Citation Nr: 21005352 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 08-17 680 DATE: February 1, 2021 ORDER Entitlement to a rating in excess of 30 percent for sinusitis is denied. REMANDED Entitlement to service connection for coronary artery disease, to include as due to exposure to asbestos and lead, is remanded. Entitlement to service connection for hypertension, to include as due to exposure to asbestos and lead, is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as due to exposure to asbestos and lead, and to include as secondary to service-connected sinusitis, is remanded. FINDING OF FACT Throughout the period on appeal, the Veteran’s sinusitis manifested as six or more nonincapacitating episodes per year characterized by headaches, pain, and purulent discharge or crusting without radical surgery with chronic osteomyelitis or experienced near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. CONCLUSION OF LAW The criteria for a disability rating in excess of 30 percent for sinusitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.97, Diagnostic Code 6513. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from September 1992 to June 1996. These matters come to the Board of Veterans’ Appeals (Board) on appeal from March 2008 and March 2009 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) Roanoke, Virginia. By way of history, the Board remanded the issues to the Agency of Original Jurisdiction (AOJ) for further development in December 2010. In July 2015, the Board again remanded the issues to obtain possible missing treatment records. In March 2017, the Board denied the Veteran’s claim for entitlement to an increased rating for his sinusitis, and remanded his claims for entitlement to service connection for coronary artery disease, hypertension, and GERD. In March 2018, the Board denied the Veteran’s claims for entitlement to service connection for coronary artery disease, hypertension, and GERD. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In April 2018 Order, the Court vacated the March 2017 decision and remanded the issue of entitlement to an increased rating for service-connected sinusitis as the Court found the AOJ failed to substantially comply with the December 2010 Board remand directives. In December 2018, the Board remanded the issue of entitlement to an increased rating for sinusitis. In April 2019, the Court issued a Joint Motion for Remand (JMR) to vacate and remand the March 2018 Board decision and remanded the issues of entitlement to service connection for coronary artery disease, hypertension, and GERD as the Court found the AOJ failed to substantially comply with the March 2017 Board remand directives. Pursuant to the April 2019 Court JMR, the Board remanded the issues of entitlement to service connection for coronary artery disease, hypertension, and GERD in September 2019. This case was most recently before the Board in April 2020, at which time the appeal was remanded to the AOJ for further development. Specifically, the claim was remanded for the issuance of a Supplemental Statement of the Case (SSOC). Such an SSOC was issued in June 2020. The Board therefore finds that there has been substantial compliance with its previous remand. Stegall v. West, 11 Vet. App. 268 (1998). The case has now been returned to the Board for appellate action. Increased Rating – Sinusitis The Veteran asserts that he is entitled to a higher rating for his sinusitis because his symptoms are more severe than contemplated by the current rating assigned. Specifically, the Veteran stated he experienced seven or eight incapacitating episodes of sinusitis per year, and that he required prolonged medical treatment. See VA Form 21-4138 Statement in Support of Claim, April 7, 2008. The Veteran’s attorney asserts that the VA examination of record did not sufficiently inquire into the degree and duration of symptoms that would result in a higher rating. See e.g. Notice of Disagreement, April 24, 2009. Disability ratings are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. Separate evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as “staged” ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). VA’s determination of the present level of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased-rating claim has been pending. Hart v. Nicholson, 21 Vet. App. 505, 509 (2007). The Veteran’s entire history is reviewed when making disability evaluations. See generally, Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where, as here, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of staged ratings are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Further, [w]here there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When 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). The Veteran’s sinusitis is rated under Diagnostic Code 6513. Diagnostic 6513 for maxillary sinusitis is to be rated under the General Rating Formula for Sinusitis. The General Rating Formula for Sinusitis provides a 30 percent rating is assigned for three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent rating is assigned following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. A Note to the