Citation Nr: 21004648 Decision Date: 01/27/21 Archive Date: 01/27/21 DOCKET NO. 16-15 318A DATE: January 27, 2021 ORDER Entitlement to service connection for hypertension (HTN), to include as due to exposure to ionizing radiation is denied. Entitlement to service connection for diabetes mellitus type II (diabetes), to include as due to exposure to ionizing radiation is denied. Entitlement to service connection for prostate cancer, to include as due to exposure to ionizing radiation is denied. Entitlement to service connection for colon polyps, to include as due to exposure to ionizing radiation is denied. Entitlement to service connection for a heart condition, to include as due to exposure to ionizing radiation is denied. REMANDED Entitlement to service connection for an inguinal hernia, to include as due to exposure to ionizing radiation is remanded. Entitlement to service connection for hypothyroidism, to include as due to exposure to ionizing radiation is remanded. FINDINGS OF FACT 1. The Veteran’s HTN was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease, to include as due to exposure to ionizing radiation. 2. The Veteran’s diabetes was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease, to include as due to exposure to ionizing radiation. 3. The preponderance of the evidence is against finding that the Veteran’s prostate cancer began during active service or is otherwise related to an in-service injury or disease, to include as due to exposure to ionizing radiation. 4. The preponderance of the evidence is against finding that the Veteran’s colon polyps began during active service or is otherwise related to an in-service injury or disease, to include as due to exposure to ionizing radiation. 5. The preponderance of the evidence is against finding that the Veteran’s heart condition began during active service or is otherwise related to an in-service injury or disease, to include as due to exposure to ionizing radiation CONCLUSIONS OF LAW 1. The criteria for service connection for HTN are not met. 38 U.S.C. §§ 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 2. The criteria for service connection for diabetes are not met. 38 U.S.C. §§ 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 3. The criteria for service connection for prostate cancer are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 4. The criteria for service connection for colon polyps are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 5. The criteria for service connection for a heart condition are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served active duty in the U.S. Army from August 1956 to November 1957. This case comes before the Board on appeal of a February 2015 rating decision. Service Connection Generally, to establish service connection a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d). Service connection may also be granted through the application of statutory presumptions for chronic conditions, which includes hypertension and diabetes mellitus. See 38 C.F.R. §§ 3.303 (b), 3.309 (a) (2019); see also 38 U.S.C. §§ 1112, 1137 (2012). First, a claimant may benefit from a presumption of service connection where a chronic disease has been shown during service. 38 C.F.R. § 3.303 (b). In the alternative, if a chronic disease was not shown in service, but manifested to a degree of 10 percent or more within some specified time after separation from active service, such disease shall be presumed to have been incurred or aggravated in service, even if there is no evidence of such disease during service. 38 U.S.C. §§ 1112, 1137 (2012); 38 C.F.R. § 3.307 (a)(3) (2019). The application of these presumptions operates to satisfy the “in-service incurrence or aggravation” element and establish a nexus between service and a present disability, which must be found before entitlement to service connection can be granted. Service connection for a recognized chronic disease can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303 (b), 3.309. For chronic diseases shown as such in service or within the applicable presumptive period, subsequent manifestations of the same chronic disease at any later date are service-connected unless attributable to an intercurrent cause. 38 C.F.R. § 3.303 (b). For a chronic disease to be considered to have been “shown in service,” there must be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Id. When the condition noted in-service or within the presumptive period is not a chronic disease, a showing of continuity of symptomatology after discharge is required. Id. Additionally, the Veteran contends that his disabilities were caused by exposure to ionizing radiation. Service connection for a disability attributable to exposure to ionizing radiation during service will be presumptively granted. 