Citation Nr: 21008817 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 16-30 185 DATE: February 18, 2021 ORDER Entitlement to service connection for chronic kidney disease, to include as due to exposure to herbicides and/or contaminated water at Camp Lejeune, is denied. Entitlement to service connection for hypertension, to include as secondary to coronary artery disease and/or as due to exposure to herbicides, is denied. Entitlement to a temporary total rating from March 31, 2012 to May 8, 2012 based on treatment for a service-connected disability requiring hospitalization (under 38 C.F.R. § 4.29) or convalescence (under 38 C.F.R. § 4.30) is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD), to include as secondary to service-connected coronary artery disease, is remanded. Entitlement to service connection for sleep apnea, to include as secondary to an acquired psychiatric disorder, is remanded. FINDINGS OF FACT 1. The preponderance of evidence indicates the Veteran’s chronic kidney disease did not have an onset during service or within one year of discharge from service and is not causally or etiologically due to service, to include as due to exposure to herbicides and/or contaminated water at Camp Lejeune. 2. The preponderance of evidence indicates the Veteran’s hypertension did not have an onset during service or within one year of discharge from service, is not causally or etiologically due to service, to include as due to exposure to herbicides, and is not proximately due to or aggravated by his coronary artery disease. 3. The Veteran’s in-patient VA hospital treatment from March 2012 to May 2012 was not for a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for chronic kidney disease, to include as due to exposure to herbicides and/or contaminated water at Camp Lejeune, are not met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for hypertension, to include as due to exposure to herbicides or as secondary to coronary artery disease, are not met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 3. The criteria for a temporary total evaluation for March 31, 2012 to May 8, 2012 based on treatment for a service-connected disability requiring hospitalization (under 38 C.F.R. § 4.29) or convalescence (under 38 C.F.R. § 4.30) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.29, 4.30. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1970 to January 1972. This matter comes before the Board of Veterans’ Appeals (BVA or Board) from an October 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a hearing before the Board. The requested hearing was conducted in July 2019 by the undersigned Veterans Law Judge. A transcript is associated with the claims file. In November 2019, the Board remanded these claims for additional development. Service Connection The Veteran seeks entitlement to service connection for chronic kidney disease and hypertension. Under the relevant laws and regulations, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). In general, service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Alternatively, service connection may be established under 38 C.F.R. § 3.303 (b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. The theory of continuity of symptomatology is an alternative route to establish service connection for specific chronic diseases and can only be used in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013.) Hypertension and cardiovascular renal disease are recognized as chronic diseases. VA regulations also provide that certain diseases associated with exposure to herbicide agents may be presumed to have been incurred in service even if there is no evidence of the disease in service, provided the requirements of 38 C.F.R. § 3.307 (a)(6) are met. 38 C.F.R. § 3.309 (e). Hypertension and chronic kidney disease are not presumptive diseases associated with exposure to herbicides. The regulations at 38 C.F.R. §§ 3.307 and 3.309 were amended to provide a presumption of service connection for certain diseases associated with contaminants in the base water supply at Camp Lejeune. Kidney cancer is presumptively associated with exposure to contaminated water at Camp Lejeune. See 38 C.F.R. § 3.309 (f). Where the evidence does not warrant presumptive service connection, the United States Court of Appeals for the Federal Circuit has determined that a Veteran is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Service connection may be granted on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a), (b). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on a secondary basis, there must be evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 4 (1990). Equal weight is not necessarily accorded to each piece of evidence contained in the record; not every item of evidence necessarily has the same probative value. Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 1. Entitlement to service connection for chronic kidney disease, to include as due to exposure to herbicides and/or contaminated water at Camp Lejeune. The Veteran seeks entitlement to service connection for chronic kidney disease, to include as due to exposure to herbicides and/or contaminated water at Camp Lejeune. First, the Board notes that the Veteran has a current diagnosis of chronic kidney disease. See February 2020 VA examination. As such, element (1) set forth under Shedden, current disability, for this claim has been satisfied. The Veteran’s service treatment records are silent for any complaints, treatment, or diagnoses related to chronic kidney disease. However, the Veteran’s military personnel records show that he was stationed at Camp Lejeune from May 1970 to November 1970. Thus, it is conceded that the Veteran was exposed to contaminated water at Camp Lejeune. The RO also previously conceded exposure to herbicides. See, e.g., February 2012 rating decision. As such, Shedden element (2) has been satisfied. Unfortunately, Shedden element (3), nexus, is not satisfied. A VA medical opinion was obtained in February 2020. The examiner opined that the Veteran’s chronic kidney disease is less likely than not due to his time in service, to include exposure to herbicides and exposure to contaminated water. The examiner noted that the Veteran is diagnosed with chronic kidney failure secondary to immunoglobulin A (IgA) nephropathy and Henoch-Schonlein purpura, as noted in a June 2009 consultation. The examiner explained that IgA nephropathy is a kidney disease that occurs when an antibody called IgA builds up in the kidneys and results in local inflammation that, over time, can hamper the kidneys' ability to filter waste from the blood. IgA is an antibody responsible for attacking invading pathogens and fighting infections, but in IgA nephropathy, this antibody collects in the glomeruli of the kidney, causing inflammation (glomerulonephritis) and gradually affecting their filtering ability. Continuing, the examiner stated that Henoch-Schonlein purpura, also known as IgA vasculitis, is a disorder that causes the small blood vessels in the skin, joints, intestines, and kidneys to become inflamed and bleed. The examiner noted that the Veteran’s enlistment exam and separation exam do not show clinical evidence of chronic kidney disease or Henoch-Schonlein purpura changes or treatment in service; the Veteran’s urinalysis was normal during service. As such, the examiner opined that the Veteran’s chronic kidney disease is less likely than not related to his time in service, to include exposure to contaminated water or herbicides, as his clinical diagnosis is associated with autoimmunity. The examiner stated that studies indicate end stage renal disease was found elevated and statistically significant in workers exposed to medium to high solvent exposure levels for more than 10 years; however, the Veteran spent 185 days at Camp Lejeune and the solvent levels were much lower than those in the studies. Additionally, the evidence to support autoimmune disorder with herbicide exposure showed no consistent findings indicative of immunosuppression, increased risk of autoimmunity (usually as measured with autoantibodies), or biomarkers of atopy or allergy (such as increased IgE concentrations) for Vietnam Veterans; showed no alterations in immune measures that could be extrapolated to an increased risk of a single disease or even a broader category of diseases for occupational exposure; and were inconsistent in findings of altered immune measurements for environmental exposures. There are no medical opinions to the contrary, of record. In evaluating whether entitlement to service connection has been established, the Board notes that the Veteran’s kidney disease is considered a chronic disease under 38 C.F.R. § 3.309. However, the record reflects that his kidney disease did not manifest during service or for many years thereafter. As the Veteran’s kidney disease did not have an onset within one year of separation, the chronic disease presumption does not apply. The Board also finds that the Veteran’s chronic kidney disease is not related to exposure to contaminated water at Camp Lejeune or exposure to herbicides. In this regard, the Board finds that the February 2020 VA medical opinion is the most probative medical evidence of record. The February 2020 VA examiner reviewed the Veteran’s claims file and provided an opinion that was supported by a detailed explanation. Given the fact that the February 2020 VA examiner is a member of the Subject Matter Expert Panel for the Camp Lejeune Contaminated Water Project, he is well qualified to know the current state of medical knowledge in this area. The Board therefore finds that the most probative evidence does not support the conclusion that the Veteran’s chronic kidney disease is etiologically related to his exposure to contaminated water at Camp Lejeune or exposure to herbicides. In addition, the evidence of record does not indicate that the Veteran’s chronic kidney disease is otherwise related to his period of active service; the Veteran has not asserted a relationship to service other than exposure to contaminated water at Camp Lejeune and exposure to herbicides. The Board has considered the Veteran’s own statements regarding the nature and etiology of his disorder. The Board acknowledges that the Veteran is competent to give evidence about what he experiences; for example, he is competent to discuss his observable symptoms. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). In the present case, however, the Board finds that the Veteran’s lay statements are outweighed by the service treatment records and post-service treatment records. Further, the Veteran is not competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder because he does not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence). Accordingly, though the Veteran is competent to report his symptoms, he is not competent to provide an opinion as to nature and etiology of his chronic kidney disease. Based on the foregoing, the Board finds that the preponderance of the evidence is against the Veteran’s claim for entitlement to service connection for chronic kidney disease. 2. Entitlement to service connection for hypertension, to include as secondary to coronary artery disease and/or as due to exposure to herbicides. The Veteran seeks entitlement to service connection for hypertension as due to exposure to herbicides, or in the alternative, as secondary to his coronary artery disease. For VA compensation purposes, the term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. First, the Board acknowledges that the Veteran has a current diagnosis of hypertension. See, e.g., January 2005 VA treatment record. However, after a review of all the evidence, both lay and medical, the Board finds that the Veteran’s current hypertension did not have an onset during service or within one year of service, is not causally or etiologically due to service, to include exposure to herbicides and is not proximately due to or aggravated by his service-connected coronary artery disease. A review of the Veteran’s active duty service treatment records shows no symptoms, treatment, or diagnoses referable to chronic hypertension. There was no diagnosis of hypertension at any time during active service. The January 1972 separation examination documented a blood pressure reading of 112/84. A VA medical opinion was obtained in February 2020. The examiner opined that the Veteran’s hypertension is less likely than not due to service, explaining that the service treatment records show no evidence of a diagnosis or treatment for hypertension and the Veteran did not meet the Joint National Committee’s (JNC) criteria for the diagnosis of hypertension while on active duty or within one year of separation. The examiner also opined that it was less likely than not that the Veteran’s hypertension was due to exposure to herbicides, explaining that while recent studies have shown an association with hypertension and veterans assigned to the Chemical corps who had a high exposure to herbicides, there was no association with veterans with other military occupation specialties (MOS). The examiner stated that a study revealed that ninety percent of people 55 and over will develop hypertension eventually. Based on this, the examiner stated that therefore, by definition, all Vietnam era veterans have a ninety percent chance of developing hypertension whether they were exposed to Agent Orange or not. The February 2020 VA examiner then opined that it was less likely than not that the Veteran’s hypertension is proximately due to or aggravated by his coronary artery disease. The examiner explained that while hypertension is a risk factor for developing coronary artery disease, coronary artery disease is not a risk factor for developing or aggravating hypertension. The Board affords great probative value to the service treatment and examination reports because they are probative as to both the Veteran’s subjective reports and their resulting objective findings and were generated with a view towards ascertaining the Veteran’s then-state of physical and mental fitness and are akin to statements of diagnosis or treatment. See Fed. R. Evid. 803 (4) and accompanying Notes (noting statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth); Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board’s decision). Thus, the Board finds that the most probative evidence of record weighs against the existence of hypertension during service. In addition, symptoms of hypertension were not continuous since service, including not to a degree of ten percent within one year of service separation. See 38 C.F.R. § 4.104, DC 7101. The medical evidence of record does not support a diagnosis of hypertension dating back to 1973. Thus, the first persuasive credible evidence of chronic hypertension was not demonstrated until many years after the Veteran’s service separation. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a lengthy period without complaint or treatment is evidence that there has not been a continuity of symptomatology and can weigh against the claim). As noted, the Veteran’s service treatment records weigh against a finding of continuity of hypertension since service, as hypertension is not shown in service or any event in service that could have caused it. Service connection for hypertension based on continuity of symptomatology pursuant to 38 C.F.R. § 3.303 (b) is therefore not warranted. In addition, for the reasons expressed above, the Veteran’s hypertension did not manifest to a compensable degree during the first post-service year and the evidence does not otherwise persuasively show manifestations of hypertension to a degree of ten percent within one year of service separation. Accordingly, there is no basis for presumptive service connection. 