General Rating Formula for Sinusitis provides that an incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97. Turning to the evidence, at a July 2008 VA examination, the Veteran reported he had surgery to clean the sinuses that helped for a time, and he had less frequent infections and less purulent drainage but that the alleviation of symptoms from his surgery did not last long. He reported that he still had symptoms of about once month over the last year, his mucus was again becoming more purulent and in larger amounts, and was not having symptoms on the day of the examination. He treated with steroid nasal spray twice daily, and antibiotics as needed for acute infections. The Veteran had functional endoscopic sinus surgery (FESS) surgery and septoplasty in April 1998. There was no history of trauma, neoplasm, nasal allergy, nor osteomyelitis. There was a history of incapacitating episodes of greater than 4 per year that required antibiotic treatment. There was a history of nonincapacitating episodes of greater than 6 per year; symptoms during nonincapacitating episodes included headache, purulent drainage, and sinus pain that lasted seven to fourteen days in duration. Current sinus symptoms included headaches that were at least weekly but less than monthly, constant breathing difficulty and without speech impairment. Other significant history noted included migraine headaches that started about the same time as the sinusitis, coronary artery disease that prevented the use of decongestants due to palpitations and elevated heart rate and blood pressure. Upon physical examination, the examiner noted tenderness on the maxillary sinus without any signs of nasal obstruction. There was no evidence of sinusitis found. The examiner noted the Veteran was employed and lost about four weeks of work in the last 12 month period due to acute or chronic sinusitis and noted significant effects on his usual occupation. At an April 2014 VA examination, the Veteran reported he had episodes of sinusitis and headaches attributable to his chronic sinusitis and stated that he had a monthly sinus infection with congestion and sinus headaches. The Veteran was shown to have six nonincapacitating episodes over the last 12 months and did not have any incapacitating episodes of sinusitis requiring prolonged (four to six weeks) of antibiotics treatment in the past 12 months. The Veteran did have sinus surgery that was endoscopic and not radical. He did not have repeated sinus-related surgical procedures performed. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The Veteran did not have loss of part of the nose or other scars of the nose exposing both nasal passages, one ala, or other disfigurement. The examiner noted the Veteran’s sinusitis did not impact his ability to work. A March 2014 private treatment record indicates that the Veteran had persistent sinus congestion and cough for a month, was placed on antibiotics and had sinus congestion, headache, cough, and yellow mucus from the nose. The Veteran also indicated he had some discomfort over the greater right maxillary and frontal sinus areas. A November 2016 VA treatment record indicates the Veteran was experiencing recurrence of pressure and pain of his sinus, and was currently using nasal steroid daily. He reported he was getting sinus infections for two to three weeks, and was taking antibiotics for about seven days each without complete resolution of symptoms and with quick return of symptoms thereafter. A July 2017 VA treatment record indicates the Veteran had a computed tomography (CT) scan for his sinus, and the CT scan results showed bilateral maxillary chronic sinusitis. There was no evidence of acute sinusitis or other sinus involvement. The Veteran requested antibiotics for a frontal headache; denied nasal discharge, fever, chills, pressure, nasal congestion, or cough. The treatment provider found that his current headaches did not appear to be sinugenic in origin. The Veteran was not flushing his sinuses as previously instructed, and was again instructed to begin flushing his nose. He was also instructed to continue using nasal steroid spray as prescribed. There was no indication for surgical intervention. At a September 2019 VA examination, the Veteran reported that his sinusitis had worsened over the last 18 months that was gradual and had an increased frequency of infections over the past 18 months. Current symptoms included daily nasal congestion, sinus pressure and headaches. He took medication daily to treat his symptoms. The Veteran was shown to have maxillary and ethmoid sinusitis. Findings, signs, or symptoms attributable to chronic sinusitis included episodes of sinusitis, headaches, pain of affected sinus, tenderness of affected sinus, and purulent discharge. The Veteran was shown to have no nonincapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months and did not have any incapacitating episodes of sinusitis requiring prolonged (four to six weeks) of antibiotics treatment in the past 12 months. The Veteran did not have any additional surgeries of the sinus. Diagnostic imaging studies showed mild maxillary sinus disease on a CT scan, no evidence of sinusitis on