Citation Nr: 21009103 Decision Date: 02/19/21 Archive Date: 02/19/21 DOCKET NO. 14-38 662 DATE: February 19, 2021 ORDER Entitlement to a compensable evaluation for migraine headaches, prior to January 6, 2020, is denied. Entitlement to an evaluation in excess of 10 percent for migraine headaches, during the period from January 6, 2020 through March 24, 2020, is denied. Entitlement to an evaluation in excess of 50 percent for migraine headaches, from March 25, 2020, is denied. REMANDED Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), major depression, and nervous condition, is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for back disability is remanded. FINDINGS OF FACT 1. Prior to January 6, 2020, the Veteran experienced migraines with less frequent attacks. His migraines did not manifest in characteristic prostrating attacks averaging one in 2 months over the last several months. 2. From January 6, 2020 through March 24, 2020, the Veteran experienced migraines with characteristic prostrating attacks occurring on average once every two months. His migraines did not manifest in characteristic prostrating attacks occurring on an average once a month over the last several months. 3. Since March 25, 2020, the Veteran’s headaches have more nearly approximated very frequent, completely prostrating, and prolonged attacks productive of severe economic inadaptability. A 50 percent evaluation is the maximum schedular rating available for headaches. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for migraine headaches, prior to January 6, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8100. 2. The criteria for a disability rating in excess of 10 percent for migraine headaches, during the period from January 6, 2020 through March 24, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8100. 3. The criteria for an evaluation in excess of 50 percent for migraine headaches, from March 25, 2020, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.124a, Diagnostic Code 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from October 1968 to December 1970, including wartime service in the Republic of Vietnam. He is a Purple Heart Medal recipient. These matters initially came before the Board of Veterans’ Appeals (Board) on appeal from an October 2012 rating decision. The Board remanded these matters for further development in May 2018. That development has been completed, and the case has since been returned to the Board for appellate review. In an August 2020 rating decision, the agency of original jurisdiction (AOJ) increased the evaluation assigned for the Veteran’s service-connected migraine headaches from noncompensable to 10 percent disabling, effective from January 6, 2020 through March 24, 2020, and to 50 percent disabling, effective from March 25, 2020. Nevertheless, applicable law mandates that, when a veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of “downstream” elements such as the disability rating or effective date assigned). In the May 2018 remand, the Board instructed the AOJ to, among other things, undertake appropriate development to obtain any outstanding records pertinent to the Veteran’s claims, afford the Veteran the opportunity to submit evidence in support of his claims, and afford him a VA examination to assess the severity of his service-connected migraine headaches. Pursuant to the Board’s remand, the Veteran was asked to submit any additional evidence in support of his claims, to identify any outstanding treatment records, and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records by way of letters dated in September and December 2019. Copies of the authorization forms (VA Forms 21-4142a and 21-4142) were included with the December 2019 letter. Also, VA examinations were conducted in January and March 2020 to assess the severity of the Veteran’s headaches. Therefore, the AOJ substantially complied with the Board’s pertinent remand instructions. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). As a final preliminary matter, the Board notes that in the May 2018 remand, the AOJ was instructed to issue a statement of the case (SOC) pertaining to the issue of entitlement to service connection for onychomycosis (claimed as fungus of the nails). Pursuant to the Board’s remand, an SOC was issued in August 2020. VA’s Veterans Appeals and Control Locator System (VACOLS) indicates that the appeal with respect to the issue of entitlement to service connection for onychomycosis was closed by the AOJ for failure to respond to the August 2020 SOC. Hence, the onychomycosis issue was not certified to the Board for appellate review (via a VA Form 8, Certification of Appeal). However, the Board points out that the Veteran’s representative submitted a substantive appeal (VA Form 9) in response to the August 2020 SOC in September 2020. Therefore, the AOJ should determine the status of the Veteran’s onychomycosis claim and whether the appeal with respect to this issue should be certified to the Board. If certification to the Board is appropriate, documentation of the certification should be included in the claims file. Law and Analysis Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist with respect to the issues decided herein. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where 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 for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where a veteran appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of the veteran’s disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). However, where VA’s adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or “staged” ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Veteran’s service-connected migraine headaches are currently assigned a noncompensable evaluation prior to January 6, 2020, a 10 percent evaluation from January 6, 2020 through March 24, 2020, and a 50 percent evaluation from March 25, 2020, pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8100. Under Diagnostic Code 8100, a 10 percent disability evaluation is assigned when there are characteristic prostrating attacks, averaging one in 2 months over the last several months. A 30 percent disability evaluation is contemplated for headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months. A 50 percent rating is assigned for migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a. VA regulations, including the rating criteria, do not define “prostrating” as used in Diagnostic Code 8100. The Board notes that according to WEBSTER’S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, Third College Edition (1986), p.1080, “prostration” is defined as “utter physical exhaustion or helplessness.” A similar definition is found in DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th ed. 1994) in which “prostration” is defined as “extreme exhaustion or powerlessness.” As to the term “productive of economic inadaptability,” such term could have either the meaning of “producing” or “capable of producing” economic inadaptability. Pierce v. Principi, 18 Vet. App. 440, 445 (2004). Thus, migraines need not actually produce severe economic inadaptability to warrant the 50 percent rating. See Pierce, 18 Vet. App. at 445-46. Further, “economic inadaptability” does not mean unemployability, as such would undermine the purpose of regulations pertaining to TDIU. See Pierce, 18 Vet. App. at 446; see also 38 C.F.R. § 4.16. The Board notes, however, that the migraines must be, at a minimum, capable of producing severe economic inadaptability. As set forth above, the applicable rating criteria link ratings for headaches to two elements: severity and frequency. The Board finds that staged ratings are appropriate in this case. Initially, the Board finds that the Veteran is not entitled to a compensable evaluation prior to January 6, 2020. During a February 2012 VA headaches examination, the Veteran reported having recurring headaches that typically lasted less than one day. He indicated that his most recent headache episode was the previous week. He described bilateral temporal region pressure and photophobia. The Veteran stated that he took etodolac on occasion for headaches with good response. The examiner indicated that he did not have characteristic prostrating attacks of migraine headache pain or prostrating attacks of non-migraine headache pain. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms noted on examination. Functional impact was described as being unable to work during active headache episodes; however, as set forth above, the Veteran indicated that he had occasional headaches lasting less than one day, well controlled with medication. Thus, the evidence does not show that the Veteran had characteristic prostrating attacks, averaging one in 2 months over the last several months during this time period. See February 2012 VA examination report. The examiner issued a clarification in January 2013. It was noted that an October 2012 CT scan of the head was normal. The examiner clarified that the Veteran was able to obtain and secure financially gainful employment but was unable to work during active headache episodes. See January 2013 VA examination report. The Board also finds that the Veteran is not entitled to an evaluation in excess of 10 percent for the period from January 6, 2020 through March 24, 2020. Following remand, the Veteran was afforded an additional VA examination in January 2020. At that time, he reported intermittent headaches approximately seven or eight times per month. They were described as occipital discomfort, 8/10 on the pain scale, relieved with Tylenol. The Veteran stated that head pain was typically located on both sides of the head, lasting less than one day. The examiner found that he had characteristic prostrating attacks of headache pain, on average, once every two months. He did not have very prostrating and prolonged attacks of headache pain productive of severe economic inadaptability. There were no other pertinent physical findings, signs or symptoms noted. The examiner did not find that his headache disability impacted his ability to work. See January 2020 VA examination report. These findings are consistent with a 10 percent rating. There is no other evidence indicating or suggesting that the Veteran had characteristic prostrating attacks occurring on an average of once a month over the last several months or that his headaches were productive of economic inadaptability during the period from January 6, 2020 through March 24, 2020. Therefore, the Board finds that