Citation Nr: 20051925 Decision Date: 08/05/20 Archive Date: 08/05/20 DOCKET NO. 16-55 021 DATE: August 5, 2020 ORDER Entitlement to service connection for tinnitus is denied. For the period prior to May 20, 2019, entitlement to an initial rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted. For the period since May 20, 2019, a rating in excess of 70 percent for PTSD is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. REMANDED Entitlement to service connection for migraine headaches is remanded. FINDINGS OF FACT 1. The probative evidence of record does not show the Veteran’s tinnitus is related to his active duty service. 2. For the entire appeal period, the Veteran’s PTSD was manifested by occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking or mood due to such symptoms as suicidal ideation; near continuous panic or depression affecting the ability to function independently, appropriately, and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships; and occasional hallucinations. 3. The probative evidence of record has shown the Veteran is unable to obtain gainful employment due to his service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 101, 1131, 1153; 38 C.F.R. §§ 3.6, 3.303, 3.304, 3.309. 2. Prior to May 20, 2019, the criteria for an initial rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.125, 4.126, 4.130, Diagnostic Code 9411. 3. Since May 20, 2019, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.125, 4.126, 4.130, Diagnostic Code 9411. 4. The criterial for a total disability rating based on individual unemployability (TDIU) have been met. 38 U.S.C. §§ 1155, 5110(a), (b)(2); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from November 1980 to June 1988. The claims were brought before the Board in February 2019 and were remanded for further development. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). In order to establish service connection, the record must show competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d, 1362, 1366 (Fed. Cir. 2009). When considering such a claim for service connection, the Board must consider on a case-by-case basis, the competence and sufficiency of lay evidence offered to support a finding of service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 Fed. Cir. 2007)). The mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). For the chronic diseases listed in 38 C.F.R. § 3.309(a), including tinnitus (as organic diseases of the nervous system), service connection may alternatively be established with evidence of chronicity of the disease during service or during a presumptive period following service separation, or by showing a continuity of symptoms after service. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); see Fountain v. McDonald, 27 Vet. App. 258 (2015). When chronicity or continuity is established, subsequent manifestations of the same chronic disease at any later date, no matter how remote in time from the period of service, will be service connected unless clearly attributable to causes unrelated to service (“intercurrent” causes). 38 C.F.R. § 3.303(b). Entitlement to Service Connection: Tinnitus The Veteran contends that his tinnitus is related to his active duty service. The Board acknowledges that the Veteran has a current diagnosis of tinnitus and that he was exposed to noise in service. Thus, the issue turns upon whether there is evidence of an in-service disease or injury, and whether there is a nexus between the claimed in-service disease or injury and the present. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In May 2019, the Veteran was provided a VA examination. The Veteran reported that his tinnitus began about 10 years ago and was unsure as to the circumstances of the onset. The examiner opined that the Veteran’s tinnitus was at least as likely as not a symptom of his hearing loss diagnosis and was less likely than not caused by or a result of military noise exposure. The examiner rationalized that the Veteran reported that his ringing began 10 years ago, which was 20 years after his active duty service. The Board notes that the Veteran has provided no evidence that relates his tinnitus to his active duty service. He has also provided no medical records showing complaints or treatment for tinnitus, to include any following his active duty service. In fact, the evidence of record is silent for any reports of tinnitus by the Veteran until his filing of the claim in February 2016, which is over 25 years after his active duty service. Additionally, the Board also notes that Veteran is not service-connected for any hearing loss. Accordingly, the Board finds the May 2019 VA opinion to be highly probative in finding the Veteran’s tinnitus is not related to his active duty service. The Board notes that the examiner was an audiologist who possesses the necessary education, training, and expertise to provide the requested opinion. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In addition, the VA examiner provided an adequate rationale for the opinion rendered. The conclusion was based on an evaluation of the Veteran, consideration of the Veteran’s lay statements, and a review of the Veteran’s claims folder. The Board also acknowledges the Veteran’s assertions that his tinnitus is due to in-service noise exposure. However, the Veteran’s statements that he has had tinnitus continuously since service are inconsistent with what he reported during his VA examination, and therefore the Board assigns low probative weight to them. Thus, the Board concludes that the preponderance of evidence is against the claim and the benefit of the doubt doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran’s service-connected disability adversely affects his/her ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. When an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the veteran’s claim is to be considered. See Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. However, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to an Increased Rating: PTSD The Veteran’s service-connected PTSD is rated as 50 percent disabling prior to May 20, 2019, and as 70 percent disabling thereafter under Diagnostic