x-rays and bilateral maxillary and right ethmoid sinus disease on magnetic resonance imaging (MRI) scan of the brain. The examiner noted the Veteran’s sinusitis did not impact his ability to work. Further review of the record shows that the Veteran receives VA treatment for various disabilities. However, there is no indication from the treatment notes of record that the Veteran has reported sinusitis symptoms that are worse than those noted in the various VA examination reports of record. Based on the foregoing, the Board finds a rating in excess of 30 percent is not warranted for sinusitis at any time during the period on appeal. In this regard, the Veteran has been shown to have, at worst, greater than six nonincapacitating episodes over the past 12 months and four incapacitating episodes over the past 12 months that required antibiotic treatment. The examiners also reported there was no evidence of radical sinus surgery. The next available rating of 50 percent requires radical surgery with chronic osteomyelitis or near constant sinusitis after repeated surgeries. The Veteran has not undergone radical or repeated surgery for his chronic sinusitis and the there is no allegation or evidence of near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. Therefore, a rating in excess of 30 percent for chronic sinusitis is not warranted. Consideration has been given to the Veteran and his attorney’s assertions that a higher rating is warranted for sinusitis. Specifically, the Board acknowledge the Veteran’s statements that he experienced seven or eight incapacitating episodes of sinusitis per year and that he required prolonged medical treatment as well as his attorney’s statements that the VA examination reports do not show the duration or severity of his sinusitis symptoms. While the Board does not doubt the Veteran’s sincere belief that he experienced these symptoms, he is not competent, as a lay person, to attribute even observable symptoms to a specific diagnosis. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (laypersons are competent to describe symptoms which support a later diagnosis); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). The medical evidence (VA examination report and treatment records) is probative and outweighs the Veteran’s allegations. That evidence does not show the severity of symptomatology warranting a compensable rating. Specifically, the evidence does not show the Veteran has had radical surgery or near constant sinusitis after repeated surgeries. The Veteran’s belief that he is entitled to a higher than 30 percent rating for his sinusitis is outweighed by the objective medical findings of record. That is, the Board assigns greater probative value to the pertinent objective findings on the VA examination reports and treatment records that were recorded following physical examinations of the Veteran, than to the Veteran’s general belief that he is entitled to a higher rating. The Board notes that in April 2018, the Court vacated the Board’s previous determination that the Veteran was not entitled to a rating in excess of 30 percent for his sinusitis. In that regard, the Court found the Board neither acknowledged its December 2010 remand directives nor explained how the April 2014 examiner’s reports substantially complied with its instructions that the examiner should address whether the Veteran had any listed symptoms “at any time since one year prior to filing his claim for increase in May 2008.” Specifically, the Court noted the April 2014 VA examiner reported sinus infections that were nonincapacitating and/or incapacitating for only the past 12 months. Therefore, the Court found the April 2014 VA examination failed to substantially comply with the December 2010 Board remand directives and directed the Board to discuss whether an additional medical opinion was necessary. The Board notes that the VA examination reports only indicate whether the Veteran had nonincapacitating or incapacitating episodes for sinusitis for the previous 12 months. However, the Board finds that all information required for rating purposes was provided. In this regard, the Board notes that the criteria for a higher 50 percent rating for sinusitis requires the Veteran have radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. In the instant case, the Veteran has not had radical surgery nor has he had repeated surgery. Rather, the medical evidence consistently indicate the Veteran underwent one surgical procedure in April 1998, that was not radical. The Veteran has also consistently denied any repeated surgeries. Therefore, the as the Veteran has not endorsed such surgeries and the evidence does not show he underwent such surgeries, the criteria for a higher 50 percent rating have not been ment and the record is adequate for rating purposes. The Board has considered whether staged ratings under Fenderson, supra, are appropriate for his chronic sinusitis; however, the Board finds that the Veteran’s symptomatology has been stable for the disability throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. Further, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, with regard to such claim. