Citation Nr: 21072900 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 17-41 917 DATE: December 6, 2021 ORDER Service connection for a cervical spine condition is granted. Service connection for headaches, as secondary to a cervical spine condition, is granted. Service connection for a lumbar spine condition is granted. Service connection for a right ankle condition, as secondary to a left ankle condition, is granted. A disability rating in excess of 10 percent for a left ankle condition is denied. FINDINGS OF FACT 1. The Veteran's cervical spine condition was incurred in his active-duty service. 2. The Veteran's headaches are proximately due to the Veteran's cervical spine condition. 3. The Veteran's lumbar spine condition was incurred in his active-duty service. 4. The Veteran's right ankle condition is proximately due to his left ankle condition. 5. The Veteran's left ankle condition does not manifest as marked limitation of motion. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical spine condition have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 2. The criteria for service connection for headaches as secondary to a cervical spine condition have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310. 3. The criteria for service connection for a lumbar spine condition have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 4. The criteria for service connection for a right ankle condition as secondary to a left ankle condition have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310. 5. The criteria for a disability rating in excess of 10 percent for a left ankle condition have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5271. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from May 1999 to May 2008. This case comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of April 2016 issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. These matters were previously before the Board in October 2019, at which time they were remanded for further development. The Board briefly notes that the Veteran's appeal initially included the additional issues of service connection for a gastrointestinal condition, bilateral knee conditions, and a respiratory condition. See October 2019 Board Decision at 5. The Board previously remanded these additional issues, as well as those presented above, for additional development. Id. at 6-16. However, the record reflects that these additional issues were subsequently granted by the RO and thus are therefore no longer before the Board. See August 2020 Rating Decision (granting service connection for gastrointestinal condition); see also September 2020 Rating Decision (granting service connection for respiratory and bilateral knee conditions); Grantham v. Brown, 114 F.3d 1156, 115859 (Fed. Cir. 1997). As will be discussed below, the Board finds that the RO has partially, but substantially, complied with its remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (providing that a remand confers upon a veteran the right to substantial compliance with remand instructions). Service Connection Service connection requires the existence of a present disability, the in-service incurrence or aggravation of a disease or injury, and a causal relationship between the present disability and the disease or injury incurred or aggravated during service. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (2004). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 U.S.C. § 1131; 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for a cervical spine condition. The Veteran asserts that he experiences "cracks, aches[,] and sharp [neck] pains" as a result of "nine years of sitting, standing[,] or laying in the prone unsupported position holding my rifle for long periods of time." See August 2017 VA Form 9 at 2; see also October 2015 VA Form 21-526EZ (asserting cervical spine condition secondary to right shoulder condition). The Board previously remanded this claim for a VA examination. See October 2019 Board Decision at 10-11. Two VA examiners subsequently made differing observations regarding the Veteran's cervical spine condition. In an April 2020 examination addressing the Veteran's headaches, a VA examiner noted the Veteran's assertions as follows: [The] Veteran reports [a] history of headaches beginning around 2001-2002, he reports he had to wear [a] heavy [Kevlar] helmet for long periods of time and this put strain on his neck leading to chronic neck pain and headaches. He reports he would develop pain in his neck that would travel up to his head... See April 2020 VA Examination Report (Headaches) at 1 (emphasis added); see also id. at 3-4 (noting July 2018 x-rays showing "mild" and "minor" degenerative changes of the cervical spine). This examiner ultimately opined that the Veteran's headaches were at least as likely as not due to neck pain, which was in turn due to in-service repetitive strain: [Due] to [the Veteran's] in-service use of heavy head gear and repetitive trauma to the neck it is felt the headaches are most likely related to pain from the neck leading to tension-like headaches. Please note this opinion is given before the neck exam is done, due to restrictions of in-person [appointments] related to COVID-19 several exams were done that did not need in-person interview and completed by telephone and record review. Will conduct neck exam once we are able to complete in-person [appointments]. Neck pain and headaches are