Citation Nr: 21006330 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 17-29 478 DATE: February 3, 2021 ORDER New and material evidence was received, and the claim of entitlement to service connection for a bilateral foot disorder is reopened. New and material evidence was received, and the claim of entitlement to service connection for left knee patellofemoral syndrome is reopened. New and material evidence was received, and the claim of entitlement to service connection for right knee patellofemoral syndrome is reopened. New and material evidence was received, and the claim of entitlement to service connection for right ankle anterior talar fibular strain is reopened. Entitlement to service connection for a lower back disability is granted. Entitlement to service connection for a bilateral foot disorder, to include paresthesias secondary to a service-connected lower back disability, is granted. Entitlement to service connection for left knee patellofemoral syndrome is granted. Entitlement to service connection for right knee patellofemoral syndrome is granted Entitlement to service connection for right ankle anterior talar fibular strain is granted. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include generalized anxiety disorder as secondary to service-connected disease or injury, is remanded. Entitlement to service connection for right ear hearing loss is remanded. Entitlement to service connection for temporomandibular joint dysfunction (TMJ) is remanded. FINDINGS OF FACT 1. In an October 2011 rating decision, the Regional Office (RO) denied service connection for, in pertinent part, sharp pain in both feet, right and left knee patellofemoral syndrome, and right ankle anterior talar fibular strain. The Veteran did not timely appeal this decision, nor did he submit new and material evidence within one year of the decision. 2. Additional evidence has been received since the October 2011 rating decision that relates to unestablished facts necessary to substantiate the claims for service connection for a bilateral foot disorder, bilateral knee disabilities, and right ankle anterior talar fibular strain. 3. Resolving all reasonable doubt in the Veteran’s favor, his current lower back disability is related to service. 4. Resolving all reasonable doubt in the Veteran’s favor, his bilateral foot disorder, to include paresthesias, is causally connected to his service-connected lower back disability. 5. Resolving all reasonable doubt in the Veteran’s favor, his left knee patellofemoral syndrome is related to service. 6. Resolving all reasonable doubt in the Veteran’s favor, his right knee patellofemoral syndrome is related to service. 7. Resolving all reasonable doubt in the Veteran’s favor, his right ankle anterior talar fibular strain is related to service. CONCLUSIONS OF LAW 1. The October 2011 rating decision that denied service connection for sharp pain in both feet, right and left knee patellofemoral syndrome, and right ankle anterior talar fibular strain is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. New and material evidence to reopen the claims for service connection for a bilateral foot disorder, bilateral knee disabilities, and right ankle anterior talar fibular strain disabilities has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria to establish service connection for a lower back disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 4. The criteria to establish service connection for a bilateral foot disorder, to include paresthesias, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 5. The criteria to establish service connection for left knee patellofemoral syndrome are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 6. The criteria to establish service connection for right knee patellofemoral syndrome are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 7. The criteria to establish service connection for right ankle anterior talar fibular strain are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Marine Corps from October 1991 to October 1995 and from October 1998 to October 2002, and in the Army from January 2007 to October 2007. This claim arose to the Board of Veterans’ Appeals (Board) from May 2014 and November 2018 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) in an August 2020 hearing. A transcript of that hearing is associated with the record. New and Material Evidence 1. Whether new and material evidence was received to reopen the claims of entitlement to service connection for a bilateral foot disorder, right and left knee disabilities, and right ankle anterior talar fibular strain The Veteran seeks entitlement to service connection for a bilateral foot disorder, right and left knee disabilities, and right ankle anterior talar fibular strain. Implicit in these claims is the contention that new and material evidence has been received which is sufficient to reopen previously disallowed claims for these benefits. Generally, a claim that has been denied in a final unappealed rating decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c). An exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). An adjudicator must follow a two-step process in evaluating a previously denied claim. First, the adjudicator must determine whether the evidence added to the record since the last final denial is new and material. If new and material evidence is presented or secured with respect to a claim that has been finally denied, the claim will be reopened and decided upon the merits. Once it has been determined that a claimant has produced new and material evidence, the adjudicator must evaluate the merits of the claim in light of all the evidence, both new and old, after ensuring that the VA’s statutory duty to assist the appellant in the development of his claim has been fulfilled. See 38 U.S.C. § 5108; Elkins v. West, 12 Vet. App. 209 (1999); Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA Secretary’s duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. Evidence is presumed to be credible for the purpose of determining whether the case should be reopened; once the case is reopened, the presumption as to the credibility no longer applies. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The evidence must be both new and material; if the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. Smith v. West, 12 Vet. App. 312 (1999). The Veteran filed claims for service connection for bilateral knee, foot, and right ankle disabilities and was denied in an October 2011 rating decision. The Veteran’s bilateral foot claim was denied because VA determined there was no objective diagnosis; the Veteran’s bilateral knee claim was denied because VA determined there was no in-service disease or injury related to his current diagnosis; the Veteran’s right ankle claim was denied because VA determined there was no evidence of in-service incurrence. The Veteran was notified but did not appeal the decisions. Accordingly, the October 2011 rating decision is final. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Subsequently, the Veteran filed the instant application to reopen his claims. As part and parcel of that application, the Veteran submitted several letters from VA medical providers which reflect these providers’ opinion that it is more likely than not that the Veteran’s right and left knee, right and left foot, and right ankle disabilities were related to service, or to a service-connected disability. These positive nexus opinions from medical professionals constitute evidence of previously unestablished elements of the claims (a nexus between the claimed disabilities and the Veteran’s service), and the claims will be reopened. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). In determining entitlement to service connection, the claimant receives the benefit of the doubt so that the claimant prevails whenever the evidence in support of the claim is at least in equipoise. 38 C.F.R. § 3.102; 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-55 (1990). 2. Entitlement to service connection for a lower back disability The Veteran contends he is entitled to service connection for a lower back disability which he claims stemmed from an injury he suffered when falling off the rope line of a helicopter while training in Japan in the 1990s. He has also reported several other incidents of back pain related to running and carrying heavy objects in service. At the outset, the Veteran’s VA medical records demonstrate he has been diagnosed with chronic back pain. In addition, a September 2019 VA Compensation and Pension (C&P) examination report notes a diagnosis of degenerative arthritis of the spine. Thus, the current disability element of his service connection claim has been met. See 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303(a); see also Holton, 557 F.3d at 1366. The Veteran’s service treatment records demonstrate that he was put on light duty in December 2001 due to mechanical back pain. A subsequent treatment note from December 2002 indicates ongoing back pain and spasms. Notably, at his Board hearing the Veteran explained that, as was par for the course while in the military, he generally self-diagnosed and self-medicated for all of his injuries. Following service, he testified that he continued to experience back pain. In August 2020, the Veteran’s treating VA physician submitted an opinion indicating the Veteran’s current lower back disability was most likely caused by or a result of his military service. The physician explained the Veteran suffered from chronic back pain while in service, as documented by records from 2001 through 2002, and immediately following service. The physician further stated the Veteran’s diagnostic imaging showed degenerative changes in his spine that was likely to have resulted from these in-service incidents. The physician provided a detailed opinion with specific findings regarding the Veteran’s diagnoses, indicating a thorough review of the record had been performed. In sum, the weight of the evidence supports the Veteran’s claim that his current chronic back pain is related to in-service injuries. The Board is aware there is no VA opinion of record regarding the etiology of the Veteran’s lower back disability (a September 2019 C&P report notes the Veteran’s assertions as to in-service incurrence but does not include a nexus opinion.) In any case, there is (a) documentation of treatment on multiple occasions in service for back pain; (b) credible lay statements establishing in-service injuries and ongoing symptomatology; and (c) medical evidence of record from a VA medical professional familiar with the Veteran’s case that supports a nexus between military service and the development of the Veteran’s chronic back pain. This evidence is sufficient to establish all three elements of service connection. See 38 C.F.R. § 3.303. Consequently, service connection for chronic back pain will be granted. 