Citation Nr: 21065207 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 17-64 402 DATE: October 25, 2021 ORDER Service connection for a right hip condition is denied. Service connection for obstructive sleep apnea is denied. Service connection for an acquired psychiatric disorder, to include anxiety disorder, is denied. An initial compensable rating for bilateral hearing loss prior to July 21, 2021, is denied. A rating in excess of 10 percent for bilateral hearing loss from July 21, 2012, is denied. REMANDED Entitlement to service connection for a neck condition is remanded. Entitlement to service connection for a back condition is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had a right hip condition at any time during or approximate to the pendency of the claim. 2. The preponderance of the evidence is against finding that the current obstructive sleep apnea began during active service, or is otherwise related to an in-service injury or disease. 3. The preponderance of the evidence is against finding that any current psychiatric symptoms began during active service, or are otherwise related to an in-service injury or disease. 4. For the period of appeal prior to July 21, 2021, the Veteran's hearing loss is manifested by no more than Level II hearing acuity in the right ear and Level II hearing acuity in the left ear based on pure tone threshold average and speech discrimination. 5. For the period of appeal from July 21, 2021, the Veteran's hearing loss is manifested by no more than Level IV hearing acuity in the right ear and Level IV hearing acuity in the left ear based on pure tone threshold average and speech discrimination. CONCLUSIONS OF LAW 1. The criteria for service connection for a right hip condition are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for obstructive sleep apnea are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for an acquired psychiatric disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for an initial compensable rating for bilateral hearing loss prior to July 21, 2021, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100. 5. The criteria for a rating in excess of 10 percent for bilateral hearing loss from July 21, 2021, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Air Force from July 1983 to March 1992. In November 2019, the Veteran testified at a videoconference hearing before the undersigned, and a transcript of that hearing is of record. The Board remanded the issues in April 2021 for further development, including obtaining outstanding private treatment records, obtaining a VA medical opinion on the etiology of the sleep apnea, and affording the Veteran a VA audiological examination to determine the severity of the bilateral hearing loss. Private treatment records have since been associated with the record, a VA opinion on the etiology of the sleep apnea was obtained in July 2021, and the Veteran had a VA audiological examination in July 2021. The Board therefore finds there has been substantial compliance with the remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Stegall v. West, 11 Vet. App. 268 (1998). Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). A disability may be service connected on a secondary basis if it is proximately due to or the result of a service-connected disease or injury; or, if it is aggravated beyond its natural progress by a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310(a), (b). 1. Service connection for the right hip. The Veteran contends that his right hip was injured in a motor vehicle accident in Italy. He swerved to avoid another car and collided with a brick wall on the Italian Army Base. He thinks that he lost consciousness in the accident and he was taken to the local hospital. The Veteran had "some stiffness and stuff," but he did not indicate that the right hip was hurt, nor did anyone at the hospital look at the right hip. Afterward, he looked at the car he was driving and the windshield was broken on the driver and passenger side. See the November 2019 Board hearing transcript. Service treatment records (STRs) document that the Veteran was in a motor vehicle accident in January 1985. His extremities were noted to have no tenderness, swelling, or limitation of range of motion. Subsequent STRs are silent for mention of any complaints, diagnosis, or treatment of any right hip condition, including an August 1987 report of medical history and a March 1990 examination. In August 1991, the Veteran declined a medical examination in conjunction with his separation from active service. Post-service private treatment records associated with the claims file are also silent for any complaints, diagnosis, or treatment of any right hip condition. The Board acknowledges that the Veteran indicated in the Board hearing that he sought treatment for his right hip about three or four years after he separated from service. The Board notes that the Veteran chose to participate in the Fully Developed Claims (FDC) program