Citation Nr: 21026374 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 19-37 418 DATE: April 30, 2021 ORDER Service connection for chronic fatigue syndrome (CFS), also claimed as a qualifying chronic disability under 38 C.F.R. § 3.317(a), is denied. Service connection for fibromyalgia, also claimed as a qualifying chronic disability under 38 C.F.R. § 3.317(a), is denied. Service connection for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to an initial compensable rating for a bilateral hearing loss disability is remanded. Entitlement to service connection for a skin condition, including folliculitis and residuals of basal cell carcinoma and chronic folliculitis, is remanded. Entitlement to service connection for a headache condition is remanded. Entitlement to service connection for an acquired psychiatric disorder, other than PTSD, is remanded. FINDINGS OF FACT 1. The Veteran served in the Southwest Asia theater of Operations during the Persian Gulf War. 2. The Veteran does not have a current diagnosis of CFS, and a medically unexplained, chronic multi-symptom illness (MUCMI) is not demonstrated. 3. The Veteran does not have a current diagnosis of fibromyalgia, and a MUCMI is not demonstrated. 4. The Veteran does not have a current diagnosis of PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for CFS, also claimed as a qualifying chronic disability under 38 C.F.R. § 3.317(a), have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2020). 2. The criteria for service connection for fibromyalgia, also claimed as a qualifying chronic disability under 38 C.F.R. § 3.317(a), have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2020). 3. The criteria for service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty from March 1988 to July 1991, including service in Southwest Asia. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board also considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been raised. Here, however, the evidence indicates that the Veteran has been employed for the entire period on appeal, and there is no indication that such employment is marginal. Thus, Rice is inapplicable since there is no evidence that raises the issue of unemployability due to the service-connected disabilities. The Board has recharacterized the claims on appeal as reflected herein. The issue on appeal was developed as a claim for service connection for PTSD; however, in light of the multiple psychiatric diagnoses of record, the Board has expanded the matter to include all acquired psychiatric disorders pursuant to Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). Further, given that service connection for PTSD requires application of different legal criteria, the matter has been bifurcated and recharacterized as reflected herein. See Locklear v. Shinseki, 24 Vet. App. 311 (2011) (bifurcation of a claim generally is within VA's discretion); Tyrues v. Shinseki, 23 Vet. App. 166, 178-79 (2009), aff'd, 631 F.3d 1380 (Fed. Cir. 2011) (holding that it is permissible to bifurcate a claim and to adjudicate the distinct theories of entitlement separately). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the appellant and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Specific to claims of PTSD, service connection requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f). The U.S. Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). A disability for VA purposes includes any condition that results in functional impairment of earning capacity. Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020). However, with respect to mental conditions, compensation is limited to disabilities that conform to a DSM-5 diagnosis. Id. Service connection may be established for a chronic disability manifested by certain signs or symptoms which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2021, and which, by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). The term "Persian Gulf Veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. The Southwest Asia theater of operations includes, in pertinent part, Saudi Arabia. 38 C.F.R. § 3.317(d). A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): an undiagnosed illness; a medically unexplained, chronic multi-symptom illness that is defined by a cluster of signs or symptoms; or any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a). An undiagnosed illness is defined as a condition that by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. Regarding claims based on an undiagnosed illness under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more, the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location, or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A medically unexplained, chronic multi-symptom illness is one defined by a cluster of signs or symptoms and specifically includes CFS and fibromyalgia. The term medically unexplained, chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs, and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a). Signs or symptoms which may be manifestations of an undiagnosed illness or a medically unexplained, chronic multi-symptom illness include, but are not limited to: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs and symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a). The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012); Kahana, 24 Vet. App. at 433-34. