Citation Nr: 20044569 Decision Date: 07/02/20 Archive Date: 07/02/20 DOCKET NO. 18-34 193A DATE: July 2, 2020 ORDER Service connection for an abrasion of the right hand is denied. Service connection for a right knee condition is denied. Service connection for a left elbow condition is denied. Service connection for insomnia is denied. Service connection for headaches is granted. Service connection for a throat infection/strep throat is denied. Service connection for a low back condition, to include intervertebral disc syndrome (IVDS), is denied. An effective date earlier than January 16, 2014, for the grant of service connection for major depressive disorder, is denied. REMANDED Entitlement to service connection for sinus drainage/allergies is remanded. Entitlement to a rating in excess of 50 percent, prior to August 29, 2015, and in excess of 70 percent, from August 29, 2015, for major depressive disorder, with panic and avoidant personality disorder, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU rating) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has a current disability manifested by abrasion of the right hand that began during active service, or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that the Veteran has a current right knee condition that began during active service, or is otherwise related to an in-service injury or disease. 3. The preponderance of the evidence is against finding that the Veteran has a current left elbow condition that began during active service, or is otherwise related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that the Veteran has insomnia that began during active service, or is otherwise related to an in-service injury or disease. 5. Resolving reasonable doubt in the Veteran's favor, his headaches are proximately due to and aggravated by his service-connected major depressive disorder. 6. The preponderance of the evidence is against finding that the Veteran has a current disability manifested by throat infection or strep throat that began during active service, or is otherwise related to an in-service injury or disease. 7. The preponderance of the evidence is against finding that the Veteran has a current low back condition, to include IVDS, that began during active service, or is otherwise related to an in-service injury or disease. 8. The Veteran's formal claim for service connection for major depressive disorder was received on January 16, 2014; there is nothing in the record received prior to that date which may be construed as a claim for service connection. CONCLUSIONS OF LAW 1. The criteria for service connection for an abrasion of the right hand have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a right knee condition have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a left elbow condition have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for insomnia have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for secondary service connection for headaches have been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for service connection for a throat infection/strep throat have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for service connection for a low back condition, to include IVDS, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for an effective date earlier than January 16, 2014, for the grant of service connection for major depressive disorder, have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from January 1981 to January 1985. 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 (Fed. Cir. 2004). 1. Entitlement to service connection for an abrasion of the right hand. The Veteran contends he has an abrasion of the right hand related to service. 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. The Veteran’s service treatment records (STRs) include an undated notation that he stuck his hand into a compartment of the aircraft and was assessed as having an abrasion of the right hand. However, the remainder of the record does not demonstrate that the Veteran has a current disability related to a right-hand abrasion, or a current diagnosis of a right hand abrasion, nor has he had one at any time during the pendency of, or recent to the filing of, the claim. Romanowsky v. Shinseki, supra. On a VA scars/disfigurement examination in September 2015, it was noted that the Veteran had no diagnosis for claimed condition of abrasion of right hand. Additionally, it was noted that the Veteran could not recall the onset of his right-hand symptoms and could not remember when or where he hurt his right hand. The examiner opined that the Veteran’s claimed condition (right hand abrasion) was less likely than not incurred in or caused by service, and noted for rationale that after review of the old medical record and current examination, the abrasion over time was fading, was hardly visible, and the Veteran had full range of motion, a good grasp, and no chronic sequelae; therefore, there was no pathology to render a diagnosis. It is acknowledged that during a VA hands and fingers examination conducted that same day, the Veteran reported he had a right hand condition status post an injury. He could not recall the onset of his symptoms or where or when he hurt his right hand, but he reported having arthritis in his right hand. Despite this report of right hand arthritis, the Board finds it is not supported by the record. The Veteran’s postservice treatment records are silent for such a diagnosis and during the September 2015 VA examination, the examiner also found that the Veteran did not have a current diagnosis, to include any arthritis, associated with the claimed right hand condition status post injury. Accordingly, the Board concludes that, while the evidence shows that the Veteran was treated in service for a right hand abrasion, the preponderance of the evidence weighs against finding that the Veteran has a current right hand disability related to that in-service incident. While the Veteran is competent to report he had an abrasion of the right hand in service, as well as any current symptoms, he is a lay person and therefore not competent to provide a diagnosis in this case, or to relate an abrasion in service or any symptoms to a current disability. The issue is medically complex and requires specialized medical education. Jandreau v. Nicholson, supra. Consequently, the Board gives more probative weight to the competent medical evidence of record. 