and the notice that accompanies VA Form 21-526EZ informs claimants of the information and evidence necessary to substantiate various types of claims, to include claims for service connection. In addition, in accordance with the Board's April 2021 remand, an authorization form to obtain any relevant outstanding treatment records was sent to the Veteran in May 2021. Private treatment records have since been submitted and associated with the claims file; however, they are silent for mention of any right hip complaints, diagnosis, or treatment. The Board finds that the Veteran does not have a current diagnosis of any right hip condition, and has not had a relevant diagnosis at any time during the pendency of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The Board cannot rely on the Veteran's assertions regarding a medical diagnosis. The issue is medically complex, as it requires specialized medical education and knowledge. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence, which is silent for mention of any right hip condition. Without competent evidence of a diagnosed disorder, service connection for the disorder cannot be awarded. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("In the absence of proof of a present disability, there can be no valid claim."); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004) (holding that service connection requires a showing of current disability). As such, service connection for a right hip condition is not warranted. 2. Service connection for sleep apnea. The Veteran contends that he has a deviated nasal septum, which he may have gotten from the in-service car accident, and that he had been diagnosed with sleep apnea approximately 10 years ago. He was given a CPAP machine, but he did not like using it and he lost weight, which "seemed to help a little bit." The Veteran states that his wife started complaining about his snoring in 2004 or 2005, and that it was not as bad since he had lost weight. See the November 2019 Board hearing transcript. Private treatment records indicate that the Veteran was diagnosed with severe obstructive sleep apnea in July 2013 after a split-night sleep study. He was started on a CPAP machine. Thus, the current disability requirement for service connection for sleep apnea is satisfied. The question for the Board is whether the Veteran's current sleep apnea either began during active service, or is etiologically related to service. The Board finds that probative evidence of record does not establish that the Veteran's sleep apnea is etiologically related to the Veteran's active service. STRs are silent for mention of any complaints, diagnosis, or treatment for any sleep problems or a deviated nasal septum. In July 2021, a VA medical opinion was obtained. After reviewing the claims file, a VA physician opined that the Veteran's sleep apnea was less likely than not caused by or the result of his military service, to include the in-service motor vehicle accident. The examiner noted that STRs showed no evidence of a nasal deviation, including a March 1990 examination in which the Veteran's nose was noted to be clinically normal. There was also no objective evidence in the STRs or in the post-service medical treatment records that the Veteran's service or accident in service would have predisposed him to development of obstructive sleep apnea more than 20 years after military discharge. The Board finds the VA medical opinion to be of at least some probative value. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The opinion was rendered after reviewing the Veteran's STRs and other medical records, and the examiner provided the facts and rationale on which the opinion was based. See Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the examiner's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion). Furthermore, neither the Veteran nor his representative has produced a medical opinion to contradict the conclusions of the VA examiner. There is no evidence suggesting that any portion of the current sleep apnea is attributable to the Veteran's military service, including a car accident in service. As such, there is no competent evidence that relates the sleep apnea to military service, to include as secondary to or aggravated by the service-connected right knee disability. The Board also finds that although the Veteran can describe observable symptoms, his statements cannot be used to determine whether any sleep apnea diagnosis is related service or to a service-connected disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran may be competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). There is no evidence that the Veteran has the medical education and training required to make a competent medical diagnosis, or to attribute such diagnoses to specific events or diseases. As such, the Board finds the Veteran's statements probative with regard to establishing his symptoms, but finds little probative value with regard to establishing service connection. In any case, their probative value is outweighed by the probative value assigned to an evaluation conducted by a person who has medical expertise and training. In sum, the weight of the competent and credible evidence of record weighs against the claims for service connection for a left knee condition. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Service connection for an acquired psychiatric disorder. The Veteran contends that he has a mental health condition due to an incident that occurred in September 1987 on the flight line at Barksdale Air Force Base. A refueler aircraft ignited and burned to the ground and a friend of the Veteran's died of smoke inhalation. The Veteran witnessed the incident from about 100 yards away after being thrown back and knocked out from the fire, although he did not know until later that his friend was there and had been killed. Since then, he had been prescribed Xanax to take before getting on airplanes, but he was not treated for any psychological disability in service, and only started receiving treatment in 2015, when he was having some difficulties at a job at the Bureau of Prisons at Fort Dix. See the November 2019 Board hearing transcript. STRs document that in October 1988, the Veteran requested to be evaluated for depression, with symptoms of irritability, less interest in pleasurable activities, low energy, sleeping through the night but awakening unrested. He was assessed as having depressed mood, not chronic for major depression, most likely stress-related. Subsequent STRs are silent for mention of any complaints, diagnosis, or treatment of any mental health symptoms, including a March 1990 examination in which the Veteran was noted to be psychiatrically normal. In August 1991, the Veteran declined a medical examination in conjunction with his separation from active service. In May 2016 VA mental disorders examination, the Veteran reported symptoms of difficulty falling asleep or awakening within 3-4 hours followed by a light sleep, for which he took Ambien. Other symptoms included feeling anxious more than depressed, being worried about money, worries about his job before retiring, a history of mood swings and irritability, being uncomfortable in social situations, and some difficulty with short term memory. He also lost interest in activities he used to find enjoyable, but continued to enjoy riding his motorcycle, and denied difficulty with attention and concentration. The Veteran had been with his wife since 1997, and indicated that he was happily married. He worked at the Federal Bureau of Prisons for 22 years until retiring in 2016. The Veteran stated that he had anxiety flying due to his in-service experience being near the aircraft that exploded, and used Xanax for the acute anxiety when flying. He limited the use of Xanax to when he had to fly. The examiner indicated that the Veteran's symptoms included depressed mood, anxiety, chronic sleep impairment, and mild memory loss. The Veteran was pleasant and cooperative in the interview, and did not display any signs of acute anxiety or depression. The examiner concluded that the Veteran did not meet the DSM-5 criteria for anxiety disorder, major depression, or any other mental health disorder. The Veteran had a history of worrying about a few areas of his life, but his condition had improved since retiring earlier that year. The anxiety while flying did not significantly disrupt his life. Moreover, it was not evident that any current mild symptoms were caused by experiences in service. The Board finds the VA medical opinion to be of at least some probative value. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The opinion was rendered after reviewing the Veteran's STRs and other medical records, soliciting a medical history from the Veteran, and physical examination of the Veteran. See Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the examiner's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion). Furthermore, neither the Veteran nor his representative has produced a medical opinion to contradict the conclusion of the VA examiner. The Board acknowledges that the Veteran indicated in the Board hearing that he sought mental health treatment in 2015, and that a January 2021 private treatment record notes a history of anxiety/depression. However, as discussed above, in accordance with the Board's April 2021 remand, an authorization form to obtain any relevant outstanding treatment records was sent to the Veteran in May 2021. To date, no relevant authorization or treatment records have been received. While a Veteran can in some cases be competent to report a diagnosis, in this case the Board gives more probative weight to the VA examination, which indicates that the Veteran does not have a relevant diagnosis. Specifically, the examiner also considered the Veteran's report of past treatment but clearly explained that the Veteran did not meet the diagnostic criteria. As such, the Board finds the Veteran has not had a relevant diagnosis at any time during the pendency of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). Without competent evidence of a diagnosed disorder, service connection for the disorder cannot be awarded. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("In the absence of proof of a present disability, there can be no valid claim."); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004) (holding that service connection requires a showing of current disability). As such, service connection for an acquired psychiatric disorder is not warranted. Increased Rating Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. 4. Increased rating for bilateral hearing loss prior to July 21, 2021 5. Increased rating for bilateral hearing loss from July 21, 2021. Where the evaluation of hearing loss is at issue, an examination for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a pure tone audiometry test. Examinations will be conducted without the use of hearing aids. 38 C.F.R. § 4.85(a). A rating for hearing loss is determined by a mechanical application of the rating schedule to the numeric designations assigned based on audiometric test results. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). Evaluations of bilateral hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity, as measured by a controlled speech discrimination test and the average hearing threshold, as measured by pure tone audiometric tests at the frequencies of 1000, 2000, 3000 and 4000 hertz. The rating schedule establishes 11 auditory acuity levels designated from Level I, for essentially normal hearing acuity, through level XI for profound deafness. Under 38 C.F.R. § 4.85, Table VI (Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination) is used to determine a Roman numeral designation (I through XI) for hearing impairment based on a combination of the percent of speech discrimination (horizontal rows) and the pure tone threshold average (vertical columns). The Roman numeral designation is located at the point where the percentage of speech discrimination and pure tone average intersect. 38 C.F.R. § 4.85(b). The pure tone threshold average is the sum of the pure tone thresholds at 1000, 2000, 3000 and 4000 hertz, divided by 4. This average is used in all cases to determine the Roman numeral designation for hearing impairment. 38 C.F.R. § 4.85(d). Table VI Numeric designation of hearing impairment based on puretone threshold average and speech discrimination. % of discrim- ination Puretone Threshold Average 0-41 42-49 50-57 58-65 66-73 74-81 82-89 90-97 98+ 92-100 I I I II II II III III IV 84-90 II II II III III III IV IV IV 76-82 III III IV IV IV V V V V 68-74 IV IV V V VI VI VII VII VII 60-66 V V VI VI VII VII VIII VIII VIII 52-58 VI VI VII VII VIII VIII VIII VIII IX 44-50 VII VII VIII VIII VIII IX IX IX X 36-42 VIII VIII VIII IX IX IX X X X 0-34 IX X XI XI XI XI XI XI XI Alternatively, VA regulations provide that in cases of exceptional hearing loss, when the pure tone thresholds at each of the four specified frequencies (1000, 2000, 3000 and 4000 hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). The provisions of 38 C.F.R. § 4.86(b) further provide that, when the pure tone threshold is 30 decibels or less at 1,000 Hertz, and 70 decibels or more at 2,000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. Table VIA Numeric designation of hearing impairment based only on pure tone threshold average: 0-41 42-48 49-55 56-62 63-69 70-76 77-83 84-90 91-97 98-104 105+ I II III IV V VI VII VIII IX X XI The findings for each ear from either Table VI or Table VIA, are then applied to Table VII (Percentage Evaluations for Hearing Impairment) to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear. The horizontal rows represent the ear having the better hearing and the vertical columns the ear having the poor hearing. The percentage evaluation is located at the point where the rows and column intersect. 38 C.F.R. § 4.85(e). Table VII Percentage evaluation for hearing impairment (diagnostic code 6100) Poorer Ear XI 100* X 90 80 IX 80 70 60 VIII 70 60 50 50 VII 60 60 50 40 40 VI 50 50 40 40 30 30 V 40 40 40 30 30 20 20 IV 30 30 30 20 20 20 10 10 III 20 20 20 20 20 10 10 10 0 II 10 10 10 10 10 10 10 0 0 0 I 10 10 0 0 0 0 0 0 0 0 0 XI X IX VIII VII VI V IV III II I Period of Appeal Prior to July 21, 2021 A March 2016 VA hearing loss examination report indicates the following puretone thresholds, in decibels: HERTZ 1000 2000 3000 4000 Average RIGHT EAR 30 25 25 30 28 LEFT EAR 25 25 25 30 26 Speech recognition scores were 90 percent in the right ear and 90 percent in the left ear, and the examiner indicated that the puretone thresholds were valid for rating purposes and that use of word recognition scores was appropriate. Applying these results to Table VI results in a designation of Level II for the right ear and Level II for the left ear. In December 2018, the Veteran reported in a VA appointment that his hearing