38 C.F.R. §§ 3.307, 3.309. The Board further finds that the weight of the evidence demonstrates that hypertension, which first manifested many years after service, was not caused by any in-service event, including presumed exposure to herbicides during service. Hypertension is, by regulation, not a disease for which service connection may be presumed as being the result of exposure to herbicides. Accordingly, the Board finds that entitlement to service connection based on exposure to herbicides on a presumptive basis is denied. See 38 U.S.C. § 1116; 38 C.F.R. §§ 3.303, 3.307, 3.309. Notwithstanding the foregoing presumption provisions, the United States Court of Appeals for the Federal Circuit has determined that a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Unfortunately, however, the weight of the evidence does not support a finding that this Veteran’s hypertension was caused by his exposure to herbicide agents during service. The Board acknowledges the NAS upgrade of hypertension to the “sufficient” category from “limited or suggestive,” indicating that “there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. See Veterans and Agent Orange: Update 11 (2018). As stated above, however, VA has not established a presumption of service connection. Thus, service connection must be substantiated by proof of direct causation. Here, the medical opinion evidence considered the upgrade in categories, yet still opined that the Veteran’s hypertension was less likely than not due to exposure to herbicides. The February 2020 VA examiner’s opinion is probative as the examiner considered the NAS findings and based his opinion upon the Veteran’s individual history and circumstances, including his age as a risk factor for developing hypertension. The February 2020 VA medical opinion is based on an accurate history, and medical expertise and training, and it is supported by a sound rationale, and is therefore of significant probative value. Importantly, the Veteran has not provided a contrary medical opinion. See Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009) (holding that it is the claimant’s general evidentiary burden to establish all elements of the claim). As such, direct and presumptive service connection for hypertension may not be established, including as due to exposure to herbicides. 38 C.F.R. §§ 3.303, 3.307, 3.309. Finally, there is also no persuasive evidence that the Veteran’s hypertension is proximately due to or aggravated by his coronary artery disease. As noted, the February 2020 examiner opined that the Veteran’s hypertension was less likely than not secondary to his service-connected coronary artery disease, explaining that while hypertension is a risk factor for developing coronary artery disease, coronary artery disease is not a risk factor for developing or aggravating hypertension. As such, the only evidence of record supporting the Veteran’s contentions that his hypertension had an onset during service, is etiologically related to his active service or to his service-connected coronary artery disease is his lay evidence. The Veteran is competent to report symptoms and provide diagnoses that are capable of lay observation but is not competent to establish that which would require specialized knowledge or training, such as medical expertise. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The record does not show, nor does the Veteran contend, that he has specialized education, training, or experience that would qualify him to render a diagnosis or render a medical opinion on this matter. The development of hypertension, the effects of herbicides on internal processes, and the interrelationship of coronary artery disease and hypertension are complicated medical determinations requiring specialized knowledge and are not capable of lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). For these reasons, the Board finds that the weight of the lay and medical evidence shows that the Veteran’s hypertension was not incurred in service, is not otherwise related to service, to include presumed exposure to herbicides, and is not proximately due to or aggravated by service-connected coronary artery disease. As such, service connection for hypertension is not warranted. 3. Entitlement to a temporary total rating from March 31, 2012 to May 8, 2012 based on treatment for a service-connected disability requiring hospitalization (under 38 C.F.R. § 4.29) or convalescence (under 38 C.F.R. § 4.30). The Veteran seeks entitlement to a temporary total rating from March 2012 to May 2012. He asserts he was in the hospital and was on life support. A temporary total disability rating may be assigned under either 38 C.F.R. § 4.29 or 38 C.F.R. § 4.30. Under 38 C.F.R. § 4.29, a temporary total disability rating will be assigned when it is established that a service-connected disability has required hospitalization at a VA medical center or other approved hospital for more than 21 days or for hospital observation at VA expense for a service-connected disability for more than 21 days. 38 C.F.R. § 4.29. A temporary total disability rating will be assigned, effective from the date of a hospital admission and continuing for a period of 1, 2, or 3 months from the first day of the month following such hospital discharge, if the hospital treatment of a service-connected disability resulted in: (1) surgery necessitating at least one month of convalescence, (2) surgery with respect to postoperative residuals such as incompletely healed surgical wounds, stumps and recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited), or (3) immobilization by cast, without