Citation Nr: 21027045 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 07-04 666 DATE: May 4, 2021 ORDER Entitlement to service connection for a respiratory disability is denied. Entitlement to service connection for a lumbar spine disability is denied. REMANDED Entitlement to service connection for hiatal hernia is remanded. Entitlement to service connection for hepatitis C is remanded. FINDINGS OF FACT 1. The Veteran's respiratory disability was not incurred during active duty; the disability was not otherwise etiologically related to an in-service injury or disease to include exposure to herbicide agents therein. 2. The Veteran's lumbar spine disability, diagnosed as degenerative disc disease, was not noted in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; the disability was not otherwise etiologically related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a respiratory disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for a lumbar spine disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1965 to July 1977, including service in the Republic of Vietnam. He was the recipient of the Vietnam Service Medal, among other commendations. He died in November 2013, and the appellant is his surviving spouse, who has been substituted as the claimant for purposes of processing the Veteran's claims (which were pending at the time of his death) to their completion. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March and June 2005 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In January 2010, the Veteran and the appellant appeared at the RO and testified at a videoconference hearing conducted by the undersigned sitting in Washington, DC. In August 2010 and June 2013, the Board remanded the claims for further evidentiary development; the case has now been returned to the Board for further review. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) 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 in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In addition, certain chronic diseases, including arthritis, will be presumed related to service if they were shown as chronic (reliably diagnosed) in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303, 3.307, 3.309. In addition, if a veteran was exposed to an herbicide agent (to include Agent Orange) during active service, certain diseases [enumerated in the regulation, COPD not being among them] shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for a respiratory disability Prior to his death, the Veteran contended that his respiratory disability was related to active duty. In a January 2007 substantive appeal statement, he appeared to attribute his "breathing disease" to "Agent Orange." At the Board hearing in January 2010, he testified that during active service, he had a "hard time breathing," became short of breath, and went to the dispensary where he was given an inhaler. He stated that his symptoms first occurred about 1972. He stated that he did not continue treatment for his pulmonary problems "until recently" at the VA but that he did receive some treatment beginning in 2002 from a private physician (Dr. C). He related his current respiratory disease to his exposure to Agent Orange in Vietnam. The Veteran served on active duty from October 1965 to July 1977, with a tour of duty in the Republic of Vietnam from August 1970 to August 1971. His service treatment records (STRs) do not show complaints, treatment, or diagnosis of a respiratory disability, including in the following instances. In February 1973, he had complaints of pain in the chest, difficulty breathing, and dizziness for the past several weeks. On evaluation, the lungs were clear; the impression was within normal limits and rule out skeletal chest pains. On a periodic physical examination in October 1973, his lungs were clinically evaluated as normal. When hospitalized for an unrelated ailment from August 1975 to September 1975, it was noted he complained of no chest pain or shortness of breath (SOB) and he did not have a history of cigarette smoking. In March 1977, he complained of chest pains but denied SOB; a chest X-ray was negative, and the diagnosis was osteochondritis. After service, private treatment records from Dr. C show that in July 2002, the Veteran complained of chest congestion and difficulty breathing; the assessment was SOB/chest pain. In August 2002, he had complaints of congestion with an onset date earlier that month and that he was starting to get SOB; the diagnosis was bronchitis. In October 2002, he complained of cough and congestion and the diagnoses were sinusitis, upper respiratory infection, and bronchitis. In September 2003, his diagnoses were chronic obstructive pulmonary disease (COPD) and bronchitis. He was seen in 2003 and 2004 for COPD and bronchitis. In April 2004, the VA received the Veteran's claim of service connection for a respiratory disability. VA treatment records show that on a September 2009 VA pulmonary consult, the Veteran was seen with worsening dyspnea and uncontrolled COPD. It was noted he was actively smoking 1 pack per day (which was reduced from two to two and a half packs per day) and complained of dyspnea all the time. He claimed he had had difficulty breathing since coming back from Vietnam. The assessment was COPD (severe disease). On a September 2009 VA examination, the Veteran alleged that he had a respiratory condition since the 1970s. The examiner furnished a diagnosis of COPD, confirmed by pulmonary function tests, and opined that it was less likely than not related to any event, disease, or injury during military service. In his rationale, the examiner noted that the Veteran's STRs were negative for chronic respiratory complaints and concluded that the Veteran's COPD was "almost certainly" due to smoking 1 to 2 packs of cigarettes per day for more than 40 years. A VA examination in