often connected because a stiff neck, herniated cervical disc, or irritated spinal nerves can cause headaches. Headaches that result from neck discomfort or neck injury are called cervicogenic headaches. Pain in the back of your neck or head can also cause severe cluster-like headaches or tension headaches. See April 2020 VA Medical Opinion (Headaches) at 2 (emphasis added). The Board notes that the Veteran's assertions of wearing a Kevlar helmet for long periods of time are consistent with the circumstances of his active-duty service. See August 2008 Discharge Certificate (noting military operational specialty as tactical unmanned aerial vehicle operator for eight years); see also id. (noting service in Iraq from April 2003 to April 2004 and from November 2005 to November 2006, as well as receipt of the Iraq Campaign Medal with Bronze Service Star). The Board therefore finds it at least as likely as not that the second Shedden factor has been met. A different VA examiner subsequently examined the Veteran in person and provided several medical opinions in July and August 2020. As an initial matter, the Board notes that this examiner diagnosed the Veteran with cervical strain. See July 2020 VA Examination Report (Cervical Spine) at 2. The Board therefore finds that the first Shedden factor has been met as well. This second VA examiner ultimately opined that the Veteran's cervical spine condition was less likely than not incurred in or a result of his active-duty service, nor proximately due to or the result of his right shoulder condition. In reaching these conclusions, however, this second examiner relied almost exclusively on the absence of corroborating medical treatment in the Veteran's service treatment records (STR): [The] cervical spine disability is not the result of the shoulder strain, they are not medically related. The claimed disorder is a separate entity entirely from the service-connected condition and unrelated to it. The medical literature does not support a medical relationship. A nexus has not been established. See August 2020 VA Medical Opinion (Cervical Spine I) at 2. During service, condition was acute only. There is no evidence of chronicity of care. A nexus has not been established. The separation exam all normal [sic]. [The Veteran's] cervical strain was [diagnosed] [in July 2018]. [He] was not seen or treated for cervical [spine] issue in service. See August 2020 VA Medical Opinion (Cervical Spine II) at 2; see also August 2020 VA Medical Opinion (Cervical Spine III) at 2 (repeating same and noting that while "[the Veteran] [reports] that the heaviness of the helmet caused the neck strain[,] [his] separation exam is silent for musculoskeletal complaints"). The Board is mindful that generally, it may not consider the absence of evidence as substantive negative evidence when adjudicating a claim. See Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); see also id. (contrasting with Federal Rule of Evidence 803(7) for the proposition that the absence of a record may be substantive negative evidence if such a record would ordinarily be recorded); see also Maxson v. Gober, 230 F.3d 1330 (2000) (providing that evidence of a prolonged period without medical complaint can be considered along with all the other evidence of record). The July 2020 VA examiner's opinions do not provide any explanation as to why the absence of specific treatment for neck pain in the Veteran's STR would be medically dispositive of causation. Furthermore, the Board notes that the Veteran indicated back pain on several post-deployment questionnaires, which did not otherwise provide a distinction between back pain and neck pain. See May 2008 STR at 58; see also November 2015 STR at 70; cf. November 2015 STR at 54 (report of medical history at separation indicating no recurrent back pain or back problems). In other words, the Board does not find the absence of specific treatment for neck pain in the Veteran's STR dispositive of the possibility that such neck pain in fact occurred, but was not treated contemporaneously because of the exigencies and circumstances of the Veteran's service. The Board has considered whether to remand this issue for an addendum opinion, as the July 2020 VA examiner's opinions are conclusory and inadequate to support adjudication. "Relevant points that can be discussed in an examination report include, but are not limited to, why the examiner finds cited studies persuasive or unpersuasive, whether the veteran has other risk factors for developing the claimed condition, and whether the claimed condition has manifested itself in an unusual way." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). However, the Board is also mindful of regulatory constraints on its ability to remand for further development, which "should not be undertaken when [the] evidence present is sufficient for this determination." 38 C.F.R. § 3.304(c). Because the April 2020 VA examination considers the Veteran's assertions, explains the medical theory of causation for his cervical spine condition, and because his assertions are consistent with the circumstances of his active-duty service, the Board finds it adequate to support adjudication despite the fact that it was not conducted in person. The Board therefore concludes, based on the April 2020 VA examiner's findings and resolving all reasonable doubt in the Veteran's favor, that it is at least as likely as not that the third Shedden factor has been met. 38 U.S.C. § 5107; Gilbert, supra. Therefore, the assignment of service connection is therefore warranted. 