2. Entitlement to service connection for a right knee condition. The Veteran contends he has a right knee condition related to service. In the claim filed in October 2014, the Veteran reported that he had a bilateral knee disability that began in September 1982. The question for the Board is whether the Veteran has a current right knee disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of right knee degenerative joint disease, the preponderance of the evidence weighs against finding that his current right knee disability began during service or is otherwise related to an in-service injury, event, or disease. The Veteran’s STRs are silent for any complaints, findings, or diagnosis related to the right knee, and the record shows that the Veteran was not diagnosed with right knee degenerative joint disease (DJD)/arthritis until 2015, after an x-ray was taken in conjunction with the VA examination, over 30 years after his separation from service. During the VA examination in July 2015, for medical history, it was noted that the Veteran gave a history of a right knee condition for years. He did not, however, remember any specifics during service concerning his right knee condition or any injury. He remembered the right knee always being a problem but could not specify any particular date. The examiner opined that the Veteran’s right knee condition was not caused by or a result of service. For rationale, the examiner noted that the Veteran’s right knee condition was age related, and that the x-ray on the day of the VA examination showed he had DJD, which was over 30 years after service separation. The examiner noted a literature review of “UpToDate” supported this opinion, and that the x-ray showed that the DJD of the knees was equal on both sides, which also supported age as the etiology. It was also noted that the Veteran’s service separation examination was negative for history of any knee condition or complaint; that STRs were negative for any chronic right knee condition; and that there was no evidence of any chronic right knee condition since service separation according to the available medical records. The Board finds the VA examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While the Veteran is competent to report having experienced right knee symptoms since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of a right knee disability. The issue is medically complex, as it requires interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, supra. Consequently, the Board gives more probative weight to the 2015 VA examiner’s opinion. 3. Entitlement to service connection for a left elbow condition. The Veteran contends he has a left elbow condition related to service. 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. The Board concludes that the Veteran does not have a current diagnosis of a left elbow disability has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, supra. As there is no evidence of a current left elbow disability, the cornerstone element of a service connection claim has not been met. Brammer v. Derwinski, supra. STRs show that in August 1981, the Veteran was seen for pain in the left elbow, and he reported he could not bend it. The assessment was unidentified infection. The next day he was seen for a swollen left elbow, and an x-ray was normal. A week later it was noted that the Veteran’s left elbow was completely healed, with no problems, and he was to return to full duty. On a December 1984 Report of Medical History at separation, the Veteran responded "yes" to having or having had swollen or painful joints, which was noted to occur with big changes in the weather, and a painful or trick shoulder or elbow, to which it was noted he had an infected elbow in Memphis. On a VA examination in September 2015, it was noted there was no current left elbow diagnosis. For medical history for the left elbow, it was noted that the onset of symptoms was in 1981-85, and the Veteran stated it began at Norfolk NAS when he woke up to left elbow pain. He reported that the left elbow condition had gotten better, and reported one flare up of pain in the 1990's. The examiner opined that the Veteran’s claimed left elbow condition was less likely than not incurred in or caused by service, noting for rationale that although he had left elbow complaints in August 1981, the current examination did not indicate any injury, and he had full range of motion and good strength in the left elbow, and no follow up visits for the elbow condition, and currently there was no pathology. While the Veteran is competent to report any left elbow symptoms and he believes he has a current left elbow condition related to service, he is not competent to provide a diagnosis. The issue is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, supra. Consequently, the Board gives more probative weight to the competent medical evidence. 