Citation Nr: 21000439 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 16-46 287 DATE: January 5, 2021 ORDER Entitlement to service connection for right shoulder disability is denied. Entitlement to service connection for left shoulder disability is denied. Entitlement to service connection for disability manifested by bilateral vision loss is denied. Entitlement to service connection for gastroesophageal reflux disease (GERD) is denied. REMANDED Entitlement to service connection for an acquired psychiatric disability, to include depression and anxiety, is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for a sleep disability is remanded. Entitlement to service connection for left ear hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. FINDINGS OF FACT 1. There is no current right shoulder disability. 2. A chronic left shoulder disability did not become manifest in service or for many years thereafter and the Veteran’s current left shoulder disability is not shown to be related to service. 3. Disability manifested by bilateral vision loss, which can be subject to service connection, did not become manifest in service or for many years thereafter and is not shown to be related to service. 4. A gastrointestinal disability, to include GERD, was not shown in service or for many years thereafter and is not shown to be related to service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for right shoulder disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for left shoulder disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to service connection for disability manifested by bilateral vision loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.9. 4. The criteria for entitlement to service connection for a gastrointestinal disability, to include GERD, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1981 to November 1983. This matter is on appeal before the Board of Veterans Appeals (Board) from October 2014 and November 2015 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that in an August 2018 rating decision, the RO denied entitlement to a temporary total rating under 38 C.F.R. § 4.30. The Veteran initially appealed by filing a September 2018 notice of disagreement (NOD). An October 2019 statement of the case was then issued, continuing the denial of the claim. The Veteran did not subsequently perfect an appeal to the Board by filing a timely Form 9. Accordingly, this matter is not on appeal before the Board. The Board also notes that the Veteran’s attorney has submitted Social Security Administration (SSA) records for consideration in relation to the matters on appeal. See e.g. April 2019 and October 2020 filings. As the Veteran has attorney representation and as the attorney has submitted the SSA records, the Board presumes the attorney has reviewed the Veteran’s SSA records and located and submitted any records deemed relevant to the matters currently decided. Thus, the Board will not delay adjudication of the appeal by remanding for a search for any additional SSA records. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). Finally, the Veteran has submitted additional evidence relevant to the claims on appeal subsequent to the most recent adjudication of the claims by an April 2017 statement of the case and April 2017 supplemental statement of the case. However, because the Veteran’s Form 9s in this case were received after February 2013 (i.e. in September 2016 and April 2017) waiver of initial review by the agency of original jurisdiction is presumed. The Veteran’s attorney has also submitted VA treatment records subsequent to these most recent adjudications. See e.g. submission received October 2020. However, these records are either duplicative or cumulative of the VA treatment records already associated with the claims file. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Establishing entitlement to direct service connection generally requires: (1) competent and credible evidence confirming the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of his claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a relationship or correlation between the disease or injury in service and the currently claimed disability - which is the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain listed, chronic disabilities, including arthritis, are presumed to have been incurred in service if they become manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 3.102. Factual Background The Veteran’s service treatment records do not show any left or right shoulder problems or vision problems. In November 1981, the Veteran was seen by medical personnel for stomach aches with vomiting over the past day. The diagnostic assessment was gastritis and the Veteran was prescribed a clear liquid diet for 24 hours along with Mylanta. In March 1982, the Veteran was seen for a complaint of stomach pain. Physical examination was unremarkable, and the Veteran was prescribed some short-term medication. At his July 1983 discharge examination, the Veteran’s eyes, upper extremities, abdomen and viscera were all found to be normal. The Veteran’s vision was 20/20 distant vision bilaterally, 20/20 near vision in the right eye and 20/20-1 near vision in the left eye. On his July 1983 report of medical history at separation, the Veteran reported that he was in perfect health. He indicated that he did not have any history of eye trouble, painful or trick shoulder, frequent indigestion, or stomach, liver or intestinal trouble. Post-service VA treatment records include findings pertaining to vision, GERD and shoulder problems. At a March 2010 optometry evaluation, the Veteran was found to have blurred vision, corneal arcus, astigmatism and presbyopia. It was noted that bifocals were ordered for him. In an April 2010 telephone note, the Veteran reported to his VA treatment team that he