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. CFS and Fibromyalgia The Veteran is seeking service connection for CFS and/or fibromyalgia, including as a qualifying chronic disability under 38 C.F.R. § 3.317(a). As noted above, the Veteran served in the Southwest Asia theater of operations during the Persian Gulf War. After review of the lay and medical evidence, the Board finds that the weight of the evidence is against a finding of current CFS or fibromyalgia disability. Service treatment records and post-service treatment records show no diagnosis or treatment CFS or fibromyalgia. In March 2017, the Veteran was afforded a VA examination. The VA examiner stated that the Veteran did not have a current diagnosis of CFS or fibromyalgia. The Veteran reported that he had some joint pains in his upper extremities and neck pain, which had existed since he was in his early 20’s. The neck pain had progressively increased over the years. On average, he rated his joint and neck pain as 3-4/10. Pain occurred intermittently, about once a week, lasting about 2 hours with dull pain. He did not associate the neck pain with his daily headaches. The Veteran denied any sequela from a remote fracture to his collar bone when in high school. He denied any other fractures or joint dislocations. The Veteran recalled the onset of chronic fatigue as about 1999-2000. He had self-diagnosed depression, but had not sought medical care. The Veteran reported symptoms of no motivation for extracurricular activities after work. The Veteran also had a history of sleep apnea, and stated that others had been bothered by his snoring and sleep disturbances. He had a history of hypertension, controlled by medication. Diagnostic testing was conducted, and the results indicated a very low likelihood of the Veteran’s having a sleep breathing disorder. Screening, using the American College of Rheumatology criteria for fibromyalgia, indicating that the Veteran did not meet the modified criteria for a diagnosis of fibromyalgia. The VA examiner opined that the Veteran’s current chronic fatigue was most likely secondary to chronic depression. The examiner also indicated that the Veteran did not meet the diagnostic criteria for fibromyalgia or CFS. Furthermore, the VA examiner diagnosed the Veteran with chronic cervical spine strain and upper extremity chronic musculoskeletal myofascial pain. Finally, the VA examiner opined that the Veteran’s chronic fatigue was less likely than not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. The VA examiner explained that, based on current clinical findings, the Veteran’s fatigue was most likely attributable to chronic depression. The Board notes that sufficiently trained examiners are competent to reach diagnoses or find the absence of diagnosable disorder. See Guerrieri v. Brown, 4 Vet. App. 467 (1993). Here, the VA examiner personally examined the Veteran, reviewed his file and performed extensive testing before concluding that the Veteran had no current diagnosis of CFS or fibromyalgia. Furthermore, because the VA examiner has medical training and expertise, based the medical opinion on an accurate medical history, and provided adequate rationale for the medical opinion, the Board finds that the March 2017 VA medical opinion is both adequate and of significant probative value. In this case, the Veteran is a registered nurse; therefore, he is competent to diagnose a medical disability and provide an etiology opinion. However, the Board finds that the absence of medical treatment evidence weighs against the Veteran’s self-diagnosis of CFS or fibromyalgia, as the Veteran would ordinarily be expected to seek treatment for such disability. The Board also finds that the Veteran’s etiology opinion is inadequate, as it is not supported by a sufficient rationale. Furthermore, the Board finds that the Veteran’s self-interest in the present claim for disability benefits limits the probative value of his competent self-diagnosis and etiology opinion. See Pond v. West, 12 Vet. App. 341 (1999) (although the Board must take into consideration the Veteran’s statements, it may consider whether self-interest may be a factor in making such statements). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer, 3 Vet. App. at 225 (1992); see also Rabideau, 2 Vet. App. at 143-44 (1992). Because the weight of the evidence is against finding a current diagnosis of CFS, the service connection claim for CFS must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. To the extent that the Veteran is seeking service connection for the symptoms of fatigue, neck pain, and upper extremity pain as an undiagnosed illness, the Board finds the VA examiner's opinion that these symptoms are attributable to the non-service connected unspecified depressive disorder, chronic cervical spine strain, and upper extremity chronic musculoskeletal myofascial pain to be highly probative. The Board notes that the VA examiner indicated that the fatigue is a symptom of the unspecified depressive disorder, and not a separately diagnosed disability for which service connection should be considered. Therefore, the Board finds that the Veteran's symptom of fatigue is related to the non-service connected unspecified depressive disorder, and his neck and upper extremity pain are independently diagnosed disabilities. Therefore, fatigue, neck pain, and upper extremity pain do not meet the criteria for classification as an undiagnosed illness under 38 C.F.R. § 3.317(a)(1)(ii). For these reasons, service connection for an CFS or fibromyalgia, including as a qualifying chronic disability under 38 C.F.R. § 3.317(a), is not warranted. PTSD The Veteran contends that he has current PTSD that is related to, or caused by, service. However, the Veteran has not met the threshold element of any service connection claim, namely a current disability. In this case, an April 2017 VA examination report affirmatively indicated that the Veteran did not have a current diagnosis of PTSD. Although the Veteran reported having current symptoms of an acquired psychiatric disorder, the VA examiner opined that the Veteran does not meet the full diagnostic criteria for PTSD and instead diagnosed the Veteran with unspecified depressive disorder and alcohol use disorder. Specifically, the examiner indicated that the Veteran did not adequately endorse PTSD criteria