38 C.F.R. § 3.303. The claim is granted. 2. Entitlement to service connection for headaches as secondary to a cervical spine condition. As discussed above, the April 2020 VA examiner opined that the Veteran's headaches were secondary to his cervical spine condition. See April 2020 VA Medical Opinion (Headaches) at 2; see also April 2020 VA Examination Report (Headaches) at 1 (diagnosing tension headaches). This examiner later provided an addendum opinion in September 2020, in which she opined as follows: ... as stated prior [sic] the headaches described on interview are most consistent with tension type headaches, felt to be secondary to the chronic neck pain as well as the noted muscle spasms in this region of the cervical spine noted on imaging... Do not note that this began while active duty, however noted again to be secondary to a chronic neck condition. Not noted to have occurred as well since [sic] 1 year from separation from service as separation date is noted to be 2008 and symptom beginning [sic] much later than this time frame. Not an organic disease of the nervous system, again felt to be a symptom related to a diagnosable neck condition... ... The cause of a cervicogenic headache is often related to excessive stress to the neck. The headache may result from cervical osteoarthritis (spondylosis), a damaged disc, or whiplash-type movement that irritates or compresses a cervical nerve. The neck's bony junctures (e.g., facet joints) and its soft tissues (e.g., muscles) can contribute to the development of a cervicogenic headache. See September 2020 VA Addendum Opinion at 2. Based on these opinions, and because the Veteran's cervical spine condition is now service-connected as discussed above, the Board finds that each of the Shedden factors has been met. The assignment of service connection on a secondary basis is therefore warranted. 38 C.F.R. §§ 3.303, 3.310. The claim is granted. 3. Entitlement to service connection for a lumbar spine condition. As discussed above, the Veteran underwent VA examinations in July 2020 following the Board's prior remand. The July 2020 VA examiner diagnosed the Veteran with degenerative arthritis from July 2018. See August 2020 VA Examination Report (Lumbar Spine) at 2; see also id. (noting Veteran's assertion that pain began after sleeping on hard surfaces during deployment to Iraq and that no contemporaneous treatment was sought); see also August 2018 Medical Treatment Records at 2 (providing July 2018 x-rays observing "mild degenerative changes" of the lumbar spine). However, the examiner ultimately opined that this condition was less likely than not incurred in or a result of his active-duty service: Symptoms are subjective only. Objective exam is normal. There is no objective evidence of a chronic condition. A nexus has not been established. During service, condition was acute only. There is no evidence of chronicity of care. A nexus has not been established. [The Veteran] states the back symptoms are from sleeping on the concrete in service. There is no medical records in the noted [sic] the back symptoms during service. Degenerative arthritis [diagnosis] of the spine [in July 2018.] See July 2020 VA Medical Opinion (Lumbar Spine I) at 2. ... [In] the past 10 years [the Veteran's] occupation has been plumber which causes stress on the lower back. No medical records from 2008 to 2018 regarding treatment or x-rays of lower back problems. On the separation exam 2008 no complaints of back complaints all normal [sic]. On exam, objectively did not note a chronic disability... See August 2020 VA Medical Opinion (Lumbar Spine II) at 2; see also August 2020 VA Medical Opinion (Lumbar Spine III) at 2 (repeating same and opining that "DJD of the spine is less as likely than not [sic] began during active service[,] manifested within one year after discharge from service[,] or is related to an in-service injury or disease including the thoracic strain in August 1999"). As discussed above, these opinions are too conclusory and reliant on the absence of corroborating STR to support adjudication. See Buczynski, 24 Vet. App. at 224; see also Stefl, 21 Vet. App. at 124. While the July 2020 VA examiner identifies the Veteran's civilian employment as a plumber as a potential alternative etiology for his lumbar spine condition, her opinion does not offer any reasoning as to why this alternative etiology is more likely than not. The Board again notes multiple reports of back pain in the Veteran's STR. See May 2008 STR (I) at 58; see also November 2015 STR at 70; see also May 2008 STR (II) at 21 (noting August 1999 treatment for back pain). While the Veteran's separation examination does not reflect a diagnosed lumbar spine condition at that time, the Board does not find this absence dispositive when considered in conjunction with the other evidence of record and the circumstances of the Veteran's active-duty service. The Board likewise does not find the absence of medical treatment during the period following the Veteran's active-duty service dispositive in light of the Veteran's assertions of subsequent financial and personal difficulties. See May 2019 Correspondence at 2-3. The Board finds that remand for an addendum opinion would be futile in light of the inadequate July 2020 VA opinion. 