Citation Nr: A21020209 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 190827-26212 DATE: December 17, 2021 ORDER 1. Entitlement to an earlier effective date prior to August 22, 2015, for the grant of service connection for painful scars of the head is denied. 2. Entitlement to an initial disability rating in excess of 10 percent for painful scars of the head is denied. REMANDED 3. Entitlement to an initial disability rating in excess of 10 percent for a keloid scar, posterior head, for the period prior to August 7, 2018, is remanded. 4. Entitlement to an increased disability rating in excess of 30 percent for a keloid scar, posterior head, for the period since August 7, 2018, is remanded. FINDINGS OF FACT 1. Although the Veteran initially filed a claim for entitlement to service connection for acne keloids to the back of the head in a Veteran's Application for Compensation and/or Pension (VA Form 21-526), which was received by VA on July 22, 2011, entitlement to service connection for painful scars of the head did not arise until August 22, 2015, as the evidence does not show that the Veteran's head scar was painful prior to this later date. 2. The Veteran did not have three or four scars of the head that were painful or unstable at any time during the appeal period. CONCLUSIONS OF LAW 1. The criteria for entitlement to an earlier effective date prior to August 22, 2015, for the grant of service connection for painful scars of the head have not been met. 38 U.S.C. §§ 5101, 5110; 38 C.F.R. §§ 3.1, 3.151, 3.155, 3.400. 2. The criteria for entitlement to an initial disability rating in excess of 10 percent for painful scars of the head have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, Diagnostic Code (DC) 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty from November 1985 to November 1989. This case was previously before the Board of Veterans' Appeals (Board) in January 2019, at which time the Board remanded the matters on appeal for readjudication and issuance of a statement of the case (SOC) by the Agency of Original Jurisdiction (AOJ). See Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). The record shows that the AOJ issued an SOC in July 2019; thus, there was substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that although the rating decisions on appeal were issued in January 2013 and October 2015, on August 27, 2019, the Veteran elected the modernized review system by submitting a VA Form 10182 Decision Review Request: Board Appeal, in which he requested the Direct Review lane, which includes not wanting a Board hearing, and he indicated that he would not submit additional evidence in support of this appeal, in response to a July 2019 SOC. 38 C.F.R. § 19.2(d). Accordingly, pursuant to 38 C.F.R. § 20.202(b)(1), the Board will consider only the evidence of record as of the date of the respective decision, dated July 31, 2019. This decision has been written consistent with the Appeals Modernization Act (AMA) framework. This case was again before the Board in April 2020, at which time the Board denied the matters on appeal. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). Per a July 2021 Joint Motion for Remand (Joint Motion), the Court issued an order vacating the Board's April 2020 decision, and remanding the matters to the Board. Specifically, in the July 2021 Joint Motion, the Veteran and the Secretary of VA (parties) agreed that the Board did not provide adequate reasons and bases regarding the increased rating claim for the keloid scar disability, which the Board shall discuss below. Furthermore, the parties determined in the Joint Motion that the Board erred when it did not address a January 2012 VA surgery consultation note that showed that the Veteran reported that his lesions get irritated/inflamed two times per month in denying the claim for an earlier effective date for the grant of service connection for painful scars of the head. Likewise, the parties agreed that the Board erred when it did not address the symptomatology of bleeding, sensitivity, and inflammation, which was noted during the August 2015 VA skin diseases disability benefits questionnaire (DBQ), when it denied an initial disability rating in excess of 10 percent for the painful scar of the head. 1. Entitlement to an Earlier Effective Date for the Award of Service Connection for Painful Scars of the Head. The Veteran is seeking an effective date earlier than August 22, 2015, for the grant of service connection for his painful scar located on the back of his head. Specifically, in numerous statements throughout the appeal, including in the November 2016 notice of disagreement (NOD) under the legacy system and in the October 2021 statement, the Veteran and his attorney contended that an effective date of July 22, 2011, was warranted for this disability because that is when the Veteran filed the claim for service connection for acne keloids to the back of the head and the painful scar is part and parcel of this claim. Furthermore, in the October 2021 statement, they contended that an earlier effective date of July 22, 2011 was warranted for the painful head scars with a rating of at least 20 percent disability because the evidence showed that the Veteran's keloid scars have been both painful and unstable for the entire period on appeal. The law regarding effective dates provides that, unless specifically provided otherwise, the effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(a). This statutory provision is implemented by a VA regulation, which provides that the effective date of an evaluation and award of compensation based on an original claim or a claim reopened after final disallowance will be the date of receipt of the claim or the date entitlement arose, whichever is the later. See 38 C.F.R. § 3.400. For claims specifically reopened on the basis of new and material evidence after a final disallowance under 38 C.F.R. § 3.156(a), the effective date is the date of receipt of the new claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(q)(2). A specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA. 