Citation Nr: 21068906 Decision Date: 11/15/21 Archive Date: 11/15/21 DOCKET NO. 15-33 671 DATE: November 15, 2021 ORDER An initial rating in excess of 30 percent for headaches prior to August 4, 2021, is denied. A rating in excess of 50 percent for headaches since August 4, 2021, is denied. Service connection for a right knee disorder is denied. Service connection for a left knee disorder is denied. Service connection for rheumatoid arthritis (RA) is denied. REMANDED Service connection for hypertension. FINDINGS OF FACT 1. The Veteran had active duty from June 1978 to March 1986; he has been 100 percent disabled since June 2018. 2. Prior to August 4, 2021, headaches were manifested by subjective complaints of severe headaches; objective findings include, at worst, migraines that do not include very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 3. Since August 4, 2021, the Veteran is in receipt of the maximum schedular rating for migraine headaches. 4. A current right knee disorder, diagnosed as osteoarthritis, was not shown in service, was not shown to a compensable degree within one year of service, symptoms were not continuous since service; a current right knee disorder is not causally or etiologically related to service, and was not caused by or permanently worsened in severity by a service-connected disability. 5. The Veteran sustained a left knee injury in service; symptoms of a left knee disorder were not chronic in service, were not continuous since service, and were not shown to a compensable degree within one year of service. A current left knee disorder, diagnosed as osteoarthritis, is not causally or etiologically related to service, and was not caused by or permanently worsened in severity by a service-connected disability. 6. RA was not shown in service or to a compensable degree within one year of service; symptoms of RA were not continuous since service; current RA is not causally or etiologically related to service, and is not caused or aggravated by service-connected disability. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 30 percent for headaches prior to August 4, 2021, have not been met. 38 U.S.C. §§ 1131, 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code (DC) 8100 (2021). 2. The criteria for a rating in excess of 50 percent for headaches since August 4, 2021, have not been met. 38 U.S.C. §§ 1131, 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, DC 8100 (2021). 3. A right knee disorder was not incurred in service, was not proximately due to, aggravated by, or the result of a service-connected disability, and may not be presumed to have been incurred in service. 38 U.S.C. §§ 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2021). 4. A left knee disorder was not incurred in service, was not proximately due to, aggravated by, or the result of a service-connected disability, and may not be presumed to have been incurred in service. 38 U.S.C. §§ 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2021). 5. RA was not incurred in service, was not proximately due to, aggravated by, or the result of a service-connected disability, and may not be presumed to have been incurred in service. 38 U.S.C. §§ 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In August 2018, December 2020 and June 2021, the Board remanded the issues for further development. The issue of an increased rating for headaches was also denied in August 2018 and appealed by the Veteran to the Veterans Claims Court. The Court Clerk granted a joint motion for remand (JMR) in January 2021. There has been substantial compliance with the remand directives, and there is no bar to proceeding with the appeal. Stegall v. West, 11 Vet. App. 268, 271. Increased Ratings for Headaches Turning to the relevant laws and regulations, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The Veteran was in receipt of a 30 percent rating under DC 8100 for headaches prior to August 4, 2021, and 50 percent thereafter. Under DC 8100, a 50 percent rating is the highest permitted rating and is warranted when the objective medical evidence shows migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. In a March 2016 VA examination, the Veteran reported headaches which sometimes turned into migraines. He denied any complaints of memory impairment, attention, concentration, or executive functions. He was always oriented to person, place, and time, had no issue with motor activity, and normal visual spatial orientation. He reported only mild or occasional headaches, with head pain, pulsating, or throbbing with pain on both sides of his head. He stated that he had missed work for a total of four times and treating with acetaminophen. Despite his description to the contrary, in June 2016, his girlfriend submitted a statement saying that he had severe headaches daily which came with blackouts, mood swings and forgetfulness. He echoed these sentiments with a January 2017 statement where he reiterated having constant pulsating and throbbing headaches. A review of the VA and private treatment records noted only occasional headaches which were treated with acetaminophen and he admitted that he had decreased headaches several times in VA treatment notes. Despite occasional complaints of worsening in later VA treatment records, there was no evidence of migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. At a January 2021 VA examination, the Veteran reported an increase in the intensity of headaches by at least 30 percent. He admitted that he had not seen a neurologist or received any follow up treatment since the last VA examination and treated it only with Tylenol. He experienced headaches beginning in his bilateral temples with pressure and throbbing occurring 4-5 per week lasting approximately 2 hours. He noted that 