surgery, of one major joint or more. 38 C.F.R. § 4.30 (a). The medical evidence of record demonstrates that the Veteran was admitted to the VA hospital in March 2012 with an admitting diagnosis of acute pancreatitis and renal insufficiency. The Veteran was discharged in May 2012. A review of the claims file indicates that service connection has not been awarded for acute pancreatitis and/or renal insufficiency. Neither the Veteran nor his representative has argued otherwise. A threshold legal requirement for establishing entitlement to a temporary total rating 38 C.F.R. §§ 4.29 and 4.30 is that the hospital treatment, observation or a period of convalescence must have been for a service-connected disability. It is not in dispute that the Veteran was admitted to the hospital for over 21 days. However, as indicated above, service connection has not been awarded for pancreatitis or renal insufficiency. Accordingly, the hospital treatment was not for a service-connected disability and, therefore, the threshold requirement for benefits under §§ 4.29 or 4.30 are not met. Of note, the Veteran’s representative acknowledged in a January 2021 statement that the Veteran was not service connected for the conditions of acute pancreatitis and renal insufficiency for which he was admitted to the hospital for in March 2012. Absent specific argument from the Veteran or his representative, the Board is unable to identify any basis upon which this claim may be granted. In Sabonis v. Brown, 6 Vet. App. 426, 430 (1994), the Court held that where the law is dispositive, the claim should be denied because of lack of legal entitlement under the law. Accordingly, the appeal in this matter must be denied. REASONS FOR REMAND 4. Entitlement to service connection for an acquired psychiatric disorder, including PTSD, to include as secondary to service-connected coronary artery disease. This issue was remanded by the Board in November 2019 to obtain a medical opinion as to whether the Veteran’s diagnosed depression was secondary to his service-connected coronary artery disease, noting that a December 2012 VA examiner opined that the Veteran’s depressed mood may be secondary to his health issues, medication regimen, and recent near-death experience. The Board also noted that the Veteran testified during the July 2019 Board hearing, that he has had several heart attacks, has stents in his heart and is constantly being monitored, causing him stress. Importantly, the Veteran is service connected for coronary artery disease. A VA medical opinion was obtained in January 2020. The examiner opined that the Veteran’s depression was not proximately due to his coronary artery disease, as his diagnosis of depression predated the onset of his coronary artery disease. The examiner then opined that the Veteran’s depression was not aggravated by his coronary artery disease based upon a lack of “clear persistent worsening.” The examiner explained that global assessment of functioning (GAF) scores prior to 2008, the year of onset of coronary artery disease, ranged from 40-50 (moderate impairment) and after 2008, they ranged from 28-60 (severe to mild). The VA examiner, however, did not note and discuss the Veteran’s lay statements that specifically his heart attacks, stents in his heart and constantly being monitored caused him stress. Thus, the Board finds an addendum opinion is necessary. 5. Entitlement to service connection for sleep apnea, to include as secondary to an acquired psychiatric disorder. The Veteran asserts his sleep apnea is secondary to his acquired psychiatric disorder. As such, the Board finds that this issue is inextricably intertwined with the pending appeal for entitlement to service connection for an acquired psychiatric disorder. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that two issues are inextricably intertwined when the adjudication of one issue could have significant impact on the other issue). This issue is deferred pending development ordered on remand for the issue of entitlement to service connection for an acquired psychiatric disorder. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated treatment records. 2. Obtain an addendum VA medical opinion for the Veteran’s claimed acquired psychiatric disorder. If deemed necessary, afford the Veteran a VA examination. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The claims folder must be provided to the examiner for review. The examiner must state in the examination report that the claims folder has been reviewed. *The examiner should opine as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that the Veteran’s acquired psychiatric disorder, to include, but not limited to depression, is proximately due to or aggravated (beyond a natural progression) by his service-connected coronary artery disease. *In rendering this opinion, the examiner is asked to consider and comment on the December 2012 VA examination, which indicated the Veteran’s depression may be secondary to his health issues, medication regimen, and recent near-death experience, as well as the Veteran’s assertions that his heart trouble and constant monitoring of his heart causes him stress. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. (continued on next page) TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Andersen, 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.