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151(a). The term "claim" or "application" means a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). VA must look to all communications from a claimant that may be interpreted as applications or claims - formal and informal - for benefits and is required to identify and act on informal claims for benefits. Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). The essential elements for any claim, whether formal or informal, are: (1) an intent to apply for benefits; (2) an identification of the benefits sought; and (3) a communication in writing. See Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). For claims received on or after March 24, 2015, VA amended its regulations governing how to file a claim. The effect of the amendment was to standardize the process of filing claims, as well as the forms accepted, in order to increase the efficiency, accuracy, and timeliness of claims processing, and to eliminate the concept of informal claims. See 38 C.F.R. § 3.155; 79 Fed. Reg. 57660-01. However, prior to the effective date of the amendment, VA law provided that any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA, from a veteran or his representative, may be considered an informal claim. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the veteran, it will be considered filed as of the date of receipt of the informal claim. Even with respect to informal claims, such informal claim must identify the benefit sought. 38 C.F.R. § 3.155 (for claims received prior to March 24, 2015). In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). In the July 2021 Joint Motion, the parties noted that the initial rating of the keloid scar, to include a separate initial rating for its manifestation of pain, is part-and-parcel of the appeal stemming from the initial claim for service connection for the keloid scar, which was received by VA on July 22, 2011. This fact is not in question. Rather, the issue to be resolved is whether the Veteran had a painful scar of the head prior to August 22, 2015, at which time the VA examination report showed one painful scar. In support of the claim for an earlier effective date for the grant of a separate rating for a painful scar of the head, the Veteran and his attorney note that a January 2012 VA surgery consultation note showed that the Veteran complained of lesions that get irritated/inflamed two times per month. Furthermore, the Veteran's attorney noted in the October 2021 statement that a 1989 treatment record showed that the Veteran experienced numerous inflamed papules, and that the 2012 VA examination report showed the Veteran's complaints of inflammation at least once per month. A review of the record shows that a September 1989 treatment record, which was created more than 20 years prior to the current appeal period, shows that the Veteran had numerous inflamed papules/nodules on the occipital region. These symptoms were assessed as acne keloidalis nuchae (AKN). A December 2011 VA primary care note showed that a review of the Veteran's skin showed a 3 centimeter (cm.) by 1.5 cm. lesion on the posterior neck, which was flat. The medical professional assessed his symptoms as an unspecified skin lesion, acne, and keloid, and a dermatology consultation was ordered. The January 2012 VA surgery consultation note shows that the Veteran was referred to the service for a skin lesion on the posterior neck, which was flat. The Veteran reported that the lesion has been present since 1985 and that it gets irritated/inflamed two times per month. The Veteran was being treated by a private dermatologist and was told that it was a keloid. A physical evaluation showed that the Veteran had a flat area of scarring at the base of the skull, which was 3 cm. by 2 cm. in size, with no signs of inflammation. The medical professional's clinical impression was keloid scarring. An April 2012 VA treatment record showed that the Veteran complained of keloids on the back of his head, which started in the military after a bad haircut. He reported that sometimes the back of his head still bumps up and gets infected, but the physical evaluation showed that the skin was flat. He was noted to have a 3 cm. by 2 cm. scar on the back of the head, as well as 5 millimeter (mm.) papules on his chest and a 5 mm. papule on the left leg. The medical professional's assessment was history of keloid scar and history of AKN. During the December 2012 VA examination for scars and/or disfigurement, the Veteran specifically denied having any painful or unstable (meaning that there was frequent loss of covering of skin over the