Citation Nr: 21003363 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 16-31 282 DATE: January 21, 2021 ORDER Entitlement to service connection for residuals of a traumatic brain injury claimed as an aneurysm causing seizures and a stroke with memory loss and impaired thoughts, as secondary to service-connected panic disorder with bipolar disorder, is denied. FINDING OF FACT The competent evidence of record demonstrates that the Veteran does not have current residuals of a traumatic brain injury associated with his post-service head injury. CONCLUSION OF LAW The criteria for service connection for residuals of a traumatic brain injury have not been met. 38 U.S.C. §§ 1110; 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1972 to September 1973. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2016 rating decision. In January 2018, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a video-conference hearing. A transcript of that hearing is of record. The Veteran’s claim for service connection was remanded by the Board in November 2018 and June 2020 for further development. The Veteran originally claimed service connection for residuals of a traumatic brain injury including chronic headaches and an aneurysm causing seizures and a stroke with memory loss and impaired thoughts, as secondary to his service-connected panic disorder with bipolar disorder. See VA Form 21-526b, dated December 9, 2015; VA Form 21-0958, dated April 15, 2016; VA Form 9, dated May 2, 2016; and Hearing transcript, dated January 16, 2018. Since the Board’s June 2020 remand, service connection was granted in an August 2020 rating decision for a nasal bone fracture and post-traumatic headaches associated with the Veteran’s head injury. Thus, the remaining issue on appeal is service connection for residuals of a traumatic brain injury claimed as an aneurysm causing seizures and a stroke with memory loss and impaired thoughts. Entitlement to service connection for residuals of a traumatic brain injury, to include as secondary to service-connected panic disorder with bipolar disorder, is denied. The Veteran and his attorney maintain that he currently has residuals of a traumatic brain injury due a physical altercation that occurred in August 2014 that they believe occurred because of his service-connected panic disorder with bipolar disorder. For the following reasons, the Board finds that service connection is not established. Service connection means that a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence shows that the disease was incurred in service. 38 C.F.R. § 3.303(d). Entitlement to service connection is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or “medical nexus” between the current disability and the disease or injury incurred or aggravated during service. See 38 C.F.R. § 3.303(a); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires: (1) competent evidence of current disability; (2) evidence of a service-connected disability; and (3) competent evidence that the current disability was either: (a) caused by; or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); see Allen v. Brown, 7 Vet. App. 439 (1995). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim, or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Veteran does not assert, nor does the evidence show, that he suffered a traumatic brain injury during service. His service treatment records are silent for a traumatic brain injury or other head injury. The Veteran’s VA treatment records demonstrate that he complained of suffering a traumatic brain injury after sustaining a head injury in a physical altercation in August 2014. It appears that the Veteran’s VA treatment records contain a diagnosis of traumatic brain injury based solely on the Veteran’s reported history. The Veteran’s VA treatment records also indicate that he advised of experiencing memory loss, poor concentration, worsening mood, and headaches following this head injury. The Veteran’s VA treatment records further provide that the Veteran reported a seizure, stroke, and aneurysm as a result of his head injury. While the VA treatment records note that the Veteran reported a traumatic brain injury and related symptomatology, the evidence discussed below shows that the Veteran has not been diagnosed with current residuals of a traumatic brain injury based on clinical findings. The Veteran’s VA treatment records demonstrate that he underwent neuropsychological testing in May 2015 after a referral from the Veteran’s attending psychiatrist following his reports of significant memory problems from an apparent August 2014 head injury. The corresponding report states that the Veteran has a notable past medical history that includes hypertension, diabetes mellitus, type II, hepatitis C, acute renal failure syndrome, abnormal liver function tests, peripheral nerve disease, ulnar neuropathy, and erectile dysfunction. The Veteran also has PTSD, unclear mood disorder with remote psychotic symptoms, polysubstance use disorder, and legal problems. A March 2000 brief neuropsychological evaluation to assess suspiciousness and possible paranoid delusions showed that the Veteran has an estimated IQ in the high average range with no signs of inefficiency in general cognitive functioning and an average performance on a measure of verbal memory. The March 2000 evaluation provided that the Veteran has an extensive history of substance abuse and mental illness and the diagnostic summary included bipolar disorder with psychotic features, paranoid personality disorder, and that schizoaffective disorder may be considered because of a suspected predisposition to schizoform disorder, however the psychotic features tend to be rather low grade even at the extremes of his illness. The May 2015 neuropsychological report states that the Veteran’s