38 C.F.R. § 3.309 (d). Service connection can be demonstrated by three methods: (1) under 38 C.F.R. § 3.309 (d), if the veteran is radiation-exposed and diagnosed with one of the 15 types of cancer, which are presumptively service connected; (2) under 38 C.F.R. § 3.311 (b), if the veteran is diagnosed with a radiogenic disease and certain conditions are met, or (3) by establishing the elements for direct service connection. See Davis v. Brown, 10 Vet. App. 209, 211 (1997). A radiation-exposed veteran is defined by 38 C.F.R. § 3.309 (d)(3) as a veteran who, while serving on active duty or on active duty for training or inactive duty training, participated in a radiation-risk activity. Radiation-risk activity is defined to mean onsite participation in a test involving the atmospheric detonation of a nuclear device; the occupation of Hiroshima, Japan or Nagasaki, Japan by United States forces during the period beginning on August 6, 1945, and ending on July 1, 1946; or internment as a prisoner of war (or service on active duty in Japan immediately following such internment) during World War II which resulted in an opportunity for exposure to ionizing radiation comparable to that of the United States occupational forces in Hiroshima or Nagasaki during the period from August 6, 1945 through July 1, 1946. Second, radiogenic diseases will be service connected provided certain processing conditions are met. 38 C.F.R. §§ 3.303 (d), 3.311. Pursuant to 38 C.F.R. § 3.311, when it is determined that: (1) the Veteran was exposed to ionizing radiation in service; (2) he subsequently developed a radiogenic disease; and (3) such disease first became manifest within a period specified by the regulations, a request for available records concerning the veteran’s exposure to radiation will be made and the case will be referred to the Under Secretary for Health for review as to whether sound scientific medical evidence supports the conclusion that it is at least as likely as not that the veteran’s disease resulted from radiation exposure during service. 38 U.S.C. § 501 (2012); 38 C.F.R. § 3.311 (b). The term radiogenic disease means a disease that may be induced by ionizing radiation. 38 C.F.R. §§ 3.311 (b). The diseases listed in 38 C.F.R. § 3.309 (d) are diseases in which the VA has determined that a positive association with radiation exposure exists. For cancer, the disease must have manifested five years or more after exposure. 38 C.F.R. § 3.311 (b)(5). This section does not provide presumptive service connection for radiogenic diseases, but only outlines a procedure to be followed for adjudication purposes. Medical opinions are ultimately the criteria upon which service connection rests under this regulation. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Likewise, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be more persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b) (2012). 1. Entitlement to service connection for hypertension (HTN), to include as due to exposure to ionizing radiation Here, the Veteran contends that his HTN was caused by active duty service to include as due to exposure to ionizing radiation. Based on the evidence, the Board disagrees. At the outset, the Veteran has a current diagnosis of hypertension. See October 2019 VA examination. Thus, the first element of service connection is met. Additionally, the second element is met as the Veteran was exposed to ionizing radiation during service. Specifically, the Veteran’s personnel records confirmed that he was assigned to Camp Desert Rock, Nevada during Operation PLUMBBOB. During the operation, there were 24 nuclear detonations and six safety tests that lasted from April to October 1957, and involved about 14, 000 DoD personnel, mostly military service personnel, participating in observer programs, tactical maneuvers, and scientific and diagnostic studies. See Third Party Correspondence. As such, the second element of an in-service event is met. Therefore, to warrant service connection there must a nexus, or link, between the Veteran’s in-service exposure and his current disability, which is proven by medical evidence. In that regard, in the October 2019 VA examination, the examiner opined that the Veteran’s HTN was less likely than not incurred in nor due to, nor caused by military service, to include exposure to ionizing radiation at the Nevada Testing Site during service. The examiner reasoned that there is no evidence of a diagnosis of hypertension within a year of the Veteran’s discharge. The Veteran explained that he was diagnosed with hypertension in 2016 at a VA medical center. The examiner stated that as the diagnosis happened many years after military service, made it less likely than not of any relation to military service. Lastly, the examiner explained that there was no recorded evidence in the medical literature of any etiological link between ionizing radiation exposure and hypertension. The Board finds the examiner’s opinion to be competent, credible and highly probative. The examiner reviewed the pertinent evidence, examined the Veteran, accounted for his lay statements and provided an opinion based on medical principles. Although the Board acknowledges the Veteran’s contention, without appropriate medical training and expertise, which he has not demonstrated, the Veteran is not competent to provide an opinion regarding the etiology of his hypertension. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Jones v. West, 12 Vet. App. 383, 385 (1999). Additionally, the Veteran is not entitled to a presumption for hypertension as his disability was not shown to have developed during service or within a year of his discharge. The Veteran was diagnosed with hypertension in September 1981, decades after his discharge from service. See VA treatment records. Furthermore, hypertension is not one of the enumerated diseases subject to the presumption under 38 C.F.R. § 3.309 (d), nor is a “radiogenic disease” under § 3.311. Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). 2. Entitlement to service connection for diabetes mellitus type II (diabetes), to include as due to exposure to ionizing radiation Here, the Veteran contends that his diabetes was incurred during service or as a result of exposure to ionizing radiation. Based on the evidence, the Board disagrees. At the outset, the Veteran has a current diagnosis of diabetes mellitus type II. See October 2019 VA examination. Thus, the first element of service connection is met. Likewise, as discussed above, the second element is met. The Veteran was exposed to ionizing radiation while at the Nevada Testing Site in 1957. As such, the second element of an in-service event is met. Therefore, to warrant service connection there must a nexus, or link, between the Veteran’s in-service exposure and his current disability, which is proven by medical evidence. In that regard, in the October 2019 VA examination, the examiner opined that the Veteran’s diabetes was less likely than not incurred in or caused by service, to include the claimed in-service event. The examiner reasoned that the pertinent medical evidence did not show any signs, symptoms, complaints, diagnosis, treatment, or any chronic disability pattern regarding diabetes during military service or within a year after separation from service. The examiner explained that the diagnosed diabetes was developed many years after active service; thus, not qualifying for presumptive consideration. Lastly, the examiner stated that VA has not found that positive association exists between exposure to ionizing radiation and diabetes. The Board finds the examiner’s opinion to be competent, credible and highly probative. The examiner reviewed the pertinent evidence, examined the Veteran, accounted for his lay statements and provided an opinion based on the evidence and medical principles. Although the Board acknowledges the Veteran’s contention, as discussed above, the Veteran is not competent to provide an opinion regarding the etiology of his diabetes. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, the Veteran is not entitled to the chronic disease presumption for diabetes as his disability was not shown to have developed during service or within a year of his discharge. The Veteran was diagnosed with diabetes in 1981, decades after his discharge from service. See VA treatment records. Furthermore, diabetes is not one of the enumerated diseases subject to the presumption under 38 C.F.R. § 3.309 (d), nor is a “radiogenic disease” under § 3.311. Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). 3. Entitlement to service connection for prostate cancer, to include as due to exposure to ionizing radiation Here, the Veteran contends that his prostate cancer was caused by his exposure to ionizing radiation during service. Based on the evidence, the Board disagrees. As stated above, service connection for a disability attributable to exposure to ionizing radiation can be demonstrated by three methods: (1) under 38 C.F.R. § 3.309 (d), if the veteran is radiation-exposed and diagnosed with one of the 15 types of cancer, including brain cancer, which are presumptively service connected; (2) under 38 C.F.R. § 3.311 (b), if the veteran is diagnosed with a radiogenic disease and certain conditions are met, or (3) by establishing the elements for direct service connection. See Davis v. Brown, 10 Vet. App. 209, 211 (1997). In this instance, prostate cancer is not a disease listed under § 3.309 (d), thus the Veteran is not entitled to the presumption. However, prostate cancer is a “radiogenic disease,” and given that the conditions under § 3.311 (b)(i) – (iii) are met, the claim was referred to the Under Secretary for Benefits to determine whether service connection is warranted. In the February 2020 memorandum, DO P.H. and health physicist D.M. prepared a report that concluded that it was unlikely that the Veteran’s prostate cancer was caused by exposure to ionizing radiation while in military service. They reasoned that since the Veteran’s prostate cancer did not qualify for presumptive service connection, the Interactive Radio Epidemiological Program (IREP) was used to calculate the likelihood that exposure to ionizing radiation was the cause of his prostate cancer. They used the doses provided by the Defense Threat Reduction Agency (DTRA), then the IREP calculated a 99th percentile value for probability of causation. The IREP probability came to 22.74 percent. Based on that percentage, they opined that it was unlikely that the Veteran’s prostate cancer was caused by exposure to ionizing radiation. Moreover, based on the February 2020 memo, VA Director of Compensation Service provided an advisory opinion that it was