Citation Nr: 20031972 Decision Date: 05/06/20 Archive Date: 05/06/20 DOCKET NO. 15-09 818 DATE: May 6, 2020 ORDER Entitlement to service connection for degenerative arthritis of the spine is denied. Entitlement to service connection for right shoulder degenerative joint disease is denied. Entitlement to service connection for a left shoulder disability is denied. Entitlement to service connection for a right hand disability is denied. FINDINGS OF FACT 1. The preponderance of the evidence of record is against a finding that the Veteran’s currently diagnosed degenerative arthritis of the spine is related to lower back pain symptoms he experienced in service, that he was diagnosed with arthritis within a year after separation from service, or that he experienced a continuity of degenerative arthritis of the spine symptomology since service. 2. The preponderance of the evidence of record is against a finding that the Veteran’s currently diagnosed right shoulder degenerative joint disease is related to symptoms he experienced in service, that he was diagnosed with arthritis within a year after separation from service, or that he experienced a continuity of right shoulder degenerative joint disease symptomology since service. 3. The preponderance of the evidence of record is against a finding that the Veteran’s reported left shoulder pain is related to the in-service left shoulder strain. 4. The preponderance of the evidence of record is against a finding that the Veteran has a currently diagnosed right hand disability that is related to the in-service right hand fracture. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for degenerative arthritis of the spine have not been met. 38 U.S.C. §§ 1110, 1131, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 2. The criteria for entitlement to service connection for right shoulder degenerative joint disease have not been met. 38 U.S.C. §§ 1110, 1131, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 3. The criteria for entitlement to service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1110, 1131, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 4. The criteria for entitlement to service connection for a right hand disability have not been met. 38 U.S.C. §§ 1110, 1131, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1986 to December 1993, and again from February 2003 to September 2003. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a July 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). These matters were previously before the Board and remanded in June 2018 for further development. Specifically, the Board remanded the matters in June 2018 to obtain any outstanding VA treatment records, and to afford the Veteran the opportunity to identify or submit any outstanding private treatment records. The matters were also remanded to obtain new medical opinions regarding the nature and etiology of the Veteran’s reported bilateral shoulder, right hand, and back disabilities. The Board noted that the VA examiner who conducted the February 2014 VA examinations was unable to provide nexus opinions for the Veteran’s claimed disabilities because the Veteran’s complete private treatment records were not yet uploaded to his claims file. Subsequent to the June 2018 Board remand, the Veteran’s VA treatment records were associated with the claims file. Further, in a March 2019 notification letter, the RO requested that the Veteran identify any and all pertinent treatment records that pertained to the care and treatment of his disabilities currently on appeal. The Veteran was also sent a blank VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs, and VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs, to complete. However, the Veteran did not identify any further private treatment records. Further, the Veteran was scheduled for new VA examinations in June 2018 for his bilateral shoulders, back, and right hand disabilities. Notations in the file from the VA examiner indicate that the Veteran failed to appear for all of his scheduled VA examinations. These notations do not provide any reasoning for the Veteran’s failure to appear. The Board notes that the September 2019 Supplement Statement of the Case further notified the Veteran that he had scheduled VA examinations, and that he failed to appear. The record contains no statements from the Veteran providing good cause for his failure to appear. Further, the submitted April 2020 hearing brief proffers no good cause or reasoning for the Veteran’s failure to appear. The Board notes that the duty to assist a claimant is not a one-way street, and in the instant case, the Veteran has failed to cooperate to the full extent in the development of his claim. Wood v. Derwinski, 1 Vet. App. 406 (1991). Further, when a claimant, without good cause, fails to report for an examination scheduled in conjunction with an original claim for compensation the claim should be rated based on the evidence of record. 38 C.F.R. § 3.655(a)-(b). Accordingly, the Board finds that VA has fulfilled its duty to notify and assist to the extent possible, and that the June 2018 remand has been substantially complied with by VA. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, the Board will proceed with determinations of the matters on appeal based on the evidence currently of record. Service Connection Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In general, service connection requires the following: (1) evidence of a current disability; (2) evidence of an in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Board notes that where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including arthritis and organic diseases of the nervous system, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease under 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptomology to establish service connection is limited only to those diseases listed under 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Moreover, every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111. To rebut this presumption of soundness at service entry, there must be clear and unmistakable evidence showing that the disorder preexisted service and there must be clear and unmistakable evidence that the disorder was not aggravated by service. The Veteran is not required to show that the disease or injury increased in severity during service before VA’s duty under the second prong of this rebuttal standard attaches. VAOPGCPREC 3-2003 (July 16, 2003); Jordan v. Principi, 17 Vet. App. 261 (2003); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). However, where a preexisting disease or injury is noted on the entrance examination, section 1153 of the statute provides that “[a] preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease.” 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). Further, aggravation may not be conceded where the disability underwent no increase in severity in service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 C.F.R. § 3.306(b). For veterans who served during a period of war or after December 31, 1946, clear and unmistakable evidence is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service, and clear and unmistakable evidence includes medical facts and principles which may be considered to determine whether the increase is due to the natural progression of the condition. Id. Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered “aggravation in service” unless the underlying condition itself, as contrasted with mere symptoms, has worsened. See Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993). Given these provisions, the standard of proving a claim based on “aggravation” changes depends on whether the pre-existing disability was noted on the entrance examination report, or whether it was not but the presumption of soundness was nevertheless rebutted. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Back The Veteran maintains that entitlement to service connection is warranted for a back disability. A review of the evidence of record reflects that the Veteran has a current diagnosis of degenerative arthritis of the spine; thus, the currently disability element for this claim has been established. The Board notes that the record reflects the Veteran reporting, and being treated for, lower back pain during his first period of service. Specifically, the Veteran reported back problems in March 1988; he was provided an assessment of muscular neck pain. The Veteran was also seen twice in September 1993 for lower back pain. A separation examination does not appear to have been conducted. The Board notes that a periodic examination conducted in October 1995, not during active service, noted that the Veteran experienced periodic lower back pain. The Veteran also reported recurrent back pain in an accompanying Report of Medical History. Also of record is a March 1994 Employer’s Report of Injury to Employee from the North Carolina Industrial Commission. Therein, it was noted that the Veteran “threw [his] lower back out” on the job. The Board notes that the Veteran’s service treatment records contain an annual medical certificate completed in August 1997, which indicates that the Veteran was out for four weeks due to a back injury. It is unclear if this was the same as the reported March 1994 back injury. The Board notes that it does not appear from the Veteran’s service records that he was provided an entrance examination for his second period of service. The Board notes that when the Veteran has not been examined on entrance into service, the presumption of soundness does not attach. See Crowe v. Brown, 7 Vet. App. 238, 245 (1994); Smith v. Shinseki, 24 Vet. App. 40, 45 (2010). Service treatment records from this second period of service reflect the Veteran reporting recurrent back pain. Specifically, a September 2003 Post-Deployment report reflects the Veteran reporting back pain and muscle aches. In February 2014, the Veteran was provided a VA examination for his back disability. He was provided a diagnosis of degenerative arthritis of the spine. The VA examiner indicated that a date of diagnosis was not able to be provided because of a lack of medical records. As discussed in the introduction above, the Veteran’s private treatment records were not associated with the claims file during the time of the February 2014 VA examination. The Veteran reported that he developed lower back pain in service. He denied a specific injury, and indicated that it started hurting if he did too much manual labor. He indicated that his back pain had progressed since leaving service. He indicated that he went to physical therapy in North Carolina in 1996 or 1997 for his back, and was told that he had a slipped disc. The Veteran did not report any intervening work-related injuries to the VA examiner. The VA examiner indicated that she was unable to provide a nexus opinion regarding the Veteran’s claimed back disability because the Veteran’s complete private treatment records were not available for review. Also of record are VA and private treatment records, which the reflect the Veteran reporting, and being treated for, back pain. Private treatment records from as early as October 2013 reflect evidence of degenerative disc disease being found on imaging studies. VA treatment records indicate that the Veteran was involved in a motor vehicle accident in October 2016, and experienced residual lower back pain. However, in January 2018, the Veteran