Citation Nr: 21062562 Decision Date: 10/08/21 Archive Date: 10/08/21 DOCKET NO. 17-31 728 DATE: October 8, 2021 ORDER As new and material evidence has not been received, the previously denied claim of entitlement to service connection for posttraumatic stress disorder (PTSD) remains denied. New and material evidence has been received sufficient to reopen the claim for entitlement to service connection for a lumbar spine disability. REMANDED Entitlement to service connection for headaches, to include as secondary to tinnitus is remanded. Entitlement to service connection for major depressive disorder, to include as secondary to bilateral hearing loss and tinnitus, is remanded. Entitlement to an initial rating in excess of 10 percent for bilateral hearing loss from December 19, 2013 to August 21, 2017, and 20 percent, thereafter, is remanded. Entitlement to service connection for diabetes mellitus type II (diabetes), to include as secondary to depressive disorder is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a lumbar spine disability is remanded. FINDINGS OF FACT 1. By an unappealed March 1998 rating decision, the RO denied the Veteran's claims for service connection for a lumbar spine disability, finding no nexus between current diagnoses and service, and PTSD, finding no confirmed military stressor or diagnosis of PTSD. 2. Additional evidence received since the RO's March 1998 rating decision does not satisfy an unestablished fact necessary to substantiate the claim for service connection for PTSD, and it does not raise a reasonable possibility of substantiating the claim. 3. Evidence received since the RO's March 1998 rating decision relates to nexus to service and, therefore, raises a reasonable possibility of substantiating the service connection claim for a lumbar spine disability. CONCLUSIONS OF LAW 1. The March 1998 rating decision denying entitlement to service connection for a lumbar spine disability and PTSD is final. 38 U.S.C. § 7104, 7105; 38 C.F.R. §§ 20.302, 20.1103. 2. New and material evidence has not been received sufficient to reopen the claim for entitlement to service connection for PTSD. 38 U.S.C. §§ 5107, 5108; 38 C.F.R. §§ 3.102, 3.156. 3. New and material evidence has been received sufficient to reopen the claim for entitlement to service connection for a lumbar spine disability. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.156. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January 1979 to January 1982. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2014 rating decision issued by a VA Regional Office (RO). By way of background, in the May 2014 rating decision, the RO granted service connection for bilateral hearing loss and tinnitus effective December 19, 2013 and assigned it a 10 percent disability rating. The RO also denied the Veteran's remaining claims noted above and the Veteran subsequently appealed. During the pendency of the Veteran's appeal, in August 2017, the RO granted an increased rating for his bilateral hearing loss to 20 percent effective December 13, 2014, the date of the Veteran's claim. The increased rating constitutes a partial grant of the benefits sought on appeal; therefore, the issue remains on appeal and is for consideration by the Board. See AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original or an increased rating remains in controversy when less than the maximum available benefit is awarded). In June 2019, the Board remanded all claims for further development to include obtaining Social Security Administration (SSA) records, private treatment records, and Workers' Compensation benefits records. A review of the claims file now shows that there has been substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). New and Material Evidence Generally, a claim which has been denied in an unappealed AOJ decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). An exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the VA Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. New evidence means evidence not previously submitted. Material evidence means existing evidence that by itself or when considered with previous evidence relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final decision and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). If the evidence is new, but not material, the inquiry ends, and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999). In Shade v. Shinseki, 24 Vet. App. 110 (2010), the Court interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." The Court further held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what new and material evidence is, rather than a separate determination to be made after the Board has found that evidence is new and material. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). As a final matter before turning to the specific facts of the Veteran's case, the Board notes that it has considered the applicability of 38 C.F.R. § 3.156(b), which provides that when new and material evidence is received prior to the expiration of the appeal period it will be considered as having been filed in connection with the claim that was pending at the beginning of the appeal period. In the instant case, no new and material evidence was submitted within the appeal period. Accordingly, 38 C.F.R. § 3.156(b) is not applicable. See Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011); Roebuck v. Nicholson, 20 Vet. App. 307, 316 (2006); Muehl v. West, 13 Vet. App. 159, 161-62 (1999). 