September 2013 was arranged because the previous examiner failed to address the likelihood of onset of the respiratory disability in service including based on lay-asserted symptoms. The examiner, noting that the claims file was not made available, rendered a diagnosis of COPD "in military," determining that it was at least as likely as not that the Veteran's respiratory problems were related to his military service. His sole rationale appeared to be based on the Veteran's report of medical history ("The Veteran states his respiratory problems originated in military."). In a December 2013 VA addendum medical opinion after review of the claims file, the same examiner indicated that other than the Veteran's statement on a pulmonary consult in 2009 that he had difficulty breathing since his return from Vietnam, the examiner was "not able to provide any further opinions/explanations based upon scientific principles without resort to speculation and conjecture." An additional VA medical opinion was obtained in August 2020. After review of the Veteran's claims file, the examiner opined that the Veteran's respiratory disability was less likely than not incurred in or caused by in-service injury, event, or illness. In her rationale, the examiner indicated that she considered the Veteran's statements regarding the onset of respiratory symptoms in service but found that, without coinciding objective evidence, they were insufficient for a diagnosis. She concluded that the Veteran's COPD was not related to service. She observed that his STRs were negative for complaints of SOB, cough, or wheeze to include on physical examination in September 1975 and on a March 1977 medical record. She also found he was not diagnosed with COPD until decades after separation from service. (Her statement that the initial COPD diagnosis was in 2013 is not wholly accurate because the record clearly shows an initial diagnosis of COPD in 2003. Given her stated review of all medical records, remand documents, and statements of the Veteran (all of which reflect a COPD diagnosis years before 2013), this appears to be an oversight or typographical error on her part. In any case, as the testimony of the Veteran indicated, he did not receive medical treatment for a respiratory disability until after he began to see Dr. C in 2002. Thus, the basis for the examiner's opinion that the Veteran did not have a diagnosis of COPD for decades after service is correct.) After review of the evidence, the Board finds that service connection is not warranted for a respiratory disability. With regard to the first element of a service connection claim, the evidence shows that the Veteran had a current diagnosis of a respiratory disability. The September 2009 and September 2013 VA examinations, as well as medical treatment records, noted a diagnosis of COPD. In addressing the second element, although the record reflects that a respiratory disability was not diagnosed during active duty, the evidence shows that the Veteran competently and credibly reported that he experienced a "hard time breathing" while on active duty. He also reported on a post-service treatment record that since returning from Vietnam, he had had difficulty breathing. The Veteran was competent to provide such assertions, as his experiences during the military were within the realm of first-hand knowledge. He was deemed credible because he remained consistent in his assertions. See Layno v. Brown, 6 Vet. App. 465, 470 (1994); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Moreover, the Veteran served a tour of duty in Vietnam and is thus presumed to have been exposed to Agent Orange during such service. With respect to the third element, the nexus requirement, the Board finds that the probative evidence is against a finding that the Veteran's respiratory disability was causally related to active service, to include exposure to herbicide agents (Agent Orange) therein. The Board assigns great probative weight to the August 2020 VA medical opinion, as the examiner reviewed the Veteran's claims file in its entirety, including the Veteran's contention regarding onset in service. After considering the record, the examiner concluded that the Veteran's respiratory disability was not causally related to active duty. As previously discussed, she provided a reasoned conclusion and clear rationale to support her determination that the evidence did not establish a connection between the Veteran's current respiratory disability and service, explaining that there were no documented respiratory symptoms in service to support a diagnosis of COPD and that his current COPD was not identified until decades after separation from service. Notably, she acknowledged the Veteran's lay statements to the effect that the onset of respiratory symptoms were in service, but she determined that it was not sufficient, absent objective evidence at that time, in which to provide a respiratory diagnosis. There is no medical opinion evidence to the contrary. The Board assigns less probative weight to the September 2009 VA examination, where the examiner failed to consider the likelihood that the Veteran's respiratory disability began in-service based on the Veteran's lay-asserted symptoms. The Board also assigns less probative weight to the September 2013 VA examination and subsequent December 2013 addendum opinion, as the examiner appeared to rely solely on the Veteran's report of medical history in rendering his opinion. In addition, the Board assigns less probative weight to the Veteran's statements indicating that his respiratory disability was caused by active duty. Although the Veteran was competent to describe symptoms, he was not competent to determine the cause of his symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and were not within the competence of the Veteran in this case, who had not been shown by the evidence of record to have had medical training or skills. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Questions of competency notwithstanding, it is notable that when the Veteran complained of difficulty breathing or chest pain in service, chest X-rays were negative, and his complaints were not attributed to a respiratory disability. In short, the Board assigns more probative weight to the findings of the August 2020 VA examiner, given her review of the claims file, clinical expertise, and rationale. Furthermore, since the Veteran's diagnosis of COPD in 2003, there has been no medical opinion that associates COPD with his military service, including exposure to Agent Orange therein. It is not in dispute that he is presumed to have been exposed to Agent Orange during his Vietnam service; however, COPD is not a presumptive disease listed in 38 C.F.R. § 3.309(e). The Veteran has asserted a belief that his COPD is related to exposure to Agent Orange, but he is not competent to provide a nexus opinion in this matter because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Based on the foregoing, as the probative evidence is against the Veteran's claim of service connection for a respiratory disability, the benefit-of the-doubt rule is not for application. See 38 U.S.C. § 5107, 38 C.F.R. § 3.102. Accordingly, the Board finds that the elements of service connection are not met, and the Veteran's claim for a respiratory disability is denied. 2. Entitlement to service connection for a lumbar spine disability Prior to his death, the Veteran contended that his lumbar spine disability was related to his active duty. At the Board hearing in January 2010, he testified that he began to experience back pain during active service, possibly about 1966 (he said he was told he had a strained muscle), and that his back problems have continued since that time. He asserted that he had back surgery in 1982 and that he currently did not receive treatment but experienced back pain. (Attempts to obtain the private surgical records from Dr. N at Southwest Memorial Hospital were to no avail.) In a January 2007 substantive appeal statement, the Veteran indicated that he was given a "bad diagnosis" in service regarding his lumbar spine. The Veteran's STRs show that with the exception of one episode, he did not have complaints, findings, or diagnosis of a low back disability. In July 1973, he was initially seen in the early morning hours for complaints of low back pain for many days. The notation reflects an impression of low back pain; the Veteran was given valium and told to return to the clinic if the pain persisted. A subsequent notation reflects that he returned later that day with a dull, constant throbbing pain. Following evaluation, the impression was lumbosacral strain. He returned for a re-check two days later, and his condition was noted to be about the same. There was no further documentation of his low back condition. On a periodic physical examination in October 1973, the spine was clinically evaluated as normal. When he was hospitalized for an unrelated ailment from August 1975 to September 1975, his back showed full range of motion without difficulty. In April 2004, the Veteran filed a claim for service connection a back disability. He indicated that he had two discs removed in 1982. On a September 2009 VA examination, the examiner in essence concluded that the Veteran did not have a low back disability, with contemporaneous treatment records reflecting neither findings nor treatment for such disability. The examiner noted that the Veteran used a wheelchair but attributed it to the Veteran's severe COPD and portal hypertension rather than due to any low back problem. In addition, the examiner expressed considerable doubt that a laminectomy performed in 1982 from L4 to S1 was due to back pain, as the Veteran had alleged. On a September 2013 VA examination, the Veteran reported that most of his back pain was due to his metastatic liver cancer. After an examination and review of the claims file, the examiner provided a diagnosis of degenerative disc disease and opined that the Veteran's lumbar spine disability was not related to his period of service. In pertinent part, the examiner determined that the Veteran's back problems were due to an on-the-job injury (a chemical explosion) in 1982, which resulted in a laminectomy from L4 to S1. The examiner explained that although during service the Veteran complained of low back pain during one month in 1973, there was no documentation to show he had any further back complaints for the duration of his active duty (i.e., for the remaining four years of service). Additionally, the examiner found it notable that the Veteran began receiving treatment from the VA in 2004 but did not mention a back problem to his primary care provider until 2009. After a review of the evidence, the Board finds that service connection is not warranted for a lumbar spine disability. With regard to the first element of a service connection claim, the evidence shows that the Veteran had a current diagnosis of a back disability. The September 2013 VA examination reflected a diagnosis of degenerative disc disease. In addressing the second element, the Board finds that the evidence shows that in July 1973 the Veteran presented with complaints of low back pain for many days, which was diagnosed as lumbosacral strain. He was also seen on a follow-up visit two days later, when his condition was about the same, although there were no further references to a low back condition in service. Therefore, the evidence establishes that the Veteran incurred a low back injury during active duty. With respect to the third element, the nexus requirement, the Board finds that the probative evidence is against a finding that the Veteran's lumbar spine disability was causally related to active service. The Board