indicated that while the 2016 motor vehicle accident increased his lower back pain, he had a history of lower back pain since service. In light of the foregoing, the Board finds that entitlement to service connection for degenerative arthritis of the spine, claimed as a back disability, is not warranted. Although the evidence of record reflects that the Veteran has a currently diagnosed back disability, and that there is an indication of an in-service incurrence, the Board notes that there is no competent evidence of record to establish a nexus. Initially, the Board notes that due to the Veteran’s failure to appear (without good cause) for his scheduled VA examination, there is no VA nexus opinion of record. Thus, there is no opinion of record indicating whether the Veteran’s currently diagnosed degenerative arthritis of the spine was related to the lower back pain he reported during his first period of service, or whether this reported lower back pain was aggravated by the Veteran’s post-service work-related injuries. The Board acknowledges that lay evidence can be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Here, there are statements of record from the Veteran indicating that he has experienced lower back pain since separation from service. While the Veteran is competent to report experiencing lower back pain, the Board does not find him competent to opine as to the etiology of his currently diagnosed degenerative arthritis of the spine. Specifically, due to the multiple possible etiologies of the Veteran’s currently diagnosed disability discussed above, the Board does not find that the Veteran possesses the requisite medical knowledge or experience to render a nexus opinion which attributes his back disability to service, as opposed to a post-service incident. Further, the Board acknowledges that the Veteran has been diagnosed with degenerative arthritis of the spine, and that arthritis is considered a chronic disability under 38 C.F.R. § 3.309(a). However, the earliest indication in the record of a diagnosis of degenerative arthritis of the spine was in October 2013, which was more than a year after separation from service. And while the Veteran reported back pain continuously from service, as indicated above, the Board does not find the Veteran competent to render an opinion as to whether his reported continuous back pain was due to his currently diagnosed degenerative arthritis of the spine, or was of another etiology. Accordingly, the Board finds that entitlement to service connection based on a presumptive theory of entitlement is not warranted. Thus, as the Board finds that entitlement to service connection for degenerative arthritis of the spine is not warranted; the Veteran’s claim is denied. Right Shoulder The Veteran maintains that entitlement to service connection is warranted for a right shoulder disability. A review of the medical evidence of record reflects a current diagnosis of degenerative joint disease of the right shoulder; thus, the current disability element for this claim has been established. The Board notes that the Veteran’s September 1985 enlistment examination noted normal extremities. It was noted that the Veteran fractured and dislocated his right shoulder in 1974, however, there was noted to be no subsequent problems. Thus, since the Veteran was noted to have normal upper extremities upon service entry, he is presumed sound. 38 U.S.C. § 1111. Service treatment records for the Veteran’s first period of service reflect that the Veteran reported right shoulder pain. Specifically, in June 1991, the Veteran reported right shoulder pain as a result of lifting furniture. He was diagnosed with right deltoid tendonitis. A separation examination does not appear to have been conducted. In an August 2000 periodic examination conducted after service, the Veteran was found to have normal upper extremities. There was noted to be no right shoulder deformity. Further, in a contemporaneous Report of Medical History, the Veteran denied a painful shoulder. As discussed above, there was no entrance examination for the Veteran’s second period of service. Further, while the service treatment records for this period of service reflect the Veteran reporting generalized muscle aches, there is no indication of the Veteran reporting, or being treated for, a shoulder disability. In February 2014, the Veteran was provided a VA examination for his claimed shoulder disabilities. He was noted to have degenerative joint disease of the right shoulder that was confirmed by imaging studies. The Veteran reported that both of his shoulders began hurting him in service due to exercises. He indicated that he sought treatment in service, and was offered cortisone injections, but that he declined and was given over-the-counter pain medication. The Veteran indicated that he sought follow-up treatment for his right shoulder in 2011 or 2012 and was given cortisone injections; he indicated that these treatments did not help. He indicated that he returned for treatment in 2013 for continued right shoulder pain. He reported that he was having pain in the right shoulder that was radiating down his arm and fingers. He indicated that he was sent for imaging studies and was told that he had disc problems in his neck, and that his neck was causing his symptoms rather than his shoulders. On the date of the examination, the Veteran reported severe pain in the neck, posterior shoulder, down the right arm, and into the 4th and 5th fingers. He indicated that his symptoms would come and go, and that he had not experienced numbness in his 4th and 5th fingers since June or July 2013. Arthritis of the right shoulder was found on imaging studies. The VA examiner indicated that the