Citation Nr: 21014300 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 13-31 447A DATE: March 11, 2021 ORDER Entitlement to revision of a February 2008 rating decision that assigned a noncompensable disability rating for a skin condition based on clear and unmistakable error (CUE) is denied. The reduction of the 60 percent rating for lichen planopilaris effective July 31, 2013, was improper; entitlement to restoration of a 60 percent disability rating for lichen planopilaris from July 31, 2013, is granted. Entitlement to an effective date of July 1, 2013, but no earlier, for a 60 percent disability rating for lichen planopilaris is granted. REMANDED Entitlement to a separate disability rating for scars or other disfigurement of the head, face, or neck is remanded. Entitlement to service connection for a respiratory condition, to include as due to an undiagnosed illness or secondary to service-connected anxiety, is remanded. Entitlement to service connection for a cardiovascular condition, to include as due to an undiagnosed illness or secondary to service-connected anxiety, is remanded. Entitlement to service connection for a neurological condition, to include as due to an undiagnosed illness or secondary to service-connected anxiety, is remanded. Entitlement to service connection for chronic fatigue, to include as due to an undiagnosed illness or secondary to service-connected anxiety, is remanded. Entitlement to service connection for a digestive condition, claimed as a bowel and digestive condition, to include as due to an undiagnosed illness or secondary to service-connected anxiety, is remanded. Entitlement to service connection for a genitourinary condition, claimed as a urinary and prostate condition, to include as due to an undiagnosed illness or secondary to service-connected anxiety, is remanded. Entitlement to service connection for chronic joint and muscle fatigue and weakness, to include as due to an undiagnosed illness or secondary to service-connected anxiety, is remanded. FINDINGS OF FACT 1. The Veteran was awarded service connection for a skin condition in a February 2008 rating decision and assigned a noncompensable disability rating. This decision became final because the Veteran did not submit a notice of disagreement or new and material evidence within the appeal period. 2. The correct facts, as known at the time, were before the adjudicators in February 2008 and the statutory and regulation provisions extant at the time were correctly applied. 3. The June 2016 rating decision’s reduction of the 60 percent rating for lichen planopilaris to 30 percent from July 31, 2013, was improper as the February 2015 rating decision’s assignment of a 60 percent rating was not clearly and unmistakably erroneous. 4. The Veteran’s claim for an increased rating for his skin condition was received on July 31, 2013; there is evidence of a factually ascertainable increase in disability on July 1, 2013, within one year of this date. CONCLUSIONS OF LAW 1. The criteria for entitlement to revision of a February 2008 rating decision assigning a noncompensable disability rating for a skin condition based on CUE have not been met. 38 U.S.C. § 5109A; 38 C.F.R. §§ 3.104, 3.105(a). 2. The criteria to reduce the 60 percent rating for lichen planopilaris based on a finding of CUE have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105, 4.118, Diagnostic Code 7806 (2015). 3. The criteria for entitlement to an effective date of July 1, 2013, but no earlier, for entitlement to a 60 percent rating for lichen planopilaris have been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from November 2003 to November 2007. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from February 2015, September 2015, and June 2016 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). Previously, these matters were before the Board in November 2018, when the Board remanded them for additional development. The matters now return to the Board. With respect to the Veteran’s claim for an increased rating for his skin condition, the Board notes that the RO assigned a 60 percent rating for the skin condition from August 20, 2019, in a September 2020 rating decision. Although 60 percent is the highest rating available under diagnostic code 7806, the increased rating is not effective throughout the entire period on appeal. As this was not a full grant of the benefits sought, the Veteran’s claim for an increased disability rating thus remains on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). Clear and Unmistakable Error By way of procedural history, the Veteran was awarded service connection for a skin disability in a February 2008 rating decision, which assigned a noncompensable disability rating (0%) under diagnostic code 7806 for eczema on the scalp. The record reflects that the Veteran was later diagnosed with lichen planopilaris (LPP); the RO eventually recharacterized his service-connected disability as LPP with scarring alopecia to recognize this fact. See February 2015 Rating Decision. The Veteran challenged the rating assigned in the February 2008 rating decision on the grounds of “clear and unmistakable error,” or CUE, in March 2015 correspondence. More specifically, he alleges that the rating decision contained CUE to the extent that it did not assign a compensable disability rating. He asserts that VA failed to properly discharge its duty to assist him by not obtaining biopsies to diagnose his skin disease. Because no biopsies were obtained by VA, he argues, VA misdiagnosed his skin condition as eczema, and he did not receive the correct treatments for LPP until he sought the care of a private physician. But for this error, he alleges, VA would have properly diagnosed his skin condition and provided appropriate care, including necessary systemic medications, steroid injections, and additional treatments such that a higher disability rating would have been warranted. The Board has broadly construed this claim as one that the RO had the improper facts before it at the time of the February 2008 rating decision. In the November 2018 remand decision, the Board directed the RO to issue a statement of the case with respect to the issue of CUE in the February 2008 rating decision pursuant to Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). Thereafter, the RO issued a statement of the case with respect to this issue in June 2020 and the Veteran filed a timely substantive appeal. Hence, the Board now has jurisdiction over the CUE claim. A previous RO determination that is final and binding will be accepted as correct in the absence of CUE. Where evidence establishes such error, the prior decision will be reversed or amended. 38 C.F.R. § 3.105(a).  Here, the record indicates that the RO issued the February 2008 rating decision addressing several claims, including a claim for a skin disability that was assigned a noncompensable disability rating. Although the Veteran filed a timely “notice of disagreement” with respect to the February 2008 rating decision, he indicated that he only disagreed with the RO’s decision on a different, unrelated claim. The record reflects that the Veteran did not file a notice of disagreement with respect to the rating assigned for his skin disability or submit new and material evidence within the relevant appellate period. As such, the February 2008 rating decision assigning a noncompensable rating for a skin disability became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104(a), 3.160(d), 3.156(b), 20.302, 20.1103. Once a decision becomes final, it may only be revised by a showing of CUE. 38 C.F.R. §§ 3.104, 3.105.  