Citation Nr: 21009383 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 13-18 403 DATE: February 22, 2021 ORDER Entitlement to service connection for right knee condition is denied. Entitlement to service connection for left knee condition is denied. Entitlement to service connection for lower back condition is denied. FINDINGS OF FACT 1. The November 2020 VA examiner is competent to provide a medical opinion on the Veteran’s lower back and bilateral knee conditions. 2. The preponderance of the evidence is against finding that the Veteran’s right knee condition began during active service or is otherwise related to an in-service injury or disease. 3. The preponderance of the evidence is against finding that the Veteran’s left knee condition began during active service or is otherwise related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that the Veteran’s lower back condition began during active service or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for right knee have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 1154; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for entitlement to service connection for left knee have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 1154; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 3. The criteria for entitlement to service connection for lower back condition have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 1154; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served active duty in the United States Marine Corp from May 2000 to May 2004. This matter comes to the Board of Veterans’ Appeals (Board) on appeal of January 2011 and November 2013 rating decisions of the Department of Veteran Affairs (VA) Regional Office (RO). The Board remanded the issues in September 2017 for examination, ultimately denying the claim in a October 2018 decision. The decision was vacated in part and returned to the Board pursuant to a September 2019 Joint Motion for Partial Remand before the United States Court of Appeals for Veterans Claims (CAVC) for failure to provide an adequate statement of reasons or bases for its determination. In July 2020, the Board remanded the issues on appeal for additional development and the case has since been returned for further appellate review. A remand by the Board confers on the claimant a legal right to substantial compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). The Board’s July 2020 remand directed the RO to make at least two requests to obtain the Veteran’s private treatment records pertaining to knee surgery and the potential of a pre-existing knee condition. The RO sent a letter in July 2020 requesting further information from the Veteran and provided him with the appropriate disclosure forms. There is no indication the RO received sufficient information from the Veteran to locate the private records. However, updated VA treatment records were associated with the claims file in October 2020. The Board’s remand also instructed the RO to provide the Veteran with an in-person examination to determine the nature and etiology of his bilateral knee and lower back conditions, which were both provided in November 2020. As such, substantial compliance with the Board’s prior remand directives was achieved and the medical opinions and merits of the claim are discussed below. Id. at 271. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires 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. 38 C.F.R. § 3.310 (a); Allen v. Brown, 7 Vet. App. 439 (1995). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency of evidence is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno, 6 Vet. App. at 465. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. 1. Entitlement to service connection for right knee condition, and 2. Entitlement to service connection for left knee condition The Veteran contends he is entitled to service connection for a right and left knee condition that is related to his active duty military service. Specifically, he asserts while on a convoy, he jumped from a truck during a missile attack and felt a pop in the right knee. He reports receiving treatment immediately following the event and also noting the injury to the physician during his separation exam. The Veteran contends he reinjured his right knee while kicking in a door on patrol in Iraq and has continued to have problems since service. The Veteran reports his left knee began to buckle and become painful as a result of placing extra weight on it due to the right knee injury. The question for the Board is whether the Veteran has a current knee disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board finds the preponderance of the evidence weighs against finding that the Veteran’s bilateral knee condition began during service or is otherwise etiologically related to his service. As a preliminary matter, the Board finds that the Veteran has a current knee condition, as evidence by his most recent VA examination. He has current diagnoses of knee strain and patellofemoral pain syndrome. See C&P Exam, 11/24/2020, pg 2/17. Accordingly, the element requiring a current disability is met. The Board also finds that the Veteran experienced an in-service event or injury. The Veteran’s military personnel record confirms he served in a combat zone during the Gulf War era (specifically Kuwait and Iraq in 2003) with a military