scar) scars of the head, face, or neck. In fact, the record does not show that the Veteran complained of having a painful scar until the August 22, 2015, VA examination, in which he reported that he had one painful scar. He described the pain as a stinging sensation and increased itching. The examiner noted that the Veteran did not have any scars that were unstable and no scars that were both painful and unstable. Given this evidence, the Board finds that entitlement to an earlier effective date prior to August 22, 2015, for the grant of service connection for painful scars of the head is not warranted. Specifically, although the Veteran initially filed a claim for entitlement to service connection for acne keloids to the back of the head on July 22, 2011, entitlement to service connection for painful scars of the head did not arise until August 22, 2015, as the evidence does not show that the Veteran's head scar was painful prior to this later date. To the extent that the Veteran and his attorney contend that the symptoms of irritation, inflammation, and/or infection of the papules/lesions noted in the September 1989, January 2012, and April 2012 VA treatment records amounts to a painful scar and should entitle the Veteran to a separate compensable disability rating for the painful scar of the head prior to August 22, 2015, the Board notes that assigning a compensable disability rating under DC 7804 for these symptoms would violate the provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding). While separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition, here, the Veteran's keloid scar disability is rated under DC 7800-7828 for acne, and DC 7828 specifically contemplates the presence of inflamed nodules and pus-filled cysts. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994); see also 38 C.F.R. § 4.118, DC 7828. Overall, the preponderance of the evidence is against a finding that the Veteran's head scar was painful or unstable prior to the August 22, 2015, VA examination in which he reported for the first time that he had one scar that was painful in the sense that he had a stinging sensation and increased itching. In fact, he denied having any such painful scar in the December 2012 VA examination report. Accordingly, given that the Veteran's scar was not painful until August 22, 2015, the Board finds that the preponderance of the evidence is against entitlement to an earlier effective date for the award of service connection for such disability. Although the Veteran filed a claim for service connection on July 22, 2011, the AOJ assigned the earliest effective date possible for painful scars of the head, which was from the date that entitlement arose on August 22, 2015, when he reported to the examiner that his scar was painful. Thus, the claim of entitlement to an effective date prior to August 22, 2015, for the grant of service connection for painful scars of the head is denied. See 38 U.S.C. § 5110(a); 38 C.F.R. §§ 3.155(a), 3.400; 38 C.F.R. § 3.155(a) (2011). 2. Entitlement to an Initial Disability Rating in Excess of 10 Percent for Painful Scars of the Head. The Veteran asserts that his scar of the head should be rated higher than the currently assigned disability rating of 10 percent. Specifically, in the July 2021 Joint Motion, the parties agreed that the Board provided an inadequate statement of reasons and bases in the April 2020 decision when it did not address whether the symptomatology of bleeding, sensitivity, and inflammation noted during the August 2015 VA examination amounted to an unstable scar in denying a higher disability rating for this disability. Furthermore, the Veteran's attorney contended in the October 2021 statement that this disability has been both painful and unstable for the entire period on appeal, which warranted a rating of at least 20 percent. The attorney noted that the August 2015 VA examination report showed such symptoms as bleeding, sensitivity, and inflammation, and the August 2018 VA examination showed scattered papules surrounding the keloid with tenderness to palpation, as well as increased tenderness, with lesions two-to-three times per month, itching and stinging with drainage and pain at each lesion in the previous 18 months. VA has adopted a Schedule for Rating Disabilities (Schedule) to evaluate service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R., Part IV. Disability evaluations assess the ability of the body as a whole, the psyche, or a body system or organ to function under the ordinary conditions of daily life, to include employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Id. The Schedule assigns DCs to individual disabilities. DCs provide rating criteria specific to a particular disability. If two DCs are applicable to the same disability, the DC that allows for the higher disability rating applies. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the claimant. 38 C.F.R. § 4.3. The Schedule recognizes that a single disability may result from more than one distinct injury or disease; however, rating the same disability or its manifestation(s) under different DCs a practice known as pyramiding is prohibited. See 38 C.F.R. § 4.14. In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as "staged ratings." The Veteran appealed the initially assigned disability rating; thus, the appeal period stems from August 22, 2015. The record shows that this scar has been rated as 10 percent disabling since August 22, 2015 under 38 C.F.R. § 4.118, DC 7804. DC 7804 rates unstable or painful scars, and sets forth the following disability ratings: 30 percent for five or more scars that are unstable or painful; 20 percent for three to four scars that are unstable or painful; or, 10 percent for one or two scars that are unstable or painful. 