Citation Nr: 21075551 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 15-40 053 DATE: December 20, 2021 REMANDED Service connection for a traumatic brain injury (TBI) is remanded. Service connection for a left shoulder/arm disability is remanded. Service connection for a right shoulder/arm disability is remanded. Service connection for a left foot/ankle disability is remanded. Service connection for a right foot/ankle disability is remanded. Service connection for bilateral ear pain is remanded. Service connection for sinusitis is remanded. Service connection for a lung mass is remanded. Service connection for residuals of pneumonia is remanded. Service connection for an enlarged heart is remanded. Service connection for hematochezia is remanded. Service connection for blood in the stool is remanded. Service connection for colon polyps is remanded. Service connection for an enlarged prostate is remanded. Service connection for thalassemia is remanded. Entitlement to a compensable rating for hypertension is remanded. Entitlement to a compensable rating for rhinitis is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1991 to October 2011. His military occupational specialty (MOS) was a fire protection specialist. He had service in the Persian Gulf during the Persian War and therefore, consideration must be given to exposure to toxins in the Southwest Asia Theater of Operations as well as whether any of his claimed disabilities are unexplained illnesses or medically unexplained chronic multisymptom illnesses (MUCMIs). See 38 C.F.R. § 3.317. These claims come to the Board of Veterans' Appeals (Board) from May 2012 and November 2016 rating decisions. In July 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A copy of the transcript from that hearing is associated with the evidence of record and has been considered. Although the Board regrets the delay, a remand is required for additional development and readjudication. Initially, at his hearing before the Board, the Veteran testified that he had Tricare and that he received his medical treatment at Moody Air Force Base. See July 2021 Hearing Transcript, p. 8. These records are not associated with the evidence before the Board, and therefore, VA must take all steps in accordance with VA regulation to obtain these outstanding records on remand. Further, the Veteran has claimed he was exposed to asbestos and cadmium during his active service and that his service records would reflect this. See July 2012 Notice of Disagreement. Although the Veteran's service treatment records are associated with the evidence of record, his service personnel records are not. Therefore, attempts to obtain these in accordance with VA regulation must be made on remand. Following receipt of the records, the AOJ should make formal findings as to the Veteran's claimed exposure and compile these findings (in addition to steps taken to reach the findings) in a written memorandum and associate it with the evidence of record. Service Connection Claims 1. Service connection for a TBI is remanded. Service treatment records reflect the Veteran suffered a concussion on April 16, 1998. He was playing basketball, jumped, and his legs came out from under him, and he fell approximately three to four feet on the back of his head. He denied loss of consciousness but indicated he had one to two minutes of tingling in his hands and fingertips. A CT scan of the head was normal. At his hearing before the Board, the Veteran testified he fell three to four feet and landed on the back of his head; he had no loss of consciousness but was disoriented after the fall and was in "bad shape" for a year. See July 2021 Hearing Transcript, p. 10. He has further indicated that his service records show he fell on a wooden floor but that the floor was actually concrete. See id. at 12; see also July 2021 Notice of Disagreement. At a 2011 VA TBI examination, the examiner diagnosed a mild TBI by history with no known residuals. Thus, it is conceded that the Veteran had a TBI; now, the question before the Board is whether he has any residual symptoms. The Board finds the 2011 examination is incomplete as it does not discuss the Veteran's reported symptoms such as vertigo and numbness of the arms/hands. Accordingly, a new examination and opinion is required. 2. Service connection for a left shoulder/arm disability is remanded 3. Service connection for a right shoulder/arm disability is remanded. 4. Service connection for a left foot/ankle disability is remanded. 