responses during the clinical interview were vague when discussing certain topics like psychiatric symptoms, substance use, and legal problems. Therefore, the information contained in the report should be supplemented and corroborated by collateral information. Since 2000, the Veteran has had 13 VA admissions for psychiatric and substance-related issues. During these visits, the Veteran’s psychiatric presentation included auditory hallucinations, mania, and PTSD symptoms, without complaints of significant neurocognitive issues by the Veteran or his providers. The Veteran first reported cognitive difficulties during a psychiatric admission in December 2014 as he was admitted at that time for passive suicidal ideation after being released from prison and subsequently relapsing on alcohol and cocaine. The admission note provides that the Veteran was involved in a physical altercation in August 2014, which resulted in neurologic, cognitive, and psychiatric problems. The note further states that the Veteran was hit over the head, had an aneurism, stroke, and a seizure due to the head trauma and was treated at the Brigham and Women’s Hospital. After that incident, he was in jail for three months due to the fight. He described his mood as tired, affect is irritated, and his sleep is broken with nightmares about getting hit over the head. The Veteran’s neurologic examination during the December admission was unremarkable and his cognition was listed as a strength. More recently, outpatient psychiatry notes indicate increasing psychiatric distress associated with the physical altercation in August 2014, characterized by dysphoria, worsening PTSD symptoms with associated nightmares and insomnia, and agoraphobia. On current evaluation, the Veteran reported suffering a significant closed head injury with subsequent neurobehavioral changes following a physical altercation. While the Veteran had minimal recollection for this event, he was told later by others that he was attacked by several unknown men outside his residence who struck him on the left side of the head with a 40-ounce beer bottle rendering him unconscious and subsequently proceeded to kick him on the ground. He reported that he thinks he lost consciousness again while his fingerprints were taken. He had poor recollection of this detention and noted that he was in and out of consciousness for the next 8 days. The Veteran advised that his lawyer said he had a seizure and aneurysm when he was jailed and as a result was sent to Morton Hospital and later Beth Israel Deaconess Medical Center. The Veteran denied any cognitive or neurologic difficulties prior to this event. While he noted that his cognitive difficulties have improved since the incident, his cognitive functioning has not returned to baseline per his reporting. Residual neurobehavioral changes include a variety of cognitive problems, including memory, neurologic symptoms of gait disturbance and headaches, and what appears at least in part an exacerbation of existing PTSD symptoms. The Veteran advised that he lost the ability to remember his grandchildren’s names during his incarceration. He also reported difficulty remembering recent events, concentrating, trouble reading and writing, disarticulation while speaking, analyzing situations, problem-solving, and overestimating threats. He endorsed trouble with hand-eye coordination when reaching for objects, but denied any trouble with understanding speech or remote memory. Specifically, the Veteran denied any trouble performing most complex activities of daily living, except for remembering medical appointments. Neurologic changes since the incident include headaches three to four times per week that are accompanied by trouble thinking, irritability, sensitivity to light and sound, and occasional nausea. He also endorsed continued balance difficulty and “sluggish legs” when walking. Other symptoms since incident include some numbness in fingers and toes, urinary incontinence, and dulled senses. He denied any episodes of seizure or vascular accidents apart from his reported seizure and aneurysm that he sustained at the police department. Treatment records from Morton Hospital and Beath Israel Deaconess Medical Center were not available for review. Notable emotional and behavioral changes since the August 2014 incident include decreased frustration tolerance and patience, increased emotional dysregulation, increased distrust of others, and hypervigilance and exaggerated startle. He endorsed experiencing nightmares one to two times per week and distressing thoughts one to two times per day, which appeared related to racial discrimination in military and the recent physical altercation. Evaluation findings revealed memory functioning that was variable, ranging from intact to substantially impaired. The neuropsychological report states that the evaluation findings are consistent with a diagnosis of Mild Unspecified Neurocognitive Disorder at this time. There is some indication of cognitive decline in at least memory since his previous neuropsychological evaluation in 2000 based on his poorer performance on a story memory task. This finding should be qualified, however, due to fluctuating attention clearly undermining his performance on this task. The current deficits on testing are mostly modest in nature and characterized by trouble with memory and aspects of complex attention/executive functioning. While the Veteran’s performance fell in the substantially impaired range on two measures—variable attention and/or effort appeared to contribute to these performances and thus they may reflect an overestimation of the actual degree of impairment. The etiology of his neurocognitive difficulty is likely multifactorial, including his recent closed head injury superimposed upon more chronic risk