4. Entitlement to service connection for insomnia. The Veteran essentially contends he has insomnia related to service. The question for the Board is whether the Veteran has a current disability of insomnia or a disability manifested by insomnia that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current disability of insomnia or disability manifested by insomnia, and has not had one at any time during the pendency of, or recent to the filing of, the claim. McClain v. Nicholson, supra. As there is no evidence of a current disability, the cornerstone element of a service connection claim has not been met. Brammer v. Derwinski, supra. STRs show that in September 1982, the Veteran was seen for a possible syncopal episode, and he reported feeling sleepy and having declining sleep habits. The assessment was that his symptoms seem to fall into patter of moderate depression. On the December 1984 Report of Medical History at separation, the Veteran responded "yes" to having or having had frequent trouble sleeping. On a VA examination in February 2015 to assess his psychiatric condition, the examiner determined that the Veteran’s poor sleep and sleep disturbance were attributed to his depressive condition. In August 2015, the VA examiner opined that the Veteran’s sleeping disturbance was associated with anxiety and depression. Notably, the Veteran is service-connected for a major depressive disorder and the rating assigned for that disability contemplates sleep impairment. Of record are statements by the Veteran that attribute insomnia to service. While his lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events, the question of whether he has insomnia or another sleep disorder that is separate from his already service-connected major depressive disorder, and that may be related to his service is not something that can be determined by mere observation. The Veteran is competent to report he had ongoing sleep problems/symptoms in and since service, however, the Board does not believe that a sleep disorder such as insomnia is subject to lay diagnosis. The issue is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, supra. Consequently, the Board gives more probative weight to the competent medical evidence. 5. Entitlement to service connection for headaches. The Veteran contends his headaches are related to service. The record shows there is a current diagnosis of headaches. The issue is whether his headaches are caused, or aggravated, by a service-connected disability. STRs show that the Veteran was treated for headaches on three occasions in 1981. On a December 1984 - Report of Medical History at separation, the Veteran responded "yes" to having or having had frequent or severe headaches, and the examiner noted that the Veteran did not eat well in boot camp. The September 2015 VA examination report shows that the Veteran has a diagnosis of migraine headaches. For medical history, he reported he could not recall when his headaches began, and stated they came on when he had constipation, stress, or stayed up too long. The examiner opined the Veteran’s headaches were not related to service, citing for rationale that although he was treated for headaches in service, that was about 24 years ago, and the current headache was mostly caused by the Veteran’s allergy, and, therefore, was less likely as not a chronic condition. In September 2019, a private physician, Dr. S.E., completed a Disability Benefits Questionnaire (DBQ) form and rendered an opinion, with rationale, that the Veteran’s mood disorder with histrionic personality features and depression aided in the development of and permanently aggravated his migraine headaches. For rationale, Dr. S.E. cited to the medical record, statements by the Veteran, his spouse, and his daughter, and medical research. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current headaches are related to and aggravated by his service-connected major depressive disorder. Accordingly, resolving all doubt in favor of the Veteran, the Board finds that service connection for headaches is warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310. 6. Entitlement to service connection for a throat infection/strep throat. The Veteran essentially contends he has a throat infection/strep throat related to service. 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. The Board concludes the Veteran does not have a current throat condition, diagnosis of a condition manifested by a throat infection, or strep throat, and has not had one at any time during the pendency of, or recent to the filing of, the claim. Romanowsky v. Shinseki, supra. There is also no indication that he has throat pain or symptoms which causes functional impairment. Saunders v. Wilkie, supra. As there is no evidence of a current disability, the cornerstone element of a service connection claim has not been met. Brammer v. Derwinski, supra. Review of STRs shows that in September 1981, the Veteran was seen for a scratchy throat and flu symptoms. The assessment was serous otitis media versus. sinusitis. In August 1982, he was seen for a two-day history of sores in the throat, dysphagia, and throat infection. The impression was upper respiratory infection. On a VA examination in September 2015, it was noted that the Veteran had not been diagnosed with any sinus, throat, larynx, or pharynx condition. The examiner opined that the Veteran’s claimed condition (throat infection) was less likely than not incurred in or caused by service, noting for rationale that in service he was seen in August 1981 for a scratchy throat/slight sinus drainage and this was only one episode therefore it was less likely as not that service caused the condition. Additionally, it was noted that VA treatments dated from 2013 showed no report of or treatment for any throat condition. The Board acknowledges that the VA examiner indicated that there was only one episode in service, but that as noted above, in August 1982, he was seen for sores in the throat, dysphagia, and throat infection. However, the diagnosis at that time in service was upper respiratory infection, and there has been no subsequent report of or finding of any throat problems or condition. Moreover, the VA examiner found no current throat condition, and review of the other medical evidence of record has shown no indication or diagnosis of any current throat disorder, which is a threshold issue for granting service connection. Brammer v. Derwinski, supra. While the Veteran may believe he has a current throat condition, he is not competent to provide a diagnosis. The issue is medically complex and requires specialized medical education. Jandreau v. Nicholson, supra. Consequently, the Board gives more probative weight to the competent medical evidence. 