Citation Nr: 21068781 Decision Date: 11/12/21 Archive Date: 11/12/21 DOCKET NO. 16-59 984 DATE: November 12, 2021 ORDER Entitlement to service connection for skin lesions is granted. An initial rating of 100 percent, but not permanent, for major depressive disorder is granted. Entitlement to an initial compensable rating for an abdominal scar prior to September 24, 2019 is denied. Entitlement to a rating in excess of 20 percent from September 24, 2019 for an abdominal scar is denied. Entitlement to special monthly compensation (SMC) based on housebound status is denied. Entitlement to SMC based on the need for aid and attendance is denied. FINDINGS OF FACT 1. There is a relative equal balance of competent and credible evidence for and against a finding that the Veteran's skin lesions were caused by treatment for service-connected depression. 2. There is a relative equal balance of evidence for and against whether the Veteran's PTSD is shown to most closely approximate manifestations of total occupational and social impairment. 3. Prior to September 24, 2019 the Veteran's abdominal scar was not shown to be painful or unstable. 4. From September 24, 2019 the Veteran's abdominal scar is manifested by one scar that is painful and unstable; five or more scars that are painful or unstable; or three or four scars that are painful and unstable are not shown. 5. The Veteran is not blind, is not bedridden, and her service-connected disabilities do not render her unable to care for most of her daily personal needs or to protect herself from the hazards and dangers incident to her daily environment. The Veteran now has a service-connected disability that is rated 100 percent, but additional service-connected disabilities are not independently rated 60 percent or above and are not shown to be of such a nature and severity as to confine her to her home. CONCLUSIONS OF LAW 1. The criteria for service connection for skin lesions as secondary to treatment for service-connected depression are met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2020). 2. The criteria for a rating of 100 percent for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (Code) 9411 (2020). 3. Prior to September 24, 2019 the criteria for a compensable disability rating for an abdominal scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Code 7804 (2020). 4. From September 24, 2019 the criteria for a disability rating in excess of 20 percent for an abdominal scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Code 7804. 5. The criteria for establishing entitlement to SMC based on the need for regular aid and attendance or at the housebound rate are not met. 38 U.S.C. §§ 1114 (s), 5107 (2012); 38 C.F.R. § 3.350 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Navy from June 1980 to February 1986 with additional service in the Naval Reserve through 1993. These matters are before the Board of Veterans' Appeals (Board) on appeal from November 2015, April 2016, and July 2017 and rating decisions. A May 2017 rating decision granted individual unemployability (TDIU) from February 12, 2016. A December 2018 Board decision denied entitlement to a rating in excess of 30 percent for residuals of fibroid cysts and remanded these matters for additional development. An August 2021 rating decision increased the rating for the Veteran's abdominal scar to 20 percent from September 24, 2019. 1. Entitlement to service connection for skin lesions. Service connection may be established for disability due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. To establish service connection for a claimed disability, there must be evidence of: (i) a present claimed disability; (ii) incurrence or aggravation of a disease or injury in service; (iii) and a causal relationship between the present disability and the disease or injury in service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303 (a). Secondary service connection may be granted 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). To substantiate a claim of secondary service connection there must be evidence of (i) a current chronic disability for which service connection is sought; (ii) an already service-connected disability; and (iii) that the already service-connected disability (a) caused or (b) aggravated the disability for which service connection is sought. See Allen v. Brown, 7 Vet. App. 439 (1995). Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159 (a)(2). Competent medical evidence is necessary where the determinative question requires medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). 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); 38 C.F.R. § 3.102. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Service treatment records show that the Veteran sought treatment in May and June 1981 for rash in the inguinal and breast areas respectively. The treatment was with surface medication and there was no follow-up. Physical examinations in June 1984, December 1985, and April 1986 were silent for any skin abnormalities other than birth marks and minor scar. Concurrent with the last two examinations, the Veteran denied any history or current skin disorders in medical history questionnaires. In February 2016, the Veteran sought VA mental health treatment. A clinician diagnosed depression and referred the Veteran for medication management. In March 2016, a VA psychiatric nurse practitioner prescribed a mild antidepressant medication (mirtazapine). The same month, the Veteran underwent a mental health examination by a VA psychologist who found that the depression was a recurrence of a prior disorder due to the loss of childbearing ability associated with gynecological treatment in service. There was no mention of skin rashes in these encounters. In April 2016, the RO granted service connection for major depressive disorder. Starting in late 2016, outpatient records inconsistently note the use of surface medication for rash but also contain multiple Veteran denials of any rashes. On December 2016 dermatology record, a clinician noted that it was unclear which medication caused a rash (or if medication was the cause). It was recommended that the Veteran restart Wellbutrin as an anti-depressant medication. A February 2017 VA dermatological treatment note indicates that the Veteran reported doing well since going back on Wellbutrin and has full confidence in the medication. The specialist noted that the Veteran did not think that the medication caused her skin rashes. She still gets mild flare-ups once in a while In June 2017 correspondence the Veteran reported experiencing a skin condition that sometimes would not increase when she stopped taking her prescribed medication for depression. A new medication seemed to make the symptoms worse, but she reported a need to continue the medication to treat mental health disorder. In June 2017, the Veteran underwent a VA examination for the skin disorder, performed by an internist who referred to the previous dermatology outpatient records. The examiner noted a diagnosis by the dermatologists of pityriasis lichenoides chronica (PLC) based on a biopsy and a date of diagnosis noted as "end of 2016." The clinician opined that it was less likely than not that the Veteran's skin condition was related to her service-connected depression. The clinician noted, "PLC is an idiopathic acquired dermatosis that is classified as groups of erythematous scaly papulaes which can persist for months. It appears to be due to a hypersensitivity reaction to infectious agents such as EBV, adenovirus or parvovirus. Initially, a consideration of a medication side effect due to her anti-depressants was considered due to the fact it was started around the time of the onset of her rash. However, discontinuing it did not affect the rash at all per dermatology note dated 1/17/17 making it very unlikely that the medication was the culprit. The examiner found that the PLC was less likely than not caused by medication taken for depression. In an October 2017 Notice of Disagreement, the Veteran vehemently disagreed with the VA examiner's findings. She questioned the examiner's qualifications as an internist and not a dermatologist. She challenged the examiner's conclusions that the Veteran's PLC was due to hypersensitivity reactions to infectious agents. She contends that her dermatologist concluded her lesions were due to her various antidepressants not just one. She said once she stopped all antidepressants, the lesions dissipated. In October 2017, the same internist provided a more detailed opinion in response to request by the RO to consider the skin treatment in service in 1981 and the June 2017 letter from the Veteran. The internist first explained that the fungal rash treated in service was different from the current PLC and not a progression of the fungal infection in service. The internist summarized the outpatient dermatology records in detail. The internist noted, "The cause of pityriasis lichenoides is not well understood. It has been found that there is a proliferation of immune cells, called T-cells, in the skin. It is believed that genetically susceptible individuals mount an inappropriate immune response to a foreign agent, such as a virus or medication, which causes inflammation in the skin. The internist noted that her research found that some medications for depression causes itching or hives and that antihistamines can cause PLC or PLEVA, but the Veteran was not taking those medications. The internist stated that the cause of PLC is almost never found but acknowledged that she was not a dermatologist and therefore could not provide an opinion without speculation. In December 2018, the Board remanded the claim to obtain a medical opinion from a dermatologist. In September 2019 skin diseases disability benefits questionnaire (DBQ), the diagnosis was pityriasis lichenoides et varioliformis acuta (PLEVA). The examiner is a neurologist and noted the onset as "service" without explanation. Following an examination, the dermatologist noted only that there was no correlation between depression and PLEVA without discussing the effects of medication. On November 2020 medical opinion, a nurse practitioner (NP) who summarized the dermatological records since 2017. The NP opined that it was at least as likely as not that the Veteran's pityriasis lichenoides chronica (PLC) proximately due to or aggravated by her service-connected depression to include any medications taken to treat the Veteran's depression. The clinician noted that the etiology of the Veteran's skin disorder was unknown, but it is possible for the Veteran's service-connected depression to aggravate the skin episodes and noted also that it was reported that