5. Service connection for a right foot/ankle disability is remanded. The Veteran is claiming service connection for a bilateral shoulder/arm disability, a left foot disability, and a right ankle disability. See August 2011 Fully Developed Claim. The Board is also considering the Veteran's left ankle and right foot pursuant to Clemons v. Shinseki, 23 Vet. App. 1, 7 (2009). Initially, at his hearing before the Board, the Veteran acknowledged widespread joint pain and full body aches. ŽSee July 2021 Hearing Transcript, p. 17-18. As discussed in the introduction, given his service in the Persian Gulf during the Persian Gulf War, consideration must be given to exposure to toxins in the Southwest Asia Theater of Operations as well as whether any of his claimed disabilities are unexplained illnesses or MUCMIs. See 38 C.F.R. § 3.317. The Veteran's representative also raised the theory that he may have fibromyalgia. See July 2021 Hearing Transcript, p. 19. Notably, VA regulation provides that fibromyalgia is a MUCMI. See 38 C.F.R. § 3.317. He has further suggested his joint pains may be rheumatoid arthritis. See May 2012 Correspondence. Accordingly, on remand an examination must consider whether the Veteran's joint symptoms are related to his service in the Southwest Asia Theater of Operations, to include consideration of whether it is an undiagnosed illness or a MUCMI (including, but not limited to, fibromyalgia). Consideration must also be given to whether the Veteran has rheumatoid arthritis. If it is demonstrated that there are identifiable diagnoses pertaining to the bilateral shoulders/arms, left foot/ankle, and right foot/ankle, then opinions regarding direct service connection must be obtained. With respect to his claim for the bilateral shoulders, the Veteran denied any injuries during service but believes he has bilateral shoulder disabilities which are due to repetitive use and lifting while performing his duties as a firefighter during service. See July 2021 Hearing Transcript, p. 14-15. He reported experiencing pain, numbness, and tingling during and since service. See id. Service treatment records contain several references to shoulder/arm pain. See April 1997 (right hand, shoulder, and arm pain); August 2004 (right shoulder pain for the past week); December 2010 (left shoulder soreness and crepitus). In June 2012, approximately seven months following the Veteran's separation from active duty, he sought treatment for right shoulder pain for the past five to ten years. Following an MRI, the examiner diagnosed tendinosis of the rotator cuff with a partial tear and edema at the deltoid muscle likely related to muscle strain. At a 2015 VA examination, the examiner found no diagnosis pertaining to the right shoulder and diagnosed left shoulder tendonitis. Next, the Board will discuss evidence relating to the claims for bilateral foot/ankle disabilities. The Veteran testified at his hearing that he believed he injured his feet or ankles playing basketball during service and that he twisted his ankle on stairs before; he further endorsed full body aches and pain since service. See July 2021 Hearing Testimony, p. 17-18. He also indicated he believes he was told to get a certain type of shoe, but he could not remember what kind. Id. at 18. Service treatment records reflect he injured his right ankle and foot playing basketball in August 1992. X-rays revealed a fracture of the fifth metatarsal (the long bone in the outside of the foot that connects to the little toe). He twisted his left ankle running upstairs in 1994. The examiner providing the opinions with respect to these claims must consider the above evidence. 6. Service connection for bilateral ear pain is remanded. 7. Service connection for sinusitis is remanded. The Veteran's service treatment records document several instances where he complained of pressure in his ears. See February 1998, July 2000, January 2001, February 2006 Service Treatment Records. At his hearing, the Veteran testified that he would experience pain and pressure when flying in aircraft and that he continued to experience the same symptoms to this day. See July 2021 Hearing Transcript, p. 21. The Veteran's representative suggested that the Veteran's bilateral ear pain may also be related to his claim for sinusitis and his already service-connected tinnitus. Given that there are no examinations or opinions pertaining to the Veteran's claims for bilateral ear pain and sinusitis, a remand is required. With respect to the claim for the bilateral ears, consideration should be given as to whether this symptom is secondary to the Veteran's sinusitis and/or tinnitus. 8. Service connection for a lung mass is remanded. 9. Service connection for pneumonia is remanded. At his hearing before the Board, the Veteran testified he had breathing problems which he felt were due to his lung mass and/or pneumonia. See July 2021 Hearing Transcript, p. 22-24. Service treatment records dated December 1998 reflect the Veteran had a fever for the past two weeks and the examiner assessed possible pneumonia. A December 1998 chest x-ray revealed an infiltrate contiguous to the chest wall in the left mid-chest (left upper lobe); the remainder of the lungs were clear. The Veteran's service treatment records document a chest x-ray of a likely granulomata in June 2008. A November 2010 radiology report reflects the presence of a calcified granuloma and August 2011 radiology reports indicate it remained stable at 8 millimeters. At a 2011 respiratory examination, when asked about symptoms, the Veteran stated he was unable to talk to anyone when he was running and would experience coughing; he denied a history of lung disease and identified as a non-smoker. The examiner noted the lung mass was an incidental finding in 2008 and that it did not cause any respiratory symptoms, however, there was no rationale for the finding that it did not cause symptoms and no opinion on the etiology of the lung mass. The 2011 respiratory examination did not address pneumonia. Accordingly, the Board finds a new examination is warranted for the lung mass to determine (a) whether it began during or is etiologically related to service; and (b) whether it causes any symptoms, such as respiratory problems. Additionally, an examination for the claim for residuals of pneumonia is warranted to determine if the Veteran has any residuals which began during or are related to his active duty service. 