unlikely that the Veteran’s prostate cancer was caused by exposure to ionizing radiation during service. See March 2020 Advisory Opinion. Given the advisory opinion, the Veteran’s claim for prostate cancer may only be awarded on a direct service connection basis. In that regard, the Veteran’s diagnosis of prostate cancer meets the first element of service. Likewise, the second element is met, as the Veteran was exposed to ionizing radiation based on his participation in Operation PLUMBBOB. Therefore, to warrant service connection there must a nexus, or link, between the Veteran’s in-service exposure and his prostate cancer, which is proven by medical evidence. In the May 2020 VA examination, the examiner opined that the Veteran’s prostate cancer was less likely than not incurred in or caused by active duty service, to include exposure to ionizing radiation. The examiner reasoned that the issue was difficult as the Veteran was most likely exposed to ionizing radiation during Operation PLUMBBOB and a review of research literature from May 2003, titled “Cancer and workers exposed to ionizing radiation” showed a connection of workers in England with prostate cancer who had been exposed to ionization. However, the National Research Council determined that prostate cancer is relatively insensitive to ionizing radiation. Likewise, a June 2019 report, titled “Occupational risk factors for prostate cancer: A meta-analysis,” published in the Journal of Cancer Prevention, did not provide evidence that exposure to ionizing radiation increased the risk of prostate cancer. Additionally, the examiner cited another article that failed to show evidence of increased prostate cancer for those exposed to ionizing radiation. Based on the medical literature, the examiner concluded that the Veteran’s prostate cancer was less likely than not caused by active duty service, to include exposure to ionizing radiation. The Board finds the examiner’s opinion to be competent, credible and highly probative. The examiner reviewed the pertinent evidence, examined the Veteran, accounted for his lay statements and provided an opinion based on the evidence and medical literature. Although the Board acknowledges the Veteran’s contention, as discussed above, the Veteran does not have the requisite medical training to provide an opinion regarding the etiology of his prostate cancer. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). 4. Entitlement to service connection for colon polyps, to include as due to exposure to ionizing radiation Here, the Veteran contends that his colon polyps were caused or incurred by active duty service, to include as due to exposure to ionizing radiation. Based on the evidence, the Board disagrees. At the outset, the Veteran had a diagnosis of colon polyps during the pendency of the appeal. See October 2019 VA examination. Thus, the first element of service connection is met. Additionally, the second element is met. Although there was no evidence of colon polyps immediately following service, the Veteran was exposed to ionizing radiation during Operation PLUMBBOB. Therefore, to warrant service connection there must a nexus, or link, between the Veteran’s in-service exposure and his colon polyps, which is proven by medical evidence. In the October 2019 VA examination, the Veteran reported that he underwent a colonoscopy in 2004, where he was found to have had colon polyps that were benign. The Veteran reported a second colonoscopy in 2012 but reported no recurrent colon polyps. On examination, the Veteran did not report any gastrointestinal complaints. Following the examination, the examiner opined that the Veteran’s colon polyps were less likely than not incurred in or caused by active duty service, to include as due to exposure to ionizing radiation. The examiner reasoned that there was no evidence of a diagnosis of benign colon polyps within a year of discharge from service, as the Veteran’s service treatment records (STRs) were unavailable for review. The examiner stated that per the Veteran, he was diagnosed with colon polyps in 2004 for the first time by colonoscopy. The polyps were reported as benign and a second colonoscopy in 2012 showed no evidence of recurrence. The examiner explained that the Veteran’s first diagnosis happened many years after his discharge from service, which made it less likely than not that there was any relation with his benign colon polyps and military service. The examiner concluded that there is no recorded evidence in the medical literature of any etiological link between ionizing radiation exposure and benign colon polyps. The Board finds the examiner’s opinion to be competent, credible and highly probative. The examiner reviewed the pertinent evidence, examined the Veteran, accounted for his lay statements and provided an opinion based on the evidence and medical literature. Although the Board acknowledges the Veteran’s contentions, the Veteran does not have the requisite medical training or expertise to provide an opinion regarding the etiology of his prostate cancer. Jones v. West, 12 Vet. App. 383, 385 (1999). Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). 