Citation Nr: 21024986 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 16-21 814 DATE: April 27, 2021 ORDER Entitlement to service connection for a left wrist disability is denied. Entitlement to service connection for sleep apnea is denied. REMANDED Entitlement to service connection for a right shoulder disability is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran’s sleep apnea is related to active duty service. 2. The preponderance of the evidence is against a finding that the Veteran’s left wrist disability is related to active duty service. CONCLUSIONS OF LAW 1. The criteria for service connection for Veteran’s sleep apnea have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5103(a), 5103A; 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309. 2. The criteria for service connection for Veteran’s left wrist disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5103(a), 5103A; 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served with the Air Force Reserve and National Guard with periods of active duty from May 1974 to November 1974 and December 1998 to March 1999. Review of the military personnel record show periods of active duty for training (ACDUTRA) on May 16, 2010; September 29, 2010 to September 30, 2010; from July 29, 2012 to August 11, 2012; from September 6, 2012 to September 21, 2012; and from January 10, 2013 to January 24, 2013. This matter is on appeal from a February 2015 rating decision. The Board remanded this appeal in May 2020 for additional development. Service Connection Service connection is granted on a direct basis when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a), (d). Alternately, service connection may be established under 38 C.F.R. § 3.303 (b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. Certain chronic diseases, including arthritis, may be service connected if manifested to a degree of 10 percent disabling or more within one year after separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309.b. The term “active military, naval, or air service” includes active duty, any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C. § 101 (21), (24); see also 38 C.F.R. § 3.6. Diseases or injuries incurred or aggravated while performing ACDUTRA are eligible for service connection. 38 U.S.C. §§ 101 (24), 106, 1110, 1131. When a claim is based on a period of Reserve or National Guard service, it must be shown that the individual concerned became disabled (or died) as a result of a disease or injury incurred or aggravated in the line of duty (on Reserve ACDUTRA/INACDUTRA or during federalized National Guard service). Smith v. Shinseki, 24 Vet. App. 40 (2010). Otherwise, the period would not qualify as “active military, naval, or air service” and the claimant would not achieve “veteran status” for purposes of that claim. 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. See Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). In relevant part, 38 U.S.C. § 1154(a) requires that the VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim to disability. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. 38 U.S.C. § 5107 (b); see Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Left wrist disability The Veteran asserts that her left wrist disability is related to her military service. In a May 2014 VA examination, the examiner diagnosed the Veteran with bilateral arthralgia of the wrists. As such, the Board finds the Veteran with a current disability. Review of the Veteran’s service treatment records (STRs) show examinations in April 1974, December 1981, March 1989, December 199, and February 20102 found the Veteran with normal upper extremities and no reports of swollen or painful joints. The Board notes in March 1989 the provider noted the musculoskeletal as abnormal but did not provide any detail or clarification for that finding. In September 2007 the Veteran reported right and left wrist problems relating to carpal tunnel syndrome affecting the right hand; right hand pain in September 2009;and in January 2012 a sick slip from a medical officer instructed the Veteran to not lift with the left hand until January 2013. The Board notes that these reports were made during a period of reserve service. In a January 25, 2013 emergency room visit, the Veteran reported a recent slip and fall while carrying a heavy box, landing onto her left wrist and then backwards onto her right upper extremity. The Veteran currently complained of persistent pain to her left wrist, right shoulder and back. The Veteran also denied any previous injury to these areas prior to this visit. The Veteran also noted her plans to retire in August 2013. A January 2013 x-ray of the Veteran’s left wrist found normal alignment without fracture or dislocation. No evidence of aggressive osseous lesion, significant degenerative change or soft tissue swelling was found. The evaluating provider found no radiographic evidence of acute osseous abnormality of the left wrist but did note a mild ulnar positive variance. In an April 2013 informal line of duty (LOD) determination, the officer noted the Veteran suffered a fall at work on January 19, 2013 while trying to open a door while carrying a box full of records. The Veteran landed on her left wrist and then backwards onto her shoulder; the Veteran later reported the pain in her shoulder and wrist woke her from