10. Service connection for an enlarged heart is remanded. The Veteran believes his enlarged heart began during or is etiologically related to service. He described symptoms such as pain/fullness, "like a heavy pressure," in his chest. See July 2021 Hearing Transcript, p. 25. His representative raised the theory that his heart condition may be secondary to his service-connected hypertension. See id. Initially, the Board notes that service connection for a heart murmur/valve condition was denied in an unappealed and final December 2016 rating decision. A July 2008 echocardiogram showed functional heart murmurs. A December 2010 echocardiogram revealed mild aortic insufficiency and valvular heart disease was diagnosed at that time. The Veteran has not been afforded an examination to determine whether he has an enlarged heart and, if so, whether it is related to his active duty service or is secondary to his hypertension. 11. Service connection for hematochezia is remanded. 12. Service connection for blood in the stool is remanded. 13. Service connection for colon polyps is remanded. 14. Service connection for an enlarged prostate is remanded. The Veteran is claiming he has blood in the stool (hematochezia), colon polyps, and an enlarged prostate which he believes began during and are related to his active service. Notably, during service he reported blood in the stool on several occasions and was diagnosed with hemorrhoids. Service connection is already in effect for hemorrhoids. A 1999 colonoscopy revealed lymphoid hyperplasia. The Veteran indicated his last colonoscopy was in 2012 or 2013 and he was instructed to take more fiber. Accordingly, a remand is required to determine the etiology of the Veteran's claimed disorders and also to determine whether the Veteran's blood in his stool (hematochezia) represents a separate and distinct symptom of another disability other than his already service-connected hemorrhoids. 15. Service connection for thalassemia is remanded. In August 1991, it was noted the Veteran had low hemoglobin and that he was precluded from flying. An August 1999 service treatment note indicates the Veteran had anemia since 1991. In 2008, he was diagnosed with the thalassemia trait. Service connection is already in effect for anemia. The Veteran's representative has argued that because thalassemia was not noted on the Veteran's entrance examination that the presumption of soundness applies. See July 2021 Hearing Transcript, p. 33-34. The representative also argued that it is possible something in service aggravated the Veteran's thalassemia to cause it to become an actual disabling condition rather than a dormant trait. See id, p. 34. It appears the representative was insinuating that the Veteran's anemia aggravated the Veteran's thalassemia. The evidence suggests that thalassemia (a blood disorder) is a hereditary genetic trait. VA's Office of General Counsel has distinguished between hereditary diseases and defects, emphasizing that the former is capable of improvement or deterioration while the latter is static. VAOPGCPREC 82-90 (O.G.C. Prec. 82-90). A "defect" is defined as an imperfection or structural abnormality, while a "disease" is any interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs. Id. Congenital defects are not diseases or injuries within the meaning of applicable legislation for disability compensation purposes. 38 C.F.R. §§ 3.303(c), 4.9 (emphasis added). Congenital defects also automatically rebut the presumption of soundness, and are therefore, considered to have preexisted service. Id. However, VA General Counsel has confirmed that the existence of a congenital hereditary disease under 38 C.F.R. § 3.303(c) does not always rebut the presumption of soundness, and that service connection may be granted for congenital hereditary diseases which either first manifest themselves during service or which preexist service and progressed at an abnormally high rate during service. See VAOPGCPREC 67-90; see also VAOPGCPREC 82-90 (service connection for congenital, developmental or familial diseases is warranted if the evidence as a whole establishes that the familial conditions in question were incurred or aggravated during service within the meaning of VA law and regulations.). On remand, an examination and opinion is required to determine whether the Veteran's thalassemia is a congenital defect or disease and, if it is a disease, whether service connection is warranted. Increased Rating Claims 16. Entitlement to an initial compensable rating for allergic rhinitis is remanded 17. Entitlement to an initial compensable rating for hypertension is remanded The Veteran is claiming his allergic rhinitis and hypertension have worsened since he was last examined several years ago. See June 2021 Hearing Testimony; see also November 2016 Brief. Accordingly, a remand is required for examinations to assess the current severity of his conditions. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (requiring a new examination where the claimant asserts that a disability has increased in severity since the time of the last VA examination). While this case is in remand status, all outstanding VA treatment records must be obtained and associated with the evidence of record before the Board. See Bell v. Derwinski, 2 Vet. App. 611 (1992). The Veteran and his representative have the right to submit additional evidence and argument on the matters the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records and associate them with the evidence of record. 2. Obtain all outstanding medical records from Moody Air Force Base in accordance with VA regulation. 3. Obtain all outstanding service personnel records and associate them with the evidence of record. 4. Following completion of step 3, make a formal finding regarding the Veteran's claims that he was exposed to (a) asbestos; and (b) cadmium. The AOJ must outline all attempts to verify the Veteran's claimed exposure in a memorandum and provide an explanation for the findings. If exposure to asbestos and/or cadmium is conceded, the AOJ must ensure that the below requested opinions consider this exposure. 5. Following completion of steps 1-4, afford the Veteran an examination to determine the etiology any residuals of the conceded traumatic brain injury (TBI). The examiner must obtain from the Veteran and document in the examination report the onset and continuity of symptoms he has experienced. All appropriate diagnostic testing should be accomplished. Following a review of the evidence and with consideration of the Veteran's statements, please provide the following: (a) Is it at least as likely as not (50 percent probability or higher) that the Veteran has any residuals of a TBI? Why or why not? The examiner must specifically identify which symptoms are attributable to residuals of a TBI and which are not and must provide an explanation for these findings. A complete rationale for each opinion is required. Citation to accepted medical principles and/or literature would be of great assistance to the Board. If the examiner is unable to provide any opinion without resorting to speculation, he or she must explain why this is so. 6. Following completion of steps 1-4, afford the Veteran an examination to determine the etiology of any joint pain/body aches, with specific attention directed to, but not limited to, the bilateral shoulders/arms and bilateral feet/ankles. The examiner must obtain from the Veteran and document in the examination report the onset and continuity of symptoms he has experienced. All appropriate diagnostic testing must be accomplished, to include x-rays. Following a review of the evidence and with consideration of the Veteran's statements, please provide the following information: (a) Does the Veteran have a diagnosis of fibromyalgia? Why or why not? (b) Does the Veteran have a diagnosis of rheumatoid arthritis? Why or why not? If yes, is it at least as likely that the Veteran's rheumatoid arthritis began during or is etiologically related to his active duty service, to include as due to exposure to toxins in the Southwest Asia Theater of Operations. Why or why not? (c) Identify all diagnosed disabilities pertaining to the Veteran's bilateral (i) shoulders, (ii) arms, (iii) feet; and (vi) ankles. The examiner is informed that pain may be a disability in the absence of a formal diagnosis. (d) With respect to each diagnosis in (c), determine whether it is at least as likely as not (50 percent probability or higher) that the disability began during or is etiologically related to the Veteran's active duty service, to include as due to exposure to toxins in the Southwest Asia Theater of Operations. Why or why not? As noted above, even if there is no formal diagnosis pertaining to the bilateral (i) shoulders, (ii) arms, (iii) feet, and (vi) ankles, the examiner still must provide an opinion considering pain as a disability. (e) If there are no diagnoses to explain the Veteran's complaints of widespread body and joint pain, (to include, but not limited to the specific areas identified above) the examiner must determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran's has signs or symptoms of an undiagnosed illness or a MUCMI. Why or why not? A complete rationale for each opinion is required. Citation to accepted medical principles and/or literature would be of great assistance to the Board. If the examiner is unable to provide any opinion without resorting to speculation, he or she must explain why this is so. 7. Following completion of steps 1-4, afford the Veteran the appropriate examination to determine the etiology of his lung mass and pneumonia (to include residuals). The examiner must obtain from the Veteran