CUE is a very specific and rare kind of “error.”  It is the kind of error, of fact or of law, that when called to the attention of later reviewers compels the conclusion, to which reasonable minds could not differ, that the result would have been manifestly different but for the error.  Simply to claim CUE on the basis that previous adjudications had improperly weighed and evaluated the evidence can never rise to the stringent definition of CUE.  Similarly, neither can broad-brush allegations of “failure to follow the regulations” or “failure to give due process,” or any other general, nonspecific claim of “error.” Fugo v. Brown, 6 Vet. App. 40, 43-44 (1993).  In addition, failure to address a specific regulatory provision involves harmless error unless the outcome would have been manifestly different. Id. at 44.  Where evidence establishes CUE, the prior decision will be reversed or amended. 38 C.F.R. § 3.105(a).  For the purpose of authorizing benefits, the rating or other adjudicatory decision which constitutes a reversal of a prior decision on the grounds of CUE has the same effect as if the corrected decision had been made on the date of the reversed decision. Id.  CUE is established when the following conditions are met: (1) either (a) the correct facts in the record were not before the adjudicator, or (b) the statutory or regulatory provisions in existence at the time were incorrectly applied; (2) the alleged error must be “undebatable,” not merely “a disagreement as to how the facts were weighed or evaluated”; and (3) the commission of the alleged error must have “manifestly changed the outcome” of the decision being attacked on the basis of CUE at the time that decision was rendered.  Evans v. McDonald, 27 Vet. App. 180, 185 (2014), aff’d, 642 F. App’x 982 (Fed. Cir. 2016); Damrel v. Brown, 6 Vet. App. 242, 245 (1994); Russell v. Principi, 3 Vet. App. 310, 313-14 (1992).  The error must be of a type that is outcome-determinative, and subsequently developed evidence may not be considered in determining whether an error existed in the prior decision.  See Porter v. Brown, 5 Vet. App. 233, 235-36 (1993); Glover v. West, 185 F.3d 1328 (Fed. Cir. 1999).  A manifest change in the outcome of an adjudication means that, absent the alleged CUE, the benefit sought would have been granted at the outset.  King v. Shinseki, 26 Vet. App. 433, 441 (2014).  The standard is not whether it is reasonable to conclude that the outcome would have been different.  Id. at 442.  As a threshold matter, the Board finds that the arguments advanced by the Veteran allege CUE with the requisite specificity.  See Simmons v. Principi¸ 17 Vet. App. 104 (2003).  The Board will thus adjudicate the merits of the claim.  Relevant evidence before the RO at the time of its decision to award a noncompensable disability rating for a skin condition included the Veteran’s July 2007 application for VA disability benefits, service treatment records from November 2003 to November 2007, and a pre-discharge VA medical examination conducted on August 16, 2007. In his July 2007 claim, the Veteran claimed entitlement to service connection for a rash on the “scalp area.” He did not fill out the portions of the form asking for him to describe when the disability began, when he was treated, what medical facility or doctors treated him, or the address of those facilities, or the portion of the form asking for him to explain how his disabilities were related to service. The Veteran’s service treatment records reflect that in December 2006, he reported to the Aviation Medicine Clinic at Fort Campbell, Kentucky, with complaints of a “scalp problem.” His scalp showed some erythema with scaling at the base of his hair follicles that was nonpustular. He was diagnosed with dermatophytosis tinea capitis and instructed to use Selsun Blue UD on his scalp. The treatment provider informed him that he should follow up in one month if there was no improvement to his scalp. Subsequent service treatment records do not reflect additional complaints of or treatment for any scalp conditions. In a July 2007 report of medical history form, the Veteran did not endorse any history of skin diseases. In a July 2007 report of medical assessment, however, the Veteran indicated that he would be applying for VA disability for his “scalp” and indicated that his health had worsened since his last medical examination. In August 2007, the Veteran underwent a pre-discharge medical examination with respect to claims for a lumbar spine condition, right wrist cyst, allergic rhinitis, and a rash on the scalp area. The Veteran described the scalp condition as having existed for one year and causing itching, shedding, and crusting. He did not report any exudation or ulcer formation. Additionally, he described symptoms that occurred intermittently, as often as once a day, with each occurrence lasting two hours. He also indicated that he had had 25 attacks within the past year. The examiner noted that the skin disease involved areas exposed to the sun, including the head, but not the face, the hands, or the neck. He reported that over the past 12 months, he had only received topical medication for the skin with no side effects from treatment. On examination, there was no scarring present. The examiner noted an eczema condition on the left lateral scalp, with hyperpigmentation of less than six square inches and abnormal texture of less than six square inches. There was no ulceration, exfoliation, crusting, tissue loss, induration, inflexibility, hypopigmentation, or limitation of motion as a result of skin lesions, which covered 2 percent of the exposed area and 1 percent of the whole body. The examiner noted that the skin lesions were not associated with systemic disease or a manifestation of a nervous condition. In the diagnosis portion of the examination report, the examiner diagnosed eczema of the scalp. The examiner also indicated that a color photograph of his scalp had been taken at the examination and was attached to the examination report. In the February 2008 rating decision, the RO granted entitlement to service connection for eczema of the scalp from November 20, 2007, and assigned a noncompensable rating under diagnostic code 7806. The rating decision indicated that the Veteran’s service treatment records showed treatment for dermatophytosis and tinea capitis in December 2006, but not ongoing treatment for scalp irritation throughout the remainder of his service. The RO also noted that at his pre-discharge VA examination he described itching, crusting, and shedding over the past year, and that he had only been prescribed topical medications during that time. The Board also noted the August 2008 examiner’s findings and the color photograph attached to the examination report. Ultimately, the RO stated, the color photograph confirmed that there was no significant disfigurement over the scalp due to the skin condition. As such, a noncompensable rating was assigned for eczema that involved 2 percent of the exposed skin area and 1 percent of the total body surface, with no characteristics of disfigurement. Then, as now, eczema was evaluated under diagnostic code 7806. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2008). The then-extant version of diagnostic code 7806 provided that a noncompensable rating would be assigned for eczema covering less than 5 percent of the entire body or less than 5 percent of the exposed areas affected, as well as no more than topical therapy was required during the past 12-month period. A 10 percent rating would be assigned where at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas were affected, or where intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating was warranted where 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas were affected, or where systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of at least six weeks, but not constantly, during the past 12-month period. Last, a 60 percent rating was available where more than 40 percent of the entire body or more than 40 percent of exposed areas were affected, or where constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-months period. Id. Additionally, the language for the then-extant version of diagnostic code 7806 provided that eczema could be rated as disfigurement of the head, face, or neck, under diagnostic code 7800, or scars, under diagnostic codes 7801, 7802, 7803, 7804, or 7805, depending on the predominant disability. Id. The then-extant rating criteria for disfigurement of the head, face, or neck provided for eight characteristics of disfigurement. These included a scar that is five or more inches (13 or more centimeters) in length; a scar at least one-quarter inch (0.6 centimeters) wide at its widest part; a surface contour that is elevated or depressed on palpation; a scar adherent to underlying tissue; skin that is hypo- or hyperpigmented in an area exceeding six square inches (39 square centimeters); skin texture that is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 square centimeters); underlying soft tissue missing in an area exceeding six square inches (39 square centimeters); and skin indurated and inflexible in an area exceeding six square inches (39 square centimeters). See 38 C.F.R. § 4.118, Diagnostic Code 7800 n.1 (2008). A 10 percent rating was warranted under diagnostic code 7800, for disfigurement of the head, face, or neck, where there was one characteristic of disfigurement. A 30 percent rating was warranted with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with two or three characteristics of disfigurement. A 50 percent rating was assigned for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chine, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or for four or five characteristics of disfigurement. Last, an 80 percent rating was assigned for visible or palpable tissue loss and either gross distortion or asymmetry of three or more features of paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or for six or more characteristics of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). Then-extant diagnostic codes 7801 and 7802 pertained to scars not on the head, face, or neck, and are thus irrelevant to the Board’s analysis here. However, then-extant diagnostic code 7803 applied to superficial, unstable scars and provided for a 10 percent disability rating. 38 C.F.R. § 4.118, Diagnostic Code 7803 (2008). Additionally, diagnostic code 7804 provided for a 10 percent disability rating for superficial scars that were painful on examination. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). Last, diagnostic code 7805, for other scars, allowed for a rating based on limitation of function of an affected part. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2008). Having reviewed the relevant evidence and applicable law at the time of the February 2008 rating decision, the Board acknowledges his argument that VA failed to fully discharge the duty to assist him by not properly diagnosing his condition or providing suitable care, which exacerbated his symptoms and resulted in him not receiving appropriate treatment. Nevertheless, a breach of the duty to assist cannot constitute CUE. Cook v. Principi, 318 F.3d 1334, 1345-47 (Fed. Cir. 2002); see also Caffrey v. Brown, 6 Vet. App. 377, 384 (1994). As noted by the Court of Appeals for the Federal Circuit (Federal Circuit) in Cook, the requirements that a clear and unmistakable error be both outcome determinative and based on the record that existed at the time of the original decision make it impossible for a breach of the duty to assist to form the basis for a CUE claim. Cook, 318 F.3d at 1346. Additionally, the Board has considered his argument that the February 2008 rating decision contained CUE because it was based on a misdiagnosis. The Board acknowledges that although the Veteran was initially granted service connection for “eczema,” he was later diagnosed with LPP instead. Nonetheless, even if the Veteran is correct that he was misdiagnosed at his August 2007 pre-discharge VA examination, the Board cannot find that CUE is present in the February 2008 rating decision based on a misdiagnosis. See Russell, 3 Vet. App. at 314; Henry v. Derwinski, 2 Vet. App. 88, 90 (1992). As a matter of law, the Veteran cannot prevail on a CUE motion based on a prior misdiagnosis. This is because a claim of misdiagnosis could be interpreted as either assertion of a failure to satisfy the duty to assist or a disagreement with the weighing of facts, neither of rise to the level of clear and unmistakable error. See Shockley v. West, 11 Vet. App. 208 (1998). To reiterate, a finding that CUE existed in a prior, final rating decision requires that either the incorrect facts were before the RO or that the RO applied the incorrect law, and that, but for this error, the outcome of the decision being challenged would have been manifestly different. Having carefully considered the record before the RO at the time of the February 2008 rating decision, the Board finds that the correct facts were before the RO and that the RO correctly applied the then-extant regulations. For instance, the evidence before the RO at the time did not indicate that the Veteran’s scalp condition required systemic therapy during the past year such that a compensable rating would have been warranted. Indeed, his service treatment records from the year prior to his discharge only reflect that he was told to use certain shampoo. Moreover, the August 2007 examiner noted that his skin condition covered 2 percent of his exposed skin and only one percent of his total skin surface, and that only topical medications had been prescribed during the past year. These findings are consistent with a noncompensable rating, which applied in cases where less than 5 percent of the entire body or less than 5 percent of the exposed areas of the body were affected, and no more than topical therapy had been required during the past year. As such, the Board cannot say that it was undebatable that the Veteran should have been entitled to a compensable disability rating under diagnostic code 7806. Moreover, the evidence of record at the time of the February 2008 rating decision did not clearly and unmistakably show that a compensable rating should have been awarded under diagnostic codes 7800, 7803, 7804, or 7805. To that end, a color photograph taken at the time of the examination did not reveal any significant disfigurement from his skin condition at that time. Indeed, although the August 2007 examiner noted that there was hyperpigmentation and abnormal texture of the skin on his scalp, the hyperpigmentation and abnormal texture were less than six square inches in area. Additionally, the evidence then of record did not indicate that the Veteran had unstable or painful scars or scars that limited his function as a result of his skin condition. The adjudicator was thus reasonable in finding that a compensable rating was not warranted under another diagnostic code, such as diagnostic code 7800, 7803, 7804, or 7805, either. Ultimately, the Veteran’s arguments amount to a disagreement over how the RO weighed or interpreted the evidence before it at the time it assigned the noncompensable rating in February 2008.  