3. Entitlement to service connection for a bilateral foot disorder, to include paresthesias The Veteran contends he is entitled to service connection for a bilateral foot disorder, which he alleges ultimately resulted from his in-service helicopter injury. He testified that, following that injury, he experienced pain and tingling in both feet. The only remedy he undertook for his pain was to put inserts in his shoes. The Veteran’s VA outpatient treatment records demonstrate he was diagnosed with chronic bilateral paresthesias of the feet, to include reports of numbness and sharp, needle-like pain. Thus, the current disability element of his service connection claim has been met. See 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303(a); see also Holton, 557 F.3d at 1366. In August 2020, the Veteran’s treating VA physician submitted an opinion stating it was more likely than not the Veteran’s chronic foot pain was related to in-service trauma. The physician explained the Veteran suffered from paresthesias or “tingling of feet,” noting diagnostic imaging showed stenosis and moderate foraminal to severe right and moderate left neuroforaminal narrowing in his spine that was likely to cause the nerve problems the Veteran was experiencing. The Board notes that in April 2011 the Veteran underwent a VA examination in which he reported bilateral foot pain; at that time, however, no diagnosis was rendered. Nonetheless, this examination report shows the Veteran has consistently reported foot pain since shortly after his discharge from service. In sum, the Board finds the weight of the evidence tends to support the Veteran’s claim that his current bilateral foot pain, to include paresthesias, is related to his service-connected lower back disability. Specifically, the August 2020 opinion from the Veteran’s VA physician establishes a likely causal link between the in-service trauma that led to the Veteran’s lower back disability and his current nerve symptoms. The physician noted specific findings in the Veteran’s imaging studies that appeared consistent with nerve damage involving the feet. Moreover, there is credible lay evidence of record that supports a nexus between military service and the development of the Veteran’s chronic foot pain. See 38 C.F.R. § 3.310. The Board notes the Veteran underwent a C&P back examination in September 2019 indicating no nerve damage to his lower extremities. However, in light of the positive evidence discuss above (that, notably, appeared after the VA examination in question), the Board finds the evidence is in equipoise as to the question of nexus. As a result, the elements of service connection for a bilateral foot disorder, to include paresthesias, are met and service connection will be granted. 4. Entitlement to service connection for patellofemoral syndrome of the knees The Veteran contends he is entitled to service connection for patellofemoral syndrome of both knees, which he claims was caused by in-service injuries incurred during training. The Veteran testified there were at least 10 to 15 different incidents in service in which he injured his knees, and his only medical recourse was to consume several Motrin and move on. The Veteran’s VA outpatient medical records demonstrate he was diagnosed with chronic knee pain and receives his treatment through VA. In an April 2011 C&P report, a diagnosis of bilateral knee patellofemoral syndrome is noted. In September 2019, the Veteran received another C&P examination; at that time, diagnoses of bilateral knee strain were indicated. Thus, the current disability element of his service connection claim has been met. See 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303(a); see also Holton, 557 F.3d at 1366. The Veteran’s service treatment records demonstrate that he complained of chronic knee pain on multiple occasions, including in a post-deployment assessment. In 1995, on examination, he reported problems with both knees, stating the knees would give out, lock, crack, and swell. Several years later, in the early 2000s, there are myriad records of right knee pain; in December 2001, an assessment of probable chondromalacia was noted. The Veteran testified that, as with many of his other disabilities, he generally self-diagnosed and self-medicated for all of his injuries. Following service, he continued to experience bilateral knee pain. In April 2011, the Veteran was afforded a C&P examination in which he reported pain in both knees “for years” (he denied any problems prior to service). In December 2019, a VA C&P examiner provided a negative nexus opinion, reasoning the Veteran’s knees “are more likely than not due to wear and tear plus age degradation,” as well as due to a 2012 motorcycle accident. The examiner further reasoned the Veteran’s ability to continue performing his service duties throughout the years as well as engage in recreational activities such as biking and weight lifting indicated his knees were not severely damaged in service. The examiner seemed to conclude the most significant cause of the Veteran’s current symptoms was his 2012 motorcycle accident. In August 2020, the Veteran’s treating VA physician submitted a nexus opinion stating it was more likely than not that the Veteran’s chronic patellofemoral syndrome was related to his service. The physician explained that, upon reviewing the Veteran’s service treatment records, the Veteran suffered from knee pain while in service and immediately following service. Moreover, diagnostic imaging showed degenerative