90 percent of the headaches were debilitating. The Veteran denied an aura with headaches but reported blurred vision and photo and phonophobia, with dizziness, and occasional nausea and vomiting. He denied any issues with weakness, gait, speech, or mentation. Based on his description, the examiner determined that he had migraines with prostrating attacks once every month, that were not productive of severe economic inadaptability. These findings were consistent with the findings of no complaints or treatment for headaches. At an August 2021 VA examination, the Veteran reported headaches five to six times per week lasting four to eighteen hours in duration with 25 days of headaches per month. He reported that they were occasionally so severe he experienced dizziness and blurred vision for which he had to leave work. He treated them with Tylenol but reported missing work two to three times a week for headaches. The examiner found that the Veteran had migraines with prostrating attacks once every month that were productive of severe economic inadaptability. After considering the totality of the evidence, the Board finds that the Veteran's headaches were properly contemplated by the assigned 30 percent rating prior to August 4, 2021. Specifically, while he reported severe headaches several times a week, he did not report missing work prior to the August 2021 VA examination. Additionally, no VA examiner found that the headaches were productive of severe economic inadaptability prior to that time. Importantly, this was largely consistent with the available treatment records and the Veteran's own admissions that despite his allegedly severe symptoms, he failed to seek treatment. As such, headaches with prostrating attacks productive of economic inadaptability was not demonstrated prior to August 4, 2021. Since August 4, 2021, the Veteran has been in receipt of a 50 percent rating for headaches and contend that he is entitled to a higher rating; however, a 50 percent rating for headaches represents the maximum schedular rating available under DC 8100 and there are no other applicable diagnostic codes. Therefore, there is no higher schedular rating available regardless of the level of symptomatology. The Board has also considered the Veteran's lay statements that his disability is worse. While he is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of these disorders according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's headaches has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which this disability is evaluated. Moreover, as the examiners have the requisite medical expertise to render medical opinions regarding the degree of impairment caused by the disability and had sufficient facts and data on which to base the conclusions, the Board affords the medical opinions great probative value. As such, these records are more probative than the Veteran's subjective complaints of increased symptomatology. In sum, after a careful review of the evidence of record, the benefit of the doubt rule is not applicable, and the appeals are denied. Service Connection Claims Service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection may be granted on a presumptive basis for diseases listed in 38 C.F.R. § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Bilateral Knee Disorders The Veteran contends that the bilateral knee disorders are a result of the marching, heavy lifting of rucksacks, and other demanding physical activities in service. Alternatively, he suggests that the knee disorders are a result of, or aggravated beyond their natural progression by, the other service-connected musculoskeletal disabilities to include pes planus, radiculopathy, and lumbar spine. As to a current diagnosis, the Veteran was diagnosed with bilateral synovitis of the knees in 2015, as well as left knee osteoarthritis in March 2011 with indications of right knee osteoarthritis appearing in 2014. Thus, current diagnoses are shown, and the first element of service connection is met. As to an in-service incurrence, the service treatment records (STRs) are silent as to any right knee injury or treatment during service. Additionally, an October 1988 medical examination revealed no complaints for a right knee disorder and the lower extremities were normal upon examination. Regarding the left knee, the records reflect that the Veteran fell into a trench and injured the left knee in March 1981. Upon examination, stability was equal bilaterally, slight edema was shown, and probable strain was diagnosed. There were no further complaints or treatment for the left knee and the lower extremities were normal at a periodic examination in October 1988, two years after discharge. While the STRs do not shown any notations of, or diagnosis for a right knee disorder during service, he has given a history of activity which may be accepted as an in-service incurrence. Thus, the second elements of both direct and secondary service connection are also met. As to a medical nexus between the Veteran's bilateral knee synovitis and osteoarthritis and an in-service injury, evidence weighing against the appeals consists of several VA examination and opinion reports which failed to find an etiological connection. Specifically, a September 2015 VA examiner reviewed the file, examined the Veteran, and opined it was less likely than not that the bilateral knee disorders were related to service. The examiner reasoned that the Veteran was diagnosed with RA in 2013 and that record review documents migratory joint issues. The examiner noted that while the STRs revealed a left knee strain, it healed as would be anticipated in a young person with X-rays showing no significant arthritis. Further, an examination of both knees was consistent with mild synovitis