B and C (presence of one or more intrusion symptoms and persistent avoidance of stimuli associated with the traumatic event(s)), and that the Veteran’s symptoms under criteria D and E (negative alternations in cognitions and mood and marked alterations in arousal and reactivity, both associated with the traumatic event(s)) are related to other diagnosed acquired psychiatric disorders. The VA examiner noted that the Veteran said the depressive symptoms first developed after service and therefore they are not thought to relate to any specific in-service event/stressor. The Board finds this opinion to be both adequate and highly probative, as it is based on a review of the record and examination of the Veteran, and is supported by a detailed rationale. In this case, the Veteran is a registered nurse; therefore, he is competent to diagnose a medical disability and provide an etiology opinion. However, the Board finds that, to the extent that the Veteran has provided an etiology opinion, such opinion is inadequate, as it is not supported by a sufficient rationale. In addition, it is not clear that the Veteran’s self-diagnosis of PTSD conforms to the DSM-5, as is required. See Martinez-Bodon, 32 Vet. App. 393. Finally, the Board finds that the Veteran’s self-interest in the present claim for disability benefits limits the probative value of his competent self-diagnosis of PTSD and etiology opinion. See Pond, 12 Vet. App. 341. In sum, the Board finds that the weight of the evidence demonstrates that the Veteran does not have a diagnosis of PTSD; therefore, the claim must therefore be denied. 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 Veteran's claim for service connection, that doctrine is not helpful to the Veteran. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND Bilateral Hearing Loss The Veteran's most recent VA compensation examination for his bilateral hearing loss disability occurred in April 2017. More recently, in the December 2019 VA Form 9, he indicated that he had an appointment for VA auditory testing in October 2019 and had an appointment in December 2019 to be fitted for bilateral hearing aids. The Board finds that this is evidence of possible worsening. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). Therefore, a new VA examination is needed to assist in determining the current severity of the bilateral hearing loss disability. On remand, the Veteran’s updated VA treatment records should also be obtained and associated with the claims file. Skin Disorder (including folliculitis and residuals of basal cell carcinoma and chronic folliculitis) Once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, it must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In February 2017, the Veteran was afforded a VA Gulf War General Medical Conditions examination. Diagnoses of chronic folliculitis and basal cell carcinoma, forehead, status post excision with residual healed scar, were noted. The VA examiner opined that these diagnoses were less likely than not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. The VA examiner explained that there was no evidence of record found for evaluation and treatment of skin cancer or chronic rash during his service in Southwest Asia. In addition, the VA examiner stated that the Veteran noted a change in a mole which was diagnosed as basal cell carcinoma by a dermatologist in 2016, several years after completing his service in the Southwest Asia region in 1991. The VA examiner further noted the history of onset of rash after completing service in the Southwest Asia region, and eventually treated by a dermatologist in 2016. The current diagnosis was consistent with a history of chronic rash as described by the Veteran, and was most likely due to keratosis pilaris over the skin regions of his legs and buttocks, which was typical for this type of folliculitis in adults. The VA examiner also noted that, according to a review of medical literature via Up To Date, basal cell carcinoma was more likely to occur in men and white populations in the United States. Both environmental and genetic factors contribute to the development of basal cell carcinoma, with exposure to ultraviolet radiation in sunlight as the most important risk factor. Other risk factors including chronic arsenic exposure, radiation therapy, long-term immunosuppressive therapy, and the basal cell nevus syndrome. Finally, the VA examiner explained that keratosis pilaris is caused by the plugging of the follicle by keratin that has failed to exfoliate, leading to a sterile papular or pustular eruption. The Board finds this opinion inadequate as the examiner did not provide an opinion based on the theory of direct service connection for either of the Veteran’s diagnosed skin conditions. Moreover, this opinion is inadequate as it largely contains data and conclusions, rather than evidence specific to the Veteran. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, remand is warranted to obtain an adequate etiology opinion. Headaches In February 2017, the Veteran was afforded a VA Gulf War General Medical Conditions examination. Diagnoses of migraine headaches and tension headaches were noted, as well as history of “cluster headaches” which was reported by the Veteran and appear to be self-diagnosed. The VA examiner opined that the current clinical findings were most consistent with a diagnosis of chronic tension-type headaches, with history of typical migraine headaches without aura, described as “cluster headaches.” The VA examiner further opined that the Veteran’s chronic headaches were less likely than not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. In support of this opinion, the VA examiner cited the Veteran’s May 1991 separation examination, which noted a history of treatment for cystic acne, chronic cough, allergies with hay fever, leg cramps, and dental