had been having bad back and right shoulder pain for the last 2 to 3 days. At a July 2011 medical visit, the diagnostic assessments included GERD and omeprazole was prescribed. At a November 2012 medical visit, the Veteran reported left shoulder pain of 1-month duration. He denied any injury. At a December 2013 medical visit, the Veteran mentioned that he hurt his left shoulder during service when he was firing his weapon. He noted that although he was right-handed, he had to shoot on the left side and the gun jammed against his shoulder. He reported that the pain had increasingly gotten worse and that he had been taking Tylenol for it. At a May 2014 orthopedic consultation, it was noted that the Veteran had been experiencing pain in the left shoulder for about six months and an MRI had shown impingement syndrome and an assessment of imaging showed rotator cuff tendonitis. The Veteran received a left shoulder pain injection. At a July 2016 VA optometry evaluation, diagnostic assessments included dry eye and presbyopia. At a May 2013 visit with Digestive Health Specialists, the Veteran was seen to discuss having a colonoscopy. It was noted that the Veteran had a history of GERD with reflux 1 to 2 times per week. 1. Right shoulder disability The above summarized evidence does not show that the Veteran has a current right shoulder disability. In this regard, the Veteran was noted to be complaining of right shoulder pain in April 2010, but an underlying diagnosis of right shoulder disability does not appear to have been rendered. Rather, VA treatment records show only clear disability of the left shoulder. Moreover, other than filing the claim for service connection, the Veteran has not provided a specific assertion concerning the presence of a current right shoulder disability. In the absence of a showing of current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Accordingly, the claim for service connection for right shoulder disability must be denied based on the lack of current disability. Also, even if a current right shoulder disability is shown, there is no indication of any right shoulder problems in service or for many years thereafter, no medical evidence, which even suggests a current relationship between any current right shoulder problem and service and no specific allegation by the Veteran that a current right shoulder problem is related to service. Thus, even assuming some current right shoulder problem, there is no indication of a nexus between such problem and service. Moreover, a VA examination was not necessary in this case because a right shoulder injury, disease or event in service is not established, there is no medical evidence which even suggests a relationship between any current right shoulder problem and service and the Veteran has not alleged continuity of right shoulder symptomatology since service. 38 C.F.R. § 3.159(c)(4). The Veteran appears to be generally asserting that he has a current right shoulder problem related to service. However, as a layperson without any demonstrated expertise concerning the etiology of right shoulder disability, this general assertion, which is not shown to be based on assertion of continuity of symptomatology, may not be afforded any probative value. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In sum as a current right shoulder disability has not been established and as any current right shoulder problem is not shown to have become manifest in service or to otherwise be related to service, the preponderance of the evidence is against the claim and the appeal for service connection for right shoulder disability must be denied. Alemany, 9 Vet. App. 518 (1996). 2. Left shoulder disability As noted above, the service treatment records are negative for any left shoulder injury. The Veteran has reported that he did injure his left shoulder during service in the process of firing his weapon. Notably, he is competent to report such an injury. However, it is not shown that such injury resulted in the development of any chronic shoulder problem during service. In this regard, at his April 1983 separation examination, the Veteran’s upper extremities were found to be normal. Also, on his April 1983 report of medical history at separation, the Veteran reported that he was in perfect health and that he did not have any history of painful or trick shoulder. The Board presumes that if the Veteran was continuing to have problems with his shoulder (e.g. pain) at the time of separation, he would have reported this on his medical history report. Also, there is no post-service medical evidence of left shoulder disability until 2012, approximately 29 years after service. This is a factor that weighs against a claim for direct service connection. See Maxson v. West, 12 Vet. App. 452 (1999), affd, 230 F.3d 1330 (Fed. Cir. 2000). Additionally, there is no medical evidence of record which even suggests a relationship between the Veteran’s current left shoulder disability and his military service. Notably, the Veteran has alleged continuity of left shoulder problems since injuring the area in service. However, the Board again notes that the Veteran specifically reported on his April 1983 report of medical history at separation that he had no history of painful or trick shoulder. The Board presumes that had the Veteran been experiencing continuity of left shoulder symptomatology since injury in service, he would have reported a history of painful or trick shoulder on his separation medical history report. Thus, in the absence of such a report, the Board does not find credible the Veteran’s report of continuity of left shoulder symptomatology since service. Moreover, because there is no medical evidence, which even suggests a relationship between current left shoulder disability and no credible evidence of continuity of left shoulder symptomatology since service, a VA examination or medical opinion was not necessary in this case. 38 C.F.R. § 3.159(c)(4). To the extent the Veteran is generally asserting that his current left shoulder disability is related to service on a basis other than continuity of symptomatology, as a layperson without any demonstrated expertise concerning the etiology of left shoulder disability, this general assertion may not be afforded any probative value. See Jandreau, 492 F.3d 1372 (Fed. Cir. 2007). In sum, a chronic left shoulder disability was not shown during service or for many years thereafter and the Veteran’s current left shoulder disability is not shown to be related to service. Accordingly, the preponderance of the evidence is against this claim and it must be denied. Alemany, 9 Vet. App. 518 (1996). 