the Veteran did not meet the criteria for an increased evaluation during this time period. An additional VA examination was conducted in March 2020 at which time the Veteran’s symptoms were described as pulsating or throbbing head pain on both sides of the head, exacerbated by physical activity. He indicated that his head pain typically lasted less than one day. Non-headache symptoms included light and sound sensitivity and vision changes. The examiner noted that he had characteristic prostrating attacks of migraine headache pain, on average, once per month over the last several months. The examiner also indicated that the Veteran had very prostrating and prolonged attacks of headache pain productive of severe economic inadaptability. Other pertinent findings included tinnitus (now a service-connected disability). With regard to functional impact, the examiner stated that the Veteran was not currently employed but described severe headaches that could interfere with employment. See March 2020 VA examination report. In an August 2020 rating decision, the agency of original jurisdiction (AOJ) increased the evaluation for migraine headaches to 50 percent disabling, effective March 25, 2020, the date of the March 2020 VA examination. A 50 percent evaluation is the maximum schedular evaluation for migraine headaches under Diagnostic Code 8100. It is unclear exactly when following the January 2020 VA examination the Veteran’s headaches increased in frequency and severity so as to warrant a 50 percent rating, and the earliest that it is factually ascertainable that his headaches met the criteria for a 50 percent rating is March 25, 2020 (the date of the March 2020 VA examination). As the Veteran has been awarded a maximum 50 percent disability rating under the rating criteria for migraine headaches, a higher rating is not available. See 38 C.F.R. § 4.124(a), Diagnostic Code 8100; Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). The Board observes that the Veteran has been awarded a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities, effective from November 4, 2011, the date of the Veteran’s claim for an increased rating for migraine headaches. Neither the Veteran nor his representative has raised any other issues arising from the migraine headaches rating claim, nor have any other issues been reasonably raised by the record. See 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). REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disability, to include PTSD, major depression, and nervous condition, is remanded. The service treatment records document that the Veteran was severely injured in a land mine explosion in May 1969 during service in the Republic of Vietnam. On the September 1970 report of medical history, he indicated a history of nervous trouble and stated that he woke up thinking about Vietnam. After discharge from service, the Veteran continued to complain of symptoms including insomnia, nightmares, irritability, homicidal ideation, and moodiness. He was prescribed Thorazine which he stated was ineffective. Diagnoses at that time included pre-psychotic turmoil; mild to moderate anxiety neurosis, chronic; anxiety reaction with paranoid traits, moderately severe; and severe schizophrenia, latent type. See February 1971, March 1971, May 1971, September 1971, August 1972, April 1973 medical treatment records. In November 2011, the Veteran reported insomnia and nightmares. He complained of feeling depressed over the last two to three weeks, fatigued, and unmotivated. He also reported anxiety. A mental status examination was within normal limits and he denied any prior psychiatric treatment or hospitalization. He was diagnosed with a depressive disorder, not otherwise specified (NOS). See November 2011 VA treatment records. The Veteran was afforded a VA examination in connection with his claim of service connection for psychiatric disability in September 2012. The examiner noted the Veteran’s sleep disorder diagnosis, as well as the medical evidence of nervous behavior and impression of schizophrenia. The examiner found insufficient evidence for a formal diagnosis of PTSD and opined the sleep disorder bore “no temporal association with military stressors.” She further stated that the record was not clear as to whether the mental condition had been treated continuously since service. The Board found this medical opinion was inadequate for adjudication purposes. The examiner failed to fully discuss the evidence of mental health treatment as well as the evidence of complaints in service of a nervous condition and nightmares. Thus, the issue was remanded to obtain a new VA examination. See May 2018 Board decision. Following remand, an additional VA examination was performed in January 2020. The examiner noted that the Veteran had worked as an accountant for 30 years and retired in 2009. There was no history of any psychiatric treatment since 2011. The examiner noted the history of a land mine explosion during service and symptoms at the time of the examination consisted of chronic sleep impairment and disturbance of motivation and mood. A mental status examination was within normal limits. The examiner found that the Veteran did not satisfy the diagnostic criteria for PTSD. He was diagnosed