changes in his knees that were almost certainly related to in-service incidents. In sum, the Board finds the weight of the evidence supports the Veteran’s claim that his current chronic knee pain is related to service. Regarding the December 2019 negative opinion authored by the VA C&P examiner, the Board first notes it is unreasonable to “punish” the Veteran for continuing to perform his service duties, thereby assuming his in-service knee problems had resolved; it is perfectly reasonable, alternatively, to accept the Veteran’s contentions that he was able to perform his duties despite chronic knee pain. Second, the Board finds the C&P examiner’s conclusion that the Veteran’s 2012 motorcycle accident was the most significant cause of his current knee problems to be inconsistent with the record, as the Veteran reported bilateral knee pain at his April 2011 C&P examination, more than a year prior to the motorcycle accident. Finally, the December 2019 C&P examiner did not meaningfully address the myriad documented instances of the Veteran reported knee pain in service. A finding that the Veteran’s current disability is due to “wear and tear” does not preclude the possibility that that “wear and tear” in fact occurred in service—particularly given the fact the Veteran reported knee pain in service on multiple occasions. The Board finds there is credible lay and medical evidence of record that supports a nexus between military service and the development of the Veteran’s chronic knee pain. See 38 C.F.R. § 3.303. To the extent the December 2019 C&P nexus opinion weighs against his claim, the Board will resolve reasonable doubt in the Veteran’s favor. Service connection for bilateral knee patellofemoral syndrome will therefore be granted. 5. Entitlement to service connection for right ankle anterior talar fibular strain The Veteran contends he is entitled to service connection for a right ankle anterior talar fibular strain, related to a serious fall out of a helicopter in which he twisted his ankle. Additionally, he testified that he twisted and turned his ankle in service more times than he could count, which also contributed to his current disability. Again, he reported that he self-medicated and on multiple occasions did not report his injuries. The Veteran’s VA outpatient medical records demonstrate he was diagnosed with right ankle anterior talar fibular strain and receives his treatment through VA. In addition, a September 2019 VA C&P report notes a diagnosis of degenerative arthritis. Thus, the current disability element of his service connection claim has been met. See 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303(a); see also Holton, 557 F.3d at 1366. The Veteran’s service treatment records show that in June 2008, he was taken to the hospital after twisting his right ankle while running; a statement of medical examination confirms this occurred during active duty. Subsequent military personnel records indicate this injury occurred during a period of active duty for training (ACDUTRA). In the context of Reserve or National Guard service, “active service” includes active duty and any period of ACDUTRA during which the individual concerned was disabled from a disease or injury incurred in the line of duty. See 38 U.S.C. § 101(21), (24); 38 C.F.R. § 3.6(a). “Active service” also includes any period of inactive duty for training (INACDUTRA) during which the individual concerned was disabled from an injury incurred in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. Id. Accordingly, service connection may be granted for disability resulting from disease or injury incurred in, or aggravated, while performing ACDUTRA, or from injury incurred or aggravated while performing INACDUTRA. In April 2011, the Veteran received a C&P examination. The report noted a diagnosis of right ankle anterior talar fibular strain; the Veteran stated he first rolled his ankle in basic training and had had multiple re-injuries of the ankle since. In September 2015, the Veteran was afforded another C&P examination; the report noted a diagnosis of osteoarthritis of the right ankle. In a subsequent nexus opinion, the examiner noted the Veteran had a documented active duty injury in July 2008. In April 2011, the examiner noted, there was objective evidence of a chronic right ankle condition on physical examination. The examiner further noted the Veteran had unilateral degenerative joint disease and radiographic evidence of a probable prior avulsion fracture. The examiner opined, based on the above, that “[a] nexus for direct service connection right ankle degenerative joint disease exists.” In September 2019, the Veteran underwent yet another C&P examination, at which he again reported rolling his ankle multiple times in service. However, the examiner authored a negative nexus opinion in December 2019, finding the Veteran’s current osteoarthritis was “from wear and tear plus age degradation, despite his ankle strain in 2008.” The examiner’s rationale was similar to the rationale provided in support of the negative opinion for the Veteran’s knees—namely, that the Veteran was able to exercise and engage in recreational activities, which precluded any connection to service. In August 2020, the Veteran’s treating VA physician submitted an opinion stating it was more likely than not the Veteran’s chronic right ankle disability was related to service. The physician explained the Veteran suffered from ankle pain while in service and immediately