sleeping that evening and became progressively worse over the next three days. The officer recommended that this injury was incurred in the line of duty. The Veteran was afforded a May 2014 VA examination. The examiner diagnosed the Veteran with bilateral wrist arthralgia. The Veteran reported a fall at work in January 2013 resulting in a “sprained right wrist and shoulder by hitting on the ground” and now complaining of pain in the right wrist. The Veteran stated that there were no x-rays, MRIs, surgery or physical therapy; the Veteran further stated that she did not have any further appointments after her initial appointment for a sprain because she “didn’t know could go to VA.” The examiner noted the Veteran’s “right wrist hurts no more than left wrist.” The Veteran demonstrated full range of motion with no objective evidence of painful motion. The examiner noted that x-rays did not find evidence of arthritis. The examiner remarked the Veteran’s wrist arthralgia “appears to be consistent with fibromyalgia rather than the fall 16 months ago as has same pain on the left and did not injure the left.” The examiner found it was less likely than not the Veteran’s claimed condition was related to service. The examiner opined the Veteran had polyarthralgia of the hands, wrists, elbows, shoulders, knees, ankles, and hips and met the criteria for fibromyalgia “which is unlikely to be service connected.” The examiner stated that it was unlikely the right wrist was related to the fall as the Veteran “has the same pain on contralateral side and by own admission did not injure the left side.” However, the Board notes the examiner did not address the January 2013 x-ray report noting a mild ulnar positive variance or the January 2013 hospital report and April 2013 LOD report that the Veteran fell and injured the left wrist. As such, the Board finds the opinion inadequate and affords it less probative weight. In a May 2014 statement, the Veteran noted that they were an active reserve technician for 22 years with an additional 8 years as active, totalling 30 years. The Veteran stated that her claimed disabilities were treated “as if I had never been in the military” and that her records including LOD determinations were being overlooked. The Veteran noted that as a reserve technician, she could go to any private medical facilities or providers for treatment during her time in service. The Veteran stated that during her military career “all these conditions existed within my health” and claimed carpal tunnel in both hands from typing for 30 years. In a separate May 2014 statement, the Veteran stated that her left and right wrists were sprained and her right hand and thumb were caught in a door, causing her right thumb and right shoulder to dislocate and tear off the nail of her right index finger. In a September 2014 addendum VA opinion, the examiner reviewed the conflicting medical evidence and findings from the May 2014 VA examination. The examiner found the Veteran with a documented left wrist injury in the military with no objective residuals found on the examination. The examiner stated that no x-rays of the left wrist were taken at the May 2014 examination and “were unable to verify any radiographic evidence of left wrist injury is present.” However, the examiner also did not address the January 2013 x-ray of the left wrist and findings of the mild ulnar positive variance. In an April 2016 statement, the Veteran stated that she was on active duty when her fall and injury occurred. The Veteran stated that her supervisor sent her to the base doctor where she was given medication and was told “if I have a doctor, I can continue to see my own private doctor.” The Veteran stated that her supervisor “made a mistake and not keeping me in active duty until [the military air force base] got my wrist completely taken care of.” The Veteran stated that she was hurt really bad when she fell down with a heavy box in hand and has continued to suffer from injury. Review of the medical treatment record shows the Veteran reported involvement in motor vehicle accidents in June 2015 and July 2016. Following a May 2020 Board decision to remand for a VA opinion, the Veteran was afforded a December 2020 VA examination opinion. The examiner found the Veteran did not have a left wrist disability diagnosis related to the Veteran’s service. The examiner found that the Veteran fell in 2013, sustaining injury to the left wrist and right shoulder with bilateral trapezius muscle spasm. The examiner noted at the January 2013 emergency department visit, the Veteran reported no prior injuries to these areas. The examiner found that these injuries had resolved with no residuals by the time of the Veteran’s reported motor vehicle accident. The examiner addressed the January 2013 x-ray findings and noted the wrist was in anatomical alignment and there was no evidence of fracture, dislocation, or soft-tissue injury. The examiner addressed the finding of mild ulnar positive variance and stated that there were a variety of causes for this but “as the x-rays are otherwise normal, therefore, unrelated to any known traumatic causes.” After review of the evidence, the Board finds the preponderance of the evidence is against a finding that the Veteran’s left wrist disability is related to her active duty service. The Board notes that service connection may