with a sleep disorder, in remission. It was noted that insomnia is currently service-connected. The examiner stated that although the Veteran reported an in-service stressor, he did not meet other criteria for a PTSD diagnosis such as persistent re-experiencing, avoidance, increased anxiety and emotional arousal. The examiner found no social or occupational impairments. See January 2020 VA examination report. The Board finds the January 2020 examination is insufficient for several reasons. It is internally inconsistent insofar as the examiner stated that the Veteran met Criterion A but not the remaining PTSD criteria, but elsewhere stated that the reported in-service stressor of a land mine explosion did not meet Criterion A and is not related to fear of hostile military activity. In addition, the examiner did not discuss the medical treatment records documenting complaints of nervous trouble and nightmares in service, or the post-service medical records showing complaints of nightmares, irritability and moodiness after service and diagnoses of latent schizophrenia and anxiety. Nor did the examiner discuss the November 2011 diagnosis of depressive disorder, NOS, which was within the relevant appeal period. The Board also notes that although the January 2020 examiner stated that the Veteran did not have any psychiatric treatment after 2011, he continued to complain of nightmares. See, e.g., May 2016 VA treatment record. Therefore, the Board determines that a remand is necessary to obtain a medical opinion addressing the nature and etiology of any acquired psychiatric disability that may be present, including PTSD. Moreover, the evidence indicates that there may be outstanding relevant VA treatment records. The most recent VA treatment records in the claims file are from the VA Caribbean Healthcare System and are dated to August 2020. Any VA treatment records are within VA’s constructive possession and must be obtained regardless of their relevance as long as they are sufficiently identified. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (VA has a duty to assist in obtaining sufficiently identified VA medical records regardless of their relevance). See also Jones v. Wilkie, 918 F.3d 922 (Fed. Cir. 2019) (confirming the holding in Sullivan). A remand is required to allow VA to obtain them. 2. Entitlement to service connection for hypertension is remanded. The Veteran was afforded a VA hypertension examination in January 2020. The examiner noted that the Veteran was diagnosed with hypertension in 2002. The examiner opined that his hypertension is less likely than not related to military service, explaining that the service treatment records are negative for diagnosis or treatment of hypertension. The Board finds the examiner’s negative nexus opinion is inadequate, as it is wholly conclusory and unsupported by medical rationale. The examiner did not explain the significance of the gap in time between separation from service and diagnosis or why the Veteran’s hypertension could not be related to service. The examiner relied solely on the lack of treatment during service. The Board also points out that as the Veteran served in Vietnam, he is presumed to have been exposed to herbicide agents, including Agent Orange. The National Academy of Sciences (NAS) has indicated that there is sufficient evidence of an association between hypertension and Agent Orange exposure. See Veterans and Agent Orange: Update 11 (2018). An opinion has not been provided as to whether the Veteran’s hypertension is related to his herbicide agent exposure in service. As such, a remand is necessary to obtain a new medical opinion as to the etiology of the Veteran’s hypertension. Also, all outstanding VA treatment records should be secured upon remand. 3. Entitlement to service connection for back disability is remanded. The Veteran was afforded a VA back examination in January 2020. The January 2020 examiner noted the diagnosis of lumbar spondylosis in 2007 and the history of a land mine explosion during service. However, the examiner opined that the Veteran’s current back disability is less likely than not related to service, explaining that he did not suffer any back injuries as a result of the land mine explosion, just the left foot. The examiner stated that there is no evidence of any back injuries, diagnosis or treatment. The examiner opined that the Veteran’s back disability causing back pain is most likely due to the aging process. See January 2020 VA examination report. The post-service treatment records document complaints of back pain radiating to the left lower extremity with a provisional diagnosis of herniated nucleus pulposus (HNP). See November 1971 medical treatment records. See also March 1972 medical treatment record (noting complaints of low back pain radiating to the left lower extremity since he was wounded in Vietnam). The examiner did not address this evidence. Also, there is some indication in the treatment records that the Veteran’s complaints of low back pain could be related to his service-connected left foot disability (see e.g., a March 1972 medical record which indicates that the Veteran had chronic lumbosacral pain secondary to faulty podiatric gait due to wound and left foot fracture). A medical opinion has