1. As new and material evidence has not been received, the previously denied claim of entitlement to service connection for posttraumatic stress disorder (PTSD) remains denied. The Veteran's claim for service connection for PTSD was denied in a March 1998 rating decision which found that the evidence did not indicate that the Veteran had a diagnosis of PTSD nor that there was evidence of an in-service stressor. The Veteran did not timely appeal and the decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. In December 2013, he sought to reopen the claim and a May 2014 rating decision determined there was no new and material evidence sufficient to warrant reopening. The Veteran timely appealed. Evidence of record at the time of the March 1998 decision included the Veteran's STRs and military personnel records. His service entrance examination as well as separation examination did not reflect any in-service stressors or mental health issues. Evidence added to the record since the March 1998 decision included two "buddy" statements, a January 2016 private examination and medical opinion by Dr. H.H.G., and several medical articles. The "buddy" statements indicate the Veteran had ongoing back pain and that his behavior and personality had changed since returning from service. Dr. H.H.G., a licensed psychiatrist, diagnosed the Veteran with major depressive disorder and provided a positive nexus opinion. While this evidence is "new" as it was not before the adjudicator at the time of the March 1998 rating decision, the Board finds none of the "new" evidence is "material." That is, the RO denied the Veteran's claim in March 1998, noting no diagnosis of PTSD and no identified in-service stressor. Thus, for "new" evidence to be "material" here it would have to relate to a diagnosis and/or an in-service stressor. In this case, however, none of the new evidence submitted indicates the Veteran has been diagnosed with PTSD during any time of the pendency of the appeal nor does any of the new evidence identify an in-service stressor. As such, the "new" evidence is not material for purposes of reopening the PTSD issue as the evidence does not relate to any of the unestablished facts necessary to substantiate the claim. Accordingly, the claim to reopen is denied. 2. New and material evidence has been received sufficient to reopen the claim for entitlement to service connection for a lumbar spine disability. The Veteran's claim for service connection for a lumbar spine disability was denied in a March 1998 rating decision which found that the evidence did not indicate that the Veteran had a diagnosed lumbar spine condition nor that there was evidence of an in-service injury or event. The Veteran did not timely appeal and the decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. In December 2013, he sought to reopen the claim and a May 2014 rating decision determined there was no new and material evidence sufficient to warrant reopening. The Veteran timely appealed. Evidence of record at the time of the March 1998 decision included the Veteran's STRs and military personnel records. His service entrance examination as well as separation examination did not reflect any in-service stressors or low back issues. Relevantly, evidence added to the record since the March 1998 decision included two "buddy" statements, a January 2016 private examination and medical opinion by Dr. H.H.G., and several medical articles. The "buddy" statements indicate the Veteran had ongoing back pain which began during service and has continued ever since. VA treatment records further indicate a history of low back pain that has been treated with prescribed medications. See June 2009 MRI, August 2015 Outpatient Note, October 2018 Treatment Note. Based on the foregoing, the Board finds that new and material evidence has been added to the record since the February 2016 decision. That decision found that there was no in-service injury or onset. Medical evidence added to the record since then demonstrated that the Veteran has a history of low back pain with noted degenerative changes. Additionally, the submitted lay statements support the Veteran's assertion that his current lumbar spine pain had its onset in service. For purposes of reopening, the Board considers evidence to be credible. As such, the Board finds that this additional evidence relates to unestablished facts necessary to substantiate the Veteran's claim for service connection. Accordingly, new and material evidence has been received and the claim is reopened. REASONS FOR REMAND 3. Entitlement to service connection for headaches, to include as secondary to tinnitus is remanded. The Veteran asserts that his currently diagnosed migraine headaches are caused by his service-connected tinnitus. The Board notes, that the Veteran is currently service connected for tinnitus and has been formally diagnosed with tension headaches. In support of his claim, the Veteran submitted a private examination and medical opinion dated from August 2015 by Dr. H.S. The report indicates, "when I spoke to this [V]eteran on 8/13/2015 he reported that his headaches began in service around the same time his tinnitus started. He reported that his headaches have become more severe over the years." Although an examination was conducted at the time, it does not appear the examiner reviewed any records at the time. Rather, based solely on the Veteran's self-reported history, the examiner opined that the Veteran's "headaches are caused by his service-connected tinnitus". In support, Dr. H.S. referenced medical literature which has documented the association between tinnitus and headaches. The Board finds Dr. H.S.'s opinion unpersuasive and contradictory as the opinion, on the one hand, notes that the headaches began in-service, but on the other hand, are caused by service-connected tinnitus. There is also no provided supporting rationale for this opinion other than the Veteran's self-reports, which are inconsistent with the lack of documentation in his service treatment records (STRs). Indeed, the private physician does not mention review of the STRs at all. In any case, the opinion nonetheless raises the possibility of a nexus to service or a service-connected disability and, therefore, the Board finds a VA examination is warranted to address whether the Veteran's headaches were manifested in service or, alternatively are caused or aggravated by service. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet.App. 79, 85-86 (2006). 4. Entitlement to service connection for major depressive disorder, to include as secondary to bilateral hearing loss and tinnitus, is remanded. The Veteran contends that his currently diagnosed major depressive disorder is caused by service. Alternatively, the Veteran also contends that his depressive disorder was aggravated by his service-connected hearing loss and tinnitus. The Veteran's military personnel records indicate that the Veteran was reduced in rank in November 1980 and subsequently discharged from service due to "unsuitability, apathy, defective attitudes, or inability to expend efforts constructively". STRs, are silent for treatment or a diagnosis of any mental health condition, however, there are reports by the Veteran that wanted a referral to a private mental health clinic and was dealing with "multiple problems in his unit and with his family". See November 1980 STR. Lay statements in support of the Veteran's claim were submitted in June 2017. Both indicate a change in the Veteran's personality occurred after service to include becoming more isolated and quicker to anger. In further support of his claim, the Veteran submitted a private mental disorders examination and medical opinion dated January 2016 by Dr. H.H.G. At which time, the Veteran was formally diagnosed with major depressive disorder with recurrent psychotic features. Upon examination, Dr. H.H.G. noted symptoms of depressed mood, anxiety, suspiciousness, panic attacks, near-continuous panic or depression, mild memory loss, impairment of short and long-term memory, disturbances of mood, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, suicidal ideation, persistent delusions or hallucinations and intermittent inability to perform activities of daily living. Observationally, the examiner noted that the Veteran's attention and concentration appeared variable, struggles to remember basic information, mood was anxious and nervous, affect was restricted and appeared "rather paranoid when speaking with this examiner". Ultimately, Dr. H.H.G. opined contradictorily that on the one hand that the Veteran's depression "more likely than not began in military service," but on the other hand is "aggravated by his bilateral hearing loss and tinnitus." The distinction is relevant as direct service-connection is a superior benefit to secondary service-connection. In any case, the opinion at a minimum raises the possibility of a nexus and thus triggers VA's duty to provide the Veteran with a VA examination to address both direct and secondary service connection. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet.App. 79, 85-86 (2006). 5. Entitlement to an initial rating in excess of 10 percent for bilateral hearing loss from December 19, 2013 to August 21, 2017, and 20 percent, thereafter, is remanded. The Board notes, that while a new examination is not required simply because of the time which has passed since the last examination, VA's General Counsel has indicated that a new examination is appropriate when there is evidence of an increase in severity since the last examination. VAOPGCPREC 11-95 (1995). Here, the Veteran and his representative have continued the appeal, asserting that a rating in excess of 20 percent is warranted for bilateral hearing loss. The Veteran was last afforded a VA examination in June 2016. In addition, medical evidence of record supports a finding that a worsening of the Veteran's hearing loss has occurred. Specifically, audiology notes indicate the Veteran was fitted for hearing aids, in contrast, the June 2016 examiner did not contain any notation of a prior or current use of such aids. Accordingly, the Board finds that a new VA examination is necessary to determine the current severity of the Veteran's service-connected bilateral hearing loss disability. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994), see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (holding that a Veteran is entitled to a new examination when there is a contention that the pertinent disability had increased in severity). The Board also notes that the Veteran was previously scheduled for a VA hearing loss examination in February 2019. Unfortunately, it was reported that the Veteran failed to appear for this examination. However, there is no indication in the claims file that the Veteran ever received notice of this examination. As such, a duty to assist violation has occurred therefore, the Veteran must be afforded an updated VA examination for his bilateral hearing loss. 6. Entitlement to service connection for diabetes mellitus type II (diabetes), to include as secondary to depressive disorder is remanded. The Veteran asserts that his diabetes is related to his major depressive disorder. As noted above, the Veteran's claim for service connection for the primary disability of major depressive disorder has been remanded for additional development. Accordingly, the diabetes claim is remanded as inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (holding two or more issues are inextricably intertwined if one claim could have significant impact on the other). 