occupational specialty as a legal service specialist. See Military Personnel Record, 12/10/2010; Certificate of Release, 11/25/2013. He reports, in addition to his regular duties, he also participated in combat patrols and enemy fire as a machine gunner. See MTR- Government, 6/14/2013, pg 2/9. Although the Veteran’s service treatment record does not show indication of the in-service knee injury he reports, the Veteran argues he is entitled to consideration under the combat provision of 38 U.S.C. § 1154(b). The Board finds his statements and reports consistent with the circumstances and conditions of his service and resolves reasonable doubt in his favor. Accordingly, the Veteran’s statements regarding his in-service injury are given full consideration and the element requiring an in-service event is satisfied. As evidence in the Veteran’s treatment records indicated he had arthroscopic knee surgery at Cedar Sinai in 1998, and therefore his knee condition preexisted military service, the Board’s July 2020 remand directed the AOJ to obtain an opinion on the matter. The Veteran was examined in November 2020 and the examiner concluded no scar from previous surgery was present on either knee and the Veteran likely did not have a preexisting condition. See MTR- Government, 7/1/2010, pg 20/22. Additionally, the Veteran’s entrance exam does not note a knee condition upon entry and the Board finds the record does not contain clear and unmistakable evidence the Veteran’s knee condition pre-existed his service period. On the remaining medical nexus element, the November 2020 examiner provided several opinions relating to the Veteran’s bilateral knee conditions. The examiner reports the Veteran’s current knee conditions as knee strain diagnosed in December 2017, and patellofemoral pain syndrome diagnosed in November 2020. See C&P Exam, 11/24/2020, pg 2/17. The Veteran reported an onset of symptoms in 2006 with current flare-ups in the morning and in colder temperatures. He reports that he is unable to run or stand for prolonged periods and avoids stairs, kneeling down, and squatting movements. See pg 4/17. Tenderness was noted at the medial and lateral joint space and over the patellar tendon in the right knee, with both knees exhibiting consistency with a diagnosis of patellofemoral pain syndrome. Both knees showed normal muscle strength and joint stability and demonstrated a lack of ankylosis. See pgs 10-12/17. The examiner noted the Veteran’s range of motion (ROM) to be 120 degrees in both knees with mild discomfort at full flexion (140 degrees). However, he indicated the Veteran’s body habitus due to morbid obesity as the likely cause of the limitation. The examiner concluded it was less likely than not (less than 50 percent probability) incurred in or caused by an in-service event, including those reported by the Veteran. See C&P, 11/24/2020, pg 3/8. His rationale points to a lack of corroborating evidence in the record that the Veteran had an in-service onset, such as receiving treatment for pain to include corticosteroid injections, or a diagnosis of osteoarthritis as reported. The examiner indicates diagnostic imaging performed in October 2020 showed no degenerative or other abnormal changes to either knee. He notes results of the current examination reveal mild patellofemoral pain syndrome which was also not present at the Veteran’s exam in 2017. The examiner reasons that, although he gives the Veteran the benefit of the doubt that he experienced an injury in-service, the evidence suggests the acute injury did not progress into his chronic problem. The examiner finds it is more likely that the Veteran’s morbid obesity has brought on his condition in the absence of evidence of trauma. He explains a significant amount of stress has been placed on the knees, hips, and back, causing the Veteran’s ROM limitation rather than a pain or structural problem in the joints examined. The examiner concludes the knee condition was not caused by the events suggested by the Veteran, such as kicking a door or repetitive trauma from carrying heavy gear while on active duty. Additionally, the examiner addresses the left knee under a secondary theory of entitlement. He explains that no medical study supports the contention a contralateral joint is affected by an injured, partner joint. See pg 5/8. He notes medical studies tend to show this is not the case unless it is shown there is a significant alteration in gait such that a shortening of the injured extremity causes a limb length discrepancy of more than four to five centimeters, thus creating a clinically “lurching gait”. In order for this altered gait to impact the uninjured leg, a lurching gait would need to be present over an extended period of time. A temporary abnormal gait for weeks to months is unlikely to have an impact on an uninjured opposite leg. Further, the examiner’s rationale relies on a lack of medical literature to suggest an injury to a lower extremity has a significant impact on the opposite uninjured limb unless the injury resulted in major muscle or nerve damage causing at least partial or complete paralysis of the injured leg. As neither of these characteristics were demonstrated upon examination, he concludes left knee condition is not due to compensation for the right knee in this case. He notes, instead, that obesity and increased body weight have been shown