factors, such as a longstanding history of polysubstance abuse, psychiatric illness, vascular risk factors, and possibly hepatitis C. While the physical signs of withdrawal from alcohol and opiates were mild and the detoxification protocol was discontinued on day three of admission, it is possible that acute/sub-acute effects of alcohol withdrawal further undermined his neurocognitive functioning given that testing was completed on day 6 of admission. The extent to which the Veteran’s current cognitive difficulties reflect the contribution of his head injury independent of these other risk factors is unclear without more comprehensive medical and neurologic work-up, additional collateral information, sustained sobriety time, and psychiatric symptom stabilization. Based on the Veteran’s report, it appears that he suffered noticeable neurocognitive decline and neurologic changes following the head injury, which have improved somewhat since the incident but not returned to baseline. Indeed, this head injury may very well have exacerbated his longstanding PTSD symptoms, resulting in increased intrusion symptoms, emotional dysregulation, impulsivity, hypervigilance and distrust of others, and exaggerated startle. The Veteran’s substance use has resulted in significant functional consequences and is likely to further undermine his cognitive functioning in the community. A May 26, 2015 VA EEG Lab Report shows that an electroencephalogram was performed to assess the Veteran’s epilepsy risk and evaluate mental status changes. The electroencephalogram was normal and in particular there were no seizures or events. The Board notes that the Veteran advised of being hospitalized following his post-service head injury. In particular, the Veteran stated that he spent 8 days at Beth Israel Deaconess Medical Center, and also received treatment at Brigham and Women’s Hospital and Morton Hospital following his post-service head injury. VA provided the Veteran a VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA) and VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA), in correspondence dated July 16, 2020. The Veteran did not respond to the opportunity to allow VA to request these potentially relevant treatment records. The Veteran was afforded a VA Review Evaluation of Residuals of Traumatic Brain Injury (R-TBI) Disability Benefits Questionnaire in August 2020. The examination report provides that the Veteran does not have and has not ever had a traumatic brain injury or any residuals of a traumatic brain injury. Regarding the Veteran’s medical history, the examination report states that the Veteran has a history of head trauma on August 3, 2014. A police report states that the Veteran was involved in an altercation in front of his home in which a witness indicated that the Veteran was struck in the face, causing a nasal bone fracture. The Veteran was seen walking into his home after the altercation where the police interviewed him and subsequently took him into custody. Then, the Veteran was taken to Morton Hospital for a medical evaluation and then Brigham and Women’s Hospital after an incidental 10 millimeter unruptured left posterior cerebral artery aneurysm was discovered and coiled. The Veteran was not diagnosed with a traumatic brain injury and a small area of infarct adjacent to the coiling site was noted on follow up scans. The August 2020 examination report states that there are somewhat varying descriptions of the Veteran’s post-service head injury and the immediate aftermath. For example, the Veteran maintains that he was struck with a 40-ounce beer bottle, lost consciousness, and collapsed in jail cell due to a seizure. The Veteran reported a history of traumatic brain injury in VA treatment records dated July 19, 2017, November 2, 2017, and August 20, 2019, for example. However, the examination report provides that the Veteran’s relaying of information relating to the head injury and the incidental aneurysm appear to be merged. The Veteran reported chronic headaches following his nasal bone fracture. He had an electroencephalogram on May 26, 2015, which was normal and showed no corroborated history of seizure. Neuropsychology testing on May 22, 2015 showed a marginal decline from 2000 of unclear etiology, although head injury, polysubstance abuse, small vessel disease, and aging were considered. The Veteran has a history of bipolar disorder strongly established in his treatment records dating back to the 1980s according to the August 2020 examination report. The Veteran’s service treatment records feature a November 1971 Report of Medical History indicating positive for a head injury, but clarified to consist of a scalp laceration without indication of brain injury. An August 1973 Report of Medical Examination featured a denial of any history of head injury. Concerning the assessment of facets of traumatic brain injury-related cognitive impairment and subjective symptoms of traumatic brain injury, the August 2020 examination report also indicates that the Veteran does not have any complaints of impairment of memory, attention, concentration, or executive function. The Veteran has normal judgment, routinely appropriate social interaction, is always oriented to person, time, place, and has normal motor activity and visual spatial orientation. The Veteran does not have any subjective symptoms or any neurobehavioral effects. The Veteran is able to communicate by spoken and written language and to comprehend spoken and written language and his consciousness is normal. The August 2020 examination report provides that the Veteran does not have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a traumatic brain injury. Neuropsychological testing that occurred on May 22, 2015 showed that the Veteran has a minimal change in frontal executive and verbal