7. Entitlement to service connection for a low back condition, to include IVDS. The Veteran contends he has a low back condition related to service. In the claim filed in October 2014, he reported his lower back pain began in February 1982. The question for the Board is whether the Veteran has a current low back disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of IVDS, and evidence shows that he reported back pain in service, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of IVDS began during service or is otherwise related to an in-service injury, event, or disease. On a VA examination in 2015, the diagnosis was IVDS of the low back. For medical history, the Veteran stated his back condition started during service, and that he fell a few times but did not recall any specific injuries. The examiner opined it was less likely as not that the Veteran’s lower back condition was incurred in or caused by service. For rationale, the examiner noted that a review of STRs and post-service records showed no chronic lower back condition/complaint. The examiner also cited to medical literature and noted that degenerative disc disease in the lower back refers to a syndrome in which a compromised disc causes low back pain. The examiner noted that calling this condition a "disease" was misleading because these changes occurred with normal aging and that this phenomenon was no longer considered to be abnormal but an age-related involutional change. The examiner concluded that the current medical literature supported the finding that the Veteran’s degenerative changes of the lumbar spine were more likely secondary to the expected aging process as commonly seen in his age group (40+) and were likely accelerated or/aggravated by him having an overweight status (BMI > 34). The Board finds that the VA examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is no competent medical evidence to the contrary. While the Veteran may believe he has a low back condition related to service, he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex and requires medical knowledge and interpretation of complicated diagnostic testing. Therefore, it is outside the competence of the Veteran. Jandreau v. Nicholson, supra. Consequently, the Board gives more probative weight to the 2015 VA examiner’s opinion. 8. Entitlement to an effective date earlier than January 16, 2014, for the grant of service connection for major depressive disorder. The Veteran contends he should be entitled to an earlier effective date for the grant of service connection for major depressive disorder Generally, the effective date of an award based on an original claim for disability compensation shall be the day following separation from service or the date entitlement arose, if the claim is received within one year after separation service; otherwise, the effective date will be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. In a September 2015 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for major depressive disorder, effective from January 16, 2014, the date of his claim. In that regard, on January 16, 2014, the Veteran submitted a formal claim for service connection for PTSD (posttraumatic stress disorder), depression, and anxiety. See January 2014 VA Form 21-526EZ. Since the Veteran initially submitted the claim nearly 30 years after his separation from service, the effective date of the grant of service connection will be the date of receipt of the claim, or date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.400. Turning to the question of whether the Veteran submitted an informal or formal claim for service connection for PTSD prior to January 2014, the Board finds that he did not, under either 38 C.F.R. § 3.155 or § 3.157. In a November 2019 letter, the Veteran’s representative contended on his behalf that records from the Social Security Administration file showed his problematic issues in the workplace due to major depressive disorder since at least 2008. While this may be true, there is no indication, and neither the Veteran nor his representative, have reported he filed a claim for service connection for a psychiatric disorder prior to January 2014. Review of the record shows nothing was submitted prior to January 2014 to indicate he intended to file a claim for service connection for major depressive disorder (or other psychiatric symptoms or condition). Rather, the first indication he intended to file such a claim was when the formal claim received in January 2014. 38 C.F.R. § 3.155. As noted above the effective date of the award will be the date of receipt of the claim (herein, January 16, 2014), or the date entitlement arose (review of the record shows that this may have been prior to January 2014), whichever is later. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.400. Comparing those dates, the Board concludes that an effective date earlier than January 16, 2014, for the grant of service connection for major depressive disorder is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for sinus drainage/allergies is remanded. The Veteran contends he has sinus drainage and allergies that are related to his service. A review of his STRs shows that in a January 1981 Report of Medical History completed at enlistment, the Veteran responded “yes” to having or having had hay fever, and an occupational cough due to an allergic reaction to feathers, in the Summer of 1980, which subsided with a change of jobs, was noted. In January 1981, the Veteran was seen for reports of sinus drainage, headache, loss of balance, and cough. The assessment was viral upper respiratory infection. In September 1981, he was seen for scratchy throat and flu symptoms, and the assessment was serous otitis media versus sinusitis. In December 1984, on a Report of Medical History at separation, the Veteran responded “yes” to having or having had ear, nose, or throat trouble, and responded “don’t know” as to whether he had sinus trouble. The examiner noted that the Veteran reported his ears “stopped up” during cold season, and that he had a cold for a few days in the Summer and in the Winter. On the separation examination in December 1984, the Veteran’s nose and sinuses were assessed as clinically normal. The Veteran’s VA treatment records from 2013 show that on multiple occasions, in response to the question of whether he had allergies, it was noted that he had no known allergies (“NKA”). When the Veteran was afforded a VA examination in September 2015, it was also found that for the claimed conditions of sinus drainage, allergies, and throat infection, there were no diagnoses because the conditions had resolved. Subsequently, VA treatment records from March 2018 show that the Veteran requested an inhaler and was coughing and wheezing; he stated it was allergy season and he always had this problem. Although no diagnosis was rendered at that time, the Board notes that the Veteran reported that his inhaler had been prescribed originally from an “outside provider” and that the VA provider spoke with the outside provider’s office to obtain a copy of that prescription. As the record indicates that there may be outstanding and relevant records not yet associated with the claims file, the Board will remand the claim to attempt to obtain such records. Also, with regards to the September 2015 VA examination, it is noted that when the examination request was made, the AOJ requested that the examiner opine as to whether the Veteran’s sinus drainage/allergies, which clearly and unmistakably existed prior to service, were aggravated beyond their natural progression by sinus drainage/allergies treated during service. The VA examiner then provided an opinion accordingly. However, every veteran is presumed to have been in sound condition at entry into service except as to defects, infirmities, or disorders noted at the time of such entry, or where clear and unmistakable evidence demonstrates that the injury or disease existed before entry and was not aggravated by such service. 38 U.S.C. § 1111. The term “noted,” refers to “[o]nly such conditions as are recorded in examination reports.” 38 C.F.R. § 3.304 (b). In this case, at entrance into service, the Veteran responded “yes” to having hay fever, but the examining physician at that time noted this was related to an occupational cough due to an allergic reaction to feathers, in the Summer of 1980, which subsided with a change of jobs. A “[h]istory of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions.” 38 C.F.R. § 3.304(b)(1); see also Crowe v. Brown, 7 Vet. App. 238, 245 (1994). Accordingly, the Board finds another medical examination is necessary so that the examiner may provide an opinion in accordance with the correct legal standards of this case. 2. Entitlement to a rating in excess of 50 percent prior to August 29, 2015, and in excess of 70 percent from August 29, 2015, for major depressive disorder, with panic and avoidant personality disorder, is remanded. 3. Entitlement to a TDIU rating is remanded. According to an Exam Scheduling Request, uploaded in June 2020, the Veteran is to be scheduled for an examination to determine the severity of his service-connected major depressive disorder, with panic and avoidant personality disorder. Although this appeared to be a duplicate of a prior examination request from December 2019, which was subsequently cancelled, this new examination request was created by a different individual. In light of the foregoing, and because of the potential relevance of such VA examination to the claim for an increased rating for major depressive disorder, with panic and avoidant personality disorder, a remand is required pending the outcome of this development. Additionally, the TDIU claim must also be remanded as it is inextricably intertwined with the increased rating claims remanded herein. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following actions: 1. Obtain all outstanding records pertaining to any recent VA examination(s) the Veteran has received for his major depressive disorder with panic and avoidant personality disorder, to specifically include the reports of any examination(s) held in response to the June 2020 exam scheduling request. If such examinations have not been scheduled, the should arrange for them to be scheduled. If any such records are unavailable, the reason for their unavailability must be noted in the record, and the Veteran should be so advised. 2. Ask the Veteran to complete a VA Form 21-4142 for the “outside provider” who treated him for sinus drainage/allergies and prescribed an inhaler for him in the past (see March 2018 VA treatment record). Make two requests for the authorized records from any private treatment provider identified by the Veteran, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any sinus drainage/allergies. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including the sinus issues for which the Veteran received treatment during service. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Casula 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.