Citation Nr: 21071918 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 17-49 832 DATE: December 1, 2021 ORDER An initial compensable rating for service-connected hearing loss is denied. Service connection for posttraumatic stress disorder (PTSD) is denied. Service connection for a psychiatric disorder other than PTSD is denied. REMANDED Service connection for a disability manifested by dizziness and imbalance. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's hearing loss has been manifested by no worse than level II in the right ear and level IV in the left ear. 2. The Veteran does not have a psychiatric disorder, to include PTSD. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for hearing loss are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.85, Diagnostic Code (DC) 6100. 2. The criteria for service connection for PTSD are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3. The criteria for service connection for a psychiatric disorder other than PTSD are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1969 to June 1971, December 1990 to May 1991, and from July 2002 to January 2003. The case is on appeal from a December 2015 rating decision. In June 2019, the Veteran testified at a Board hearing. In a June 2019 decision, the Board remanded the present matters for further development. Additional evidence was received subsequent to the supplemental statement of the case (SSOC) issued in June 2021. As the evidence is not pertinent to the claims decided herein, a remand for RO consideration of the evidence is not necessary. See 38 C.F.R. § 20.1305(c). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating Legal Criteria Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. 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. Disability evaluations for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Examinations are conducted using the controlled speech discrimination tests together with the results of the pure tone audiometry test. See 38 C.F.R. § 4.85. The results are analyzed using the tables contained in 38 C.F.R. § 4.85, Tables VI and VII, DC 6100. The rating schedule for hearing loss provides that evaluations of hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000 and 4000 cycles per second (Hertz). To evaluate the degree of disability from defective hearing, the rating schedule established eleven auditory acuity levels designated from level I for essentially normal acuity through level XI for profound deafness. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Analysis 1. An initial compensable rating for service-connected hearing loss. The Veteran contends that the severity of his disability warrants an initial compensable rating for his service-connected hearing loss. The Veteran was initially afforded a VA audiological examination in connection with his claim of service connection in October 2015. The examiner reported the following pure tone thresholds, in decibels: HERTZ 10/29/2015 1000 2000 3000 4000 Avg CNC RIGHT 25 25 35 40 31.25 84% LEFT 25 30 55 65 43.75 78% As shown above, the average pure tone threshold for the right ear was 31.25 decibels with a speech discrimination score of 84 percent. The results correspond to level II hearing loss in the right ear. With respect to his left ear, the average pure tone threshold was 43.75 decibels with a speech discrimination score of 78 percent. The results correspond to level III hearing loss for the left ear accordingly. The results represent a noncompensable rating for his hearing loss pursuant to 38 C.F.R. § 4.85, Tables VI and VII. Pursuant to the June 2019 Board's remand, the Veteran was afforded a VA audiological examination in January 2020. The Veteran reported difficulty hearing others, which in turn causes frustration and embarrassment. The examiner reported the following pure tone thresholds, in decibels: HERTZ 01/15/2020 1000 2000 3000 4000 Avg CNC RIGHT 30 30 40 45 37 86% LEFT 35 40 60 70 51 76% As shown above, the average pure tone threshold for the right ear was 37 decibels with a speech discrimination score of 86 percent. The results correspond to level II hearing loss in the right ear. With respect to his left ear, the average pure tone threshold was 51 decibels with a speech discrimination score of 76 percent. The results correspond to level IV hearing loss for the left ear accordingly. While the results show an actual increase in severity for the Veteran's hearing impairment bilaterally, they still, however, represent a noncompensable rating for his hearing loss pursuant to 38 C.F.R. § 4.85, Tables VI and VII. In consideration of this evidence, the Board finds a compensable rating for the Veteran's hearing impairment is not warranted at any point during the appeal. While the Veteran contends an initial compensable rating must be warranted for his hearing loss, the mechanical hearing testing results from the VA audiological examinations of record show that the Veteran's hearing loss is correctly evaluated as noncompensably disabling. The evidence supports that throughout the pendency of the appeal he has experienced no worse than level II hearing loss in his right ear and no worse than level III in his left ear (see October 2015 VA examination report); or more recently, no worse than level II hearing loss in his right ear and no worse than level IV in his left ear (see January 2020 VA examination report). Thus, upon application of the rating criteria under DC 6100 to the audiological results, an increased rating is not warranted for the Veteran's bilateral hearing loss. In addition, the findings do not show an exceptional pattern of hearing impairment and, thus, 38 C.F.R. § 4.86 is not applicable. 