problems, but no history of chronic headaches. Furthermore, the VA examiner noted that the Veteran’s April 1989 military examination indication no significant history other than a fractured clavicle in 1982. The VA examiner also noted that the Veteran was treated in March 1989 after a fall from a deuce one-half with abrasions on forehead and laceration to lower lip, and a slight headache, but examination showed a stable neurological examination. The VA examiner cited Up To Date for the distinguishing characteristics of cluster headaches, migraine, and migraine without aura, and concluded that the Veteran’s headache symptoms are most likely characterized as daily tension-type headache with history of migraine headache. The examiner opined that the symptoms do not describe a cluster headache. Finally, the VA examiner opined that there is no evidence of record found for evaluation and treatment of chronic headaches during service in the Southwest Asia region. There is a single traumatic event in 1989 with a fall and occurrence of a slight headache, but no evidence found for significant head trauma. This event precedes the veteran’s service in the Southwest Asia region. The Board finds this opinion inadequate as the examiner did not provide an opinion based on the theory of direct service connection. Moreover, this opinion is inadequate as it largely contains data and conclusions, rather than evidence specific to the Veteran. Stefl, 21 Vet. App. at 124; see also Nieves-Rodriguez, 22 Vet. App. 295. Finally, the opinion is inadequate as it is largely and improperly based on the absence of medical evidence of treatment during service, and does not address the Veteran’s competent lay reports that the onset of the headaches was shortly after his deployment in 1991. Therefore, remand is warranted to obtain an adequate etiology opinion. Acquired psychiatric disorder, other than PTSD In April 2017, the Veteran was afforded a VA PTSD examination. The VA examiner diagnosed the Veteran with unspecified depressive disorder and alcohol use disorder, and opined that the Veteran does not meet the full diagnostic criteria for PTSD. As to the unspecified depressive disorder and alcohol use disorder, the VA examiner opined that both are thought to be less likely than not results of any in-service stressor or related event. The examiner noted that the Veteran endorsed six out of eleven criteria for several alcohol use disorder which is common co-morbid/secondary condition to depression and likely exacerbates depression. However, the VA examiner did not provide a rationale to support the negative nexus opinion for the unspecified depressive disorder. Therefore, the opinion is inadequate, and remand is necessary to obtain an addendum opinion as to whether the Veteran’s current unspecified depressive disorder is related to or caused by service. The matters are REMANDED for the following action: 1. Obtain and associate with the claims folder the Veteran’s updated VA treatment record. 2. Schedule the Veteran for a VA examination to determine the current severity of his bilateral hearing loss disability. The entire claims file, including a copy of the Remand, should be made available to, and be reviewed by, the VA examiner(s). All appropriate tests, studies, and consultation should be accomplished, and all clinical findings should be reported in detail. 3. Obtain an addendum medical opinion from the February 2017 VA examiner, or a suitable substitute, addressing the nature and etiology of the claimed skin conditions. An examination is not required; however, if the VA examiner indicates that s/he cannot adequately respond to the Board's questions without examination of the Veteran or additional medical evidence, an examination should be afforded to the Veteran. After review of the claims file, the VA examiner should provide an opinion as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that the Veteran’s currently diagnosed skin conditions, including basal cell carcinoma and chronic folliculitis, are related to or caused by service, to include as secondary to exposure to potential environmental hazards while deployed to Saudi Arabia during Desert Storm. A detailed rationale should be provided for the opinions rendered. 4. Obtain an addendum medical opinion from the February 2017 VA examiner, or a suitable substitute, addressing the nature and etiology of the Veteran’s migraine headache condition. After review of the claims file, the VA examiner should provide an opinion as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that the Veteran’s currently diagnosed migraine and tension headaches are related to or caused by service, to include as secondary to exposure to potential environmental hazards while deployed to Saudi Arabia during Desert Storm. **In providing this opinion, the examiner should specifically address the Veteran’s competent lay reports that the onset of headaches was shortly after his deployment in Saudi Arabia in 1991. A detailed rationale should be provided for the opinions rendered. 5. Obtain an addendum medical opinion from the VA examiner that conducted the April 2017 VA psychiatric examination, or a suitable substitute. A new examination is only required if deemed necessary by the examiner. the entire claims file, including a copy of this Remand, should be made available to, and be reviewed by, the examiner. After a complete review of the record, the examiner is asked to provide an opinion as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that the Veteran’s currently diagnosed unspecified depressive disorder is related to or caused by service. A detailed rationale should be provided for the opinion(s) rendered. 6. Then, readjudicate the remanded issues on appeal. Romina A. Casadei Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Thomas, 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.