Citation Nr: 21024383 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 15-08 341 DATE: April 22, 2021 ORDER Entitlement to service connection for allergic rhinitis (also claimed as sinusitis) is denied. Entitlement to an evaluation of 20 percent for service-connected status post right ankle injury with degenerative changes is granted. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran’s allergic rhinitis began during active service, or is otherwise related to an in-service injury, event, or disease. 2. Resolving reasonable doubt in favor of the Veteran, his right ankle disability has been manifested by symptoms of pain, stiffness, and marked limitation of motion. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for allergic rhinitis (also claimed as sinusitis) have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303 (2019). 2. The criteria for establishing entitlement to an evaluation of 20 percent for service-connected status post right ankle injury with degenerative changes have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2014); 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.40, 4.45, 4.59, 4.71(a), Diagnostic Code 5271-5010 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Navy from February 2005 to November 2005. In recognition of his exemplary service, he was awarded the Global War on Terrorism Service Medal, Iraq Campaign Medal, Armed Forces Reserve Medal with “M” device, and Sea Service Deployment Ribbon. This claim stems from April and August 2013 rating decisions. Pursuant to an October 2020 Board decision, this matter was remanded for additional development to include scheduling the Veteran for a new VA examination. As the requested development is now complete, this matter has been returned to the Board for appellate consideration. Duty to Assist and to Notify VA is required to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2019). Copies of compliant VCAA notices were located in the claim’s file. VA’s duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. Peters v. Brown, 6 Vet. App. 540, 542 (1994). In this case, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Thus, upon careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service Connection Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C. § 1110, 1131; 38 C.F.R. §§ 3.303 (a), 3.304. Entitlement to service connection benefits is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and, (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the medical ‘nexus’ requirement). See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303 (a). Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) and (b). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and, (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the Veteran. Id. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). Rather, the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant). Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue. 1. Entitlement to service connection for allergic rhinitis (also claimed as sinusitis) The Veteran contends that he is entitled to service connection for allergic rhinitis as causally related to active service. As discussed more fully below, the preponderance of the evidence is against his claim. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of allergic rhinitis, the preponderance of the evidence weighs against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. Service treatment records are largely silent for complaints of respiratory symptoms or any related condition during active service. In a report of medical examination, dated June 2004, a normal physical examination was indicated. No abnormalities were identified. One year later, in January 2005, a medical record shows that the Veteran was evaluated for complaints of flu-like symptoms over a 3-day period. Reports of chills, sweating, congestion, and a general malaise was noted. A slight fever was documented. The Veteran was advised to rest for 2-days and return if symptom improvement was not achieved. No formal diagnosis was rendered. A post-deployment health assessment, dated October 2005, referenced frequent exposure to industrial pollen, sand, and dust. Periodic exposure to fuels, fog oils, solvents, burn pits, vehicle exhaust fumes, heater smoke, environmental and pesticide treatments notes a deployment to Kuwait (February 2005) and Iraq (June 2005). Post-service treatment records show that in May 2010, the Veteran denied any symptoms of rhinitis, nasal congestion, postnasal drip, or nose bleeds during a primary care treatment note. No sinus tenderness was observed during a follow-up examination in May 2010. In December 2011, a VA nurse practitioner’s opinion was associated with the claim’s file. Therein, a history of treatment at a VA medical center was acknowledged. Reportedly, the Veteran complained of chronic sinusitis, dysphagia, and biopsy-proven eosinophilic esophagitis dating back to his return from active service. While stationed in Iraq and Kuwait, he reports exposure to burn pits and other hazardous chemicals/agents. On examination in December 2012, a diagnosis of allergic rhinitis was indicated. Reportedly, it was first rendered in 1995. During the clinical evaluation, the Veteran reported problems with congestion and rhinitis. While stationed in Iraq, he reported driving a dump truck used to haul materials to a land fill over a 3-month period. He also reported exposure to burn pits and inhaled solvents. Upon his return from Iraq, the