5. Entitlement to service connection for a heart condition, to include as due to exposure to ionizing radiation Here, the Veteran contends that his heart condition was caused or incurred by active duty service, to include as due to exposure to ionizing radiation. Based on a preponderance of evidence, the Board disagrees. At the outset, the Veteran has current diagnoses of coronary artery disease (CAD), congestive heart failure (CHF), cardiomyopathy, and atrial fibrillation. Thus, the first element of service connection is met. Additionally, the second element is met as the Veteran was exposed to ionizing radiation during service. Therefore, to warrant service connection there must a nexus, or link, between the Veteran’s in-service exposure and his heart condition, which is proven by medical evidence. In the October 2019 VA examination, the Veteran reported that for many years he had been having heart problems. He stated that several years ago he was found with cardiac arrythmia and a slow heart. He explained that he was hospitalized several times and defibrillator was placed. After the evaluation, the examiner opined that the Veteran’s heart conditions were less likely than not incurred in or caused by active duty service, to include as due to exposure to ionizing radiation. The examiner reasoned that the Veteran’s heart conditions were diagnosed decades after his discharge from service making their onset less likely related to active duty. The examiner added that a review of medical literature failed to show that the Veteran’s heart conditions were caused by, a result of, or aggravated by exposure to ionizing radiation at the Nevada Testing Site. Furthermore, he explained that the Veteran’s heart conditions are not presumptive diseases related to ionizing radiation. The Board finds the examiner’s opinion to be competent, credible and highly probative. The examiner reviewed the pertinent evidence, examined the Veteran, accounted for his lay statements and provided an opinion based on the evidence and medical literature. Although the Board acknowledges the Veteran’s contentions, the Veteran does not have the requisite medical training or expertise to provide an opinion regarding the etiology of his heart conditions. Jones v. West, 12 Vet. App. 383, 385 (1999). Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2019). Entitlement to service connection for hypothyroidism and an inguinal hernia, to include as due to exposure to ionizing radiation is remanded. In the December 2017 Board decision, the Veteran’s service connection claims for hypothyroidism and an inguinal hernia was remanded for further evidentiary development. However, there was no remand directive for the AOJ to afford the Veteran a VA examination and/or medical opinion on whether his hypothyroidism and inguinal hernia was a result of active duty service to include as due to exposure to ionizing radiation. Given that the Veteran has a current diagnosis of hypothyroidism and an inguinal hernia that may be linked to his in-service exposure to ionizing radiation, a VA examination and medical opinion must be provided. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matters are REMANDED for the following action: 1. Obtain all relevant outstanding VA treatment records, and any private treatment records identified by the Veteran. All records and/or responses received should be associated with the claims file. 2. After all outstanding treatment records have been associated with the claims file, schedule the Veteran for a VA examination to determine the etiology of his hypothyroidism and inguinal hernia. A copy of this REMAND must also be provided to the VA examiner. All necessary tests and studies should be accomplished, and all clinical findings reported in detail. The VA examiner should address the following: (a.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s hypothyroidism had its onset during service or is otherwise causally related to any event or circumstance of the Veteran’s service, to include as due to exposure to ionizing radiation. (b.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s inguinal hernia had its onset during service or is otherwise causally related to any event or circumstance of the Veteran’s service, to include as due to exposure to ionizing radiation. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as against it. 3. The examiner should cite to the pertinent medical and competent lay evidence of record and explain the rationale for all opinions given. If after consideration of all pertinent factors it remains that the opinion sought cannot be given without resort to speculation, it should be so stated, and the provider must (to comply with governing legal guidelines) explain why the opinion sought cannot be offered without resort to speculation. 4. After undertaking any additional development deemed necessary, the AOJ must readjudicate the claims on appeal. If any claim remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and afforded the requisite opportunity to respond before the case is returned to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board I. Umo, 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.