38 C.F.R. §§ 4.85, 4.86, DC 6100. In this regard, the Veteran claims as part of the severity of his hearing loss disability symptoms manifested by dizziness and imbalance. As noted above, in the June 2019 decision, the Board recharacterized these symptoms as a separate claim of service connection, to include on a secondary basis given the claimed symptoms are not contemplated by the applicable DC. See Morgan v. Wilkie, 31 Vet. App. 162, 164 (2019). As such, the matter will be further addressed in the remand portion of this decision. In sum, the Board finds that the preponderance of the evidence is against an initial compensable rating for hearing loss based on the applicable criteria. As such, the benefit of the doubt doctrine is not applicable and an initial compensable rating for hearing loss is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Although the Board is remanding another claim for additional development, remand is not necessary for this issue, as there is no reasonable possibility that further assistance would substantiate the claim. See 38 C.F.R. § 3.159(d). Service Connection Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. Regarding National Guard or Reserve service, the applicable laws and regulations permit service connection only for disability resulting from disease or injury incurred or aggravated while performing ACDUTRA, or injury incurred or aggravated while performing inactive duty training (INACDUTRA). 38 U.S.C. § 101; 38 C.F.R. § 3.6. Service connection for mental disorders requires that a mental disorder conforms to the DSM-5 criteria. In other words, with respect to psychiatric disabilities, VA regulations expressly limits compensation to disabilities confirming to a DSM diagnosis. See Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020). For PTSD, service connection specifically requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a) (i.e., under the criteria of DSM); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). In general, to establish service connection there must be a currently diagnosed disorder during the claims period. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Romanowsky v. Shinseki, 26 Vet. App. 289 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Service connection for PTSD. 3. Service connection for a psychiatric disorder other than PTSD. Analysis The Veteran contends that he has PTSD due to service. In a May 2018 statement in support of claim for PTSD, he reported that in July 1984, while conducting training maneuvers with his National Guard Unit at Fort Hood, Texas, a military vehicle gave way while trying to cross a flooded creek and slid and rolled on its side and pinned in the muddy water a fellow National Guard servicemember causing him to drown instantly. The Veteran also asserts that he has additional psychiatric disorders manifested by depression and anxiety either due to the foregoing service incident, or as secondary to his service-connected hearing loss and tinnitus. See Board transcript at p.8. During his June 2019 Board hearing, the Veteran the indicated that the in-service event to which he attributes his PTSD was at some point between 1987 and 1988, as opposed to 1984 as reported in his May 2018 statement in support of claim for PTSD. See Board hearing transcript at p.6. See also January 2020 VA Mental Disorders Examination (the Veteran again confirmed the incident took place in June or July of 1987 or 1988 at Fort Hood, Texas). Service treatment records (STRs) do not account for complaints, reports, or treatment sought for a psychiatric disability. See April 1969 and January 1971 entrance and separation medical exams respectively active duty service; see also March 1991 separation medical examination and report of medical history for service with the Army National Guard. In the June 2019 decision, the Board noted that besides the Veteran's statements suggesting the existence of a current psychiatric disorder, post-service treatment records do not reflect treatment sought for a psychiatric disorder. The Board also found that in general, VA treatment records dated from July 2006 to March 2018 reflect that generic mental health assessments conducted throughout those years resulted in negative screenings for psychiatric disorders. The Board requested to obtain updated VA treatment records dated since March 2018 and any outstanding private treatment records in support and in connection with the claim. The Board also requested from the RO to request assistance from the Veteran in obtaining missing service treatment records (STRs) for the service period between July 2002 and January 2003. Ultimately, the Board pointed out that additional efforts to request records from JSRRC in connection with the alleged 1984 incident in an effort to verify