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Additionally, the Board has considered whether an inferred claim for a total disability based upon individual unemployability has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). Neither the Veteran nor his representative has alleged that he is unable to secure and maintain substantially gainful employment. Moreover, the Veteran’s current employment status is not clear from the record. As such, a Rice claim is not raised. Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to a rating in excess of 30 percent for chronic sinusitis is not warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND Service Connection – Coronary Artery Disease, Hypertension, and GERD The Veteran asserts that he has coronary artery disease, hypertension, and GERD as a result of his active service. Specifically, he contends that his such disorders were caused by asbestos and/or lead exposure sustained during active service and that his GERD was also caused or aggravated by his service-connected sinusitis. The lengthy procedural history following the Veteran’s claims for service connection for coronary artery disease, hypertension, and GERD is noted above; and, as noted above, the claims were most recently before the Board in April 2020 when they were remanded to the AOJ for further development. In that regard, the April 2020 Board directed the AOJ to afford the Veteran additional VA examinations for his claims. With regard to coronary artery disease, the Board found the August 2017 and October 2019 VA opinions inadequate to decide the claim because they were based on an incomplete reading of the records. Specifically, the April 2020 Board remand found that both examiners used the rationale that the Veteran’s blood pressure in service was essentially normal except for a one-time situational borderline high blood pressure and that the October 2019 examiner stated his service treatment records did not show any elevated blood pressure readings. However, the April 2020 Board remand noted that the Veteran’s service treatment records showed many elevated blood pressure readings and that the Veteran’s blood pressure readings continued to be elevated in the two years following separation from active service. As such, the April 2020 Board remand found the August 2017 and October 2019 VA opinions relied on inaccurate facts. With regard to GERD, the Board found the October 2019 VA opinion inadequate because it did not substantially comply with the March 2017 Board remand order. Specifically, the Board found the October 2019 VA opinion did not address aggravation or the in-service diagnosis of gastroenteritis. In its remand directives, the April 2020 Board directed the examiner to provide opinions as to whether his coronary artery disease, hypertension, and GERD were at least as likely had its onset during active service and were otherwise etiologically related to active service. Specific to coronary artery disease and hypertension, the examiner was directed to comment on the significance of any of the numerous service treatment records showing elevated blood pressure readings, hyperventilation, and chronic cough and to address the numerous articles and medical opinion submitted by the Veteran showing a link between coronary artery disease and hypertension to asbestos and/or lead exposure. Specific to GERD, the examiner was directed to comment on the in-service diagnosis of gastroenteritis and the relationship between GERD and service-connected sinusitis. Additionally, the examiner was directed to provide a detailed rationale for the opinions rendered and if the examiner was unable to offer the requested opinion, it was “essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge.” The Veteran was afforded the directed VA examinations for his claimed coronary artery disease, hypertension, and GERD in May 2020. At that time, with regard to coronary artery disease, the examiner opined such condition was less likely than not incurred in or caused by an in-service injury, event, or illness. In that regard, the examiner acknowledged the Veteran had a history of myocardial infarction, reviewed the available medical records and stated that the presence of lead in the environment alone does not indicate absolute toxicity because it must first be absorbed by the body before it can cause poisoning. The examiner also noted that the studies that demonstrated a link between lead and hypertension show that the lead levels in the body are greater than 10 mcg/dl, and the Veteran’s medical records were limited in providing this objective evidence. Rather, the examiner noted that cardiovascular diseases have a strong tendency to run in the families and the Veteran admitted in various treatment records that his brother and both parents had hypertension. Therefore, with all evidence considered, the examiner opined that it was less likely than not that the Veteran’s coronary artery disease had its onset in service or was otherwise etiologically related to service. With regard to hypertension, the examiner opined his hypertension was less likely than not incurred in or caused by an in-service injury, event, or illness. In that regard, the