the Veteran's skin condition occasionally occurred in association with medication exposure. On April 2021 skin conditions DBQ, a VA contract dermatologist noted the diagnosis was pityriasis lichenoides chronica. The Veteran's skin condition started one week after she was diagnosed with anxiety/depression. It was noted that the rash persisted when medication stopped. The clinician opined that it was less likely than not that the Veteran's skin condition was caused or aggravated by her service-connected depression. The clinician noted that the Veteran's skin disorder was of an unknown etiology but believed to be an inflammatory response to an infection or antigenic trigger. The clinician noted that the Veteran's skin condition remained after the medication was stopped. The clinician noted that it was conceivable that medication caused the antigenic trigger like how a virus would invoke an inflammatory antigenic response and that condition would remain after stopping the drug. However, the dermatologist noted, "...there is no way that a dermatologist could say it if 50 percent or greater probability that her depression medication was the initial trigger. I do believe that is possible, maybe even likely, but there is no scientific way of assigning a 'more likely than not probability to a disease that has no known etiology. I have reviewed the literature in particular for this patient's claim ...but there simply is not enough anecdotal evidence on this drug as the triggering event." It is not in dispute that the Veteran has skin lesions (which has been diagnosed on VA examination and by biopsy). There are somewhat conflicting medical opinions in the record regarding the etiology of the skin lesions. In support of the Veteran's claim is the November 2020 opinion which found that it was at least as likely as not that the Veteran's skin condition was caused or aggravated by her depression, to include medication for depression. Against the Veteran's claim is the opinions provided in September 2019 and April 2021. The Board finds that the opinion offered in September 2019 is conclusory and warrants less probative value. In addition, the Board requested an opinion from a dermatologist not an NP. Additionally, the April 2021 opinion found that the Veteran's skin condition was less likely than not related to her service-connected depression. However, upon review of the rationale provided the Board finds that the opinion offered is more inconclusive than against the Veteran's claim. Notably, the clinician stated that it was conceivable that medication caused the antigenic trigger like how a virus would invoke an inflammatory antigenic response and that condition would remain after stopping the drug, but ultimately stated the etiology of the Veteran's skin condition was unknown. The Board finds that the cumulative evidence places at least in equipoise the matter of whether the Veteran's skin lesions are secondary to medications for her service-connected depression. Resolving reasonable doubt in her favor, as required, the Board finds that secondary service connection for skin lesions is warranted. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule). The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned When the appeal is from the initial rating assigned with an award of service connection, the entire period from the initial assignment of the disability rating to the present is to be considered, and "staged" ratings may be assigned based on facts found. See Fenderson v. West, 12 Vet. App. at 125-26 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 2. Entitlement to an initial rating in excess of 70 percent for major depressive disorder. Major depressive disorder is rated under Code 9434 and the General Rating Formula for Mental Disorders, which provide for a 100 percent rating when there is total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. In Mauerhan v. Principi, 16 Vet. App. 436 (2002), the United States Court of Appeals for Veterans Claims noted that the list of symptoms in the Board's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather is to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. When adjudicating psychiatric claims, the Board has an obligation under Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017) to conduct a three-part "holistic" analysis. The first step of the analysis is to assess the "severity, frequency, and duration of the signs and symptoms" of the Veteran's condition. The second step is to quantify symptoms." The third step is to assign an "evaluation that most closely approximates that level of occupational and social impairment. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (2013) (holding that the disability rating schedule for psychiatric disabilities reflects "objectively-observable symptomatology," and "it is the severity of the effects of the symptoms as described by the examiner that determines the rating."). On March 2016 mental disorders DBQ, the diagnosis was recurrent major depressive disorder. The Veteran reported experiencing sadness almost every day, loss of interest in usual activities, crying spells, change in appetite, sleep disturbances, fatigue/low energy, feeling of worthlessness, difficulty concentrating, occasional recurrent thoughts of death. Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, thinking and/or mood were noted. Symptoms were noted as depressed mood, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. The Veteran was noted as alert and oriented, casually dressed, and appropriately groomed. The Veteran was found to be capable of managing her financial affairs. She reported a history of physical violence and verbal altercations. The examiner noted the Veteran was not currently employed but opined that if the Veteran were to attempt to return to work, she would experience a severe level of occupational impairment in both physical and sedentary employment due to symptoms of depression. An August 2016 mental health hotline record notes that the Veteran called and reported that she had been having suicidal thoughts more frequently and that her depression was too much, and she had become scared. A September 2016 mental health record notes the Veteran reported successful outings to the park and the grocery store. She reported feeling overwhelmed while shopping but relied on her friend for support. A February 2018 mental health record notes the Veteran reported a mild panic attack a few days prior. A May 2018 mental health record notes the Veteran reported increased panic attacks in the past two weeks, occurring two to three times per week. An August 2018 mental health outpatient record notes the Veteran reported feeling tired and irritable. An August 2018 Social Security disability decision found the Veteran to be disabled due to an affective/mood disorder. A November 2018 mental health outpatient record notes the Veteran was doing well and better than the prior visit. A May 2019 mental health outpatient record notes the Veteran reported occasional panic attacks (approximately three times a month while driving). On September 2019 mental disorders DBQ, the diagnosis was major depressive disorder. The Veteran reported that when her depression feels worse, she sometimes will not get out of bed and not attend to daily things, and not attend to hygiene some days. Reported not washing up for seven days at times. The Veteran denied suicidal ideation. Occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood was noted. Symptoms of depressed mood, anxiety, panic attacks occurring weekly or less often, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or worklike setting. The Veteran was found to be capable of managing her financial affairs. The examiner noted that the Veteran's depression had not improved since she was last examined in 2016, and that the Veteran mostly stays in her home, does not have the motivation to go out and can stay in bed with little hygiene effort for up to a week at a time. Examinations in March 2016 and September 2019 found occupational and social impairment with deficiencies in most areas. The record demonstrates that on occasion the Veteran has demonstrated an inability to perform activities of daily life and has relied on the assistance of friends and family to complete activities of daily living. The Veteran reported occasionally not leaving bed for up to a week and not showering during this time. The Veteran also has reported panic attacks while driving which have required her to seek assistance from friends and family. Additionally, the record contains history of suicidal ideation as well as a history of physical violence, and verbal altercations. On March 2016 examination, the examiner opined that if the Veteran were to attempt to return to work, she would experience a severe level of occupational impairment in both physical and sedentary employment due to symptoms of depression. Under such circumstances, the Board finds that the weight of competent and credible evidence suggests that the Veteran's major depressive disorder is more severe than that contemplated by the 70 percent rating and more closely approximates that of total occupational and social impairment. Accordingly, the Board finds that a 100 percent rating is warranted for major depressive disorder. 3. 4. Entitlement to an initial compensable rating for an abdominal scar prior to September 24, 2019 and a rating in excess of 20 percent from September 24, 2019. Unstable or painful scars are rated under Code 7804. A 10 percent rating is warranted with one or two scars that are unstable or painful. A 20 percent rating is warranted for three or four scars that are unstable or painful. A 30 percent rating is warranted for five or more scars that are unstable or painful. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of the skin over the scar. Note (2) proves that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this Code, when applicable. Various treatment records note the presence of a transverse scar of the abdomen. An October 2015 gynecological examination noted a well healed lower linear abdominal scar measuring 25 cm. In October 2016 correspondence, the Veteran reported that her abdominal scar was 14 inches across the entire abdomen and that it often itches and swells. On September 2019 scars DBQ, one abdominal surgery scar was noted. The scar was described as painful (itching/burning). The scar was described as sloughing. The scar was noted as 24 x 1 cm (approximate are of 24 cm2). Prior to September 24, 2019 Prior to September 24, 2019 the Veteran's abdominal scar is noncompensable. A review of medical records prior to September 24, 2019 does not show record of the Veteran's