To the extent that there is a disagreement as to how the RO weighed or interpreted evidence, however, such a contention is not a sufficient basis to overturn a prior final decision.  Indeed, “[i]t is the prerogative of the factfinder . . . to interpret the evidence and draw reasonable inferences from it.”  Evans, 27 Vet. App. at 187 (2014).   In sum, the Board finds that the February 2008 rating decision that assigned a noncompensable disability rating for a skin condition was consistent with, and reasonably supported by, the evidence then of record and correctly applied existing legal authority. There is no undebatable error that is shown that would have manifestly changed the outcome. Consequently, the Veteran’s motion to revise the February 2008 rating decision that assigned a noncompensable rating must be denied. Rating Reduction In July 2013, the Veteran filed a claim for an increased rating for his skin condition. In a statement accompanying his claim application, he asserted that he had been diagnosed with LPP, an autoimmune condition, which was causing his skin condition. He indicated that he was being treated by Dr. G., who had prescribed prednisone, a corticosteroid immunosuppressant, as well as the antibiotic Doxycycline Hyclate, topical steroids, and Ketoconazole shampoo. He also stated that Dr. G. began treating him with ongoing intralesional Kenalog steroid injections in his scalp, which would be performed monthly and would require 30-40 injections per visit. Subsequently, in a February 2015 rating decision, the RO recharacterized the Veteran’s skin condition as LPP with scarring alopecia and increased his disability rating to 60 percent from July 31, 2013 (i.e., the date he filed his claim for an increased rating). The February 2015 rating decision indicated that the RO had considered treatment records from Dr. G., as well as the Veteran’s lay statement, VA treatment records, and a January 2015 VA examination. The RO stated that a 60 percent evaluation had been assigned based on more than 40 percent of the exposed area being affected. Subsequently, however, the RO proposed to reduce the Veteran’s 60 percent rating in a September 2015 rating decision. The RO explained that the February 2015 rating decision contained clear and unmistakable error because it stated that the criteria for a 60 percent rating had been satisfied when the criteria had not, in fact, been met. The RO proposed to reduce his rating from 60 percent to 30 percent, effective July 31, 2015. The Veteran was notified of the proposed reduction in a September 2015 notification letter. Thereafter, the reduction was effectuated in a June 2016 rating decision, which reduced his rating to 30 percent from July 31, 2015, on the basis of CUE. Relevantly, a veteran’s disability will not be reduced unless an improvement in the disability is shown to have occurred. 38 U.S.C. § 1155. A rating reduction requires an inquiry as to whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations. In this case, however, the RO did not find that there was material improvement in the Veteran’s disability, but instead determined that there was clear and unmistakable error in the February 2015 rating decision to the extent that it assigned a 60 percent disability rating for LPP. More specifically, the RO found that there had not been any evidence that the Veteran’s LPP covered more than 60 percent of the entire body or more than 40 percent of the exposed areas affected, or that he required constant or near-constant systemic therapy over the past 12-month period. The question for the Board is thus whether the RO’s February 2015 rating decision that granted a 60 percent rating for LPP with scarring alopecia was based on clear and unmistakable error. Where a rating reduction was made without observance of law, the reduction must be vacated and the prior rating restored. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In doing so, the Board has reviewed the evidence in the record at the time of the February 2015 rating decision. The content of the Veteran’s lay statement is set forth above. Additionally, the Veteran’s treatment records from Dr. G. indicate that he had been prescribed the antibiotic Doryx, which he took once a day, as well as prednisone, an immunosuppressant, which he was initially instructed to take every day for 15 days. 15 days later, Dr. G. instructed the Veteran to continue his prednisone treatments and his daily Doryx treatment. The RO also reviewed VA treatment records from the VA Medical Center in Phoenix, Arizona. The records reveal that the Veteran had continued complaining of a rash on his scalp and that he was using medicated shampoo every other day, as well as many creams, without relief. However, the records were only current through January 9, 2012. Last, the evidence before the RO included a January 2015 VA examination report. In the examination report, the VA examiner reviewed the findings from the Veteran’s previous August 2007 post-discharge examination, VA treatment records, private treatment records from Dr. G., and the Veteran’s July 2013 lay statements on his treatment and symptoms. The examiner diagnosed dermatitis or eczema and elaborated that the Veteran had LPP/eczema of the scalp based on his July 2013 diagnosis. In the medical history portion of the examination report, the examiner noted that the Veteran still had flare-ups of his skin condition each week despite his current treatments and medications, which caused bleeding of the scalp, flaking, and itching. He washed his hair with medicated shampoo but still complained of symptoms like chronic redness across the scalp and forehead. The VA examiner noted that the skin condition caused scarring or disfigurement of the face or head. She elaborated that the scarring and disfigurement were caused by alopecia with general thinning hair along the left parietal region. In the portion of the examination report describing treatment, the examiner noted the Veteran had been treated with oral or topical medications in the past 12 months. More specifically, she indicated that he had been treated with “other oral medications,” including Doyxycline and later Acticlate, on a constant or near-constant basis, and that he had been prescribed topical corticosteroids and medicated shampoos for six weeks or more, but not constantly. She also noted that he had been undergoing Kenalog scalp injections and that his most recent treatment had been on January 13, 2015, but that the total duration of the treatment in the past month was six weeks or more, but not constant. On physical examination, the January 2015 VA examiner found that the Veteran’s skin condition affected 5 percent of the total body area and 5 percent of the exposed body area on current examination. She also noted that he had mild crusting over the left parietal region and an area of indention approximately three inches by two and a half inches in an oblong shape, likely related to tissue loss from prior injections to the area. In the portion of the examination on specific skin conditions, the VA examiner noted scarring alopecia, which affected more than 40 percent of the scalp. In an opinion rendered at the end of the examination report, the examiner opined that the scarring alopecia was a complication of LPP. The February 2015 rating decision that assigned a 60 percent rating noted that more than 40 percent of the exposed area