and record in the examination report a complete description regarding the onset and continuity of symptoms. All appropriate diagnostic testing, to include pulmonary function testing, should be accomplished. Following a review of the evidence, and with consideration of the Veteran's statements, provide the following: (a) Is it at least as likely as not (50 percent probability or higher) that the Veteran has a respiratory disorder which began during or is etiologically related to his active duty service, to include as due to exposure to toxins in the Southwest Asia Theater of Operations? Why or why not? (b) If there is no diagnosis of a respiratory disorder, i. The examiner must still provide the opinion in (a) considering the Veteran's subjective reports of respiratory symptoms. ii. The examiner must also consider whether it is it at least as likely as not (50 percent probability or higher) that the Veteran's respiratory signs or symptoms are indicative of an undiagnosed illness or MUCMI? Why or why not? (c) Is it at least as likely as not (50 percent probability or higher) that the Veteran's lung mass began during or is etiologically related to his active duty service? Why or why not? If the answer is in the affirmative, the examiner must describe these symptoms. If the answer is in the negative, the examiner must explain why any reports of respiratory symptoms are not related to the lung mass. (d) Is it at least as likely as not (50 percent probability or higher) that the Veteran has residuals of pneumonia which began during or are etiologically related to his active duty service? Why or why not? If the answer is in the affirmative, the examiner must describe these symptoms. If the answer is in the negative, the examiner must explain why any reports of respiratory symptoms are not related to residuals of pneumonia. A complete rationale for each opinion is required. Citation to accepted medical principles and/or literature would be of great assistance to the Board. If the examiner is unable to provide any opinion without resorting to speculation, he or she must explain why this is so. 8. Following completion of steps 1-4, afford the Veteran the appropriate examination to determine the etiology of his enlarged heart. The examiner must obtain from the Veteran and record in the examination report a complete description regarding the onset and continuity of symptoms. All appropriate diagnostic testing should be accomplished. Following a review of the evidence, and with consideration of the Veteran's statements, provide the following: (a) Is it at least as likely as not (50 percent probability or higher) that the Veteran's enlarged heart began during or is etiologically related to his active duty service, to include as due to exposure to toxins in the Southwest Asia Theater of Operations? Why or why not? (b) Is it at least as likely as not (50 percent probability or higher) that the Veteran's enlarged heart is caused by his hypertension? Why or why not? (c) Is it at least as likely as not (50 percent probability or higher) that the Veteran's enlarged heart is aggravated by his hypertension? Why or why not? A complete rationale for each opinion is required. Citation to accepted medical principles and/or literature would be of great assistance to the Board. If the examiner is unable to provide any opinion without resorting to speculation, he or she must explain why this is so. 9. Following completion of steps 1-4, afford the Veteran the appropriate examination(s) to determine the etiology of bilateral ear pain and sinusitis. The examiner must obtain from the Veteran and record in the examination report a complete description regarding the onset and continuity of symptoms. All appropriate diagnostic testing should be accomplished. Following a review of the evidence, and with consideration of the Veteran's statements, provide the following: (a) Determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran has sinusitis (or sinus symptoms) which began during or is etiologically related to his active duty service, to include as due to exposure to toxins in the Southwest Asia Theater of Operations. Why or why not? Even if there is no formal diagnosis of sinusitis, an opinion must still be rendered considering the Veteran's reported symptoms. (b) If the examiner finds no diagnosis of sinusitis, he or she must explain why this is so. The examiner must also determine whether the Veteran's symptoms can be attributed to another disability or if they are indicative of an undiagnosed illness or MUCMI. Why or why not? (c) Determine whether it is at least as likely as not (50 percent probability or more) that the Veteran's bilateral ear pain began during or is etiologically related to his active duty service, to include as due to exposure to toxins in the Southwest Asia Theater of Operations. Why or why not? (d) Determine whether it is at least as likely as not (50 percent probability or more) that the Veteran's bilateral ear pain is caused by his tinnitus. Why or why not? (e) Determine whether it is at least as likely as not (50 percent probability or more) that the Veteran's bilateral ear pain is aggravated by his