abdominal scar being painful or unstable. Notably, an October 2015 gynecological examination notes the Veteran's abdominal scar as well healed. In October 2016 correspondence, the Veteran stated that her scar often itches and swells. However, such description does not demonstrate that the scar was painful or unstable. Accordingly, a compensable rating prior to September 24, 2019 for an abdominal scar is not warranted. From September 24, 2019 From September 24, 2019 the Veteran's abdominal scar is rated 20 percent based on a finding of one scar that is painful and unstable. See 38 C.F.R. § 4.118, Code 7804 Note 2. Accordingly, the question is whether a rating in excess of 20 percent is warranted from that time. At no time are five or more scars that are unstable or painful shown. Additionally, at no time are three or four scars that are painful and unstable shown. Accordingly, a rating in excess of 20 percent is not warranted. SMC 4. Entitlement to SMC based on housebound status. SMC at the housebound rate is payable to a Veteran who has a single service-connected disability rated 100 percent disabling and either (a) has an additional service-connected disability, or disabilities, independently rated 60 percent, which (i) is/are separate and distinct from the service-connected disability rated 100 percent and (ii) involve(s) different anatomical or bodily symptoms; or (b) is permanently housebound by reason of a service-connected disability or disabilities. The latter requirement is met when the Veteran is substantially confined to her dwelling and the immediate premises as a direct result of service-connected disabilities, and it is reasonably certain that the disabilities will continue throughout her lifetime. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). As a result of this decision, the Veteran now has a single service-connected disability rated at 100 percent (major depressive disorder). However, the Veteran's additionally service-connected disabilities are not independently rated 60 percent, and the Veteran is not shown to be permanently housebound by reason of a service-connected disability or disabilities. Accordingly, entitlement to SMC at the housebound rate must be denied for lack of legal entitlement under the law. See Sabonis v. Brown, 6 Vet. App. 426. 5. Entitlement to SMC based on the need for aid and attendance. SMC at the aid and attendance rate is payable when the veteran, due to service-connected disability, has suffered the anatomical loss or loss of use of both feet or one hand and one foot, or is blind in both eyes with visual acuity of 5/200 or less, or is permanently bedridden or so helpless as to need regular aid and attendance. 38 U.S.C. § 1114 (l); 38 C.F.R. § 3.350 (b). Determinations as to the need for aid and attendance must be based on actual requirements of personal assistance from others. In making such determinations, consideration is given to such conditions as: inability of the claimant to dress or undress himself or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which, by reason of the particular disability, cannot be done without aid; inability of the claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from the hazards or dangers incident to her daily environment. "Bedridden" will be a proper basis for the determination, and is defined as that condition which, through its essential character, requires that the claimant remain in bed. It is not required that all the disabling conditions enumerated above be found to exist before a favorable rating may be made. The personal functions that the claimant is unable to perform should be considered in connection with her condition. It is only necessary that the evidence establish that the claimant is so helpless as to need regular aid and attendance, not that there be a constant need. 38 C.F.R. § 3.352 (a). The Veteran is service connected for major depressive disorder (now at 100 percent), residuals of fibroid cysts rated 30 percent, a painful surgical abdominal scar (rated 20 percent from September 24, 2019, and 0 percent prior to that date), and residuals of a biopsy of the inside of the mouth rated 0 percent. The Veteran was previously granted TDIU effective February 12, 2016. The evidence does not show or suggest that the Veteran is blind or has loss of use both feet or of a hand and a foot due to service-connected disability. Her claim, therefore, turns on whether he is bedridden or requires aid and attendance due solely to her service-connected disabilities. Throughout the pendency of the appeal the Veteran was not shown to be permanently bedridden or hospitalized and was able to travel beyond her domicile. Notably, while some assistance was required to help the Veteran manage symptoms of depression, or adapt to daily living during increased depressive episodes, the Veteran was not shown to require regular aid and attendance. The degree to which the Veteran requires assistance with acts of daily living is contemplated by the above assigned 100 percent rating for major depressive disorder. Accordingly, the preponderance of the evidence is against the claim of entitlement to SMC based on the need for regular aid and attendance and the appeal in the matter must be denied. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Staskowski, 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.