Veteran reportedly experienced progressive seasonal allergies to include rhinitis and conjunctivitis, primarily in spring and fall. No other sinus or nasal conditions were identified. No polyps, tumors, neoplasms, or obstructions were identified. No functional impact or limitations were reported. Following the clinical evaluation, the examiner opined that it is less likely than not (less than 50 percent probability) that the Veteran’s allergic rhinitis was incurred in or caused by the claimed in-service injury, event, or illness. The opinion noted that the Veteran’s reported symptoms were associated an actual diagnosis, allergic rhinitis and not an undiagnosed illness. No rationale was provided. On subsequent examination in June 2018, current diagnoses included severe reflux esophagitis and benign squamous papilloma. Both conditions were discovered during an endoscopic evaluation in August 2009. Prescribed treatments include Fluticasone, used twice daily. A functional impact was described as bouts with reflux and periodic trips to restroom to vomit. Pursuant to a February 2019 Board remand, a new VA examination was obtained with specific attention to a possible etiological linkage between the Veteran’s current diagnosis of allergic rhinitis and service-related exposure to burn pits and other toxins. On examination in June 2019, the previous diagnosis of allergic rhinitis was confirmed. During the clinical interview, the Veteran reported intermittent bouts with seasonal allergies dating back to active service. He denied any current symptoms. A physical examination found no evidence of an obstruction of the nasal passages, hypertrophy of the nasal turbinates, or nasal polyps. No granulomatous conditions were identified. No other pertinent physical findings were identified. There is no evidence of loss of any part of the nose, nasal passages, or nasal ala. No functional impact was reported. Following the clinical evaluation, the examiner concluded that the Veteran’s symptoms were more consistent with seasonal allergies or environmental allergens and were unrelated to service-related exposure to burn pits and smoke in service. Further, service treatment records were silent for complaints of allergic rhinitis or any related symptoms during active service. After service, the Veteran underwent allergy testing in June 2011. The diagnostic findings were positive for environmental allergens include grass, trees, and flowers. According to the Veteran, his symptoms were most pronounced in the fall. In October 2020, the Board again remanded the Veteran’s claim to obtain an addendum medical opinion. Specifically, an opinion was requested to fully consider whether the Veteran’s active duty service caused or aggravated his allergic rhinitis. Accordingly, an addendum opinion was associated with the claim’s file in October 2020. Following a review of the Veteran’s service treatment records, the examiner opined that it is less likely than not (less than 50 percent probability) that his allergic rhinitis was incurred in or caused by active service or any service-related exposures. In support of the stated conclusion, the examiner noted a lack documented complaints of allergic rhinitis or sinus symptoms during service. In a post-deployment health assessment, dated October 2005, a negative response was recorded for an inquiry regarding a runny nose or related sinus symptoms. In June 2011, the Veteran reported progressive seasonal allergies. Allergy testing, dated the same month, demonstrated a positive reaction to environmental allergens including grass, trees, and weeds. An etiology for his allergic rhinitis was deemed consistent with the June 2011 allergy testing. Moreover, the Veteran denied any increase in his allergy symptoms while stationed in Iraq. Considering the above, it was unlikely that any alleged exposures in Southwest Asia were causally related to his current diagnosis of allergic rhinitis. Similarly, as the Veteran denied an increase in allergy symptoms during active service, it would be difficult to state that his allergic rhinitis was aggravated by his service, to include as due to environmental exposures in Southwest Asia. In making all determinations, the Board has fully considered all medical evidence and lay assertions of record. While the Veteran is competent to report on his experience of bouts seasonal allergies, he is not competent to provide a diagnosis or etiological opinion in this case. The issue is medically complex, as it requires specialized knowledge, training, and expertise. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). There is no evidence that the Veteran possesses this required skillset. Further, mere conclusory or generalized lay assertions that an in-service event or illness caused a current disability are insufficient to establish nexus in the absence of competent medical evidence. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Here, the Board observes that service treatment records are largely silent for complaints of sinus, allergy, or respiratory symptoms. Post-service treatment records show allergy testing which confirms sensitivity to environmental allergens including grass and trees in June 2011. On multiple occasions, the Veteran has been afforded VA examinations. While a current diagnosis of allergic rhinitis was acknowledged, at no time has the medical evidence supported a causally linkage to active service, to include as due to service-related exposure to burn pits and other toxins. In fact, in October 2020, the VA examiner noted the Veteran denied an increase in allergy symptoms during active service, thus rendering it difficult to conclude that his allergic rhinitis was aggravated by his service to include, any environmental exposures in Southwest Asia. While the Board is sympathetic to the Veteran’s subjective belief that his condition is causally related to active service, the evidence of record does not support his claim. Instead, the Board affords significant probative weight to the medical opinions of record denying an etiological relationship between his allergic rhinitis and active duty service. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran’s claim of entitlement to service connection for allergic rhinitis must be denied. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2019). The Board determines the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. The Court has held that staged ratings are appropriate for initial rating and increased rating claims when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness which causes additional disability beyond that reflected on range of motion measurements must be considered. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Consideration must also be given to weakened movement, excess fatigability, and incoordination. 38 C.F.R. § 4.45. Additionally, evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. 38 C.F.R. § 4.14. However, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. Id.; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). 38 C.F.R. § 4.59 recognizes that painful motion is an important factor of disability. Joints that are painful, unstable, or misaligned, due to healed injury, are entitled to at least the minimum compensable rating for the joint. Id. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. Id; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that § 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011) (holding that pain alone does not constitute function loss and is just one fact to be considered when evaluating functional impairment). When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to an evaluation in excess of 10 percent for service-connected status post right ankle injury with degenerative changes The Veteran contends that the current severity of his service-connected right ankle disability warrants a higher evaluation. As a preliminary matter, the Board notes that during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes “to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities.” Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran’s claim under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. In this case, the Veteran’s right ankle disability has been evaluated as 10 percent disabling, under Diagnostic Code 5271-5010. See 38 C.F.R. § 4.71a. Normal ankle motion is measured from 0 to 20 degrees of dorsiflexion and 0 to 45 degrees of plantar flexion. 38 C.F.R. § 4.71 (a), Plate II. Prior to the regulatory change, Diagnostic Code 5010 provides that arthritis due to trauma is to be evaluated as degenerative arthritis pursuant to Diagnostic Code 5003. Diagnostic Code 5003 indicates that degenerative arthritis substantiated by x-ray findings is to be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion. A 20 percent evaluation is warranted for x-ray evidence of involvement of 2 or more major or minor joints, with occasional incapacitating exacerbations. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2019). As of February 7, 2021, Diagnostic Code 5010, post-traumatic arthritis is now rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with §4.25. Similarly, prior to the regulatory change, Diagnostic Code 5271 provided a 10 percent evaluation for “moderate” limitation of motion. An evaluation of 20 disabling requires a showing of “marked” limitation of motion. See 38 C.F.R. § 4.71a. The Board notes that the words “moderate” and “marked” are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” See 38 C.F.R. § 4.6. As of February 7, 2021, the amended criteria for Diagnostic Code 5271 provides an evaluation of 10 percent disabling for moderate limitation of motion described as less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion. An evaluation of 20 percent disabling is assigned for marked limitation of motion described as less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. Id. In this case, the relevant evidence during the appeal period predates the effective date of the amended diagnostic criteria. Therefore, the amended terms are inapplicable to the Veteran’s claim. Review of the record indicates that the Veteran has been afforded multiple VA examinations. On examination in January 2014, a current diagnosis of a right ankle sprain was indicated. During the clinical interview, the Veteran reported a fracture to the right ankle that was surgically repaired using screws prior to enlistment. During active service, he twisted his right ankle and suffered persistent heel and calf pain. No new surgeries or trauma was reported. The Veteran denied any experience with flare-ups. Range of motion of the right ankle revealed plantar flexion limited to 20 degrees, and dorsiflexion limited to 10 degrees. Painful motion was observed with plantar flexion. No additional functional loss or loss of range of motion was noted with repetitive use testing. Additional factors contributing to the Veteran’s right ankle disability were listed as less movement than