following service, and that diagnostic imaging showed degenerative changes in the Veteran’s ankle that was likely related to in-service injuries. The Board finds the weight of the evidence supports the Veteran’s claim that his current right ankle disability is related to service, for many of the same reasons as were spelled out in the section above. Regarding the December 2019 negative opinion authored by the VA C&P examiner, the Board reiterates it is unreasonable to “punish” the Veteran for continuing to perform his service duties, thereby assuming his in-service ankle problems had resolved; it is perfectly reasonable, on the other hand, to accept the Veteran’s contentions that he was able to perform his duties despite chronic ankle pain. Second, the Board finds the C&P examiner’s conclusion that the Veteran’s 2012 motorcycle accident was a significant cause of his current ankle problems to be inconsistent with the record, as the Veteran reported right ankle pain at his April 2011 C&P examination, more than a year prior to the motorcycle accident. The Board notes the December 2019 C&P examiner’s finding that the Veteran’s current disability is due to “wear and tear” does not preclude the possibility that that “wear and tear” in fact occurred in service—particularly given the Veteran’s documented in-service injury. Finally, the examiner did not reconcile the positive C&P opinion provided in September 2015. The Board finds there is credible lay and medical evidence of record that supports a nexus between military service and the development of the Veteran’s chronic right ankle disability. See 38 C.F.R. § 3.303. To the extent the December 2019 C&P nexus opinion weighs against his claim, the Board will resolve reasonable doubt in the Veteran’s favor in light of the documented in-service injury, the positive nexus opinions of record, and the Veteran’s competent and credible contentions. Service connection for a right ankle disability will therefore be granted. REASONS FOR REMAND 6. Entitlement to service connection for an acquired psychiatric disorder, to include generalized anxiety disorder The Veteran contends he is entitled to service connection for an anxiety disorder; he claims this disorder is related to combat readiness: the extreme stress soldiers feel always having to wait for something to happen, the feeling of always being “locked and loaded” and never being able to relax and unwind. In addition, the Veteran has raised the issue of secondary service connection, as an October 2020 letter from his treating VA psychiatrist indicates a diagnosis of generalized anxiety disorder secondary to pain from the Veteran’s service-connected injuries. See 38 C.F.R. § 3.310. Unfortunately, however, no rationale was provided in support of this opinion. The Board finds an updated VA examination is needed to determine the etiology of any acquired psychiatric disorder, in light of the issues raised above. 7. Entitlement to service connection for right ear hearing loss and TMJ is remanded. The Veteran contends he is entitled to service connection for right ear hearing loss and TMJ. These claims were last readjudicated as part of the instant appeal stream in a May 2017 Statement of the Case (SOC). Since then, additional pertinent information has been added to the record, include updated VA medical evidence and multiple lay statements and testimony in support of the Veteran’s claims. However, the RO has not readjudicated the claims. As such, a Supplemental SOC is needed. See 38 C.F.R. § 19.31. The RO should be aware the Veteran’s representative submitted a statement in November 2020 indicating all the claimed disabilities had worsened, and should also consider affording the Veteran C&P examinations. (The Veteran was last afforded a C&P audiological examination in May 2016, and has never received an examination for his claimed TMJ.) The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination by an examiner to determine the nature and etiology of the Veteran’s acquired psychiatric disorder, to include generalized anxiety disorder. The examiner is asked to review the claims file and provide the following information: (a) Clarify whether the criteria for a current diagnosis are met. (b) Opine whether it is at least as likely as not (50 percent or greater probability) that any acquired psychiatric disorder was incurred in service or is otherwise related to service. Specifically discuss the Veteran’s lay testimony as to the onset and origins of his symptoms. (c) If it is determined that there is another likely etiology for the disorder, that should be stated. (d) Opine whether it is at least as likely as not (50 percent or greater probability) that any acquired psychiatric disorder, to include generalized anxiety disorder, was caused or aggravated by any service-connected disease or injury. Specifically discuss the October 2020 letter submitted by the Veteran’s treating psychiatrist. (Continued on the next page)   The examiner should set forth all examination findings, with a clear rationale for the conclusions reached. 2. After any indicated development has been completed, readjudicate the remaining issues on appeal, including the claims for service connection for an anxiety disorder, right ear hearing loss, and TMJ. This readjudication must include consideration of all pertinent evidence received since the most recent SOCs. If any benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Ryan, 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.