of the skin was affected by his skin condition. In February 2015, as now, diagnostic code 7806 governed ratings for dermatitis or eczema. See 38 C.F.R. § 4.118, Diagnostic Code 7806 (2015). Diagnostic code 7806 provided that a noncompensable rating would be assigned for eczema covering less than 5 percent of the entire body or less than 5 percent of the exposed areas affected, as well as no more than topical therapy was required during the past 12-month period. A 10 percent rating was available where at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas were affected, or where intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating was available where 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas were affected, or where systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of at least six weeks, but not constantly, during the past 12-month period. Additionally, a 60 percent rating was warranted where more than 40 percent of the entire body or more than 40 percent of exposed areas were affected, or where constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-months period. Id. Here, the Board finds that there was no CUE in the February 2015 rating decision to the extent that the RO assigned a 60 percent rating for the Veteran’s skin condition. To that end, it was not undebatable that a 60 percent rating should not have been assigned. As noted above, the evidence of record before the RO in February 2015 included the Veteran’s January 2015 VA examination. Although the January 2015 VA examiner noted that 5 percent of the total body area and 5 percent of the exposed body area was affected on current examination, this only reflected the physical appearance of the Veteran’s scalp during his examination. Moreover, the Veteran’s private treatment records and lay statement, which were before the RO at the time, reflected that he had been taking oral antibiotic medications on a constant or near-constant basis for the past year. As such, a reasonable adjudicator could have concluded that the criteria for a 60 percent rating (i.e., characteristic lesions involving more than 40 percent of the exposed area or constant or near-constant systemic therapy) had been satisfied at the time of the February 2015 rating decision. Ultimately, to the extent that the RO reduced the Veteran’s disability rating based on the presence of CUE in the February 2015 rating decision, this finding is essentially premised on a disagreement with how the facts were evaluated at the time, rather than a finding that the correct facts were not before the adjudicator at the time, or that the adjudicator incorrectly applied the applicable statutory or regulatory provisions. As set forth in greater detail in the previous section, this is an insufficient basis for finding the presence of CUE. In summary, the evidence of record at the time the RO issued the February 2015 rating decision did not show, clearly and unmistakably, that the Veteran had not required constant or near-constant systemic therapy for LPP during the previous 12-month period, or that there were not characteristic lesions on at least 40 percent of his scalp. The finding of CUE in the June 2016 rating decision was not proper and the prior rating must be reinstated. As such, the Board finds that the 60 percent rating assigned for his skin condition in the February 2015 rating decision should be restored. Earlier Effective Date Last, the Veteran has argued that he is entitled to an earlier effective date for his increased rating for his skin condition. His arguments for an increased rating overlap with his arguments for revision of the February 2008 rating decision. Essentially, he argues that because VA did not properly discharge its duty to assist him with his claim, he was misdiagnosed and did not receive appropriate treatment for his skin condition until several years later. Generally, the effective date for the grant of service connection based upon an original claim, a claim reopened after final disallowance, or a claim for increase is either the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service; otherwise it will be the date of receipt of the claim or the date entitlement arose, whichever is the later.  38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b). For an increase in disability compensation, the effective date will be the earliest date as of which it is factually ascertainable that an increase in disability had occurred if the claim is received within one year from such date, or, otherwise, the date of receipt of the claim. 38 C.F.R. § 3.400(o)(2). Effective March 24, 2015, VA amended various regulations governing how to file a claim.  The amended regulations require that all claims governed by VA’s adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises.  See 79 Fed. Reg. 57,660 (Sept. 25, 2014) (now codified at 38 C.F.R. §§ 3.31(p), 3.151, 3.155).  Instead of informal claims, the new regulation provides that a claimant may request an application for benefits, upon receipt of which, the Secretary shall notify the claimant of the information necessary to complete the application form or form prescribed by the Secretary.  38 C.F.R. § 3.155(a). At the time that these amendments were made, VA also deleted a regulation that allowed various documents to be considered informal claims. Notably, prior to the date the amendments became effective, a report of examination or hospitalization could be accepted as an informal claim for benefits in claims for an increased disability rating or to reopen a claim after a final disallowance. See 79 Fed. Reg. 57,660, 57,675 (Sept. 25, 2014) (removing then-current 38 C.F.R. § 3.157(b)). Having carefully reviewed the claims file, the Board finds that an earlier effective date of July 1, 2013, but no earlier, is warranted. To that end, the Veteran was awarded a noncompensable disability rating for his skin condition in a February 2008 rating decision. As set forth above in more detail, this rating decision became final. The Veteran did not file a claim for an increased rating until July 31, 2013. To reiterate, the effective date of an evaluation and award of compensation based on a claim for an increase is generally the date of the receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5100; 38 C.F.R. § 3.400. Although the Board has reviewed the Veteran’s medical treatment records, which reflect a history of treatment for skin problems, these records alone do not constitute a claim for benefits. Moreover, the record does not contain any reports of examination or hospitalization that were received prior to July 31, 2013, that could have been characterized as an informal claim for an increased rating. As such, the Veteran’s claim for an increased rating was received on July 31, 2013. Having established that the Veteran filed his claim for an increased rating on July 31, 2013, the Board must now determine whether it became factually ascertainable that an increase in benefits was warranted in the year-long period prior to July 31, 2013. In doing so, the Board has considered records from the Veteran’s dermatologist, Dr. G. The earliest private records are dated July 1, 2013, 30 days prior to filing his claim for an increased rating. These records do not specifically describe the portion of his exposed scalp that was covered with characteristic lesions and indicate that he only been prescribed topical steroids prior to this point. Nevertheless, his July 1, 2013, private treatment records also indicate that on July 1, 2013, he was initially prescribed oral antibiotics and prednisone. As