normal, pain with movement, swelling, and disturbance of locomotion of the right ankle. Muscle strength testing yielded normal findings. The was no evidence of localized tenderness or pain to palpation. Joint stability testing revealed normal findings. There was no evidence of ankylosis, muscle atrophy or crepitus. Prior surgical procedures included placement of screws to repair a right ankle fracture in 1981. The Veteran endorsed regular use of orthotics. Diagnostic testing confirmed degenerative arthritis in the right ankle. No functional impact was specifically identified. The Board subsequently deemed the April 2017 and June 2019 examinations inadequate and remanded in order to obtain medical opinions compliant with Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017). As a result, in October 2020, the Veteran’s claim was again remanded for a new opinion. Specifically, the examiner was invited to comment on functional impairment resulting from repeated use over time, to include during flare-ups. Thereafter, in the same month, the Veteran’s service-connected right ankle disability was re-evaluated. A current diagnosis of osteoarthritis of the right ankle was identified. During the clinical interview, the Veteran reported constant right ankle pain that increased with weight-bearing activities during the day. Flare-ups of severe pain occurred 2-3 times per week with physical activity and persisted for several days after onset. Functional loss was described as difficulty with prolonged standing, walking, and climbing stairs. Range of motion testing revealed dorsiflexion limited to 5 degrees and plantar flexion limited to 15 degrees. Abnormal range of motion contributed to functional loss in terms of impaired ambulation. Pain was observed with dorsiflexion and extension. Pain was observed with weight-bearing and it caused functional loss. Moderate localized tenderness was observed along the anterolateral and medial aspects of the right ankle. Objective evidence of crepitus was noted. No additional functional loss or loss of range of motion was observed with repetitive use testing, but the examiner noted that the Veteran reported that pain caused functional loss with repetitive use over time, but not a significant change in the range of motion. Pain and lack of endurance caused functional loss over time. In terms of range of motion, pain was observed at 0 degrees of dorsiflexion and plantar flexion. During flare-ups, the Veteran’s range of motion was estimated to be 0 degrees in both dorsiflexion and plantar flexion. Additional factors contributing to the Veteran’s disability include less movement than normal and disturbance of locomotion. Muscle strength testing yielded normal findings. There was no evidence of muscle atrophy or ankylosis. Suspicion of right ankle instability was noted. However, anterior drawer and Talar tilt testing yielded normal findings. Previous surgical procedures included arthroscopic surgery in the 1980’s. Related residuals were described as plates and screws. A right ankle scar was measured at 15 centimeters (cm) in length by 1 cm in width. Assistive devices included occasional use of a knee brace to manage pain and impaired ambulation. Diagnostic imaging confirmed arthritis in the right ankle only. The Veteran described a functional impact as difficulty performing activities involving weight bearing due to pain. Decreased range of motion affects ambulation and use of right lower extremity. Considering the Correia factors, objective evidence of pain was observed with non-weight bearing. Upon review of the record, the Board finds that a higher evaluation of 20 percent, the schedular maximum, is warranted for the Veteran’s service-connected right ankle disability. In reaching the stated conclusion, the Board recognizes the Veteran’s right ankle disabling has been evaluated on multiple occasions. Each time, the Veteran reported increasing pain, stiffness, decreased range of motion, and difficulty performing physical activities. VA examiners acknowledged a progression of symptoms with each examination; however, the examinations did not adequately address Correia and Sharp, and subsequent opinions were necessary. In the October 2020 examination, the examiner estimated that the Veteran’s range of motion of the ankle was reduced to 0 degrees during flare-ups, which the Veteran reported occurred 2-3 days per week and lasted for several days thereafter. Thus, the most recent, adequate VA examination reflects that the Veteran loses his range of motion during flare-ups, which occur a significant portion of the week. As a result, a rating of 20 percent, the schedular maximum, is warranted upon consideration of this additional impairment during flare-ups. The Board has also considered whether medical evidence supports the assignment of a separate evaluation under other applicable diagnostic codes. As the record to show ankylosis, astragalectomy, os calcis or astragalus involving the Veteran’s right ankle; a separate rating is not warranted under 38 C.F.R. § 4.71a, Diagnostic Codes 5270, 5272, 5273, or 5274. (Continued on the next page)   Accordingly, resolving reasonable doubt in favor of the Veteran, the severity of his right ankle disability is most appropriately characterized as “marked” under the pre-February 2021 regulations, and a 20 percent rating for the disability is warranted. Hannah Fisher Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Whitaker, 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.