Veteran’s shoulder disabilities did not result in functional impairment. The VA examiner indicated that while an incidental finding of right shoulder degenerative joint disease was noted on x-ray studies, the Veteran’s symptoms and findings from the examination were more consistent with referred pain from the cervical spine and radiculopathy rather than an actual shoulder joint pathology. Regarding the etiology of the Veteran’s shoulder disability, the VA examiner indicated that she was unable to render an opinion without the Veteran’s complete private treatment records. However, she did again note that it appeared that the Veteran’s current symptoms were more likely related to the cervical spine than the shoulders. Also of record are VA and private treatment records, which reflect the Veteran reporting, and being treated for, right shoulder pain. Private treatment records reflect that imaging studies conducted in July 2009 found moderate degenerative changes of the acromioclavicular joint. VA treatment records from February 2018 reflect the Veteran reporting right shoulder pain. There was no indication of this reported right shoulder pain being related to service. In light of the foregoing, the Board finds that entitlement to service connection for a right shoulder disability is not warranted. While the Veteran has a current diagnosis, and experienced an in-service injury, there is not sufficient evidence of record of a nexus. As the Veteran failed to appear (without good cause) for his scheduled VA examination, there is no VA nexus opinion of record. Thus, there is no opinion of record regarding whether the Veteran’s currently diagnosed right shoulder degenerative joint disease was caused by, or related to, his in-service right deltoid tendonitis. Additionally, the Board notes that the record reflects uncertainty as to the etiology of the Veteran’s current right shoulder symptomology. Specifically, as indicated by the February 2014 VA examiner, the medical evidence of record reflected that the Veteran’s currently reported right shoulder symptomology could be attributed to a cervical spine disability, rather than to a joint pathology. In this capacity, the Board notes that while the Veteran is competent to report shoulder pain, he is not competent to attribute that pain to a shoulder disability, or in-service injury, or as a result of a cervical spine disability as this requires medical training. Further, while the Veteran’s service treatment records reflect treatment for a neck disability, there is no sufficient medical nexus opinion of record to separately grant service connection for this disability as the examiner’s opinion appears to have been based, in part, on speculation, and it does not link his cervical radiculopathy to the in-service neck complaints. The Board acknowledges that the Veteran has been diagnosed with right shoulder degenerative joint disease, and that arthritis is considered a chronic disability under 38 C.F.R. § 3.309(a). However, the earliest indication in the record of a diagnosis of degenerative changes of the right shoulder was in July 2009, which was more than a year after separation from service. Further, the record does not reflect the Veteran reporting continuous symptoms of right shoulder degenerative joint disease from service. The Veteran was found to have normal upper extremities in an August 2000 periodic examination, and he was specifically noted to have no deformities in the right shoulder. The Veteran himself in August 2000 specifically indicated normal shoulders. Accordingly, the Board finds that entitlement to service connection based on a presumptive theory of entitlement is not warranted. Thus, as the Board finds that entitlement to service connection for a right shoulder disability is not warranted, the Veteran’s claim is denied. Left Shoulder The Veteran maintains that entitlement to service connection is warranted for a left shoulder disability. Service treatment records for the Veteran’s first period of service reflect the Veteran reporting generalized left shoulder pain. In December 1989, the Veteran was noted to have hurt his left shoulder while lifting 150 pounds. He was provided a diagnosis of left shoulder muscle strain. A follow-up notation from January 1990 indicates that the Veteran reported that his left shoulder was feeling better. There was noted to be no functional limitations of the left shoulder at that time. A separation examination does not appear to have been conducted. In an August 2000 periodic examination conducted after service, the Veteran was found to have normal upper extremities. Further, in an accompanying Report of Medical History, the Veteran specifically denied a painful shoulder. As discussed above, there was no entrance examination for the Veteran’s second period of service. Further, while the service treatment records for this period of service reflect the Veteran reporting generalized muscle aches, there is no indication of the Veteran reporting, or being treated for, a shoulder disability. In February 2014, the Veteran was provided a VA examination for his claimed shoulder disabilities. He was not provided a diagnosis for the left shoulder. The Veteran reported mild pain from the neck to the left shoulder. He reported that both of his shoulders began hurting him in service due to exercises. He indicated that he sought treatment in service, and was offered cortisone injections, but that he declined and was given over-the-counter pain medication. No arthritis of the left shoulder was found on imaging studies. Further, the VA examiner indicated that the Veteran’s bilateral shoulder disability did not result in functional impairment. As discussed above, regarding the etiology of the Veteran’s