to have a detrimental effect on both lower extremities and magnifies all previously discussed risk factors. In October 2020 diagnostic imaging was conducted and compared to February 2020 imaging. A history of arthritis is noted, with unremarkable findings of the knees. Normal alignment, soft tissues, joint space, and bony structure are present. There is an absence of fracture, lytic or blastic lesions, subluxation, and dislocation. The Board first notes that the Veteran has challenged the competency and adequacy of certain medical evidence, to include VA examination reports obtained by the AOJ during the appeal period. Whether an examiner is competent and whether he rendered an adequate exam are two different inquiries. Mathis v. McDonald, 834 F.3d 1347, 1351 (Fed. Cir. 2016). In advancing an argument concerning the adequacy of the medical evidence obtained by the AOJ, the Veteran raises a general challenge to the professional competence of the VA examiner who provided the opinion and conducted the examination. The Veteran submitted a June 2020 statement indicating he had not yet received a competent VA examination for his knee condition and requested a “qualified and competent medical doctor, preferably an orthopedic doctor” perform one. See Statement in Support of Claim, 6/5/2020, pg 4/5. Neither the Veteran nor his representative has challenged with any specificity the competency of the VA examiner in this case. Nor have they identified or submitted any evidence or argument that the VA examiners were not professionally qualified or lacked the training necessary to review the claims file, including the Veteran’s service treatment records and post-service VA and private treatment records, and provide competent opinions concerning the contended etiological relationships between the Veteran’s claimed disabilities and active service. See Francway v. Wilkie, 940 F.3d 1304 (Fed. Cir. 2019). The examiner, as a physician’s assistant in the Veterans Health Administration system and a Compensation and Pension examiner, is presumed competent to opine on the Veteran’s diagnosed knee strain. See Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009). To the extent the Veteran and his representative challenge the ability of any physician’s assistant to provide findings regarding the current manifestations of the Veteran’s knee disability, there is no indication that any greater level of specialized training is required for this examination. As a general matter, there is no requirement that a medical examination be conducted by a physician. See Cox v. Nicholson, 20 Vet. App. 563, 568 (2007) (citing Goss v. Brown, 9 Vet. App. 109, 114 (1996)). There has been no showing that the VA examiner who provided the medical opinion was not competent or did not report accurately what they found in their review of the claims file. Accordingly, the Board finds the November 2020 examiner competent to provide the requested medical opinions. The Board also concludes that the November 2020 examination is adequate for compensation purposes. In April 2018, the Veteran’s representative presented arguments on the inadequacies of the Veteran’s December 2017 knee examination, including the examiner’s failure to consider: the Veteran’s lay statements and relevant Buddy statements detailing his symptoms and injury, 2007 imaging evidence of degenerative changes in the knees, and 2006 and 2007 treatment records indicating complaints of knee pain. See Form 9, 4/16/2018, pg 4. However, the November 2020 examination rectifies the deficiencies of the 2017 exam report. The examiner’s opinion is based on an accurate medical history and provides a thorough explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is no indication that the VA examiner was not fully aware of the Veteran’s medical history or that he misstated any relevant fact. Taken together, the several opinions of the examiner address fully all of the Veteran’s contentions regarding his claimed disabilities. Accordingly, the Board finds the evidence probative and affords it significant weight, and thus no medical nexus is established. Even presuming the occurrence of an in-service knee injury, there remains no competent evidence to link the current disability to the in-service event. The Veteran’s treatment records show he first complained of knee pain in February 2006 with a diagnosis of arthralgia in both knees. See MTR- Non-Government, 7/28/2011, pg 44/50. Contemporaneous records indicate a diagnosis of knee sprain at that time with a minor abnormality and minimal narrowing noted on February 2007 X-ray imaging. See CAPRI, 10/22/2020, pgs 725/756. A 2007 orthopedic surgery consultation indicates examination of the knee reveal no effusion, deformity, or atrophy; full ROM; intact MCL, ACL, LCL, and PCL; good circulation, and normal muscle strength. See pg 726/756. Similarly, VA treatment records dated 2010 also indicate no limp, difficulty walking, or use of over-the-counter medication for pain, and no swelling, instability, or crepitus. See pg. 642-645/756. Lastly, while the Veteran is competent to report having experienced symptoms of knee pain since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations due to his in-service event. The issue is medically complex, as it requires knowledge of the interaction between multiple systems in the body, anatomical structures, and interpretation of complex medical diagnostic tools. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. See also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the competent medical evidence of the VA examiner. As such, the preponderance of the evidence is against the claim; therefore, the benefit of the doubt provision does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Service connection is denied. 3. Entitlement to service connection for lower back condition The Veteran contends he is entitled to service connection for a back condition that is related to his active duty military service. Specifically, he contends his lower back pain is the result of an in-service right knee injury and the subsequent left knee pain he developed. Alternatively, he argues his back condition is related to service as a consequence of performing strenuous physical activity while carrying heavy gear in the Gulf War. The Veteran also does not believe he has been given a competent VA examination by a qualified medical professional. The question for the Board is whether the Veteran has a current back disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes the preponderance of the evidence weighs against finding that the Veteran’s condition began during service or is otherwise etiologically related to his service. The Board concludes that the Veteran has a current low back condition, as evidenced by his most recent VA examination and treatment records. He has current diagnoses of degenerative disc disease of the thoracic spine diagnosed in October 2020 and degenerative arthritis of the spine diagnosed in October 2014. See C&P Exam, 11/24/2020, pg 2/12. Accordingly, the element requiring a current diagnosis is met. The Board gives the Veteran the benefit of the doubt that he experienced in-service events while serving in a combat zone. The Veteran served in Kuwait and Iraq during the Persian Gulf War era. See Military Personnel Record, 12/10/2010; Certificate of Release, 11/25/2013. He reports, in addition to his regular duties, he also participated in combat patrols and enemy fire as a machine gunner. See MTR- Government, 6/14/2013, pg 2/9. Although the Veteran’s service treatment record does not show indication of the in-service back injury, the Veteran alleges he regularly carried heavy combat gear (roughly 100 pounds) while serving overseas, placing increased strain on him physically. See Statement, 6/5/2020, pg 5/5. The Board finds his statements consistent with the circumstances and conditions of his service and resolves every reasonable doubt in his favor. Accordingly, the Veteran’s statements regarding his in-service experiences are given full consideration and the element requiring an in-service event is satisfied. 38 U.S.C. § 1154(b). On the remaining medical nexus element, the November 2020 examiner provided several opinions relating to the Veteran’s low back condition. It is noted the Veteran reported his symptoms as a tightening of the lower back with an onset of pain in 2006 following service separation. The Veteran reports he is unable to bend over and pick up items from the ground and prolonged standing is very uncomfortable. The examiner indicates the Veteran has an abnormal ROM, however, he notes the Veteran’s obesity limited flexion past 70 degrees and has excellent flexibility in lateral flexion and rotation. C&P, 11/24/2020, pg 3/12. Muscle strength, reflex, and sensory exams are noted as normal bilaterally. There is an absence of radiculopathy, ankylosis, and intervertebral disc syndrome (IVDS). The examiner opined the Veteran’s low back condition was less likely than not incurred in or caused by his service, to include repetitive trauma from carrying heavy combat gear during service and prolonged marches in the field. C&P, 11/24/2020, pgs 3-4/8. The examiner emphasized a February 2020 medical note indicating the Veteran’s pain began in 2013 as a result of lifting and caring for his ill father in 2012, almost a decade following active duty. He notes 2007 and 2010 health screenings reveal no complaints of lumbar back pain. Further, service treatment records, including his entrance and separation exams, lack complaints, treatment, or diagnosis related to his back pain and no evidence of in-service injury is present. The examiner notes the Veteran’s lack of flexibility was only limited by his morbid obesity specifically in flexion and not by complaint of pain. The 2020 examiner addressed the Veteran’s main contention of a secondary theory of entitlement and opined the Veteran’s low back condition is less likely than not proximately due to or the result of the Veteran’s bilateral knee condition. As X-rays of the knees did not demonstrate structural abnormalities in either knee, and service treatment records lack evidence of trauma to the knee, the back condition is not likely related. Instead, the examiner concludes, “Veteran has very mild patellofemoral pain syndrome in both knees which could be brought on by his morbid obesity in the absence of any trauma.” He again notes the onset of back symptoms as 2013 related to lifting his father while caring for him. The examiner also notes medical literature supports the contention an altered gait affects joints higher up in the support chain such as hips and back, known as Kinetic Chain Theory. However, this is not found on examination and is addressed in assessing the knees. As