Citation Nr: 21010016 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 13-22 544 DATE: February 23, 2021 ORDER 1. Entitlement to a rating in excess of 40 percent for thoracic scoliosis and lumbar strain (a low back disability) is denied. REMANDED 2. Entitlement to service connection for a skin disability is remanded. FINDING OF FACT At no time is the Veteran’s low back disability shown to have been manifested by unfavorable ankylosis of the entire thoracolumbar spine or incapacitating episodes of disc disease; additional (not already acknowledged and separately rated) neurological manifestations are not shown or alleged. CONCLUSION OF LAW A rating in excess of 40 percent for a low back disability is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (Codes) 5235-5243. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a Veteran who served on active duty from August 2005 to May 2009. The claim seeking an increased rating for a low back disability is before the Board of Veterans’ Appeals (Board) on appeal from a March 2012 rating decision, which granted service connection for mild thoracic scoliosis and lumbar strain and assigned an initial rating of 10 percent, effective September 6, 2011. The claim seeking service connection for a skin disability is before the Board on appeal from an April 2014 rating decision. In May 2016, a videoconference hearing was held before the undersigned; a transcript is in the Veteran’s record. In September 2016 and October 2017, the case was remanded for additional development. A June 2018 Board decision denied a rating in excess of 10 percent for thoracic scoliosis and lumbar strain. The Veteran appealed the Board decision to the U.S. Court of Appeals for Veterans Claims (CAVC), resulting in a March 2019 Joint Motion for Partial Remand (JMPR) by the parties. A March 2019 CAVC Order vacated and remanded the matter for compliance with the JMPR instructions. In August 2019, the Board remanded the matter for additional development. A May 2020 rating decision increased the rating to 20 percent effective December 3, 2019. In September 2020, the Board again remanded the matter for additional development, namely for an adequate examination that complies with Sharp v. Shulkin, 29 Vet. App. 26, 33-36 (2017). A December 2020 rating decision increased the rating for the Veteran’s low back disability to 40 percent throughout (from September 6, 2011, the date of the claim seeking service connection). Therefore, the issue has been recharacterized as set forth above. [The June 2018 Board decision also remanded the matters of service connection for left wrist and skin disabilities (for development of additional medical evidence), service connection for left shoulder and left elbow disabilities (for a Board hearing), and entitlement to an effective date prior to August 4, 2017, for the award of a 30 percent rating for sinusitis and for the award of service connection, and a compensable rating, for left sciatic nerve impingement (for issuance of a Statement of the Case (SOC) pursuant to Manlincon v. West, 12 Vet. App. 238 (1999). (Notably, an August 2020 rating decision granted service connection for a left wrist ligament injury.) Following the issuance of a February 2020 SOC on the matters of an earlier effective date for the award of service connection and an increased rating for left sciatic nerve impingement, the Veteran appealed those matters (via a March 2020 VA Form 9) and requested a Board hearing. Following the issuance of a September 2020 SOC on the matter of entitlement to an effective date prior to August 4, 2017, for the award of a 30 percent rating for sinusitis, the Veteran appealed that matter (via a September 2020 VA Form 9) and requested a Board hearing. [An August 2020 Report of General Information reflects the Veteran’s continued request for a hearing regarding the matters of service connection for left shoulder and left elbow disabilities.] December 2020 VA correspondence notified the Veteran that he has been placed on the list of people wanting to appear for a videoconference hearing. Accordingly, the Veteran’s hearing requests remain pending, and the matters of service connection for left shoulder and left elbow disabilities, entitlement to an effective date prior to August 4, 2017, for the award of a 30 percent rating for sinusitis, and entitlement to an earlier effective date for the award of service connection, and an increased rating, for left sciatic nerve impingement are not currently before the Board.] 1. Entitlement to a rating in excess of 40 percent for a low back disability is denied. Legal Criteria Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity caused by the given disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where, as here, the appeal is from the initial rating assigned with an award of service connection, the severity of the disability during the entire period from the award of service connection to the present, and the possibility of “staged” ratings for distinct periods of time when varying degrees of disability were shown, must be considered. See Fenderson v. West, 12 Vet. App. 119 (1999). When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining, including regarding degree of disability, is resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. The criteria for rating spine disabilities are found in Codes 5235 – 5243. A spine disability which includes disc pathology may be rated either under the General Rating Formula for Diseases and Injuries of the Spine (General Formula) or based on Incapacitating Episodes of Disc Disease (IVDS), whichever is more favorable. Under the General Formula, the following ratings apply to disabilities of the thoracolumbar spine: A 40 percent rating is assigned for forward flexion of the thoracolumbar spine limited to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. And a 100 percent rating is assigned ed for unfavorable ankylosis of the entire spine. Any associated objective neurologic abnormalities are to be evaluated separately, under an appropriate diagnostic code. See Note (1) following the General Formula. 