Code (DC) 9411 of the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, DC 9411. Under DC 9411, a 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. Finally, a 100 percent disability rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. In August 2012, the Veteran was brought to the VA medical center by ambulance for suicidal thoughts. The Veteran was then admitted to the psychiatric unit for several days. The Veteran reported depressive symptoms, to include poor sleep and appetite, suicidal ideation, and depressed mood. The Veteran reported anxiety symptoms, to include increased tension, excessive worry, feelings of uncertainty, and suicidal thoughts. The Veteran was reported as a risk for injury due to his thoughts of harming himself. During admission, it was noted that the Veteran had possible PTSD. The Veteran reported nightmares 1 to 2 times a week, intrusive thoughts whenever he heard planes go by, and flashbacks occasionally. He further reported being easily irritated and startled, and hypervigilance. He denied preferring to be alone or being emotionally numb. He reported a sense of foreshortened future and denied inappropriate guilt. In September 2013, the Veteran was provided a VA examination. The examiner noted the Veteran’s condition caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily. The Veteran reported he was living in the Salvation Army and spent most of his time watching television, reading, and fishing. The Veteran reported having issues with sleeping. He reported occasionally hearing someone call his name, but no one would be there. He reported occasionally having nightmares. He continued to abuse alcohol and had previous use of cocaine. The Veteran’s overall symptoms were mild memory loss and disturbances of motivation and mood. In August 2014, the Veteran was seen for a psychiatric visit at the VA medical center. The Veteran reported continuing to feel anxious and depressed. His sleep was better; however, he was still having combat nightmares 3 to 4 times a week with night sweats and startle. He reported decreased appetite and energy. He reported no hopelessness or suicidal ideation. In October 2014, the Veteran was provided another VA examination. The examiner noted the Veteran’s condition caused occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The Veteran reported living with his fiancée and was content with their relationship. He reported being estranged from his two adult children. He reported enjoying fishing and watching television, and spending most of his nights studying. The Veteran was a full-time student majoring in computer science. He reported planning to work in the field upon completing his degree and running his own business. The Veteran’s overall symptoms were anxiety, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Veteran was neatly dressed and was orientated to person, place, time, and situation. He maintained good eye contact and was in no acute distress. In October 2015, the Veteran was seen for a routine psychiatry visit at the VA medical center. The Veteran reported sleeping for only three and a half hours, decreased appetite, and fair energy. He did not report hopelessness, or suicidal ideas, intent, or plans. He reported combat nightmares 2 to 3 times a week with startle, night sweats, hypervigilance, and avoidance of crowds. The Veteran was alert and oriented to person, place, and time. He was casually dressed and had good eye contact and stable gait. His mood was good, and affect was appropriate. His speech was at normal rate and rhythm. His thought process was linear, with no delusions or hallucinations. He did not report suicidal or homicidal ideations. He had no psychomotor agitation and his insight and judgment were good. In December 2018, the Veteran submitted a PTSD disability questionnaire dated June 2018. The physician noted the Veteran’s PTSD caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood. The Veteran reported having a hard time maintaining healthy social relationships due to his PTSD symptoms, including social anxiety, avoidance of social activities and crowds, intimacy issues, isolation, irritability, suspiciousness, hypervigilance, and being easily startled in public or social places. The Veteran reported a previous history of self-medicating with alcohol and cocaine, and currently self-medicating with alcohol. The Veteran’s overall symptoms were depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic or depression, impairment of short and long term memory, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, inability to establish and maintain effective relationship, difficulty adapting to difficult circumstances, obsessional rituals, persistent delusions, hallucinations, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living. The physician further explained that the Veteran had issues sleeping and had nightmares 3 to 4 times a week. He reported negative and intrusive thoughts which led to obsessional rituals such as rechecking doors, locks, and windows, as well as walks inside and outside the perimeter of the house. The Veteran reported his mind was constantly racing with stress, worry, and anxiety regarding daily living concerns, to include financial struggles that stemmed from his inability to work. He reported persistent and paranoid delusions about people out to get him. He reported auditory and visual hallucinations, such as still hearing bombs and gunfire flashbacks that were triggered by loud noises, to include fireworks, hammering or automobile backfires. The Veteran reported passive and fleeting thoughts of suicidal thoughts with no intentions or plans. The psychologist reported that the Veteran had intermittent inability to perform activities of daily living and that his girlfriend did nearly all household tasks, including grocery shopping, meal preparation, cleaning, and assisting the Veteran with managing his finances. The Veteran reported often staying home except for doctor’s appointments. He reported participating in sedentary and solitary activities, to include watching television and drinking six beers a day. He further reported only showering approximately twice a week and would go