which was classically associated with the diagnosis of RA. As the Veteran has a separate claim pending before the Board for RA, its etiology will be discussed in greater detail below. In a November 2019 VA examination, the Veteran complained of pain with bending, kneeling, standing, walking, and sitting for prolonged periods of time. After examining the Veteran and reviewing all records, the examiner opined it was less likely than not that the bilateral knee disorders were related to service. The examiner reasoned that there was no evidence of in-service injury for the right knee, and that the left knee injury in service was acute. The examiner further noted that there was no evidence of chronicity of care. At a January 2021 VA examination, after a review of the record and examination of the Veteran, a similar opinion was rendered that it was less likely than not that the Veteran's bilateral knee disabilities were related to service. The examiner reasoned that there was no documentation noted in the provided records for complaints of, evaluation, diagnosis, or treatment for any knee condition during service. Additionally, there was no documentation for any knee diagnosis until, at the earliest, March 2011, more than 25 years after service. The examiner noted that this did not satisfy continuity of care or concern for a knee condition which began in service. Next, the examiner noted that the Veteran had mild tricompartmental osteoarthritis which was more likely than not an age related finding. These findings were confirmed by an August 2021 VA examination. Once again, after a thorough examination and review of the record, the examiner opined it was less likely than not that the Veteran's bilateral knee disorders were related to service. The examiner acknowledged a March 1981 left knee injury and noted that there were no additional knee injuries or treatment noted during service. Additionally, while the separation examination was not found, an October 1988 periodic examination revealed normal lower extremities. The examiner noted there were no additional medical records from October 1988 to March 2011 which revealed knee complaints until diagnosed with left knee osteoarthritis in 2011, and RA in 2014. Later, in November 2014, bilateral arthritic changes were found in both knees. The examiner noted that osteoarthritis was a chronic, progressive condition which worsens with age. The nature and etiology of the knee disorders were age related, as according to medical literature, the risk of developing osteoarthritis increased with age. The examiner noted that the left knee disorder specifically was less likely than not caused by the left knee strain during service as the periodic examination revealed normal lower extremities. The examiner stated that this was an indication that the Veteran's strain had resolved and allowed him to be retained for a second tour of service. Additionally, he had no more documented complaint of knee pain until March 2011. As such, the 30-year gap in any documentation of knee pain weighed against a nexus. These opinions weigh heavily against direct service connection and there are no contradictory medical opinions of record. With regard to secondary service connection, the Veteran has been service connected for bilateral pes planus since February 2016, degenerative arthritis of the spine and left lower extremity radiculopathy since December 2009, and right lower extremity radiculopathy since October 2020. As to a nexus between the service connected disabilities and current disorder, a November 2019 VA examination and opinion report reflects that the examiner examined the Veteran and reviewed the claims file and opined it was less likely than not that the bilateral knee disorders were related to a service-connected disability. The examiner reasoned that the complaints in service were acute and no chronicity of care was demonstrated and that the knee disorders were not related to any service-connected disability or its treatment. A May 2020 addendum opinion was obtained which again echoed the prior findings. Specifically, the examiner found that the STRs reveal one mention of left foot pain for a week in 1983, but that there was no mention of a limp in or out of service on the left leg from pes planus. Importantly, there was no mention of a limp at all until 2019. Specifically, the examiner noted that the only limp noted was in October 2019, on the right, and was related to L4-5 radiculopathy, with right nerve roots affected. The examiner opined that this was unrelated to either left pes planus diagnosis or bilateral knee arthritis. Additionally, that right radiculopathy causing a slight limp did not occur until 33 years after service, which is also unrelated to left foot pes planus or arthritis of the knee. The examiner continued that the only rational explanation that left foot pes planus could cause bilateral knee arthritis would be a chronic limp over several years causing a severely altered gait, significant enough to cause arthritis. Additionally, it would be expected that the limp would occur on the left, as this is the foot service-connected for pes planus. Importantly, the examiner noted, there was no evidence of any lump on the left in medical documentation, and no mention of pes planus after service. Finally, the examiner states that there is no nexus to causally connect in any way, left foot pes planus and bilateral knee arthritis, as they were separate, noncontributory entities, without relationship to one another. At a January 2021 VA examination, after reviewing the record and examining the Veteran, another VA examiner supported a similar opinion. The examiner went through and outlined each of the Veteran's service-connected disabilities noting that they were wholly unrelated