subsequent records have demonstrated, the Veteran has continued taking these medications on a constant or near-constant basis. As such, an increase in the severity of the Veteran’s skin disability was factually ascertainable within one year prior to the date he filed his claim for an increased rating. As such, an effective date of July 1, 2013, but no earlier, is warranted for his 60 percent rating. However, there is simply no evidence from any earlier date within the one-year period prior to the July 31, 2013, claim that suggests that an increase in disability was factually ascertainable. As such, July 1, 2013, is the earliest permissible effective date allowable by law. Ultimately, there is simply no evidence of record indicating that the Veteran submitted any formal or informal claim for an increased rating prior to July 2013. The pertinent legal authority governing effective dates is clear and specific, and the Board is bound by that authority. Although the Board is sympathetic to the Veteran and his situation, the earliest effective date allowable by law for entitlement to service connection has already been assigned. As such, the claim that an effective date prior to July 1, 2013, is warranted on a non-CUE basis must be denied as a matter of law. 38 U.S.C. § 5107(b); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). REASONS FOR REMAND 1. Separate ratings for scars or disfigurements due to scarring alopecia Based on the Board’s findings herein, the Veteran is entitled to a 60 percent disability rating from July 1, 2013 (i.e., the earliest date it was factually ascertainable that an increased rating was warranted within one year of filing his claim for an increased rating). This is the maximum disability rating permissible under diagnostic code 7806. As such, the issue of whether an increased rating is warranted under this diagnostic code during the period on appeal is moot. However, the Board has also considered whether a separate, additional rating is warranted for residual scarring and disfigurement stemming from his LPP and its treatment under another diagnostic code in 38 C.F.R. § 4.118. Here, the Board notes that the January 2015 VA examiner completed a scars and disfigurement disability benefit questionnaire as well as a skin diseases questionnaire. The examiner noted that there were no specific scars to measure, but that one area of the scalp had a mild scalp depression that should be accounted for as a disfigurement. Somewhat confusingly, the examiner noted one painful scar on the head, as well as two unstable scars on the head. In the description, she explained that there was generalized scalp pain with periodic bleeding of the lesions on the scalp, although this was not observed on the examination. One of the scars was characterized as painful and unstable. The examiner also noted a disfigurement on the scalp in the form of a generalized depression on the left parietal region and top of the scalp, indicating elevation, depression, adherence to underlying tissue, or missing underlying soft tissue. The depression was seven and a half centimeters long and six and a half centimeters wide at its widest part. The examiner also noted that the skin in this region of the scalp had dry or abnormal texture. The approximate total area of the scalp with an abnormal texture was 48.75 square centimeters. In a March 2015 disability benefits questionnaire provided by the Veteran in March 2015, a private treatment provider noted scars or other disfigurement of the head, face, or neck. In the description, the provider described a two-year history of alopecia leading to scarring disfigurement. The examiner noted that five or more scars were painful, but that none were unstable. When asked to provide more detailed measurements of the scars of disfigurements, the provider merely stated that there was mild scarring on the scalp over approximately 20 percent of the scalp but that there was no elevation, depression, adherence to underlying tissue, or missing tissue. The approximate area of the head, face, or neck with hypo- or hyperpigmented areas was noted as five square centimeters, although the provider also confusingly stated that there was no hypo- or hyperpigmentation. Given the conflicting evidence regarding how many painful scars the Veteran had, the RO requested a clarifying VA medical opinion. In a February 2016 VA opinion, a VA examiner was asked whether scarring alopecia was a distinct diagnosis from LPP or if the scarring alopecia was a characteristic of the LPP, and to clarify whether the Veteran had scarring for VA purposes. The examiner opined that there was no actual scarring of the scalp in a sense that VA understood, and no significant tissue loss, disfigurement, or instability or painful scarring. The VA examiner explained that the Veteran’s scarring alopecia was linked to his LPP, because LPP could lead to scarring alopecia. He explained that inflammation from LPP could damage hair follicles, but that there was no erythema or inflammatory change to the skin areas between the follicles, and no scarring in any part of the skin outside the hair follicle. He stated that the scars left in the hair follicle were not painful or tender. Additionally, he stated that the area of alopecia was not an accurate representation of the amount of scarring that had occurred, and that scarring was quite small. The examiner indicated that the January 2015 VA examiner’s opinion was consistent with his, because the January 2015 VA examiner was only describing scarring alopecia in light of his LPP diagnosis, as opposed to scarring on the scalp. To that end, the January 2015 VA examiner clearly pointed out that he had no visible scalp scars. However, the February 2016 VA opinion also stated that the January 2015 VA examiner’s reference to a “depression” in the scalp was “speculation and conjecture,” and that the Veteran’s dermatologist did not describe a depression in his private treatment records. Ultimately, the February 2016 VA opinion indicates that the veteran does not have scarring for VA purposes, and that the five or more areas of painful “scarring” described in the private disability benefits questionnaire likely represented painful, acute areas of inflamed LLP that were treated by Dr. G. on March 17, 2015. The Veteran also underwent a December 2016 VA examination in connection with his skin condition, including scars and disfigurement examination. The same examiner who performed the January 2015 VA examination performed this examination. At that examination, the examiner noted that the Veteran had scarring alopecia secondary to his LPP, and that he had scars on the head, face, or neck. She stated that despite the February 2016 VA opinion, he agreed that the Veteran had scarring related to alopecia on his scalp, as noted by Dr. G., his treating physician. She also noted no current unstable scars and indicated that the lesions on his scalp demonstrated loss of skin to multiple affected areas, with burning, sharp pain. The scars on the head, face, or neck were not painful or unstable. The December 2016 VA examiner noted a disfigurement in the form of a depression in the scalp associated with numerous Kenalog injections that measured four and a half centimeters by four and a half centimeters. The examiner noted that there was elevation, depression, adherence to underlying tissue, or missing underlying soft tissue, and that there was abnormal pigmentation of the head because the entire top of the scalp had a patchy, erythematous appearance due to LPP. There was an abnormal texture on