the alleged stressor must be conducted while in remand status. With respect to VA treatment records, while in remand status the RO associated with the Veteran's claims file contemporaneous treatment records dated from April 2018 to June 2021. The newly associated records continue to show that generic mental health assessments conducted in October 2018, April 2019, and April 2021 resulted in negative screenings for psychiatric disorders. Specifically, during the October generic assessment, the Veteran denied anxiety, depression, homicidal ideations, insomnia, mood changes, PTSD symptoms, social avoidance, and suicidal ideation. The April 2019 PTSD screening resulted negative for PTSD (PTSD Screening Score = 0). The Veteran was asked whether he has ever experienced an unusual, especially frightening, horrible or traumatic experience to which he answered that he has never experienced this kind of event. See April 1, 2019 VA Primary Care note. With respect to the private treatment records, in December 2019 the RO requested from the Veteran to complete, sign, and return enclosed VA Forms 21-4142 (Authorization to Disclose Information to the VA) and 21-4142a (General Release of Information for Medical Provider Information to the VA) in an effort to assist him in obtaining any outstanding private medical records in connection with this claim, pursuant to 38 C.F.R. § 3.159(c), and in compliance with the June 2019 Board's remand directives. The Veteran was requested to return the completed forms in 30 days. Nothing was received within the time allotted. Nevertheless, a private treatment record from the Veteran's ENT specialist dated on January 8, 2020, and received while in remand status, reflects that the Veteran denied anxiety, depression, or mania. See Doctors Hospital at Renaissance progress notes. With respect to the missing STRs for the service period between July 2002 and January 2003, in a February 2020 letter, the RO requested from the Veteran a copy of his DD-214 for his service period from July 2002 to January 2003, to include all other separation papers for that period and all periods of service in compliance with the June 2019 Board's remand directives. In March 2020, the Veteran submitted a copy of his Army National Guard Retirement Points History Statement in response to the request. No additional evidence was received. In this regard, in its June 2019 remand, the Board pointed out that per an April 2009 letter, the Veteran had been already notified by VA that STRs for such period were not available despite various request efforts performed by the RO. As to the stressor question, a June 2021 Records Research Response completed by a professional researcher from the Veterans Benefits Administration determined that, after a comprehensive research of the Veteran's claimed stressor while serving with HHC, 3rd BN, 141st Inf. Regt., the National Archives Records Administration (NARA) was unable to locate records for the Unit and dates provided by the Veteran showing the drowning of a National Guard Soldier in 1984 during maneuvers at Ft. Hood, Texas. The foregoing was substantiated by additional reviews with the NARA Defense Casualty Analysis System (DCAS), and the OMAR Casualty Database. In conclusion, it was determined that no evidence was located to support documentation of the claimed stressor. Pursuant to the June 2019 Board's remand, the Veteran was afforded a VA psychiatric examination in January 2020. The Veteran reported that he has never received mental health treatment. He also reported that worked as a County Department Supervisor for 21 years after service where he oversaw contracts focused on job training, and later worked for Communities in school. The examiner, a clinical psychologist, did not mention or found a pattern of psychiatric problems during those years. The examination report reflects that the Veteran does not have a mental health diagnosis that conforms the DSM-5 criteria. Moreover, the examiner did not acknowledge psychiatric symptoms other than noting that per the Veteran's statements, he can have nightmares and disturbing memories "every once in a great while." The examiner noted that the Veteran was given a PHQ-9 (patient health questionnaire) and his score was 3 indicating minimal symptoms. The Veteran was also given a PCL-5 (PTSD checklist self-report measure). The examiner noted that the Veteran's score of 19 is in the normal range (cutoff score between 31-33 is indicative of probable PTSD; see PTSD Checklist for DSM-5 (PCL-5) - PTSD: National Center for PTSD (va.gov)) and his reports of "bothersome" symptoms as occasional and their pattern "is not consistent with PTSD, but mild diffuse trauma related symptoms that "do not rise to justifying a diagnosis." Lastly, the VA examiner indicated that a review of the Veteran's VA treatment records does not show diagnoses for other mental health disorders. In sum, the examiner opined that the claimed psychiatric disorders were less likely as not incurred in or caused by the Veteran's military service as "the Veteran does not have a current mental disorder that meets the DMS-5 criteria. The Board finds that while there may be some discrepancies with respect to the exact dates of the alleged in-service