3. Bilateral vision loss The law provides that refractive errors of the eyes are developmental defects and not disease or injury within the meaning of applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9. In the absence of superimposed disease or injury, service connection may not be allowed for refractive error of the eyes, including myopia, presbyopia and astigmatism, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. 38 C.F.R. §§ 3.303(c), 4.9. Thus, VA regulations specifically prohibit service connection for refractory errors of the eyes unless such defect was subjected to a superimposed disease or injury creating additional disability. See VAOPGCPREC 82-90, 55 Fed. Reg. 45711 (1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). The above summarized evidence shows that during service, the only eye problem experienced by the Veteran was slight refractive error (e.g. 20/20-1 near vision in the left eye). Similarly, the VA treatment records predominantly show only that the Veteran suffers from forms of refractive error, including astigmatism and presbyopia and there is no indication that the Veteran has any disability superimposed on these conditions. Accordingly, the law provides no basis for awarding service connection for these conditions. The Veteran has also been noted to have corneal arcus (cholesterol forming deposits around the outside of the cornea) and dry eye. However, to the extent that either of these conditions are disabling, there is no indication that they are any way related to service. In this regard, they did not become manifest until many years after service, there is no medical evidence to suggest that they are in anyway related to service and the Veteran has not specifically alleged that they are related to service. Accordingly, the weight of the evidence is against a finding that either the corneal arcus or the dry eye is related to service and service connection for these conditions is not warranted. Moreover, as there is no indication of a relationship between eye disability, which could potentially be related to service (e.g. dry eye, corneal arcus) and the Veteran’s military service, either in the form of suggestive medical evidence or in the form of some allegation of continuity of symptomatology, a VA examination was not necessary in this case. 38 C.F.R. § 3.159(c)(4). The Veteran appears to be generally asserting that he has a current visual disability for which service connection can be granted, which is related to his military service. However, as a layperson without any demonstrated expertise concerning the etiology of visual disability, this general assertion, which is not shown to be based on an assertion of continuity of symptomatology, may not be afforded any probative value. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, for all the reasons explained above, the preponderance of the evidence is against this claim and it must be denied. Alemany, 9 Vet. App. 518 (1996). 4. Gastrointestinal disability, to include GERD As noted above, the Veteran was shown to have some acute gastrointestinal symptomology during service. However, on his July 1983 separation examination, the abdomen and viscera were found to be normal. Also, on his July 1983 report of medical history at separation, the Veteran reported that he was in perfect health and he indicated that he did not have any history of frequent indigestion or stomach, liver or intestinal trouble. Thus, a chronic gastrointestinal disability was not shown to have become manifest during service. Also, there is no post-service medical evidence of GERD until 2011, approximately 28 years after service. This is a factor that weighs against a claim for direct service connection. See Maxson v. West, 12 Vet. App. 452 (1999), affd, 230 F.3d 1330 (Fed. Cir. 2000). Additionally, there is no medical evidence of record, which even suggests a relationship between the Veteran’s current GERD and his military service, including the acute gastrointestinal distress experienced therein. Also, because there is no medical evidence, which even suggests a relationship between the current GERD and service and since continuity of GERD symptomatology (or any other gastrointestinal symptomatology) since service is neither shown nor alleged, a VA examination or medical opinion was not necessary in this case. 38 C.F.R. § 3.159(c)(4). The Veteran appears to be generally asserting his current GERD is related to service, including the gastrointestinal distress he experienced therein. However, as a layperson without any demonstrated expertise concerning the etiology of GERD, this general assertion, which is not shown to be based on assertion of continuity of symptomatology, may not be afforded any probative value. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In sum, a chronic gastrointestinal disability was not shown during service or for many years thereafter and the Veteran’s current GERD is not shown to be related to service. Accordingly, the preponderance of the evidence is against this claim and it must be denied. Alemany, 9 Vet. App. 518 (1996). REASONS FOR REMAND The Veteran’s claims for an acquired psychiatric disability, to include depression and anxiety; hypertension; headaches; sleep disorder; left ear hearing loss; and tinnitus are remanded. Regarding the claim for service connection for an acquired psychiatric disorder, in a November 2017 opinion a private psychologist, Dr. H. Henderson-Galligan (H.H.G.) opined that the Veteran suffered from major depressive disorder that more likely than not began in military service, continued uninterrupted to the present day and was aggravated by his service-connected right hand strain, along with non-service connected low back complications and shoulder problems. Given this opinion, the Board finds that a remand is required so the Veteran may be provided a VA mental health examination. See 38 C.F.R. § 3.159(c)(4). Regarding the claim for hypertension, in a December 2017 opinion, a private physician, Dr. H. Skaggs (H.S.), found that it is at least as likely as not that the chronic pain from the Veteran’s service-connected right-hand strain contributed to the onset and aggravation of his hypertension. Furthermore, Dr. H.S. found that it is more likely than not that the Veteran’s depression contributed to the cause and permanent aggravation of the hypertension. Given Dr. H.S.’s opinion, a remand is required so the Veteran may be provided a VA compensation examination to assess the etiology of his hypertension. Regarding the claim for headaches, in a separate December 2017 opinion, Dr. H.S. found that it is more likely than not that the Veteran’s headaches are caused and permanently aggravated by both hypertension and depression. Although neither hypertension nor psychiatric disorder is currently service connected, as noted above, claims for these disorders are subject to the instant remand. Consequently, given Dr. H.S.’s opinion, the claim for service connection for headaches is inextricably intertwined with these other claims and must also be remanded. Regarding the claim for sleep disability, an April 2019 sleep study report from Southeast Health shows a diagnostic impression of mild to moderate sleep apnea. Also, in a November 2019 opinion, Dr. M. Blevins (M.B.) found that it is as likely as not that the symptoms of the Veteran’s diagnosed major depressive disorder with psychotic features and the prescribed sedating medication for his mental health symptoms aided in the development of his sleep apnea and permanently aggravated his sleep apnea. Once again, the Veteran is not service connected for psychiatric disability. However, the Veteran’s claim for service connection for this disability is subject to this remand. Consequently, given Dr. M.B.’s opinion, the claim for service connection for sleep disability is inextricably intertwined with the claim for service connection for psychiatric disorder and must also be remanded. Regarding the claims for service connection for left ear hearing loss and tinnitus, the Veteran was afforded a VA contract examination in September 2014. At the examination, the Veteran’s pure tone threshold testing indicated that he had a left ear hearing loss. However, the examiner found that the test results were not valid for rating purposes, noting that the reliability of the audiogram was questionable for the left ear due to disagreement of SRT and positive Stenger at one frequency along with 100 percent speech discrimination at 61DB in the left ear. Additionally, the examiner opined that the Veteran’s hearing loss was less likely than not caused by or a result of an event in military service, indicating that service audiograms were normal except for a mild loss at 6000 Hz in the left ear. Moreover, the examiner found that the etiology of the Veteran’s tinnitus was at least as likely as not associated with the hearing loss. The Board notes that service connection for hearing loss cannot be denied solely because there was no evidence of the disorder during active duty. See Hensley v. Brown, 5 Vet. App. 155 (1993). Thus, as the September 2014 examiner’s opinion relied only on nearly normal audiometry findings at separation for determining that a relationship between any current left ear hearing loss and service was less likely than not, the opinion is inadequate. Also, while the examiner did not find the Veteran’s September 2014 audiometric testing valid, she did not rule out the Veteran having a current hearing loss, instead finding the audiometric findings “questionable.” Thus, the Board finds a remand appropriate to afford the Veteran a new VA audiological evaluation to determine whether current hearing loss is present and if so, to elicit a new medical nexus opinion. Also, because the September 2014 examiner found that the Veteran’s tinnitus is at least as likely as not associated with hearing loss, the claim for service connection for this disability is inextricably intertwined with the claim for hearing loss and must also be remanded. Prior to arranging for the examinations, VA treatment records dated from March 2017 should be obtained. The matters are REMANDED for the following action: 1. Obtain VA treatment records dated since March 2017. 2. Schedule the Veteran for a VA examination to assess the nature and etiology of any current psychiatric disability. The examiner must review the claims file in conjunction with the examination, including the service treatment records, pertinent post-service medical records, the November 2017 psychiatric evaluation and accompanying medical opinion authored by the private psychologist, Dr. H. Henderson-Galligan and any other information of record deemed pertinent. The examiner should then provide opinions in answer to the following questions: A) Is it at least as likely as not that the Veteran’s current psychiatric disorder is directly related to his military service? B) Is it at least as likely as not that the Veteran’s current psychiatric disorder has been caused by his service-connected right-hand strain? C) Is it at least as likely as not that the Veteran’s current psychiatric disorder has been aggravated by his service-connected right-hand strain? If aggravation is found, the examiner should identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the service-connected disability. The examiner should explain the rationale for each opinion provided. 