shoulder disability, the VA examiner indicated that she was unable to render an opinion without the Veteran’s complete private treatment records. However, she did note that it appeared that the Veteran’s current symptoms were more likely related to the cervical spine than to the shoulders. Also associated with the claims file are VA treatment records, which reflect the Veteran reporting left shoulder pain, and being provided physical therapy treatment for his reported pain in February 2018. However, there is no indication in these records that the Veteran’s current left shoulder pain was related to the in-service left shoulder strain. In light of the foregoing, the Board finds that entitlement to service connection for a left shoulder disability is not warranted. The Board acknowledges that the Veteran’s service treatment records reflect an in-service incurrence of a left shoulder strain. Regarding the current disability element, the Board notes that while the Veteran has reported mild left shoulder pain, the record does not reflect that the Veteran has been provided with a diagnosable disability for his left shoulder. Nevertheless, as the nexus element for this claim has not been established, a finding regarding whether the Veteran’s left shoulder pain reaches the level of a functional impairment of earning capacity, as thus satisfies the currently disability element, is not necessary. The Board notes that due to the Veteran’s failure, without good cause, to report for his scheduled VA examination, there is no nexus opinion of record to determine whether the Veteran’s claimed left shoulder disability is related to the in-service left shoulder strain. There is otherwise no positive evidence of record to reflect a nexus. Further, the Board notes that while the Veteran sought treatment for his left shoulder strain in December 1989, by January 1990, there was noted to be improvement with no functional impairment. The Veteran subsequently reported normal shoulders. Accordingly, as the Board finds that entitlement to service connection for a left shoulder disability is not warranted, the Veteran’s claim is denied. Right Hand The Veteran maintains that entitlement to service connection is warranted for a right hand disability. Regarding an in-service incurrence, the Board notes that service treatment records for the Veteran’s first period of service reflect that in October 1990, the Veteran fell and fractured the 4th and 5th digits of his right hand. As indicated above, the Veteran does not appear to have been provided a separation examination for this first period of service. However, a periodic examination in October 1995 noted normal upper extremities. Further, the Veteran did not report any right hand symptoms in an accompanying Report of Medical History. A periodic examination conducted in August 2000 noted normal upper extremities, and specifically noted there to be no effusion in the right hand. As discussed above, there was no entrance examination for the Veteran’s second period of service. Further, there is no indication of the Veteran reporting any specific right hand pain during this second period of service. In February 2014, the Veteran was provided a VA examination of his right hand and fingers. The only found disability was a right hand fracture from October 1990, which was resolved with no evidence of residuals. The Veteran reported that he broke his right hand in service; he indicated that he slipped in the snow and his knuckles jammed up against a door. On the date of the examination, he reported no problems with the fingers or the knuckles on the right hand. No abnormal findings were present on imaging studies, and no functional impairment was noted. No further opinion regarding this claimed disability was provided. Also associated with the claims file are the Veteran’s VA treatment records. However, there is no specific indication of the Veteran reporting residual joint pain from his in-service right hand fracture. While there are indications of the Veteran reporting mild numbness in his hands in November 2015 and February 2017, this was attributed to mild bilateral neuropathy. In February 2017, it was noted that there was no electrodiagnostic evidence for cervical radiculopathy. There was no indication that the neuropathy was related to the prior fracture. In light of the foregoing, the Board finds that entitlement to service connection for a right hand disability is not warranted. The Board acknowledges that the evidence of record reflects that the Veteran sustained a right hand fracture in service. However, the February 2014 VA examination noted that this fracture was resolved with no evidence of any residuals. Further, on the date of the examination, the Veteran did not report any related symptomology. Additionally, the Board notes that there is otherwise no indication of record that the Veteran has a currently diagnosed right hand disability related to the right hand fracture incurred in service. While the evidence of record reflects that the Veteran experienced some mild neuropathy symptoms in his bilateral hands, there is no indication of record that these symptoms are related to the in-service right hand fracture. Further, due to the Veteran’s failure to report, without good cause, for his scheduled VA examination, a VA nexus opinion was not able to be obtained regarding whether the Veteran has a currently diagnosed right hand disability related to his in-service injury. Accordingly, as the Board finds that entitlement to service connection for a right hand disability is not warranted, the Veteran’s claim is denied. M. Donohue Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. DeChiara, 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.