not been provided as to whether the Veteran’s claimed back disability is caused or aggravated by his service-connected left foot disability. Therefore, remand is necessary to obtain a new medical opinion addressing the nature and etiology of any back disability that may be present. Also, all outstanding VA treatment records should be secured upon remand. The matters are REMANDED for the following action: 1. Contact the Veteran to determine if there are any relevant, outstanding private treatment records. If so, undertake all appropriate development necessary to obtain these records from each private treatment provider and/or facility identified by him. 2. Obtain the Veteran’s outstanding VA treatment records from the VA Caribbean Healthcare System for the period since August 2020; and all such relevant records from any other sufficiently identified VA facility. 3. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, obtain an addendum opinion from an appropriate clinician regarding whether any current psychiatric disability is related to service. After reviewing the record, the clinician should: (a.) Determine whether the Veteran has experienced any acquired psychiatric disability at any point since approximately November 2011. (b.) If the Veteran has experienced an acquired psychiatric disability since approximately November 2011, the clinician should opine as to whether the disability at least as likely as not (50 percent probability or greater) (1) began during service; OR (2) is otherwise related to an injury or disease during service, including the Veteran’s reported psychiatric stressors and symptoms in service. (c.) If Veteran has experienced PTSD at any point since approximately November 2011, the clinician should also discuss whether the claimed in-service stressor(s) supports the diagnosis and explain why. In rendering an opinion, the clinician should consider the service treatment records documenting a land mine explosion during service in Vietnam; the September 1970 separation report of medical history indicating past or present nervous trouble and waking up thinking about Vietnam; the February 1971-April 1973 medical records showing symptoms including insomnia, nightmares, confusion, irritability, moodiness, marked hostility, dissociative episodes, lack of impulse control, homicidal ideation and paranoia, with diagnoses including mild to moderate anxiety neurosis, chronic, anxiety reaction with paranoid traits, moderately severe, and severe schizophrenia, latent type; the November 2011 VA treatment records documenting complaints of insomnia, nightmares, depression and anxiety, and diagnosing depressive disorder, NOS; and continuing complaints of nightmares. See September 2012 VA examination report, May 2016 VA treatment record. For purposes of the above opinions, the clinician shall presume that any reports by the Veteran of psychiatric stressors and psychiatric problems in service are accurate. A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s current hypertension is related to service. The clinician should opine as to whether any hypertension experienced by the Veteran since approximately November 2011 at least as likely as not (1) began during service; (2) manifested within one year after discharge from service; OR (3) is related to an in-service injury or disease, including his presumed exposure to herbicide agents (including Agent Orange). For purposes of the above opinion, the clinician shall presume that any reports by the Veteran of symptoms in service are accurate. A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. In this regard, the clinician should address the NAS’s determination that there is now sufficient evidence of an association between hypertension and Agent Orange exposure (See Veterans and Agent Orange: Update 11 (2018)). The fact that hypertension is not yet on the list of diseases presumed to be associated with exposure to Agent Orange should not be the basis for a negative opinion. 5. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s current back disability is related to service. The clinician should opine as to whether any back disability experienced by the Veteran since approximately November 2011 at least as likely as not (1) began during service; (2) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); (3) is related to an in-service injury or disease, including the back problems documented in his service treatment records; (4) is caused by service-connected residuals of shrapnel fragment wounds to the feet, with traumatic left foot arthritis; OR (5) is aggravated by service-connected residuals of shrapnel fragment wounds to the feet, with traumatic left foot arthritis For purposes of the above opinion, the clinician shall presume that any reports by the Veteran of back injury and symptoms in service are accurate. In rendering this opinion, the examiner should consider the November 1971 and March 1972 treatment records documenting complaints of low back pain radiating to the left lower extremity with a reported history of back pain since the injuries in service. A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Brian J. Elwood Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D.S. Chilcote, 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.