service-connection for either knee is not achieved, a secondary theory of entitlement for lower back condition cannot be granted as a matter of law. The record includes October 2014 diagnostic imaging (MRI) results of the lumbar spine. C&P, 11/24/2020, pg 1/3. The impression is noted as bilateral mild facet joint arthropathy at L4-5 and L5-S1. There is normal anatomic alignment, intervertebral discs, vertebral bodies demonstrate normal morphology and signal characteristics. No evidence of central canal or neural foramina narrowing or disc herniation. The November 2020 examiner notes this evidence in his medical assessment as “very mild arthritis in the lumbar spine and only at the L5-S1 region” and highlighted it’s proximity in time to the 2013 post-service onset. Lateral and AP X-ray imaging of the Veteran’s thoracic spine were also taken in October 2020. C&P, 11/24/2020, pg 2/3. A history of arthritis is noted with results revealing minimal dextroscoliosis of thoracolumbar junction and mild degenerative disc disease. Vertebral bodies have normal height and soft tissues are unremarkable. There is no evidence of vertebral fracture or lytic or blastic lesions. Following review of the record, however, the examiner concluded the Veteran’s lower back condition are based on the Veteran’s lack of fitness and morbid obesity, with no connection to military service. As discussed above and adopted herein, the Veteran has challenged the adequacy of his November 2020 examination and the competency of the VA examiner. In advancing an argument concerning competency, the Veteran raises a general challenge to the professional competence of the physician’s assistant who provided the opinion and conducted his back examination during the pendency of this appeal. The Board concludes the November 2020 examiner is also competent to provide the requested medical opinion on the Veteran’s back condition. There has been no showing that the VA examiner does not have the proper medical training or did not report accurately what they found in their review of the claims file. Although the Veteran requested examination by an orthopedic specialist in his June 2020 statement, the Board notes that a neither a physician nor specialist was necessary to opine on a relationship between the Veteran’s back condition and his knees or service experience. Statement in Support, 6/5/2020, pg 4/5; See Cox v. Nicholson, 20 Vet. App. 563, 568 (2007). The Veteran and his representative also contend his VA examinations are inadequate. Specifically, the representative asserts the examiner failed to consider: the Veteran’s lay statements that his gait has altered from his knee pain and limited his activities; 2014 medical records showing back pain and sciatica; and October 2014 X-rays confirming a back disability. The representative argues the 2017 examiner erred by concluding a disability did not exist. Form 9, 4/16/2018. As the 2020 examination addresses the deficiencies of the 2017 exam and provides a well-reasoned explanation for its conclusions with supporting analysis, and addresses each theory of entitlement and contention of the Veteran, the Board finds the 2020 examination adequate for rating purposes and gives it significant probative weight. De novo review of the record does not produce evidence weighing in favor of the claim. The Veteran’s service treatment record is silent as to complaints, treatment, diagnosis, or other evidence related to his back condition, and there is no indication the Veteran’s lower back symptoms began within one year of his separation from service. Routine health assessments in February 2006, January 2007, January 2008, and January 2009 reveal a lack of point tenderness, deformities, or pain and notes good range of motion in the back. See CAPRI, 3/2/2018, pgs. 395, 406, 420, 432/435. VA treatment records do not reveal complaints of lower back pain until May 2014. A treatment note indicates the Veteran’s back pain began during an exercise program, and instructs the Veteran to refrain from the specified exercise program until his back improves. See pgs. 126-127/435. The Veteran has submitted treatment notes from his chiropractor in support of his claim, however, a VA treatment from September 2020 suggests the chiropractor is concerned about spinal disease. CAPRI, 10/22/2020, pg. 11/756. The evidence, taken as a whole, weighs against the claim. Although the Veteran is competent to report his experience and symptoms, he is not competent to provide a diagnosis or determine that these symptoms were manifestations due to service. The issue is medically complex, as it requires knowledge of the interaction between multiple systems in the body, anatomical structures, and interpretation of complex medical diagnostic tools. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. See also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the competent medical evidence of the VA examiner. The 2020 VA examiner concluded the Veteran’s knee condition likely began after his service and opined the Veteran’s back condition was unlikely caused by a lower extremity condition – for which service connection is not in effect. Accordingly, the remaining nexus element of service connection has not been met. As the preponderance is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T.N. Chapman, 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.