his lifetime. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). On August 11, 2011, the Veteran suffered a myocardial infarction, for which he was granted a temporary 100 percent disability rating until December 1, 2011. Thus, for that period the Veteran met the criteria for housebound benefits on a statutory basis, due to having a single disability rating at 100 percent and additional disabilities totalling 60 percent or greater. Service connection has been granted for ischemic heart disease, rated as 60 percent prior to August 11, 2011, and from December 1, 2011; right and left leg radiculopathy, rated separately as 20 percent disabling from August 16, 2011, and as 40 percent from June 19, 2015; arthritis, thoracolumbosacral spine with degenerative disc disease and intervertebral disc syndrome, rated as 20 percent disabling; peptic ulcer disease with hiatal hernia, rated as 10 percent disabling; and hearing loss, right ear, and asbestosis, each rated as noncompensably disabling. The questions before the Board are whether the Veteran met the criteria for aid and attendance benefits for the above period and whether he otherwise met the criteria for SMC based on the need for aid and attendance or housebound status for the remaining period on appeal. For the reasons discussed below, the Board finds that he did not. As noted above, on August 11, 2011, the Veteran suffered a heart attack. An August 2011 surgical report indicated that prior to the heart attack, the Veteran had been experiencing episodic chest discomfort for the previous 3 years with some worsening since the previous Monday. Other records also indicate a previous heart attack in September 2009. A February 2012 VA back examination the Veteran had significant back pain with radiation into the extremities. He reported that he could walk at most a half block at a time with pain. He could not run or left over 30 pounds and could not do prolonged bending, twisting, sitting, or standing. A September 2012 VA back examination showed no symptoms of radiculopathy or intervertebral disc syndrome. The Veteran would have difficulty with heavy lifting and activities that required prolonged sitting or standing. A September 2012 VA stomach examination showed that the Veteran’s peptic ulcer disease caused reflux, but otherwise was inactive. A June 2015 esophageal conditions examination report indicated that the Veteran was being fed through a feeding tube since his stroke and that prior to the stroke he had experienced swallowing problems, regurgitation, bloating, and increased size of the hiatal hernia. A June 2015 back examination report indicated that since the Veteran’s stroke in 2012 he had been unable to talk or walk and was entirely bed ridden. He was on a feeding tube and had no control over his bowels. The Veteran was in so much pain that he could not do anything. A November 2015 VA treatment record indicated that a ramp had been ordered to enable access to the Veteran’s home. In April 2016, the appellant contacted VA and indicated that the Veteran was unable to speak, read, or write. He had no use of his right arm and dragged his leg. In addition, “his brain doesn’t connect, he doesn’t even know yes from no!”. As to whether SMC is warranted under 38 U.S.C. § 1114(s) at the housebound rate, other than for the period from August 11, 2011, to December 1, 2011, the Veteran is not service-connected for a single service-connected disability rated as 100 percent disabling. Thus, the question is whether the Veteran was permanently housebound by reason of his service-connected disabilities. The evidence demonstrates that the Veteran’s heart, low back, and radiculopathy disabilities clearly affected his ability to function, but did not result in his confinement to home. To the extent he was limited in leaving his home, the evidence demonstrates that it was a result of non-service connected stroke residuals. As noted, service connection is denied for that disability herein. The other service-connected disabilities were not shown to affect in any way the Veteran’s ability to leave his home. As such, entitlement to SMC benefits under the provisions of 38 U.S.C. § 1114(s) are not warranted other than for the period already awarded. As to granting benefits under the provisions of 38 U.S.C. § 1114(l), the Board notes that the evidence of record does not show that the Veteran’s service-connected disabilities caused the anatomical loss or loss of use of both feet or one hand and one foot, and he was not blind in both eyes. The Veteran has some problems with his eyesight, including loss of vision in the right eye, but not to the extent of being blind in both eyes. The Board recognizes that the Veteran had difficulty with ambulation and falls, but those issues were unrelated to his service-connected disabilities. Thus, even were the Board to presume that the Veteran had effectively lost the use of both feet, such problems were unrelated to his service-connected disabilities. The Veteran’s bilateral lower extremity radiculopathy did not result in the loss of use of both feet. Consequently, the Veteran can only establish entitlement to SMC under 38 U.S.C. § 1114(l) by showing his service-connected disabilities caused him to be permanently bedridden or so helpless as to be in need of regular aid and attendance under the criteria of 38 C.F.R. § 3.352(a) set forth above. In this regard, the medical evidence does not demonstrate that the Veteran required regular aid and attendance due to his service-connected disabilities. The Veteran had significant mobility problems due to his non-service connected stroke. His primary difficulties were due to non-service connected stroke residuals and cerebrovascular disease. These problems affected all aspects of his life, from his mobility, to ability to accomplish activities of daily living, to speech. The lay and medical evidence does not suggest that he was unable to accomplish such tasks prior to his strokes or otherwise suggesting that the Veteran was bedridden or so helpless that he required regular aid and attendance due to his service-connected disabilities. On further review of the record, the Board concludes that the evidence does not show that the Veteran was permanently bedridden, or so helpless as to be in need of regular aid and attendance due to service-connected disability. To the extent that such was required, it was due to non-service connected disabilities. In sum, the competent evidence of record does not indicate that the Veteran’s service-connected disabilities prevented him from performing any activities of daily living or rendered him housebound (other than for the period from August 11, 2011, to December 1, 2011). The Veteran and appellant have not provided or identified any evidence to the contrary. See 38 U.S.C. § 5107(a). Based on the foregoing, the Board finds that the claims for SMC based on aid and attendance or housebound status (other than for the period from August 11, 2011, to December 1, 2011) must be denied. As the preponderance of the evidence is against the claims, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. J. Houbeck, 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.