fluency since the year 2000 and that there are multiple possible etiologies including aging, polysubstance abuse, small vessel disease, or head injury as described by the Veteran. An August 2014 MRI showed small infarct on the left occipital lobe adjacent to the site of left posterior cerebral artery aneurysm. A May 2015 electroencephalogram was normal. The corresponding August 2020 VA medical opinion provides that the examiner reviewed the Veteran’s claims folder, service treatment records, and VA treatment records. The examiner noted that there appear to be significant discrepancies in the reporting over the years of events that transpired on August 3, 2014. The Veteran indicated during the January 2018 hearing, that he did not recall that night well until approximately a year after, which is highly unusual. The police records and acute hospital records from August 2014 reflect that the Veteran was punched in the head and injured that evening, but did not have loss of consciousness or altered consciousness. The Veteran was witnessed to have immediately walked back to his apartment and was subsequently conversive with other occupants of the residence as well as a police officer a few minutes later. He had no reported disorientation, cognitive complaints, headache, nausea, vomiting, light or sound sensitivity or other symptoms to signal that a mild traumatic brain injury or concussion had occurred at that time or with monitoring at the hospital in the days following. Imaging of the Veteran’s head was negative for acute hemorrhage, but revealed an incidental left posterior cerebral artery aneurysm which required timely neurosurgical management. The August 2020 medical opinion further states that the Veteran’s reports of multiple days of unconsciousness and amnesia, seizure, or traumatic brain injury associated with this event are not substantiated by the available records. In the setting of mild multifactorial cognitive impairment and comorbid conditions such as anxiety or PTSD there is an accentuated vulnerability to recall bias, perhaps making this Veteran vulnerable to a troubling but not factually substantiated account of the specifics of his August 2014 injury. A diagnosis of traumatic brain injury made by clinicians at the VA appears to have been based on inaccurate information provided by the Veteran, which conflicts with the outside hospital records and police report. The medical opinion concludes, the Veteran consistently reported post-traumatic headaches, which are likely driven by his post-traumatic nasal bone fracture and the most accurate diagnosis is nasal bone fracture. The August 2020 medical opinion concludes that the Veteran’s claimed condition is less likely than not proximately due to or aggravated beyond its natural progression by his service-connected panic disorder with bipolar disorder as the diagnosis of traumatic brain injury was made in error. The Veteran may have been experiencing enhanced vigilance and a sense of perceived threat secondary to his panic disorder at the time of the August 2014 physical altercation. Although the Veteran does not have a clear diagnosis of traumatic brain injury, his diagnosis of nasal bone fracture with associated chronic headaches is more likely than not attributable to his underlying service-connected disorder. Other symptoms such as memory difficulties are more directly attributable to underlying mental health conditions than to his nasal bone fracture. During the January 2018 hearing, the Veteran advised that he got into a physical altercation with people in front of his home. He stated that he was told by others that he was struck on the side of the head and that he did not remember the incident until a year prior to the hearing. He stated that he was struck with a bottle and does not remember stabbing a person. He spent 8 days in the hospital following the incident and was unconscious for the first two days. He did not remember the time he spent at the police station and he was told by family members and others in jail about what happened in jail. He was told that he had a seizure while in a jail cell. Per the January 2018 hearing, the Veteran advised that he has current residuals of a traumatic brain injury related to his post-service head injury, such as trouble walking, seizures, memory loss, and chronic headaches. The Veteran also stated that because of his traumatic brain injury, he has severely impaired thoughts, has memory loss and impaired judgment, and he sustained an aneurysm. See December 2015 VA Form 21-526b, Veteran’s Supplemental Claim for Compensation. The evidence demonstrates that during the Veteran’s active service, he was a specialist in the surgical suite and that he prepared patients for surgery and performed additional logistical support during surgery and generally. The Veteran’s VA treatment records also reflect that he worked at a VA Medical Center in custodial services and other evidence indicates that he worked outside of the medical field. Thus, the evidence shows that while the Veteran worked with medical professionals, his primary capacity involved logistics and support work and did not involve employment that required medical expertise regarding the diagnosis and treatment of individuals. Thus, he is considered a lay person in the field of medicine. Lay testimony is competent as to matters capable of lay observation or within a person’s first-hand experience and may be competent evidence with respect to both the diagnosis of a medical condition and its etiology or cause. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, lay testimony is not competent with respect to determinations that cannot be made based on lay observation alone due to their medical or scientific complexity. Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). The Board must determine on a case by case basis whether lay testimony is competent on the matter at issue, or whether medical evidence is required. See Davidson, 581 F.3d at 1316; Kahana v. Shinseki, 24 Vet. App. 428, 434 (2011). In this case, whether the Veteran has a diagnosis of a traumatic brain injury or experiences trouble walking, seizures, memory loss, chronic headaches, impaired thoughts and judgment, and an aneurysm because of a traumatic brain injury are medical determinations, and as such cannot be observed through the senses alone. Thus, the Veteran’s unsupported lay opinions regarding the diagnosis of a traumatic brain injury and the cause of these reported residuals of a traumatic brain injury are not competent evidence on this issue, and therefore is not probative. See Layno, 6 Vet. App. at 470-71. The findings by the August 2020 VA examiner discussed above weighs against a finding of the Veteran’s statements that he has a diagnosis of a traumatic brain injury and the above symptoms as current residuals of a traumatic brain injury. Cf. King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (indicating that the Board may properly find that a medical professional’s opinion carries more weight than a lay opinion). The clinical findings made by the objective medical professional carries more weight than the Veteran’s lay statements in support of the claim for service connection, as the former reflect informed assessment by a neutral individual with medical expertise, and is based on examination of the Veteran and review of his medical history. While the Veteran’s VA treatment records provide that he sustained a traumatic brain injury and that he has such a diagnosis, these notations are based on the Veteran’s subjective complaints, as stated by the August 2020 examiner, and do not represent a clinical finding based on an objective signs, diagnostic studies, or examination. The VA treatment records do not otherwise provide an explanation for the diagnosis of a traumatic brain injury based on objective signs, diagnostic studies, or examination. Information received from Brigham and Women’s Hospital contained in the Veteran’s claims folder do not indicate that he sustained a traumatic brain injury. The Board gives more weight to the findings by the August 2020 examiner who specifically assessed the Veteran for residuals of a traumatic brain injury. Further, the Board does not find the statements from the Veteran that he was struck with a 40-ounce beer bottle, lost consciousness, and collapsed in jail due to a seizure are credible as these statements are not consistent with more probative evidence contained in his claims folder. In determining whether statements are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). First, there is no indication that a 40-ounce beer bottle was used to strike the Veteran during the August 2014 physical altercation per the August 3, 2014 police report from the Taunton, Massachusetts Police Department included in his claims folder. Additionally, the eye-witness account of the event states that the Veteran was struck with a fist. The police report indicates that the Veteran walked back to his home after the physical altercation and spoke to police officers at that time. The January 2018 hearing demonstrates that the Veteran had very little memory of the physical altercation or the events that occurred immediately after and that the primary basis of his knowledge are statements from family members and others from jail. Lastly, a May 2015 electroencephalogram was normal and showed no corroborated history of seizure. Therefore, the Board affords these statements no weight. The Board also notes that the VA neuropsychological report states that the Veteran’s neurocognitive difficulty is likely multifactorial, including his recent closed head injury superimposed upon more chronic risk factors. However, this finding is based upon similar reporting from the Veteran that the Board does not find credible. Again, the Board affords this finding no weight. In sum, the competent and credible evidence of record does not show that the Veteran has a diagnosis of a traumatic brain injury or currently has residuals of a traumatic brain injury. See 38 C.F.R. §§ 3.303, 3.310; Holton, 557 F.3d at 1366. The Veteran has not been diagnosed as having a seizure disorder and any stroke or aneurysm (i.e., a small area of infarct adjacent and/or incidental left posterior cerebral artery aneurysm) has not been related to his head injury. Further, the Veteran’s nasal bone fracture and post-traumatic headaches arising from the post-service head injury, are service-connected. Additionally, the Veteran is service-connected for panic disorder with bipolar disorder and the symptoms of mild memory loss; depressed mood; suspiciousness; panic attacks; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; gross impairment in thought processes or communication; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships; neglect or personal appearance and hygiene; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene, have been attributed to these disorders. See June 2016 VA Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire; see also October 2015 VA Initial Posttraumatic Stress Disorder (PTSD) Disability Benefits Questionnaire. For these reasons, the Board finds that service connection for residuals of a traumatic brain injury is not warranted. Because the preponderance of the evidence is against the award of service connection for residuals of a traumatic brain injury, the benefit of the doubt doctrine is not applicable in the instant appeal and service connection is denied. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55-57. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sean Mussey, 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.