38 C.F.R. § 3.304(c); see also Coburn v. Nicholson, 19 Vet. App. 427, 434 (2006) (Lance, J., dissenting) (finding that repeated remands "perpetuate the hamster-wheel reputation of Veterans law"). Instead, based on the Veteran's assertions regarding the onset of his lumbar spine symptoms, the corroborating STR showing reports of back pain following deployment, and the corroborating circumstances of the Veteran's active-duty service, and when resolving all reasonable doubt in his favor, the Board finds it at least as likely as not that his diagnosed lumbar spine condition was incurred in his active-duty service. "Whether lay evidence is competent and sufficient in a particular case is a fact issue to be addressed by the Board[.]" Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau and providing in pertinent part that medical evidence is not always required to establish a nexus for direct service connection); see also Gilbert, supra. The assignment of service connection for this condition is therefore warranted. 38 C.F.R. § 3.303. The claim is granted. 4. Entitlement to service connection for a right ankle condition as secondary to a left ankle condition. The Veteran has variously asserted that he has developed a right ankle condition as secondary to his service-connected left ankle condition or as a result of his active-duty service. See October 2015 VA Form 21-526EZ at 3 (asserting right ankle condition secondary to left ankle condition); see also May 2019 Correspondence at 17 (asserting that "my right ankle has a condition because it is compensating for the huge weakness of my left ankle that was injured while I was in active duty") cf. August 2017 VA Form 9 at 2 (asserting that "[in] basic training I twisted my right ankle and again during PT at Fort Hood[,] it has caused me problems ever since and the left [ankle] is having to compensate for it"). It is plausible to the Board that this latter assertion is the result of confusion or misstatement, as it is not consistent with the Veteran's assertions elsewhere in the record. See June 2018 VA Examination Report at 3 (noting Veteran's assertion that it was his left ankle that was repeatedly injured in basic training and PT, not his right). As discussed above, the Board previously remanded this claim for a VA examination. See October 2019 Board Decision at 13-15. The July 2020 VA examiner diagnosed the Veteran with bilateral tendonitis. See August 2020 VA Examination Report (Ankles) at 2. As an initial matter, the Board therefore finds that the first Shedden factor has been met. Because service connection for the Veteran's left ankle condition has previously been established, the Board finds that the second Shedden factor has been met as well. However, the VA examiner ultimately opined that the Veteran's right ankle condition was less likely than not proximately due to or a result of his left ankle condition: The right ankle complaints and the left ankle [diagnosis] are not medically related. The claimed disorder is a separate entity entirely from the service-connected condition and unrelated to it. The medical literature does not support a medical relationship. A nexus has not been established. See August 2020 VA Medical Opinion (Ankle I) at 2. During service, right ankle sprain was acute only. There is no evidence of chronicity of care. A nexus has not been established. During service, tendonitis of the right ankle was acute only. There is no evidence of chronicity of care. A nexus has not been established. The right ankle tendonitis is less as likely than not [sic] began during active service[,] manifested within one year after discharge from service[,] or is related to an in-service injury or disease including the left knee injury in January 2000[,] [the Veteran's] physical duties in service[,] and his exposure to environmental contaminates [sic] in Iraq. See August 2020 VA Medical Opinion (Ankle II) at 2; see also August 2020 VA Medical Opinion (Ankle III) (repeating same and observing that "[right] ankle tendonitis objective findings were normal ROM which is inconsistent with a chronic condition" and that "[he] was observed to have a normal gait[,] there was no over compensation for the left ankle sprain"). As discussed above, these opinions are conclusory and inadequate because they rely too heavily on the absence of corroborating STR and do not adequately explain their medical reasoning. See Buczynski, 24 Vet. App. at 224; see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (providing that "most of the probative value of a medical opinion comes from its reasoning" and that "[neither] a VA medical examination report nor a private medical opinion is entitled to any weight... if it contains only data and conclusions"). While the examiner's observations as to the current functioning of the Veteran's right ankle may support a low or noncompensable disability rating for this condition, they do not establish that it is more likely than not that such a condition is not proximately due to or a result of his left ankle condition, nor do they account for the examiner's observation that he experiences greater functional impairment following repeated use over time. See August 2020 VA Examination Report (Ankle) at 8 (estimating that range of motion for the right ankle would be limited to 15 degrees of dorsiflexion and 30 degrees of plantar flexion following repeated use over time). The Board has considered remanding for an addendum opinion but finds that such a remand would be futile in light of the inadequacies discussed above. 