to the Veteran's bilateral knee disorders. Specifically, sleep apnea was related to obstruction of the posterior oropharynx by soft tissues in the throat to include the tongue, bilateral pes planus and lumbar spine arthritis were biomechanical and trauma related conditions, tinnitus was related only to loud noises, carpal tunnel syndrome was a nerve impingement syndrome, GERD was to do only with lack of potency of the esophageal sphincter, and headaches were related to spasms of the muscles of the posterior cervical spine. In addition, the examiner noted that the Veteran's bilateral osteoarthritis was more likely than not an age related finding. The examiner reasoned that as biomechanical forces go up the kinetic chain, not down, the only service connected conditions that could possibly cause bilateral knee conditions would be the bilateral foot conditions, and possibly the low back conditions. The rest of the Veteran's service-connected conditions were mutually exclusive disease processes. The examiner noted that there was no evidence of any abnormal gait to support a causal relationship between a foot or low back disorder with the Veteran's mild bilateral osteoarthritis. The examiner also stated that a mild abnormal gait was noted at a July 2020 VA examination which was noted to have resolved and therefore, any abnormal gait was too inconsistent to establish a causal relationship or one of aggravation. This evidence weighs against the appeal on a secondary service connection basis. Next, as osteoarthritis is shown, presumptive service connection must be considered. To that end, the evidence does not show a chronic bilateral knee disorder in service, no chronic knee disorder manifested to a compensable degree in the year following separation from service, and no complaints of knee pain following separation until, at the earliest, 2011. As such, the medical evidence does not support service connection of a presumptive basis. The Veteran's available treatment records have also been reviewed, but failed to provide any nexus opinion from a medical provider. As such, the medical evidence does not support service connection under any theory of service connection. Rheumatoid Arthritis The Veteran asserts that RA is due to strenuous marching and physical demands in service. Alternatively, he suggests it was caused or aggravated by the service-connected musculoskeletal disorders, specifically, the service-connected pes planus, spine, and radiculopathy disabilities or medications for such. Initially, medical records show notations of RA beginning in 2013; however, a dispositive diagnosis was not shown until January 2014. Nonetheless, a current disorder is shown, and the first element of service connection is met. As to an in-service incurrence, the STRs do not shown any notations of, or diagnosis for RA during service; however, he has given a history of activity which may be accepted as an in-service incurrence. Thus, the second elements of direct is met. As to a medical nexus, in a September 2015 VA examination, the examiner noted that RA was the most common form of autoimmune arthritis which was caused by certain cells of the immune system not working properly and beginning to attack healthy tissues, specifically the joints. There was no indication of a connection to an in-service disease or injury. An October 2016 VA examiner similarly noted that all entries in the Veteran's file were reviewed, which included numerous primary care visits, and abundant rheumatology visits, among others. The examiner noted that the Veteran had a diagnosis of left carpal tunnel syndrome, headaches, and traumatic brain injury (TBI) for which he was on multiple medications. The examiner noted that the rheumatology visits made no mention of medications taken for RA that would suggest any aggravation beyond natural progression. Next, other reports stated he used acetaminophen for headache, but other entries made mention of a violated pain contract. There was no medication treatment noted for carpal tunnel or TBI. The examiner noted that RA appeared to be progressive but at times, had great relief with pain management as noted in the rheumatology visits, thus, there was no reliable evidence found that any medications taken or RA, TBI, or carpal tunnel aggravated RA beyond its natural progression. A November 2019 VA examination echoed this opinion, noting that it was less likely than not that RA was due to service. The examiner noted that RA was an autoimmune disorder and that there was no supporting evidence that an autoimmune disorder was due to service as nothing was noted in service. The examiner also opined that it was less likely than not that RA was caused or aggravated by the service-connected disabilities. At that time, the examiner noted that he was unable to confirm a chronic diagnosis of RA. In a January 2020 addendum opinion, the examiner clarified that there was no supporting evidence that an autoimmune disorder such as RA had a link to service or service-connected disability. The examiner noted that RA was not caused by any issues with pes planus, carpal tunnel, or headaches, since it was autoimmune. The examiner also noted that the conditions were not medically related as they were separate entities entirely from one another, and medical literature did not support a medical relationship. At a January 2021 VA examination, the examiner once again opined it was less likely than not that RA was due to service or any service-connected disability. Specifically, the examiner noted that there was no documentation in the provided records for the diagnosis or treatment for RA during the Veteran's service. In this regard, he was not diagnosed with the disorder until 2014, 28 years following service, and did not satisfy continuity