without grooming or changing his clothes during extremely depressed episodes. In May 2019, the Veteran was provided another VA examination. The examiner noted the Veteran’s condition caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood. The Veteran reported it was hard to keep relationships, having been married and divorced since his last VA examination. He reported currently being single. He reported having one friend, but not being close with any family members, to include his children. He reported last working 3 years prior due to not being able to deal with people. He denied having any legal history since the last examination. He reported drinking 12 beers a week. His overall symptoms were depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and neglect of personal appearance and hygiene. The examiner noted the Veteran was casually dressed, his mood was depressed, and affect was congruent. His eye contact was within normal limits and he was fully oriented. The Veteran reported that he would go approximately one week without bathing and realized that he needed to work on his hygiene. The examiner did not find the Veteran was a current or imminent risk. After consideration of the medical and lay evidence, and affording the Veteran the benefit of the doubt, the Board finds that an initial 70 percent evaluation, but no higher, is warranted for the entire appeal period. The Board finds the majority of the medical records shows the Veteran’s symptoms have been primarily and consistently manifested by depression, near-continuous anxiety affecting the ability to function appropriately and effectively, hypervigilance, suspiciousness, social isolation, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, to include excessive drinking, suicidal ideation, and occasional hallucinations. The Board recognizes that the September 2013 and October 2014 VA examinations noted more mild symptoms; however, the Board notes that the overall evidence, to include being admitted to the psychiatric unit for several days, as well as reporting occasional auditory hallucinations, rises more to the level of moderate to severe symptoms. However, the Board finds that the evidence of record does not support a rating of 100 percent at any time during the pendency of the appeal. While the Veteran had problems relating to others, he has maintained romantic relationships, albeit strained, and reported having one friend. The Veteran has also consistently been found to be cooperative with primarily good judgment and thoughts intact. Although the Veteran reported in his June 2018 and May 2019 examinations that he didn’t bathe daily and could focus more on his hygiene, the Veteran has consistently been noted as being appropriately dressed and groomed, to include during the aforementioned examinations, as well as during his routine VA medical center visits. Thus, the Board finds the majority of the evidence does not show that the Veteran had intermittent inability to perform activities of daily living. Further, the Veteran has reported continuing to fish, read, and watch television. The Board recognizes that the Veteran has endorsed suicidal ideation and was hospitalized in the past for suicidal thoughts. However, the Veteran has since consistently reported no intent or plans, and often denied any suicidal ideation during his VA treatment visits, thereby not demonstrating that he was a persistent danger to himself. The Board acknowledges the Veteran’s recent statements that he has angry outbursts; however, there has been no evidence of violence or irrational behavior, nor has the Veteran demonstrated that he was/is a danger of hurting others. Further, these occurrences do not appear to have grossly impaired the Veteran in his thought process/communication or caused grossly inappropriate behavior. The Board recognizes that the Veteran has sometimes endorsed hallucinations, to include it being noted as persistent by the June 2018 private psychologist. However, the Board notes that the majority of the evidence of record does not show that these occurrences rise to the level of being persistent, as the Veteran has predominantly denied any hallucinations during his treatment visits and did not report persistent hallucinations in his most recent examination in May 2019. He also has never been noted as being disoriented to person, place, time, or situation, has never endorsed homicidal ideation, and has only been noted as having mild memory loss. Thus, the Board finds that a 100 percent rating is not warranted. The Board also acknowledges the Veteran’s assertions that he is entitled to a higher rating because his symptoms are worse. The Board recognizes that lay persons are competent to provide medical opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, the Board has considered the Veteran’s statements and finds them credible and consistent with the rating assigned. Accordingly, the Board concludes that an initial rating of 70 percent, but no higher, is warranted for the Veteran’s PTSD for the entire appeal period. The benefit of the doubt doctrine has been considered in this determination. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). 2. Entitlement to TDIU The Veteran contends that he is unemployable due to his service-connected disabilities, specifically his PTSD. A total disability rating based upon individual unemployability may be assigned where the schedular rating is less than total, a total disability rating for compensation purposes may be assigned when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). Consideration may be given to a Veteran’s level of education, special training, and previous work experience in arriving at whether a TDIU rating is warranted, but, the Veteran’s age or the impairment caused by nonservice-connected disabilities may not be considered in such a determination. 