3. Schedule the Veteran for a VA examination to assess the nature and etiology of current hypertension. The examiner must review the claims file in conjunction with the examination, including the service treatment records; pertinent post-service medical records; the December 2017 medical opinion by Dr. H. Skaggs indicating that it is at least as likely as not that the chronic pain from the Veteran’s service-connected right-hand strain contributes to the onset and aggravation of his hypertension, and that it is more likely than not that the Veteran’s depression contributes to the cause and permanent aggravation of the hypertension; and any other information of record deemed pertinent. The examiner should then provide opinions in answer to the following questions: A) Is it at least as likely as not that the pain from the Veteran’s service-connected right-hand disability caused his hypertension? B) Is it at least as likely as not that the pain from the Veteran’s service-connected right-hand disability aggravates his hypertension? If aggravation is found, the examiner should identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the service-connected disability. C) Is it at least as likely as not that the Veteran’s psychiatric disorder, to include depression, caused his hypertension? D) Is it at least as likely as not that the Veteran’s psychiatric disorder, to include depression, aggravates his hypertension? If aggravation is found, the examiner should identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the service-connected disability. The examiner should explain the rationale for each opinion provided. 4. If, and only if, the development above results in an award of service connection for psychiatric disorder and/or hypertension, schedule the Veteran for a VA examination to assess the nature and etiology of current headaches. The examiner must review the claims file in conjunction with the examination, including the service treatment records; pertinent post-service medical records; the December 2017 medical opinion by Dr. H. Skaggs indicating that it is more likely than not that the Veteran’s headaches are caused and permanently aggravated by both hypertension and depression; and any other information of record deemed pertinent. The examiner should then provide opinions in answer to the following questions: A) Is it at least as likely as not that the Veteran’s hypertension caused his headaches? B) Is it at least as likely as not that the Veteran’s hypertension aggravates his hypertension? If aggravation is found, the examiner should identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the service-connected disability. C) Is it at least as likely as not that the Veteran’s psychiatric disorder, to include depression, caused his headaches? D) Is it at least as likely as not that the Veteran’s psychiatric disorder, to include depression, aggravates his headaches? If aggravation is found, the examiner should identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the service-connected disability. The examiner should explain the rationale for each opinion provided. 5. If, and only if, the development above results in an award of service connection for psychiatric disorder, schedule the Veteran for a VA examination to assess the nature and etiology of current sleep disorder, to include sleep apnea. The examiner must review the claims file in conjunction with the examination, including the service treatment records; pertinent post-service medical records; the November 2019 evaluation and opinion by Dr. M. Blevins indicating that the Veteran’s major depressive disorder with psychotic features and the prescribed sedating medication for his mental health symptoms aided in the development of his sleep apnea and permanently aggravated his sleep apnea; and any other information of record deemed pertinent. The examiner should then provide opinions in answer to the following questions: A) Is it at least as likely as not that the Veteran’s psychiatric disorder, including the medications he takes for the disorder, caused his sleep apnea? B) Is it at least as likely as not that the Veteran’s psychiatric disorder, including the medications he takes for the disorder, aggravates his sleep apnea? If aggravation is found, the examiner should identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the service-connected disability. The examiner should explain the rationale for each opinion provided. 6. Schedule the Veteran for a VA audiological examination to assess the nature and etiology of any current hearing loss and tinnitus. The examiner must review the claims file in conjunction with the examination, including the service treatment records; pertinent post-service medical records; the September 2014 VA contract audiological evaluation report; and any other information of record deemed pertinent. The examiner should then provide opinions in answer to the following questions: A) Is it at least as likely as not that any current hearing loss is related to the Veteran’s military service? B) Is it at least as likely as not that any current tinnitus is related to the Veteran’s military service? The examiner should explain the rationale for each opinion provided. 7. After the above development has been completed, readjudicate all the claims. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Dan Brook, 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.