38 C.F.R. § 4.71A. Under the Formula for Rating IVDS Based on Incapacitating Episodes, the following ratings apply: A 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks per year. A 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks but less than twelve weeks per year. An “incapacitating episode” is defined as “a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician.” 38 C.F.R. § 4.71a, Code 5243, Formula for Rating IVDS Based on Incapacitating Episodes, and Note (1) following In determining the degree of limitation of motion, the provisions of 38 U.S.C. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45 Factual Background On October 2011 VA (fee basis) spine examination, the Veteran reported back stiffness, spasm, paresthesias, and numbness. He reported that he can walk without limitation; he denied fatigue, decreased motion, weakness, bowel or bladder problems, and erectile dysfunction. He described the pain as moderate, constant, localized on the lower back, and exacerbated by physical activity. He treated his pain with Flexeril. He reported functional impairment due to pain when standing for long periods of time and when bending or twisting. On examination, his posture and gait were within normal limits. Tenderness was noted, but there was no evidence of muscle spasm or radiating pain on movement. The spine was not ankylosed. Initial range of motion (ROM) testing showed forward flexion to 90 degrees (with pain noted at 80 degrees), extension to 30 degrees (with pain noted at 20 degrees), right and left lateral flexion to 30 degrees (with pain at 30 degrees), each, and right and left lateral rotation to 30 degrees (with pain at 30 degrees), each. Repetitive use testing did not result in additional loss of function or ROM. X-rays of the thoracic spine showed minimal levoconvex curvature of the mid/lower thoracic spine; x-rays of the lumbar spine were unremarkable. The diagnoses were mild thoracic scoliosis and lumbar strain; IVDS and permanent nerve root involvement were not diagnosed. The examiner opined the disability would limit activities requiring bending, lifting, and standing. A February 2012 VA primary care record notes a complaint of chronic low back pain. On examination, he had “grossly preserved axial skeletal ROM but some pain with forward bending at about 75 degrees flexion.” There were no large joint effusions or deformities. The assessment was low back pain; the physician recommended topical analgesic and continued use of a back brace. A June 2012 VA primary care record notes the Veteran’s report of low back pain which hurts more when bending backward than forward. He treated the pain with Tylenol and ibuprofen. On examination, he had “good forward flexion” and “no evidence of neuropathic pain at all.” The assessment was lumbar strain. A November 2012 VA primary care record notes a complaint of “stabbing sensation in mid back” and shooting pains/numbness in both legs. The Veteran reported that he was on sedentary duty at work (noting he works with aircraft sheet metal). X-ray of the lumbar spine showed a small radiodense fragment at the inferior aspect of the L3-L4 intervertebral disk. The assessment was low back pain with radicular symptoms with small radiodense fragment at L3-L4 level. A December 2012 addendum notes there is no fragment present; rather it was “an artifact on the x-ray.” He was advised to “Continue sedentary duty.” [Copies of VA prescriptions (submitted by the Veteran in October 2020) show he was limited to “Light duty” in November 2012 and “Sedentary Duty – Continue” in December 2012.] On January 18, 2013, the Veteran called his VA provider to request a letter “to get him off light duty.” Such a letter was provided that same day. A January 2013 addendum record notes that a nuclear bone scan was normal, and that MRI of the lumbar spine showed “some mild bulging discs which may cause pain and stiffness in the back if standing for a long time or lifting heavy things.” At his May 2016 Board hearing, the Veteran reported that since the 2011 VA examination, he had been treated at VA. He reported that in 2013 he underwent an MRI and a nuclear bone scan. He testified that he was prescribed a TENS unit, tramadol, and a pain killer. On December 2016 VA (fee basis) back examination, the diagnosis was degenerative arthritis of the spine. The Veteran reported lower back pain which he treats with tramadol at bedtime. He endorsed flare-ups that occur three times per month, described as moderate with a duration of 5-10 minutes, and which require him to roll to the floor before getting up from bed. Initial ROM testing was “all normal”; testing showed forward flexion to 90 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees, each, and right and left lateral rotation to 30 degrees, each. Repetitive use testing did not result in additional loss of function or ROM. There was no evidence of pain with weight-bearing. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time. Guarding of the thoracolumbar spine was noted, but it did not result in abnormal gait or spinal contour. No additional factors contributed to the disability. There was no muscle atrophy. Strength, reflex, and sensory examinations were normal. The spine was not ankylosed. There were no signs or symptoms due to radiculopathy. There were no neurologic abnormalities such as bowel or bladder problems. IVDS was not diagnosed. The Veteran did not use assistive devices as a normal mode of locomotion. The examiner opined that functioning is not so diminished that amputation with prosthesis would equally serve the Veteran. She opined that the impact on the Veteran’s ability to work would be no repetitive heavy lifting and she noted that he has lost 0-1 week work time in the last 12 months. An August 2017 private medical opinion from Dr. J.E. notes diagnoses of lumbosacral strain/IVDS, left sciatic L5-S1 nerve impingement, and strain of coccyx. Examination of the back showed tightness of the lumbar paraspinous muscles, greater on the left, and tenderness over the iliolumbar and sacroiliac ligaments. ROM testing showed forward flexion to 66 degrees, extension to 22 degrees, right lateral flexion to 16 degrees, left lateral flexion to 18 degrees, right rotation to 22 degrees, and left rotation to 18 degrees. There was decreased sensation to light touch and pin prick along the left L5 and S1 spinal nerves, and weakness on toe and heel walking in the left leg. Straight leg raising and Bragard’s sign were positive in the left leg and negative in the right leg. He opined that the Veteran has IVDS which warrants a 20 percent rating based on 2-4 weeks of incapacitating episodes in the prior 12 months, and that the Veteran has left sciatic nerve impairment warranting a 20 percent rating. He did not diagnose right lower extremity impairment or other neurological manifestations. On December 2017 VA (fee basis) back examination, the diagnoses were degenerative arthritis of the spine, IVDS, and mild thoracic scoliosis and lumbar strain. The Veteran reported chronic back pain that is “bothersome” and “increases through out [sic] the day as he works.” He self-treats with occasional Aleve; when he has increased pain, he uses a TENS unit, ice, or heat. He endorsed flare-ups that are moderate, occur 3-4 days per month, and last 1-2 days in duration; when they occur, he treats by staying in bed, taking hot baths, and using his TENS unit. During flare-ups he has to “call into work often,” walks with a limp, has a pain that shoots down his legs, and cannot pick up his toddler-aged child “some days because it hurts so bad.” Initial ROM testing showed forward flexion to 80 degrees, extension to 30 degrees, right and left lateral flexion to 20 degrees, each, and right and left lateral rotation to 30 degrees, each. Pain was noted on examination (specifically forward flexion, and right and left lateral flexion), but it did not result in/cause functional loss. There was no evidence of pain with weight-bearing. Repetitive use testing did not result in additional loss of function or ROM. The examiner (a nurse practitioner) opined that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time or during flare-ups; she was unable to estimate ROM during such periods without resorting to mere speculation. There was no guarding or muscle spasm of the thoracolumbar spine. Strength, reflex, and sensory examinations were normal. The spine was not ankylosed. There were no signs or symptoms due to radiculopathy. There were no neurologic abnormalities such as bowel or bladder problems. IVDS was diagnosed, but the record did not show physician-prescribed bed rest in the past 12 months. The Veteran did not use assistive devices as a normal mode of locomotion. The examiner opined that functioning is not so diminished that amputation with prosthesis would equally serve the Veteran. The examiner acknowledged the Veteran’s report that he has missed 48-56 workdays in the prior year, but she could not find documentation of this in the claims file. She also acknowledged his reports of pain down both legs during flare-ups, but explained that the symptoms found on current examination do not show functional loss that will impact on the Veteran’s ability to work or support a diagnosis of radiculopathy. On December 2019 VA (fee basis) back examination, the diagnoses were degenerative arthritis of the spine, IVDS, and mild thoracic scoliosis and lumbar strain. The Veteran reported that his back pain is worsening, and that he refuses to take any medication. He reported lost days of work, specifically taking 156 hours of leave and an additional 170 hours of leave without pay. He rated his back pain as 6/10 “on a regular day,” and 11/10 “on a flare up day,” when he cannot get out of bed. He reported treatment with cold and heat therapy, and a TENS unit; he acknowledged being prescribed opioids and daily gabapentin but explained that he refuses to take them. He described his flare-ups as occurring “all the time” and (variably) rated the pain as 8/10. During flare-ups, he again reported pain and an inability to bend and pick up his young child. Initial ROM testing showed forward flexion to 45 degrees, extension to 10 degrees, right and left lateral flexion to 25 degrees, each, and right and left lateral rotation to 25 degrees, each. Pain was noted on examination (specifically forward flexion, extension, and right and left lateral flexion), but it did not result in/cause functional loss. There was evidence of pain with weight-bearing. Pain was elicited during palpation of the soft tissues and during ROM testing (specifically noting trouble rising up from a bent position). Repetitive use testing did not result in additional loss of function or ROM. The examiner opined that pain, fatigue, weakness, and lack of endurance significantly limit functional ability with repeated use over time or during flare-ups; she was unable to estimate ROM during such periods without resorting to mere speculation. There was guarding and muscle spasm of the thoracolumbar spine, but they did not result in abnormal gait or abnormal spinal contour. Strength tests were all 4/5 or 5/5; reflex and sensory examinations were normal. The spine was not ankylosed. There were no signs or symptoms due to radiculopathy. There were no neurologic abnormalities such as bowel or bladder problems. IVDS was diagnosed, but the record did not show physician-prescribed bed rest in the past 12 months. The Veteran reported regular use of a back brace. The examiner opined that functioning is not so diminished that amputation with prosthesis would equally serve the Veteran. The examiner noted that the Veteran works as a sheet metal worker and lost 0-1 week of work time in the last 12 months. She noted that he has trouble rising from bent position (as he completed ROM testing) and opined that he must rest every two hours during work due to his back disability. In September 2020, a VA (fee basis) physician reviewed the record and explained that he was unable to provide an opinion regarding the functional impairment (in terms of any additional loss of ROM) of the Veteran’s low back disability during flare-ups or after repetitive use without speculation. He did explain that there is no objective evidence of incapacitating episodes of disc disease or periods of bed rest prescribed by a physician in the record. Lastly, he opined that the Veteran is limited to sedentary work due to decreased ROM, decreased lower extremity strength, and reliance on a back brace. On November 2020 VA (fee basis) back examination, the diagnoses were lumbosacral strain, degenerative arthritis of the spine, and left lower extremity lumbar radiculopathy. The Veteran reported back pain and tenderness; he denied taking any medication and explained that he treats with rest only. He reported missing 4-10 days of work per month. He endorsed flare-ups that occur once or twice a week, are “severe” and last 1-2 days (sometimes longer), and are precipitated by standing too long, picking up his child, or lifting more than 20 pounds. The flare-ups are alleviated by rest. Initial ROM testing showed forward flexion to 50 degrees, extension to 15 degrees, right and left lateral flexion to 20 degrees, each, right lateral rotation to 15 degrees, and left lateral rotation to 20 degrees. Repetitive use testing did not result in additional loss of function or ROM. There was objective evidence of pain on passive ROM testing and non-weight bearing testing. The examiner opined that pain, weakness, fatigability, or incoordination do not significantly limit functional ability with repeated use over a period of time. He did, however, opine that pain, fatigue, and weakness do significantly limit functional ability during flare-ups; he estimated such functional loss to manifest in ROM measurements of forward flexion to 30 degrees, extension to 10 degrees, right and left lateral flexion to 15 degrees, each, right lateral rotation to 10 degrees, and left lateral rotation to 15 degrees. There was no guarding or muscle spasm of the thoracolumbar spine. There was no muscle atrophy; the spine was not ankylosed. Strength tests were all 5/5 on the right, and all 5/5 on the left except for hip flexion, which was 4/5. Reflex testing was normal. Sensory testing was normal on the right and decreased on the left. Straight leg testing was negative on the right and positive on the left. The physician examiner diagnosed moderate left radiculopathy, but no right radiculopathy. There were no other neurologic abnormalities (such as bowel or bladder problems). IVDS was not diagnosed. The Veteran reported occasional use of a brace for back pain. The examiner opined that the Veteran’s low back disability results in work limitations such as no lifting more than 10-15 pounds, no standing for longer than 30 minutes, no sitting for longer than 10 minutes, and no walking greater than half a mile. The examiner noted that the Veteran still works as an aircraft mechanic and “he has hard time crawling, hard to go into a smaller compartment.” Analysis Throughout, the Veteran’s low back disability has been rated 40 percent. The next higher (50 percent) rating under the General Formula requires unfavorable ankylosis of the entire thoracolumbar spine. All evaluations and examinations during this period found that the Veteran retains motion of the thoracolumbar spine (even with consideration of additional limitation due to pain, on repeated use, and during flare-ups (as detailed above)). No examiner (VA or private) found the spine to be ankylosed, much less ankylosed in an unfavorable position. See October 2011, December 2016, December 2017, December 2019, and November 2020 VA back examination reports; see also August 2017 private medical opinion from Dr. J.E. Beyond the separately rated left lower extremity sciatic nerve impairment (which appeal is pending the scheduling of a Board hearing, as explained in the introduction above) no other neurologic manifestations have been shown. Although the Veteran has variably reported shooting pains and numbness in both legs, right lower extremity radiculopathy has not been diagnosed on VA or private