38 C.F.R. §§ 3.340, 3.341, 4.16(b), 4.19. The fact that a Veteran may be unemployed or has difficulty obtaining employment is not determinative. The ultimate question is whether the veteran, because of service-connected disability, is incapable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. at 363 (1993). The Veteran already meets the necessary schedular rating criteria under 38 C.F.R. § 4.16(a), as his service-connected PTSD has been given a 70 percent disability rating for the entire appeal period. The Veteran is also now service-connected for right ankle arthritis, rated as 20 percent disabling, right knee arthritis, rated as 10 percent disabling, left hand painful motion rated as 10 percent disabling, and left hand limitation of motion, rated as non-compensable. Therefore, the question at hand is whether his service-connected disabilities kept him from securing substantially gainful employment. After review of the evidence of record, the Board finds it does. The Veteran’s occupational history has primarily consisted of working in maintenance or as a cook. He also reported some college education for computers and/or heating and cooling symptoms. In December 2018, the Veteran provided a private opinion dated June 2018. The psychologist opined that the Veteran’s PTSD symptoms were of such severity to completely disable and preclude him from sustaining any form of substantial or gainful employment. The psychologist rationalized that the Veteran cannot sustain the stress from a competitive work environment. The psychologist explained that the Veteran’s hypervigilance and recurrent intrusive thoughts would interfere with his ability to complete tasks due to internal and external cues that could occur in a social or work setting, to include being easily startled by people, noises, or situations. The psychologist also noted this would cause difficulty concentrating at tasks and his ability to complete tasks and handle responsibilities. The psychologist further noted the Veteran’s depression, anxiety, and irritability would increase his likelihood of being emotionally reactive and affect his ability to function, as well as his insomnia would cause him to be irritable and lethargic at work. Further, the Veteran’s inability to maintain effective social and work relationships and difficulty in adapting stressful circumstances would cause him to isolate and avoid work social situations, become defensive, as well as cause more intense anxiety episodes, panic attacks, and angry outbursts. Lastly, the psychologist noted that the Veteran’s self-medicating with substance abuse makes him susceptible to substance abuse at work and exacerbate his symptoms to the point of functionally impairing him. Upon review of the foregoing evidence, the Board finds that the Veteran’s PTSD severely limits the occupational work the Veteran can perform. Not only would the Veteran be unable to hold a position that required interaction with others, he further would be limited in physical labor and non-physical work, as the Veteran has issues with stressful circumstances, hypervigilance, and substance abuse. Further, the Veteran’s PTSD would make it difficult for him to obtain gainful employment in his past occupations, as his previous experience as a cook or maintenance worker would require him to interact with many people and be put in high pressure or stressful circumstances. Further, on top of the Veteran’s PTSD symptoms, his service-connected right ankle, right knee, and left hand conditions would additionally limit his ability to perform physical tasks, as he would not be able to stand for long periods of time, or carry and grasp things. Accordingly, the Board concludes that the Veteran is rendered unemployable due to his service-connected disabilities and a grant of TDIU is warranted. REASONS FOR REMAND Although the Board regrets further delay, another remand is required to provide the Veteran with every possible consideration. Entitlement to Service Connection: Migraine Headaches The Veteran contends that he suffers from migraine headaches that are related to his active duty service. In May 2019, the Veteran was provided a VA examination. Although the examiner opined that the Veteran’s condition was less likely than not related to his active duty service, the Board notes that the examiner based the opinion partially on there being no complaints or treatment for headaches while he was in service. However, the Board notes that during one of his in-service annual examinations, the Veteran marked “yes” for frequent or severe headaches. Therefore, the Board finds that a remand is required in order to obtain a new opinion that considers the Veteran’s in-service report of frequent or severe headaches. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matters are REMANDED for the following action: 1. Obtain and associate with the Veteran’s electronic claims file any outstanding VA treatment records and private medical records relevant to the Veteran’s claim. 2. After all records have been associated with the file, send the file to the May 2019 VA examiner to determine the etiology of the Veteran’s headache condition. If the May 2019 VA examiner is not available, then the file should be sent to an appropriate examiner for the requested opinion. If the examiner determines that such opinion cannot be provided without an examination, then an examination should be scheduled and can be conducted by video conference to comply with any COVID-19 restrictions. A copy of this remand should be made available to the examiner.  Following a review of the entire record, the Veteran’s competent lay statements, as well as the Veteran’s report regarding the onset and progression of his current symptomatology, the examiner should opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s headache condition had its onset during, or is otherwise related to, his active duty service, to include the notation of frequent or severe headaches on one of his in-service examinations. A complete rationale for all opinions expressed should be provided and must not be based solely on the lack of any in-service records. If the examiner is unable to provide an opinion without resort to speculation, he/she should explain whether the inability is due to the limits of the examiner’s medical knowledge, medical knowledge in general or there is evidence that, if obtained, would permit the opinion to be provided. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Negron, 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.