38 C.F.R. § 4.118. According to Note (1), an "unstable" scar is a scar "where, for any reason, there is frequent loss of covering of skin over the scar." The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, DC 7804 was not changed by the August 13, 2018, amendments. The August 2015 VA examination for scars/disfigurement shows that the Veteran had one painful scar on his posterior head measuring 5.5 cm. by 2.5 cm. He described the pain as a stinging sensation and increased itching and noted that he had symptoms during the day and that he has pain when his hair is cut. The examiner specifically noted the presence of only one scar, and noted that the scar was not unstable. The Board notes that the Veteran's reports of bleeding, sensitivity, and inflammation were noted in the August 2015 VA skin diseases DBQ, which discussed the Veteran's symptoms of the keloid scar, including the skin rash and lesions associated with AKN. Furthermore, the Veteran had another examination for his keloid acne scar in August 2018, during which the examiner observed that the Veteran had one painful scar on his posterior head measuring 3 cm. by 2.5 cm stemming from acne keloid. The examiner specifically noted that the Veteran did not have any scars of the head, neck, or face that were unstable, with frequent loss of covering of skin over the scar. The Board notes that the August 2018 VA examination for skin diseases showed findings of scattered papules surrounding the keloid on the back of the head, and that the keloid was noted to be hypopigmented and abnormal in texture. The examiner noted that the Veteran reported mild tenderness to palpation. Given this evidence, the Board finds that a higher evaluation for the Veteran's surgical scar of the head is not warranted. Specifically, the preponderance of the evidence is against a finding that the Veteran had three or four painful or unstable scars of the head at any time throughout the appeal. 38 C.F.R. § 4.118, DC 7804. The evidence of record, including the August 2015 and August 2018 VA examinations for scars/disfigurement and skin diseases, shows that the Veteran has had only one painful scar, which was not unstable. The Board has considered the statements made by the Veteran's attorney that the August 2015 VA examination showed symptoms of bleeding, sensitivity, and inflammation, and that the August 2018 VA examination showed scattered papules surrounding the keloid with tenderness to palpation. However, this is not evidence indicating that the one scar was unstable, i.e. there was frequent loss of covering of skin over the scar. In fact, both examiners noted that the Veteran did not have any unstable scars on the back of his head. Furthermore, the Board notes that assigning a disability rating under DC 7804 for these symptoms would violate the provisions against pyramiding as these symptoms of superficial and deep acne, including papules, pustules, inflamed nodules, pus-filled cysts, etc.) are contemplated by the Veteran's keloid scar disability, which is rated under DC 7800-7828 for acne. See Esteban, 6 Vet. App. at 262; see also 38 C.F.R. §§ 4.14, 4.118, DC 7828. Thus, an initial disability rating in excess of 10 percent for painful scars of the head is not warranted. 38 C.F.R. § 4.118, DC 7804. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and the Veteran's claim must be denied. See 38 U.S.C. § 5107; 38 C.F.R. § 4.3. REASONS FOR REMAND 3. Entitlement to a Disability Rating in Excess of 10 Percent for a Keloid Scar, Posterior Head, for the Period Prior to August 7, 2018. 4. Entitlement to a Disability Rating in Excess of 30 Percent for a Keloid Scar, Posterior Head, for the Period From August 7, 2018. The Veteran and his attorney contend that his keloid scar disability should be rating as 60 percent disabling due to his use of topical corticosteroids applied on a constant or near-constant basis to treat this disability. While this disability is currently rated as 10 percent disabling prior to August 7, 2018, and as 30 percent disabling thereafter, under38 C.F.R. § 4.11, DC 7800-7828, which rates the Veteran's acne pursuant characteristics of disfigurement of the head, face, or neck, the Veteran's attorney contends that this disability could be rated pursuant to D 7806, which rates dermatitis or eczema. VA amended its regulations on skin disabilities effective August 13, 2018. Claims pending prior to the regulatory effective date, such as the claim at hand, shall be considered under both the old and new rating criteria, and whichever criteria is most favorable to the Veteran shall be applied. Under the prior version of DC 7806, a 10 percent rating is assigned for symptoms affecting at least 5 percent, but less than 20 percent, of the entire body or exposed areas; or when intermittent systemic therapy is required for a total duration of less than 6 weeks over the past 12-month period. 