incident to which the Veteran attributes his psychiatric disorder took place, service connection is still not warranted because the record does not show that Veteran has been diagnosed with PTSD or any other psychiatric disorder. See Martinez-Bodon, 32 Vet. App. at 395; see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Thus, there is no reasonable possibility that remanding the claim at this point would substantiate the claim. See 38 C.F.R. § 3.159(d). Here, not only the Veteran has not been treated for a psychiatric condition, but the January 2020 VA psychologist found that the Veteran does not meet the diagnostic criteria for a psychiatric diagnosis, which is persuasive. Therefore, the VA psychologist's opinion is the most persuasive evidence of record as upon review of the Veteran's medical history, an in-person interview, and review of the medical records, he found that the Veteran does not meet the DSM criteria for a psychiatric disorder. See 38 C.F.R. § 4.125. Moreover, the evidence does not show that there is functional impairment due to a psychiatric condition. See 38 C.F.R. §§ 4.125, 4.130. The Board has also considered whether service connection for an acquired psychiatric disorder, other than PTSD, could be warranted as secondary to the Veteran's service-connected hearing loss and tinnitus. See 38 C.F.R. § 3.310; see also DeLisio v. Shinseki, 25 Vet. App. 45, 53 (2011); Robinson v. Peake, 21 Vet. App. 545, 552 (2008), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009). However, as previously noted, a current psychiatric disability conforming the DSM-5 is not established, nor there is evidence of a functional impairment due to a psychiatric disability. See Martinez-Bodon, 32 Vet. App. at 395; 399. As the current disability element of the claim has not been established, therefore, service connection on a secondary basis is not warranted. See Brammer, 3 Vet. App. at 225; Romanowsky, 26 Vet. App. 289; and McClain, 21 Vet. App. at 321. The Board acknowledges the Veteran's contentions and symptoms. However, while he and his wife are competent to testify as to their observations, establishing a psychiatric diagnosis that meets the DSM criteria is a complex medical question which falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Young v. McDonald, 766 F.3d 1348, 1353 (Fed. Cir. 2014). Therefore, the Veteran's and his wife's lay opinions as to whether he has a psychiatric diagnosis are not afforded probative value. The preponderance of the evidence shows that the Veteran has not been diagnosed with PTSD or any other psychiatric disorders at any time during the pendency of the appeal. Thus, the benefit-of-the-doubt doctrine is not applicable and service connection for PTSD, or for a psychiatric disorder, other than PTSD, to include on a secondary basis, is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Although the Board is remanding other claims for additional development, remand is not necessary for this issue, as there is no reasonable possibility that further assistance would substantiate the claim. See 38 C.F.R. § 3.159(d). REASONS FOR REMAND 1. Service connection for a disability manifested by dizziness and imbalance. With respect to this issue, the Board finds that additional development must be conducted prior to adjudication of the claim on the merits. Pursuant to the June 2019 Board's remand, additional VA treatment records and private treatment records specifically related to this claim were associated with the claims file. Private treatment records from the Veteran's private attending ENT specialist show that in light of the Veteran's reports of dizziness, his attending physician provided a differential diagnosis including Meniere's disease, BPPV (paroxysmal positional vertigo), as well as other causes that are not otologic in nature. See November 6, 2019 progress notes. Shortly thereafter, the Veteran's symptoms were diagnosed as aural vertigo. See November 21, 2019 progress notes. The Veteran further reported, and his provider recorded, that "during this [dizziness] episodes [he] checks [his] blood sugar and is normal." The Veteran reiterated that the lightheaded feeling accompanied by imbalance often occur during episodes of tinnitus. The Veteran underwent an MRI in December 2019 which revealed a normal brain and auditory canals with no finding noted to account for the Veteran's presentation. Notwithstanding, in a subsequent note from the Veteran's ENT specialist ot is still noted that his symptoms are "likely Meniere's disease given his asymmetric hearing loss and tinnitus increasing with dizziness. However, the dizzy episodes are short compared to typical Meniere's disease." See January 8, 2020 progress notes. In a most recent progress notes from the Veteran's ENT provider, it seems to appear that a final diagnosis of Meniere's disease was established. See October 27, 2021 treatment records from Doctors Hospital at Renaissance. The private provider noted that the pathophysiology of Meniere's disease encompasses both hearing loss and vertigo and is related to excess fluid in the inner ear. The foregoing appears to suggest a connection between his dizziness and imbalance symptoms and his service-connected hearing loss and tinnitus. Pursuant