38 C.F.R. § 3.304(c). Instead, based on the VA examiner's diagnosis of bilateral tendonitis, the Veteran's service-connected left ankle condition, and the Veteran's competent assertions that he experiences symptoms of pain in his right ankle while favoring his left ankle, and when resolving all reasonable doubt in his favor, the Board finds it at least as likely as not that his right ankle condition is proximately due to his service-connected left ankle condition. 38 U.S.C. § 5107; see also Davidson, 581 F.3d at 1316; Gilbert, supra. The assignment of service connection on a secondary basis is therefore warranted. 38 C.F.R. § 3.310. The claim is granted. 5. Entitlement to a disability rating in excess of 10 percent for a left ankle condition. Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for a higher rating. 38 C.F.R. § 4.7. The Veteran's entire history is reviewed when making disability rating decisions. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). However, where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). In evaluating disabilities of the musculoskeletal system, consideration must be given to functional loss, including due to weakness and pain, affecting the normal working movements of the body in terms of excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. With respect to disabilities of the joints, it must be considered whether there is less movement or more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement, as well as swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. These provisions thus require a determination of whether a higher rating may be assigned based on functional loss of the affected joint on repeated use as a result of the above factors, including during flare-ups of symptoms, beyond any limitation reflected on one-time measurements of range of motion. DeLuca v. Brown, 8 Vet. App. 202 (1995). However, a higher rating based on functional loss may not exceed the highest rating available under the applicable Diagnostic Code pertaining to range of motion. See Johnston v. Brown, 10 Vet. App. 80 (1997). In determining if a higher rating is warranted on this basis, pain alone does not constitute functional loss. Similarly, painful motion alone does not constitute limited motion for the purposes of rating under Diagnostic Codes pertaining to limitation of motion. However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance as provided in 38 C.F.R. §§ 4.40 and 4.45. Functional loss due to pain is to be rated at the same level as functional loss caused by some other factor that actually limited motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Veteran's left ankle condition is rated as 10 percent disabling from October 2015 under Diagnostic Code 5271. See August 2020 Rating Codesheet at 2. The applicable rating criteria provide that a disability rating in excess of 10 percent is not assigned unless there is marked limitation of motion, defined as less than 5 degrees of dorsiflexion or less than 10 degrees of plantar flexion. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. A previous VA examination of June 2018 noted the Veteran's assertions of "pain to his ankle ever since [active-duty service] off and on... usually a sharp pain[,] mostly on weight-bearing activities... [which] [sometimes] causes him to limp." See June 2018 VA Examination Report at 3; see also id. at 5 (observing normal range of motion). This examiner opined that pain would result in further functional loss during flare-ups or after repeated use over time, but estimated that the Veteran would be capable of the same range of motion in other words, that the additional functional loss would not be so severe as to result in further restriction of motion. See id. at 7-9. As noted above, the Veteran underwent an additional VA examination in July 2020 following the Board's prior remand. The July 2020 VA examiner found a normal range of motion for the Veteran's left ankle and observed pain on motion which did not result in functional loss. See August 2020 VA Examination Report (Ankle) at 6. The examiner noted that the Veteran did not report flare-ups of this condition and estimated that repeated use over time would not produce any further restriction in range of motion. See id. at 4; see also id. at 8. The Veteran's assertions and medical records support the inference that his left ankle condition is painful, but do not otherwise support a finding that it is best approximated by a disability rating in excess of 10 percent. See November 2015 Medical Treatment Records at 10-11 (noting estimated pain level of "3" on 10-point scale in both ankles, among other joints); see also May 2019 Correspondence at 16 (asserting that "[my] left ankle causes a great deal of trouble for me"); see also November 2019 Medical Treatment Records at 116 (providing July 2018 treatment note observing "[left] ankle will roll occasionally, causes pain/aches"). The Board therefore concludes that a disability rating in excess of 10 percent for this condition is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5271. The Board has considered the doctrine of reasonable doubt but finds that it is not applicable because the balance of the evidence is against the Veteran's claim. 38 U.S.C. § 5107; Gilbert, supra. The claim is denied. JEREMY J. OLSEN Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Blore, 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.