examiner acknowledged the Veteran had a history of myocardial infarction, and reviewed the available medical records and stated that the presence of lead in the environment alone does not indicate absolute toxicity because it must first be absorbed by the body before it can cause poisoning. The examiner also noted that the studies that demonstrated a link between lead and hypertension show that the lead levels in the body are greater than 10 mcg/dl, and the Veteran’s medical records were limited in providing this objective evidence. The examiner noted and recognized that the Veteran manifested with hypertension during service, as noted in some of the blood pressure recordings and noted that cardiovascular diseases have a strong tendency to run in the families and the Veteran admitted in various treatment records that his brother and both parents had hypertension. Therefore, with all evidence considered, the examiner opined that it was less likely than not that the Veteran’s hypertension had its onset in service or was otherwise etiologically related to service. With regard to GERD, the examiner opined his GERD was less likely than not incurred in or caused by an in-service injury, event, or illness. In that regard, the examiner reviewed the available medical records and noted that the evidence provided limited objective evidence of a current, confirmed diagnosis of GERD but that a history of GERD was supposed. The examiner noted that multiple factors could increase the risk of GERD, to include obesity, smoking, hiatal hernia, delayed gastric emptying, bad eating habits, and certain food items or medications. Further, the examiner noted that having acute episodes of gastroenteritis, whether infectious or not, does not lead to the development of GERD. Therefore, the examiner opined that GERD was less likely than not etiologically related to service. Additionally, the examiner found that GERD was less likely than not aggravated beyond its natural progression by his service-connected sinusitis with headaches. The Board finds the May 2020 VA opinions incomplete to decide the claims. In this regard, the examiner did not comment on the significance of the numerous blood pressure readings, hyperventilation, chronic cough nor did the examiner address the numerous articles and medical opinion submitted by the Veteran regarding asbestos and/or lead exposure. Additionally, the examiner did not provide a detailed rationale for any of the opinions rendered and did not offer whether an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. Rather, the examiner provided mere conclusory statements that the claimed coronary artery disease, hypertension, and GERD may be related to other risk factors, to include familial history, obesity, smoking, or the like; and did not provide any supporting rationale for the conclusions reached as directed by the April 2020 Board remand. Given these deficiencies, the Board is unable to find that substantial compliance with the prior remand has been achieved. See D’Aries, 22 Vet. App. at 105; see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As such, remand is again required to afford the Veteran VA examinations that comply with the Board’s prior remand directives. See Stegall v. West, 11 Vet. App. at 268, 271 (1998). The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Return the Veteran’s claims file to the examiner who conducted the May 2020 VA DBQ examination for coronary artery disease, hypertension, and GERD so addendum opinions may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new in-person examination is only required if deemed necessary by the examiner. The examiner must provide an opinion as to the following questions: (A) Is it at least as likely as not (more than 50 percent probability) that the Veteran’s coronary artery disease had its onset in service or is otherwise etiologically related to active service, to include exposure to lead and/or asbestos? (B) Is it at least as likely as not (more than 50 percent probability) that the Veteran’s hypertension had its onset in service or is otherwise etiologically related to active service, to include exposure to lead and/or asbestos? (C) Is it at least as likely as not (more than 50 percent probability) that the Veteran’s GERD had its onset in service or is otherwise etiologically related to active service, to include exposure to lead and/or asbestos? (D) Is it at least as likely as not (more than 50 percent probability) that the Veteran’s GERD was caused or aggravated by his service-connected sinusitis, and any medication used to treat his sinusitis? The examiner must address the significance, if any, of the in-service assessments of hyperventilation in October 1992; his report of chronic cough in October 1993; the Veteran’s elevated blood pressure measurements in service; the in-service diagnosis of gastroenteritis from May 1993 and February 1995; and the medical articles and opinion submitted by the Veteran showing a link between coronary artery disease, hypertension, and GERD to exposure to lead and/or asbestos. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mariah N. Sim, 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.