tinnitus. Why or why not? (f) Determine whether it is at least as likely as not (50 percent probability or more) that the Veteran's bilateral ear pain is caused by sinusitis or sinus symptoms. Why or why not? (g) Determine whether it is at least as likely as not (50 percent probability or more) that the Veteran's bilateral ear pain is aggravated by sinusitis or sinus symptoms. Why or why not? A complete rationale for each opinion is required. Citation to accepted medical principles and/or literature would be of great assistance to the Board. If the examiner is unable to provide any opinion without resorting to speculation, he or she must explain why this is so. 10. Following completion of steps 1-4, afford the Veteran an examination the appropriate examination(s) to determine the etiology of his claims for blood in the stool, hematochezia, colon polyps, and enlarged prostate. The examiner must obtain from the Veteran and record in the examination report a complete history regarding the onset and continuity of symptoms. Following a review of the record and with consideration of the Veteran's statements, please determine the following: (a) Is it at least as likely as not (50 percent probability or higher) that the Veteran's colon polyps began during or is etiologically related to his active duty service, to include as due to exposure to toxins in the Southwest Asia Theater of Operations? Why or why not? (b) Is it at least as likely as not (50 percent probability or higher) that the Veteran's colon polyps are caused by his hemorrhoids? Why or why not? (c) Is it at least as likely as not (50 percent probability or higher) that the Veteran's colon polyps are aggravated by his hemorrhoids? Why or why not? (d) Is it at least as likely as not (50 percent probability or higher) that the Veteran's enlarged prostate began during or is etiologically related to his active duty service, to include as due to exposure to toxins in the Southwest Asia Theater of Operations? Why or why not? (e) Is it at least as likely as not (50 percent probability or higher) that the Veteran's blood in his stool began during or is etiologically related to his active duty service, to include as due to exposure to toxins in the Southwest Asia Theater of Operations? Why or why not? (f) Is it at least as likely as not (50 percent probability or higher) that the Veteran's hematochezia began during or is etiologically related to his active duty service? Why or why not, to include as due to exposure to toxins in the Southwest Asia Theater of Operations? (g) If the response to (a) and/or (b) is in the affirmative, determine whether it is at least as likely as not (50 percent probability or higher) that these symptoms are due to a condition other than the Veteran's hemorrhoids. Why or why not? A complete rationale for each opinion is required. Citation to accepted medical principles and/or literature would be of great assistance to the Board. If the examiner is unable to provide any opinion without resorting to speculation, he or she must explain why this is so. 11. Following completion of steps 1-4, afford the Veteran an examination to determine whether service connection is warranted for thalassemia. The examiner should obtain from the Veteran and record in the examination report a complete history regarding his reported onset and continuity of symptoms. Following a review of the record and with consideration of the Veteran's statements, please determine the following: (a) Is thalassemia a congenital disease or defect? Why or why not? A "defect" is defined as an imperfection or structural abnormality, while a "disease" is any interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs. (b) If thalassemia is a congenital disease, determine: i. Whether it is at least as likely as not (50 percent probability or higher) that the condition first manifested during the Veteran's active duty service. Why or why not? ii. Whether it is at least as likely as not (50 percent probability or higher) that manifestations of the disease in service constituted aggravation of the condition? Why or why not? In providing this response, the examiner must consider the Veteran's in-service diagnosis of anemia. A complete rationale for each opinion is required. Citation to accepted medical principles and/or literature would be of great assistance to the Board. If the examiner is unable to provide any opinion without resorting to speculation, he or she must explain why this is so. 12. Following completion of steps 1-2, afford the Veteran an examination to determine the current severity of his allergic rhinitis. The examiner must obtain from the Veteran and document in the examination report the symptoms and function impairment he experiences due to this disorder. 13. Following completion of steps 1-2, afford the Veteran an examination to determine the current severity of his hypertension. The examiner must obtain from the Veteran and document in the examination report the symptoms and function impairment he experiences due to this disorder. Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board O'Connell, Jessica L. 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.