examination. Bowel, bladder, and/or erectile dysfunction (as manifestations of his service-connected low back disability) have not been shown or alleged. The Board acknowledges that IVDS has been diagnosed on several VA examinations (and not diagnosed on others). Accordingly, the Board has considered whether a higher schedular rating would be warranted if the low back disability was rated under the Formula for Rating IVDS based on incapacitating episodes. Under that Formula, the next higher (60 percent) rating for IVDS requires at least 6 weeks of total incapacitating episodes in the last 12 months. A review of the evidence found that no physician-prescribed bed rest is shown, or was alleged. The Board acknowledges that the record shows the Veteran was placed on light duty and sedentary duty from November 2012 to January 2013. However, such limitations apply to work duties, and are not equivalent to physician-prescribed bed rest. To the extent Dr. J.E. opined in August 2017 that the Veteran’s IVDS warrants a 20 percent rating based on 2-4 weeks of incapacitating episodes in the prior 12 months, the Board again notes that physician-prescribed bed rest was not shown, and further notes that the Veteran is in receipt of a 40 percent rating throughout (i.e. a higher rating than the 20 percent rating argued for by Dr. J.E.). Finally, the matter of entitlement to a total disability rating based on individual unemployability (TDIU) is not raised by the record. Although the Veteran has reported that he has taken some time off work during recent VA examinations, the record shows that he continues to work full-time as a sheet metal worker. Based on the foregoing, a rating in excess of 40 percent is not warranted at any period on appeal. The preponderance of the evidence is against this claim. Therefore, the benefit of the doubt rule does not apply; the appeal in this matter must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 2. Entitlement to service connection for a skin disability The Board remanded this matter in June 2018 for a dermatological examination to ascertain the nature and likely etiology of the Veteran’s claimed skin disability, to include his acknowledge in-service exposure to chromate and polyurethane paints. The examiner was directed to comment on (express agreement or disagreement with) the August 2017 private medical opinion by Dr. J.E. In the event such disability was determined to not be related to service, the examiner was also directed to identify the etiology considered more likely. On July 2020 VA (fee basis) skin diseases examination, a nurse practitioner diagnosed scalp folliculitis. She did not diagnose a skin disability of the feet, despite diagnoses in the record. See May 10, 2012, July 25, 2012, and September 10, 2012 VA treatment records; see also August 2017 opinion by Dr. J.E. The examiner provided a negative nexus (to service) opinion; the rationale simply states that medical literature does not support that exposure to chromate and polyurethane paints can cause scalp folliculitis. The rationale fails to comment on the August 2017 private medical opinion by Dr. J.E or identify the etiology considered more likely. Accordingly, the Board finds that the July 2020 skin diseases examination report has not substantially complied with the June 2018 remand orders, and that corrective action is required. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Development to secure an advisory opinion that resolves the medical question remaining is necessary. The record shows that the Veteran receives periodic VA treatment for his skin disability. Records of all evaluations or treatment the Veteran has received for his skin disability during the evaluation period are pertinent evidence in the matter at hand, are constructively of record, and must be secured. The matter is REMANDED for the following: 1. Obtain all outstanding (updated to the present) records of VA evaluations and treatment the Veteran has received for a skin disability. 2. Thereafter, arrange for a skin diseases examination of the Veteran by an appropriate clinician to ascertain the nature and likely etiology of his claimed skin disability. The Veteran’s record (to include this remand and all records received pursuant to the development sought above) must be reviewed by the examiner in conjunction with the examination. On a review of the complete record, the examiner should: (a) Identify (by diagnosis) each skin disability found. If a skin disability of the scalp and feet is not diagnosed, reconcile that finding with the diagnoses of record (outline in part, above), including on prior VA and private examinations. (b) Identify the likely etiology for each skin disability diagnosed. Specifically, is it at least as likely as not (a 50% or greater probability) that the disability arose during (was first manifested in, or is otherwise etiologically related to) his active duty service, to include his acknowledged exposure to chromates and polyurethane paints therein? The rationale for the opinion should comment on (express, with rationale, agreement or disagreement with) the August 2017 private opinion from Dr. J.E. (c) If a diagnosed skin disability is determined to be unrelated to the Veteran’s service, identify the etiology considered more likely (and explain why that is so). The examiner must include rationale with all opinions, citing to supporting factual data and/or medical literature, as deemed appropriate. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Dupont, 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.