to the June 2019 Board's remand, the Veteran was afforded a VA ear conditions examination in July 2020. The VA examiner, a nurse practitioner, established a diagnosis of paroxysmal positional vertigo and stated that the evidence of record "does not support a diagnosis of Meniere's disease. In this regard, the examiner appears to have relied on the December 2019 MRI which revealed unremarkable brain and auditory canals with no finding noted to account for the Veteran's presentation. With respect to the direct theory of service connection, the examiner's indicated that the claimed disability is less likely as not incurred in or caused by the Veteran's military service as STRs does not show complaints or treatment sought for imbalance or dizziness issues. As to the secondary theory question, the VA examiner indicated that the claimed disability is less likely than not proximately due to or the result of the Veteran's service-connected hearing loss and tinnitus and it is at least as likely as not proximately due to the Veteran's nonservice-connected diabetes mellitus. The examiner explained that a person with diabetes can develop hypoglycemia from a decrease of food intake, or from taking too much medication (insulin or oral tablets), which results in low blood sugar levels, which in turn causes dizziness or lightheadedness because the brain lacks glucose to function properly. The Board finds that while the examiner's negative opinion as to the nexus element on a direct basis appears adequate, that is not the case for the additional causation and aggravation questions with respect to service connection on a secondary basis. First, it is not clear upon which specific evidence the VA examiner relied on to rule out a diagnosis of Meniere's disease and/or to provide a negative causation opinion for the diagnosed Vertigo. In this regard, the Veteran's ENT specialist physician, even after considering the December 2019 MRI results, did not rule out a diagnosis of Meniere's disease nor he ruled out a relationship between the Veteran's imbalance and dizziness symptoms and his service-connected hearing loss and Vertigo exist. As previously noted, the attending physician indicated that "symptoms are likely Meniere's disease given [the Veteran's] asymmetric hearing loss and tinnitus increasing with dizziness." Second, the Board notes that while the examiner provided a negative causation opinion, she failed to substantially comply with the Board's remand directives as to the aggravation question. Notwithstanding, the examiner's causation opinion appears to be based on inaccurate or incomplete information. While she attributed the Veteran's claimed symptoms to his nonservice-connected diabetes mellitus, the recently associated private treatment records expressly indicate that during these episodes the Veteran's sugar levels have remained normal, which suggest little to no relationship between his symptoms and diabetes mellitus. In light of her etiology opinion, the VA examiner should have at least addressed the private records suggesting otherwise. When VA provides a medical examination, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311-312 (2007). For the reasons set forth above, the Board finds that a remand is warranted for a VA opinion by an ENT specialist to comment on the nature, etiology and extent of the claimed disability and to reconcile the conflicting medical findings. The matters are REMANDED for the following action: 1. Request from the Veteran any updated private medical treatment records in connection with the claimed disability, to include any records from Doctors Hospital at Renaissance, or to identify such that VA may obtain them. 2. Thereafter, forward the entire claims file to an ENT specialist to comment on the nature, etiology, and extent of the Veteran's claimed disability. If the physician deems it necessary, schedule the Veteran for an in-person examination. The physician should first identify any disability manifested by imbalance or dizziness, which may include Vertigo (BPPV) or Meniere's disease. If any of the foregoing diagnoses is not warranted, it should be explained why this is so. The physician should then provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any identified disability is proximately due to, or aggravated by his service-connected hearing loss and tinnitus, or by any other nonservice-connected disabilities. Aggravation is an increase in severity beyond the natural progress of the disease. Consideration should be given to: (1) the Veteran's and his wife's statements as a to the dizziness with imbalance spells related to his service-connected hearing loss and tinnitus; (2) The Veteran's attending ENT specialist providing a diagnosis of Meniere's disease, BPPV, as well as other non-otologic conditions; (3) private treatment records indicating that the Veteran's blood sugars are normal during these dizziness episodes; and (4) the Veteran's report that his lightheaded feeling accompanied by imbalance often occur during episodes of tinnitus. A complete rationale should be provided for any opinion reached. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board William Pagan, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.