the entire scalp because of raised erythematous lesions that caused general texture changes. In August 2019, the Veteran submitted another disability benefits questionnaire for scars and disfigurement. In that questionnaire, his treatment provider noted that the Veteran had scars of disfigurement on the head, face, or neck. In the portion of the questionnaire asking for a description of the history, the provider wrote that the Veteran had LPP involving the entire scalp, as well as scarring alopecia since 2013. He noted that five or more scars were painful, but that none were unstable. Confusingly, the examiner also stated that five or more scars were both painful and unstable. In the portion of the questionnaire for details on the scar of disfigurement, the examiner indicated that the Veteran had one scar, but did not provide any measurements other than “diffuse scalp involvement.” The VA examiner found that there was no elevation, depression, adherence to underlying tissue, or missing underlying soft tissues, or abnormal pigmentation of the head, face, or neck. Confusingly, the examiner noted that an area of skin measuring five square centimeters had an abnormal texture, but he also did not check off the box indicating whether there was abnormal texture or describing it. Finally, in September 2020 the Veteran underwent another VA examination, including an examination for scars and disfigurement. The September 2020 VA examiner noted scars or disfigurement of the head, face, or neck as a result of scarring alopecia. None of the scars were described as painful or unstable. With respect to the details of the scar, the examiner identified a diffuse area of the scalp with multiple lesions and alopecia, but also stated that he was unable to measure individual occurrences, so the entire affected area was measured. This area was 18 centimeters by 14 centimeters. There was no elevation, depression, adherence to underlying tissue, or missing underlying soft tissue, abnormal pigmentation, or abnormal texture. The area was tender to palpation. At this juncture, the Board is unable to determine on the merits whether the Veteran is entitled to a separate rating or ratings for scars of disfigurement on his head residual to his service-connected LPP. Indeed, the findings of the Veteran’s private doctor are internally inconsistent and seem to be at odds with the findings of other VA examiners. However, the VA examiners’ opinions are also somewhat inconsistent with one another. For instance, the February 2016 VA opinion disagreed with portions of the January 2015 VA examiner’s examination findings, while the December 2016 VA examiner (who was also the January 2015 VA examiner) disagreed with the February 2016 VA opinion regarding how to characterize the residual effects of the Veteran’s scarring alopecia. Essentially, it is unclear to the Board whether to characterize these residuals as scars or disfigurements due to scarring alopecia; whether any scar or disfigurement has characteristics such as an abnormal texture or pigmentation; whether these residuals are painful or unstable; or even whether those “scars” or “disfigurements” can properly be classified as scars of disfigurements, or are instead areas of temporary pain and inflammation caused by LPP that dissipate after a flare-up ends. In the interest of assembling clear and reliable findings, the Board finds that remand is necessary to obtain a contemporaneous VA examination that attempts to reconcile the various somewhat contradictory findings from Dr. G. and the various VA examiners. 2. Gulf War Illness claims Additionally, the Veteran has claimed that he is entitled to service connection for respiratory, cardiovascular, neurological, chronic fatigue, joint and muscle pain, genitourinary, and digestive conditions, to include as due to undiagnosed illness or secondary to service-connected anxiety. Generally, he alleges that he has developed various conditions as a result of his service in Iraq in 2006, as well as his exposure to environmental hazards while deployed there. Alternatively, he argues that these conditions are caused or aggravated by his service-connected anxiety. In November 2018, the Board remanded these claims in order to obtain additional VA examinations. More specifically, the Board explained that additional VA examinations were necessary to obtain medical opinions addressing whether the Veteran’s subjective symptoms reached the level of functional impairment of earning capacity. If the examiner indicated that his identified symptoms had risen to the level of functional impairment of earning capacity such that they could be considered disabilities, the Board directed the examiner to opine as to whether they were secondary to service-connected disabilities. In accordance with the Board’s remand directives, the RO attempted to schedule new VA examinations in connection with these claims in March and April 2019. However, the Veteran canceled the examination appointments. In May 2019, he reported that he was having private physicians review his records instead and that he would not need any future appointments through VA with respect to his Gulf War Illness claims. This is confirmed in July 2019 correspondence, in which the Veteran elaborated on his decision. In general, he stated that he wanted no further examinations to be scheduled with VA because he had already attended three separate rounds of examinations that had yielded negative or unfavorable results. He also indicated that he believed that his previous VA examinations had been inadequate. In response, the RO issued a supplemental statement of the case denying his various claims. On one hand, the Board acknowledges that the duty to assist claimants in assembling evidence to substantiate their claims is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (holding that if a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence). If the Veteran refuses to attend additional VA examinations with respect to his Gulf War Illness claims, the Board cannot force him to. On the other hand, the Board requested additional VA examinations because the existing medical evidence of record was insufficient. The Board is prohibited from reaching its own unsubstantiated medical opinions. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Thus, where evidence as it pertains to etiology is inconclusive, as it is in this case, the Board must rely on professional opinions of medical examiners. The Board has reached an impasse until such opinions have been obtained, inasmuch as they are crucial to disposing of these issues. As set forth above, the Veteran does not wish to report for in-person VA examinations. However, this does not preclude the RO from forwarding his claims file to an appropriate clinician and obtaining the requested medical opinions on the nature, etiology, and severity of his conditions based on the evidence of record. The Board thus finds that additional remand is warranted to obtain VA medical opinions based on a review of the available evidence, even if the Veteran does not wish to attend additional in-person examinations. Additionally, the Board notes that the most up-to-date VA treatment records with respect to the Veteran’s claim are from September 2017. It appears that there are thus outstanding VA treatment records, as well as outstanding, relevant private treatment records. On remand, these records should be obtained and associated with the claims file to ensure that the Veteran is afforded every possible consideration. Last, the Board wishes to note that clarification