be granted on a presumptive basis for certain chronic diseases, including arthritis, if such disease is shown to be manifest to a degree of 10 percent or more within one year following the Veteran’s separation from active military service. See 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The Veteran has made general statements that her conditions were present during her years in service; however, service connection for a left wrist disability on a presumptive basis is not warranted as the record does not show evidence of arthritis that arose during the Veteran’s period of active military service, or within one year of separation from active duty service. Review of the medical treatment record does not show the Veteran reporting or receiving treatment for a left wrist condition following the Veteran’s separation from service other than the May 2014 VA examination. Accordingly, service connection for a left wrist disability on a presumptive basis is not warranted as a chronic disease did not manifest to a degree of 10 percent or more within one year following the Veteran’s separation from active military service. The December 2020 VA examiner provided a review and examination of the Veteran’s claims file, made references to pertinent past records and statements consistent with the evidence of record; as such, the Board finds that the VA examination report and medical records documenting the nature and extent of the Veteran’s left wrist disability, to be the most probative evidence of record. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board acknowledges the Veteran’s assertions that her left wrist disability was related to military service. Certainly, the Veteran is competent to describe experiencing symptoms in service and recurring thereafter. Indeed, treatment records corroborate at least to some extent the Veteran’s history of symptoms. Nevertheless, a lay person, the Veteran does not have the training or expertise to render a competent opinion which is more probative than the VA examiner’s opinion on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Here, the December 2020 VA examiner considered the in-service clinical findings and the Veteran’s report of symptomatology. The examiner still found that it was unlikely that the Veteran’s in-service injury was related to any current disability. The Board finds that the Veteran’s opinion is outweighed by the competent opinions of the VA examiner. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). After review of the evidence of record, the Board finds the competent evidence of record is against a finding of service connection for the Veteran’s left wrist disability. The Veteran’s diagnosis for a left wrist disability was made at the May 2014 VA examination, but medical treatment records do not show any findings of arthritis, complaints or treatments relating to the claimed issues within a year of the Veteran’s separation from service. The Board notes that the Veteran’s STRs show reports of wrist problems separate from the January 2013 fall; however, those reports occurred during a period of reserve service and the Veteran does not identify those reports as the cause of the current disability. Although the Veteran has a current disability and an inservice event in January 2013 relating to a left wrist disability, the only probative opinion of record is the December 2020 VA opinion. The December 2020 VA opinion considered the Veteran’s inservice injury but provided reasoned analysis of the case to support their opinion that the inservice injury resolved without residuals and not related to the Veteran’s current disability. The Veteran has not submitted any other opinions to be weighed against the VA examiner’s opinion. As such, the Board finds that the weight of the competent and probative evidence is against a finding of service connection for the Veteran’s left wrist disability. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Sleep apnea The Veteran claims that her sleep apnea is related to her service. Review of the medical treatment record shows in a December 2014 letter from a private physician, the physician stated that the Veteran was diagnosed with sleep apnea in July 2014. The Board notes that no sleep study was attached with this letter. In a September 2020 letter from the same physician, the physician stated that the record of the sleep study test was destroyed in a flood in 2018 and therefore was no longer available to be associated with the record. In a December 2020 VA medical opinion, the examiner found the Veteran was diagnosed with sleep apnea in 2014. The examiner stated that sleep apnea required a sleep study for diagnosis and therefore “there is no question that the Veteran was diagnosed with sleep apnea in 2014.” Resolving reasonable doubt, the Board finds the Veteran with a current disability. Review of the Veteran’s STRs show in August 1974 the Veteran reported feeling anxious to the point where she cannot concentrate. The Veteran reported dizziness when getting up and when lying down she is so tired that she cannot move. The treating provider gave an impression of anxiety and nervousness. Examinations held in December 1981, March 1989 and December 1992 note the Veteran did not complain or report any problems with sleeping. In May 2007 the Veteran reported sleep problems due to neck pain and sore