of care and concern for an RA disorder. This evidence weighs against the appeal. With regard to secondary service connection, although the Veteran alleged a relationship with the musculoskeletal disabilities, the examiner outlined the etiologies of all the Veteran's service-connected disabilities. The examiner noted that sleep apnea was causally related to obstruction of the posterior oropharynx by soft tissues in the throat, GERD was causally related to a lack of patency of the esophageal sphincter at the top of the stomach, pes planus was a biomechanical disorder, lumbar spine arthritis and lower extremity radiculopathy were biomechanical and trauma related disorders, and headaches were due to spasm of the muscles of the posterior cervical spine. With regard to RA, the examiner noted it was an autoimmune process which was unrelated. The examiner noted that after a thorough review of the current medical literature, there was insufficient medical evidence for any causal, or aggravation relationship between the Veteran's service-connected disabilities and RA. Specifically, these are all mutually exclusive disease processes with respect to RA. The examiner also noted it was less likely than not that there was any aggravation of the Veteran's RA by the service-connected disabilities. Once again, a review of current medical literature was noted which returned no evidence of an association between these disabilities and RA. The examiner again stressed that these were all mutually exclusive disease processes from RA. Although the Veteran was diagnosed with the claimed disorders and has asserted that the disorders are related to service, there is no evidence to corroborate the assertions of any in-service disease or injury related to any type of arthritis, or any other service-connected musculoskeletal disorder. In addition, he has not asserted that he has had a continuity of symptomatology since service. Of note, arthritis was first diagnosed decades after separation from service, and there is no evidence of symptoms indicative of arthritis prior to that date. As RA a chronic disease, did not manifest in service, within the one-year presumptive period or for many years thereafter, and is not otherwise related to service, entitlement to service connection is not warranted on a direct or presumptive basis. Further, there is no medical evidence establishing a nexus between any service connected disability or service, and the current RA, which was diagnosed, at the earliest, in 2013. As to the examinations undertaken, the Board finds that they were adequate for evaluation purposes. Specifically, the examiners reviewed the claims file, interviewed the Veteran, and conducted physical examinations. There is no indication that the VA examiners were not fully aware of the Veteran's past medical history or that they misstated any relevant fact. Moreover, the examiners have the requisite medical expertise to render medical opinions regarding the etiology of the disorders and had sufficient facts and data on which to base the conclusions. Finally, and perhaps most importantly, there is no contradicting medical evidence of record. Therefore, the Board finds the VA examiners' opinion to be of great probative value. The Board finds that the various VA examinations were adequate for evaluation purposes. Specifically, each examiner reviewed the claims file, interviewed the Veteran, and conducted a physical examination. There is no indication that any VA examiner was not fully aware of the Veteran's past medical history or that he misstated any relevant fact. Moreover, the examiners have the requisite medical expertise to render a medical opinion regarding the etiology of the disorders and had sufficient facts and data on which to base the conclusion. Further, there is no contradicting medical evidence of record. Therefore, the Board finds the VA examiners' opinions to be of great probative value. With regard to all appeals before the Board, the Board has also considered the Veteran's lay statements that his disorders were caused by service. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. However, he is not competent to offer an opinion as to the etiologies of the current disorders due to the medical complexity of the matters involved. Such competent evidence has been provided by the service records, clinical evidence, and examinations obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. In light of the above, the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND The Veteran contends that hypertension is secondary to service connected sleep apnea or psychiatric disorder. Medical records show he was diagnosed with hypertension in January 2012. He has been service connected for bipolar disorder and sleep apnea since July 2015. While a January 2021 VA examination provided a thorough etiology opinion regarding the relationship between hypertension and sleep apnea, the examiner did not address the bipolar disorder. Thus, an addendum opinion must be obtained. The matter is REMANDED for the following actions: 1. Identify and obtain any outstanding, pertinent, VA and private treatment records and associate them with the claims file. 2. Direct the claims file to a clinician to address whether it is at least as likely (50 percent or greater probability) that hypertension was caused or permanently worsened beyond its natural progression by, a service-connected bipolar disorder. The clinician should consider and address the medical articles submitted by the Veteran which suggest a relationship between hypertension and psychiatric disorders. A thorough rationale should be given for any opinion rendered. L. HOWELL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Yacoub, 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.