is needed with respect to the etiology of various specific claimed conditions. For instance, the Veteran has claimed that he is entitled to service connection for a respiratory condition and a condition characterized by chronic fatigue and muscle and joint pains. In doing so, he claimed that he suffered from difficulty breathing and that his wife reported that sometimes he stops breathing in his sleep. Additionally, he complained that he is often fatigued during the day and did not feel fully rested after sleeping. The record indicates that during the pendency of this appeal, the Veteran has been diagnosed with sleep apnea. It is unclear whether the Veteran’s complaints of respiratory symptoms and chronic fatigue are in fact complaints related to his sleep apnea or complaints of symptoms of a separate condition instead. This is a question that should be clarified on remand. Moreover, with respect to his claim that he has a cardiovascular condition, the Board notes that in September 2015, the Veteran underwent respiratory testing that revealed increased diffusing capacity, which could have been consistent with “left heart failure or shunting.” In addition, a previous VA examiner noted that the Veteran had subjective chest wall pain that is not cardiac in origin but did not describe whether he had a chest wall condition. On remand, the examiner should adequately address these findings. Furthermore, with respect to the Veteran’s complaints of a genitourinary condition, multiple VA examiners have noted that he has a voiding dysfunction. Nonetheless, despite consistent findings that he has a voiding dysfunction, the VA examiners have indicated that he has no diagnosis of a genitourinary condition. Remand is necessary to obtain a medical opinion that provides a sufficiently detailed rationale that considers all relevant evidence of record, including the multiple findings suggesting that he has a voiding dysfunction. Finally, it is unclear whether various symptoms that the Veteran has described, such as frequent urination and bowel movements, shortness of breath, tightness in his chest, fatigue, muscle aches, and impaired memory, are manifestations of his service-connected anxiety disability, or instead are manifestations of separate disorders. In short, remand is necessary to obtain additional VA medical opinions on the nature and etiology of the Veteran’s claimed conditions before any decisions on the merits of his claims can be made. Accordingly, the matters are REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding VA treatment records and relevant private treatment records should be obtained. 2. After the first instruction has been completed, schedule the Veteran for a scar/disfigurement examination to determine the nature and severity of any scars or disfigurements related to his service-connected skin condition. The claims file must be made available to the examiner for review prior to the examination, and the examiner must acknowledge such review in the examination report. After reviewing the claims file in its entirety and examining the Veteran, the VA examiner is asked to clarify whether the Veteran has any scars or disfigurements due to LPP and to attempt to reconcile the multiple conflicting reports from private and VA examiners regarding the nature of any scars of disfigurements. In doing so, the examiner is asked to address whether the Veteran does in fact have scars or disfigurements. To the extent possible, the examiner is also asked to address whether the previous private and VA examiners were describing scars and disfigurements, as opposed to temporary inflammation due to LPP, in the relevant disability benefits questionnaires. The examiner should describe in detail the nature and severity of any scars or disfigurements, including whether those scars or disfigurements are characterized by features such as abnormal pigmentation or texture, and whether any scars are painful and/or unstable. 3. After the first instruction has been completed, obtain VA medical opinions regarding the nature and etiology of the Veteran’s claimed respiratory, cardiovascular, neurological, digestive, genitourinary, chronic fatigue, and joint and muscle pain conditions. Because the Veteran has indicated that he does not wish to attend additional VA examinations with respect to these claims, forward the claims file to the examiner to obtain medical opinions based on the evidence of record. The examiner must review the claims file in its entirety and acknowledge such review in the examination report. After reviewing the claims file in its entirety, the examiner is asked to do the following: (a.) Identify any relevant, diagnosable disability associated with the Veteran’s complaints of respiratory, cardiovascular, neurological, digestive, genitourinary, chronic fatigue, and joint and muscle pain symptoms. In doing so, the examiner is asked to clarify whether his complaints of respiratory, cardiovascular, neurological, digestive, genitourinary, chronic fatigue, and joint and muscle pain symptoms are manifestations of his service-connected anxiety or sleep apnea, or instead are manifestations of separate disabilities. (b.) For each condition identified, provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that it had its onset during or is otherwise related to service. (c.) For each condition identified, provide an opinion as ot whether it is at least as likely as not that it is (1) caused by, or (2) aggravated by a service-connected disability, including service-connected anxiety. The examiner is reminded that “causation” and “aggravation” are distinct legal concepts that must be addressed separately. “Aggravation” is defined as worsening beyond the natural progression of the disability. If a condition is aggravated by a service-connected disability, the examiner is asked, to the extent possible, to provide an opinion as to the approximate baseline level of severity of the condition before the onset of the aggravation. (d.) If the Veteran has symptomatology that is not attributable to a known clinical diagnosis, the examiner should opine as to whether it is at least as likely as not that there are symptoms due to any undiagnosed illness, or a medically unexplained chronic multi-symptom illness resulting from service in Southwest Asia during the Gulf War. If so, the examiner should comment on the severity of the symptomatology and report all signs and symptoms necessary for evaluating the illness under the rating criteria. A complete rationale for these opinions must be provided. This rationale should include references to specific evidence in the Veteran’s claims file, including his lay assertion regarding his exposure to environmental hazards like burn pits during service. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. With respect to his claim for a genitourinary condition, the examiner is specifically asked to address the VA examinations of record that reflect that he has a voiding dysfunction. With respect to his claim for a cardiovascular condition, the examiner is specifically asked to address the respiratory study finding that he had results that could be consistent with left heart failure or shunting, as well as his subjective complaints of chest wall pain. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should so state but, more importantly, explain why an opinion cannot be provided without resorting to speculation, as merely stating this will not suffice. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Rademacher, 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.