aids were not working. An audiogram showed the following puretone thresholds, in decibels: HERTZ 1000 2000 3000 4000 Average RIGHT EAR 45 55 55 70 56 LEFT EAR 45 55 55 65 55 A Maryland CNC test was not done. The treating audiologist indicated that the Veteran's hearing had not changed significantly since his last evaluation. New hearing aids were ordered. Private treatment records indicate that in a November 2016 hearing assessment, the Veteran's approximate puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT EAR 20 15 25 35 24 LEFT EAR 25 15 25 30 24 A Maryland CNC test was not done. Applying these results to Table VIA, however, results in a designation of Level I for the right ear and Level I for the left ear. In the November 2019 Board hearing, the Veteran testified that his hearing had worsened. He had to ask his wife to repeat herself frequently and there were a lot of things he did not hear. He also wore a hearing aid. In a January 2020 private hearing assessment, the Veteran's approximate puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT EAR 20 15 45 30 28 LEFT EAR 25 15 40 40 30 A Maryland CNC test was not done. Applying these results to Table VIA, however, results in a designation of Level I for the right ear and Level I for the left ear. In sum, for the period of appeal prior to July 21, 2021, results of the VA examination and private treatment records translate to, at worst, Level II hearing loss in the right ear and Level II hearing loss in the left ear when applied to Table VI of the rating schedule (pure tone threshold average and speech discrimination). This level of hearing loss warrants a noncompensable (zero percent) rating under Table VII of the rating schedule. Therefore, a compensable schedular rating is not warranted under Diagnostic Code 6100 at any point during the period of appeal prior to July 21, 2021. See 38 C.F.R. § 4.85, Diagnostic Code 6100. Period of Appeal from July 21, 2021 A July 21, 2021 VA hearing loss examination report, the only evidence dated during this period of appeal, indicates the following puretone thresholds, in decibels: HERTZ 1000 2000 3000 4000 Average RIGHT EAR 20 25 40 45 33 LEFT EAR 35 30 40 45 38 Speech recognition scores were 70 percent in the right ear and 74 percent in the left ear, and the examiner indicated that the puretone thresholds were valid for rating purposes and that use of word recognition scores was appropriate. Applying these results to Table VI results in a designation of Level IV for the right ear and Level IV for the left ear. This level of hearing loss warrants a 10 percent rating under Table VII of the rating schedule. Therefore, a schedular rating in excess of 10 percent is not warranted under Diagnostic Code 6100 at any point during the period of appeal from July 21, 2021. See 38 C.F.R. § 4.85, Diagnostic Code 6100. REASONS FOR REMAND 1. Entitlement to service connection for a neck condition is remanded. 2. Entitlement to service connection for a back condition is remanded. The Veteran asserts that he injured his neck and back in the car accident in Italy. Although he was not treated after the accident for any neck or back problems, he started treatment on his neck a few years after he started working at the Bureau of Prisons in 1994. See the November 2019 Board hearing transcript. Private treatment records associated with the claims file indicate that in May 2015, x-rays showed spondylosis at C5-C6 and throughout the mid to lower thoracic and lumbar spine, most pronounced at the L4/sacral level; and facet arthrosis of the upper cervical spine, C7 through T2 and the lower lumbar spine. The Veteran was seen for aggravation of neck and back pain in December 2016 and March 2017. As such, the Board finds that medical opinions should be obtained to determine the nature and etiology of any relevant diagnoses. See McLendon v. Nicholson, 20 Vet. App. 79 (2006), 38 U.S.C. § 5103A(d). The matters are REMANDED for the following action: Send the claims file to an appropriate VA examiner and ask the examiner to review the record and prepare a medical opinion on the etiology of the claimed neck condition and back condition. After reviewing the entire record, the examiner should note any current relevant diagnosis of the neck and/or back. The examiner should then opine on whether it is at least as likely as not (50 percent or greater probability) that any diagnosis relevant to the claimed neck and/or back condition had its origin during, or is in some way the result of, the Veteran's periods of active military service, to include due to the in-service motor vehicle accident. All opinions and conclusions expressed must be supported by a complete rationale in a report. If the VA examiner determines that an examination is necessary in order to render the requested medical opinion(s), the AOJ should schedule the Veteran for such an examination. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Nelson 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.