38 C.F.R. § 4.118, DC 7806. A 30 percent rating is assigned for symptoms affecting 20 to 40 percent of the entire body or exposed areas; or when systemic therapy is required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. Id. A 60 percent rating is assigned for symptoms affecting more than 40 percent of the entire body or exposed areas; or when constant or near-constant systemic therapy is required. Id. Here, the August 2015 VA skin diseases DBQ showed that the Veteran had dermatitis affecting less than 5 percent of the exposed area and the total body area. The examiner noted that the Veteran had dermatitis and scarring (keloid) consistent with acne keloidalis to his posterior head. This examiner noted that the Veteran used topical corticosteroids in the form of Clobetasol and Fluocinonide ointment daily and that he has used such topical corticosteroids at a constant/near-constant basis in the previous 12 months. Likewise, the August 2018 VA examiner noted in the skin diseases DBQ that the Veteran used topical corticosteroids of Clobetasol 0.05 percent topically applied one-to-two times per day. This examiner also noted that the Veteran had used this medication at a constant/near constant basis in the previous 12 months. For entitlement to a 60 percent rating for the keloid scar disability, the Veteran would need to show "constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period." See 38 C.F.R. § 4.118, D 7806 (2018). The parties noted in the July 2021 Joint Motion that in its April 2020 decision, the Board failed to discuss whether it had adequate information to consider the question of whether the Veteran's use of Clobetasol on a constant/near constant basis in the past 12 months, as shown by the August 2015 and August 2018 VA examination reports, had a systemic effect. With regard to the meaning of "systemic therapy" under the old criteria, the use of a topical steroid could constitute "systemic therapy" within the meaning of DC 7806 depending on the factual circumstances of each case. See Johnson v. Shulkin, 862 F.3d 1351, 1356 (2017). There are at least two potential ways of showing that a topical corticosteroid is systemic: the method by which the treatment works and its side effects. See Burton v. Wilkie, 30 Vet. App. 286, 289-93 (2018). "How a topical treatment works is a factual question that may, but not necessarily, require a medical opinion for its resolution[as] the Board is limited in its ability to make its own independent medical determinations." See id. at 292 (citing to Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). One of the effects of the AMA is to narrow the set of circumstances in which the Board must remand appeals to the AOJ for further development instead of immediately deciding them directly. Nevertheless, even under the AMA, the Board still has the duty to remand issues when necessary to correct a pre-decisional duty-to-assist error. 38 C.F.R. § 20.802(a). VA's duty to assist also includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Here, the Board determines that it does not have adequate information to determine whether the Veteran's continuous use of topical corticosteroids, such as Clobetasol and Fluocinonide ointment, constituted systemic therapy prior to the July 31, 2019, decision on appeal. Thus, the claim is remanded for an addendum VA medical opinion to answer this question. The matters are REMANDED for the following action: 1. Refer the Veteran's claims file to an appropriately qualified VA examiner to determine the nature of his keloid scar disability treatment prior to July 31, 2019. The examiner should be provided a copy of the claims file and the below facts. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: An August 2015 VA examination report showing that the Veteran was using topical corticosteroids of Clobetasol PRN and Fluocinonide ointment daily on a constant/near constant basis in the previous 12 months to treat his acne keloidalis nuchae symptoms. See VBMS entry with document type "C&P Exam," receipt date 08/22/2015, at p. 2. An August 2018 VA examination report showing that the Veteran was using topical corticosteroids of Clobetasol 0.05 percent topical, applied one-to-two times per day on a constant/near constant basis in the previous 12 months to treat his acne and keloid scar on the posterior head symptoms. See VBMS entry with document type "C&P Exam," receipt date 08/07/2018, at pp. 1-2. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. Based upon a review of the evidence and sound medical principles, the examiner should provide an opinion as to as to whether the Veteran's continuous use of topical medications, including corticosteroids such as Clobetasol and Fluocinonide ointment daily, constituted systemic therapy, such as corticosteroids or other immunosuppressive drugs. Please state upon what facts and medical principles and/or medical literature upon which the opinion is based. (Continued on the next page) The examiner should note that "constant or near-constant systemic therapy" means treatment pertaining to or affecting the body as a whole; whereas, "topical therapy" means treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied. The examiner is asked to provide a rationale for each opinion given. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. D. C. JOHNSON Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Hodzic, 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.