throat; medication was prescribed to help with sleep. In March 2009 the Veteran complained of sleep disturbance associated with high stress in the family, noting her mother passed this past February, and depressed mood. A February 2010 examination did not find any reported problems with sleeping. In November 2012 the Veteran reported having five days of unrestful sleep in the past 30 days to include difficulty falling and staying asleep. The treating provider noted the Veteran reported better sleep during non-working days. The Board notes that the Veteran’s STRs show documentation that the Veteran was a reported smoker. In a May 2014 statement, the Veteran stated, “my sleep habits are going downhill…I’m quite sure I have sleep apnea.” In a December 2014 letter from a private physician, the physician stated the Veteran was diagnosed with sleep apnea in July 2014, however no opinion on the etiology of the Veteran’s sleep apnea was given. In the Veteran’s April 2016 form 9, the Veteran stated during her 30 years in the Air Force, the Veteran stated that in year 15 it was then she discovered that she had a sleeping problem. The Veteran stated that the doctors on the military base told her that she had the right to see private doctors and “failed to tell me to have these conditions documented in the military record.” The Veteran stated that at the end of her Air Force career her sleep apnea became so bad that she went to a private provider who found sleep apnea “from being in the military all those years.” The Veteran stated that working different hours and certain exercises caused the condition. The Veteran stated “a person just doesn’t get sleep apnea over-night” and stated that it came from her military career; the Veteran further stated that she was misled by doctors and supervisors that “I didn’t have to annotate anything to them as long as I had my own doctors.” In a December 2020 VA medical opinion, the VA examiner found the Veteran’s sleep apnea was not related to service. The examiner stated the Veteran was diagnosed with sleep apnea in 2014 and not during service, and there was no service-connected issue, exposure or “anything remotely connected to service” that could be considered an etiological factor for sleep apnea. The examiner stated that sleep apnea was present in 3 percent of adult women of normal weight; 9 percent in adult women who were overweight; and 22 percent of adult women who were obese. The examiner noted the Veteran was also a smoker and over the age of 60, factors the examiner stated alone or in combination caused sleep apnea. The examiner stated that there were “many conditions with known association with sleep apnea. Association is just that, meaning the conditions co-exist, not that one causes the other.” The examiner noted that if a performed sleep study comes back inconclusive or negative, and at a later stage, another sleep study comes back positive for sleep apnea, the examiner stated this meant “the aging process, smoking, alcohol, weight gain and other factors alone or in combination, caused or contributed to the onset of sleep apnea.” The examiner noted that “sleep apnea as a diagnosis, has its onset from that date going forward, not backward, even though there may have been variety of sleep related symptoms.” The examiner found that such a scenario applied to this Veteran. In December 2020 the Veteran’s son submitted a statement describing the symptoms of the Veteran’s sleep apnea. In January 2021 the Veteran asserted that her sleep apnea was documented in 2008 to 2010 and that she had gone to a medical technician for a second opinion and write to the Air Force. However, review of the claims record does not show the Veteran has submitted such record of a visit or documentation to be associated with the record. The Board acknowledges the Veteran’s assertions that her sleep apnea was related to the Veteran’s military service. Certainly, the Veteran is competent to describe experiencing symptoms in service and recurring thereafter. Indeed, treatment records corroborate at least to some extent the Veteran’s history of symptoms. Nevertheless, a lay person, the Veteran does not have the training or expertise to render a competent opinion which is more probative than the VA examiner’s opinion on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Here, the December 2020 VA examiner considered the in-service reports and Veteran’s report of symptomatology. The examiner still found that it was unlikely that the Veteran’s reported symptoms was related to any current disability. The Board finds that the Veteran’s opinion is outweighed by the competent opinions of the VA examiner. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). As the December 2020 VA examiner provided a review and examination of the Veteran’s claims file, made references to pertinent past records and statements consistent with the evidence of record, the Board finds that the VA examination report and medical records documenting the nature and extent of the Veteran’s sleep apnea, to be the most probative evidence of record. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). After review of the evidence of record, the Board finds the competent evidence on record is against a finding of service connection for sleep apnea. The Veteran’s STRs show no complaints, treatments or diagnosis for sleep apnea. The Veteran was noted to report difficulties with sleep in 2007 and 2009, but these came in the context of psychiatric complaints or from pain to the neck and a sore throat; in addition, the Board notes that these dates occurred in a period of reserve service that was not considered a period of inactive duty training or period of active duty service. The Board notes the Veteran in January 2021 asserted sleep apnea was noted in 2008 to 2010 in the National Guard records. However, the Veteran does not specify any particular date, and this also conflicts with her April 2016 form 9 statement where she asserts that the military doctors on base did not document any sleep apnea “as long as I had my own doctors.” The Board notes the only probative opinion on record is the December 2020 VA opinion. The December 2020 VA opinion considered the Veteran’s report of symptoms during intervening years but provided reasoned analysis of the case to support their opinion that the Veteran’s sleep apnea was not related to or the Veteran’s active duty service. The Veteran has not submitted any other opinions to be weighed against the VA examiner’s opinion. As such, the Board finds that the weight of the competent and probative evidence is against a finding of service connection for the Veteran’s sleep apnea. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). REASONS FOR REMAND While the Board regrets further delay, the Veteran’s right shoulder claim must again be remanded for additional development. In a submitted April 2016 VA Form 9, the Veteran stated that her tendonitis in the right shoulder came from “sitting in an office with all type of cold air, hot air, etc.” as well as “typing for 30 years” and using her right shoulders and arms for everything she did in the Air Force. A May 2020 Board decision remanded this issue for a VA medical opinion on the nature and etiology of the Veteran’s right shoulder disability. In a December 2020 VA medical opinion, the examiner opined it was likely than not that the Veteran’s right shoulder disability was related to service. The examiner found the 2013 injury was minor that resolved with no residuals until the Veteran’s later motor vehicle accident in 2016 and 2018 work injury. The examiner stated that had the 2013 injury not resolved, the Veteran would not have been hired for the job that resulted in injury in 2018. However, the Board notes that review of the medical treatment record shows in September 2018 the Veteran was seen for followup for neck, mid-back, and bilateral shoulder pain; the Veteran reported that 1 week prior to the visit she was seen at a hospital for “increased back pain after lifting heavy boxes all day at work.” A follow up October 2018 visit noted the Veteran was waiting on approval for a Worker’s Compensation claim regarding the work injury. The Board finds it unclear how the examiner determined the September 2018 reported work injury to the back lifting heavy boxes also affected the shoulder; the examiner noted that they would “welcome the opportunity to review the Workerman’s Compensation claim” and evaluation. In addition, the opinion does not address or discuss the Veteran’s April 2016 statements on the possible causes of her right shoulder disability; as such, the Board finds the opinion inadequate and clarification warranted to address the Veteran’s statements. The matter is REMANDED for the following action: 1. Obtain and associate with the claims file all updated and outstanding treatment records. 2. Contact the Veteran requesting them to identify any relevant outstanding VA or private treatment records and any other relevant evidence pertaining to her claim, to include medical treatment records relating to a 2018 workers compensation claim, or any other VA medical facility that may have treated the Veteran, and associate any outstanding records with the claims file. 3. Return the claims file to the VA examiner who provided the December 2020 opinion, if available, for clarification and additional opinions. If that examiner is not available, the claims file should be provided to another physician to obtain the requested opinion. After review of the claims file, the examiner is asked to respond to the following: Address the Veteran’s April 2016 statements regarding sitting in an office with cold and hot air; typing for 30 years; and general use of the arm and shoulder during their time in the Air Force to evaluate if the statements are sufficient for reconsideration of the opinion. The examiner is advised that the Veteran is competent to report in-service events and treatment, and the Veteran’s symptoms and history, and such reports and assertions must be specifically acknowledged and considered in formulating any opinions. If the examiners reject the Veteran’s reports, the examiners must provide a reason for doing so. A complete rationale for all opinions expressed should be provided. If any of the above requested opinions cannot be made without resorting to speculation, the examiners must state so and provide a rationale for this conclusion, including an explanation of whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion. 4. After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review, if in order. Robert N. Scarduzio Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Yang, Attorney-Advisor 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.