7. Entitlement to service connection for hypertension is remanded. The Veteran asserts that his hypertension began during service and has experienced symptoms as such along with necessary treatment ever since. Specifically, the Veteran contends that during service he experienced several elevated blood pressure readings warranting an in-service diagnosis of hypertension. The Veteran has also raised the contention that the sole VA examination of record concerning hypertension is inadequate for adjudicative purposes, thus he should be afforded a new VA examination for his hypertension claim. See April 2019 Informal Hearing Presentation. The Veteran was afforded a VA examination in May 2014. At which time the Veteran's current diagnosis of hypertension was confirmed with a noted date of diagnosis of 1988. The examiner ultimately opined that "it is less likely as not that his hypertension began in the military, but he had an isolated blood pressure elevation". The examiner explained that although the Veteran had been treated for chest pains once during service, this was an isolated incident in which other blood pressure readings were normal and his bout of chest pain was "treated as...a chest cold and as gastric or esophageal symptoms on various occasions". It was further noted that the Veteran was a two pack per day smoker. The Veteran's contention of inadequacy is based on the May 2014 examiner's failure to consider all elevated blood pressure readings during service in conjunction with the current readings and treatments. See Reonal v Brown, 5 Vet. App. 458,460-61 (1993). In addition, the Veteran asserts that there have been significant changes in the way the medical community views blood pressure. Specifically, the Veteran's representative references a November 2017 American College of Cardiology (ACC) and the American Heart Association (AHA) clinical practice guide for the prevention, detection, evaluation, and treatment of high blood pressure. This guideline redefined the diagnostic criteria for hypertension replacing the term "prehypertension" with "elevated blood pressure" and updating criteria to meet "stage 1 hypertension". As such, the Veteran and his representative contend that under the "new" criteria, the Veteran's blood pressure readings during service would be considered stage 1 hypertension thus warranting service connection. Given the new medical evidence referenced by the Veteran and his representative, coupled with the May 2014 examiner's indicated lack of consideration of post service medical evidence, the Board finds a new VA examination is warranted to address the etiology of the Veteran's hypertension. See Colvin v. Derwinski, 1 Vet. App. 171 (1991) (holding that the Board must consider only independent medical evidence to support its findings rather than provide its own medical judgment). 8. Entitlement to service connection for a lumbar spine disability is remanded. The Veteran asserts that his current lumbar spine disability began during service. The Veteran's STRs document reports of low back pain in April 1981. However, the Veteran's September 1981 separation examination contains no reports or complaints of low back pain. Post service medical treatment records indicate a lengthy history of lumbar spine pain. Treatment records indicate the Veteran suffered a back injury as the result of a serious industrial accident. Further records from the Cleveland Clinic show the Veteran reported back pain after a work-related injury in 1990. Diagnostic testing was also conducted comparing the Veteran's back from 1985 to 1992 which indicated a new disc herniation. In June 2009, an MRI of the Veteran's lumbar spine indicated disk degeneration with mild disc bulging and compression. It was further noted that he was being seen by pain management and his medication for Neurontin was increased and was started on Flexeril. Later treatment records from August 2015 and October 2018 continue to report ongoing back pain. In an Outpatient Note from August 2015, the Veteran reported that he has had low back pain since service, but it has gotten worse over the last few years. Supporting lay statements submitted in June 2017 indicate the Veteran's back pain began during service. Specifically, it was indicated that the Veteran had injured his back after falling from a howitzer. See November 2015 Lay Statement by C.F. The Board notes, that the Veteran has never been afforded an examination by VA for his lumbar spine claim. A VA examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in- service event, injury, or disease," or that a disease, manifested in accordance with presumptive service connection regulations, occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. McClendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Veteran has a present disability, has identified in-service trauma, and there is insufficient evidence to decide the case. As the Board finds that the criteria set forth in McClendon have been met as to this claim, a VA examination should be obtained. The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's headaches. A full medical history should be documented in the examination report. All opinions must be supported by a rationale. The examiner is asked to address the following: (a) Is it at least as likely as not that the Veteran's headaches were incurred in service or are otherwise due to service? In answering this question, the examiner should consider the Veteran's lay statements describing when his headaches began and the chronicity of his symptoms. (b) Is it at least as likely as not that the Veteran's headaches are caused or aggravated by his service-connected tinnitus? The examiner is cautioned that the term "aggravated," as used in 38 C.F.R. § 3.310 (b), does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for "any incremental increase in disability and any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence." See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019). The examiner is asked to consider the private medical opinion of Dr. H.S. from August 2015 and reconcile, if possible, the absence of service treatment records concerning headaches with the Veteran's own reports of in-service onset of symptoms. The examiner is asked to provide a complete rationale for any opinions expressed and conclusions reached. 2. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's major depressive disorder. A full medical history should be documented in the examination report. All opinions must be supported by a complete rationale. The examiner is asked to address the following: (a) Is at least as likely as not that the Veteran's current diagnosis of major depressive disorder had its onset in service or is otherwise related to service? The examiner should consider service treatment and personnel records indicative of a November 1980 reduced rank and request for mental health referral. (b) If not, is it at least as likely as not that the Veteran's major depressive disorder is caused or aggravated by his service-connected bilateral hearing loss and/or tinnitus? The examiner is cautioned that the term "aggravated," as used in 38 C.F.R. § 3.310 (b), does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for "any incremental increase in disability and any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence." See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019). The examiner should consider all medical evidence of record including the private medical opinion of Dr. H.H.G from January 2016. If the Veteran's and/or Dr. H.H.G.'s reports are discounted, the examiner should provide a rationale for doing so (e.g., whether there is any medical reason to accept or reject the contentions and opinions). 3. Schedule the Veteran for an appropriate VA examination to determine the current severity of the Veteran's bilateral hearing loss. The entire claims file and this remand should be made available to the examiner for review. The examiner should discuss any potential functional impact associated with the Veteran's hearing loss. The examiner must provide a complete rationale for any opinion expressed, based on the examiner's clinical and medical expertise; established medical principles; and references to the evidence of record, as appropriate. If any opinion cannot be expressed without resort to speculation, ensure that the examiner so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. If, and only if, the Veteran's major depressive disorder is found to be service connected, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's diabetes mellitus type II (diabetes). A full medical history should be documented in the examination report. All opinions must be supported by a rationale. The examiner is asked to address the following: (c) Is it at least as likely as not that the Veteran's diabetes is caused or aggravated by his service-connected major depressive disorder? The examiner is cautioned that the term "aggravated," as used in 38 C.F.R. § 3.310 (b), does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for "any incremental increase in disability and any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence." See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019). The examiner is asked to provide a complete rationale for any opinions expressed and conclusions reached. 5. Schedule the Veteran for an appropriate VA examination to determine the current nature and likely etiology of the Veteran's hypertension. A full medical history should be documented in the examination report, to include reference to the Veteran's in-service blood pressure readings. All opinions must be supported by a rationale. The examiner is asked to address the following: (a) Is it at least as likely as not that the Veteran's hypertension began during service? The examiner should consider all medical evidence of record to include all reports of blood pressure readings during and after service. The examiner should consider the November 2017 American College of Cardiology (ACC) and the American Heart Association (AHA) clinical practice guide updates concerning hypertension and if/how they relate to the Veteran's in-service blood pressure readings. The examiner is asked to provide a complete rationale for any opinions expressed and conclusions reached. 6. Schedule the Veteran for an appropriate VA examination to determine the current nature and etiology of any lumbar spine disability. A full medical history should be documented in the examination report. All opinions must be supported by a rationale. The examiner is asked to address the following: (a) Is it at least as likely as not that the Veteran's lumbar spine disability is due to an injury reported during service? The examiner should consider submitted lay statements from June 2017 which describe the onset of the Veteran's low back pain as well as a description of the injury reported during service. The examiner should also consider and reconcile, if possible, the Veteran's reports of onset in service with treatment records that indicate a post-service back injury due to an industrial accident. In addition, the examiner should consider diagnostic testing that compared the Veteran's back in 1985 to 1992 resulting in a notation that the Veteran suffered a "new" herniated disk. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. (Continued on the next page) 7. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. F. Minnitte, Attorney Advisor 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.