assigns great probative weight to the September 2013 VA examination, as the examiner reviewed the Veteran's claims file in its entirety. After examining the Veteran and considering the record, the examiner concluded that the Veteran's lumbar spine disability was less likely than not incurred in or caused by his documented in-service injury. The examiner provided a reasoned conclusion and clear rationale to support his determination that the Veteran's lumbar spine disability was not causally related to service, explaining that the nature of the current pathology was consistent with an on-the-job injury sustained in 1982 and not an in-service injury. He considered the Veteran's self-reported history and symptoms but ultimately felt that the current pathology was attributable to the post-service injury instead of the single episode of lumbosacral strain that was not shown to be chronic in the four remaining years of active duty. There is no medical opinion evidence to the contrary. The Board assigns less probative weight to the September 2009 VA examination, which was found to be inadequate to the extent the examiner failed to consider all pertinent medical records or statements from the Veteran. The Board also assigns less probative weight to the Veteran's statements indicating that his back disability began during his period of active duty. Although the Veteran was competent to describe symptoms of pain, he was not competent to determine the cause of his symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and were not within the competence of the Veteran in this case, who had not been shown by the evidence of record to have had medical training or skills. See Jandreau, 492 F.3d at 1376-77. And the extent to which the Veteran claimed ongoing back pain during and since service, his assertions are not credible in light of the contemporaneous STRs that do not show he was seen for low back complaints after July 1973, despite his medical treatment for various other complaints. Questions of competency and credibility notwithstanding, the Board assigns more probative weight to the findings of the September 2013 VA examiner, given his clinical expertise and the rationale he provided. In reaching this decision, the Board has considered the fact that the Veteran had been diagnosed as having degenerative disc disease, an enumerated disease under 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, the disability was not shown as chronic in service, was not shown to manifest to a compensable degree within the one-year presumptive period following service discharge in July 1977, and was not shown to be noted in service with attributable continuity of symptomatology since service (as noted above, his assertions of ongoing back pain during and since service are not found to be credible). As set forth above, the Veteran's STRs show that his complaints of low back pain were diagnosed as lumbosacral strain in July 1973, but he had no further back complaints for years during active duty. The post-service record on appeal shows that the Veteran was not diagnosed as having degenerative disc disease for decades after his separation from active service and well outside the applicable presumptive period. While the record contains the Veteran's recollections that he developed back pain during active duty which continued to the present, and he was competent to report having experienced such symptoms, he was not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of degenerative disc disease as the Veteran had not demonstrated the necessary medical expertise. Jandreau, 492 F.3d at 1377, 1377 n.4 (Fed. Cir. 2007). Based on the foregoing, as the probative evidence is against the Veteran's claim of service connection for a lumbar spine disability, the benefit-of the-doubt rule is not for application. See 38 U.S.C. § 5107, 38 C.F.R. § 3.102. Accordingly, the Board finds that the elements of service connection are not met, and the Veteran's claim for a lumbar spine disability is denied. REASONS FOR REMAND 3. Entitlement to service connection for hiatal hernia Pursuant to the Board's June 2013 remand instructions, the Veteran was afforded a VA examination in September 2013. The examiner rendered a diagnosis of GERD (gastroesophageal reflux disease) "in military," determining that it was at least as likely as not that the Veteran's GERD was related to his military service. For his rationale, he appeared to rely solely on the Veteran's report of medical history ("The Veteran states that his GERD problems started in the military and have been continuous up to the present."). He also did not address whether the Veteran's hiatal hernia was related to documented in-service gastrointestinal symptoms. Due to an inadequate opinion, a medical opinion was obtained from a different provider in August 2020. However, this (unfavorable) opinion is also inadequate to decide the claim. The examiner failed to explain whether the Veteran's GERD was related to his in-service complaints of upper gastrointestinal symptoms, which were assessed as gastritis and viral gastroenteritis, finding instead that the "first documented diagnosis and treatment is noted in 2011, over 30 years after separation from service." She also did not address the Veteran's claim that he has had symptoms of hiatal hernia since service and that he has been self-treating for it since service. He received a diagnosis of hiatal hernia after service (see April 2005 VA treatment records), but the examiner did not consider the claim or provide an etiological opinion regarding a hiatal hernia. While the Board greatly regrets further delay, remand is required for an addendum medical opinion for full compliance with the Board's previous remand instructions. See Barr v. Nicholson, 21 Vet. App. 303, 311; see also Stegall v. West, 11 Vet. App. 268 (1998). 4. Entitlement to service connection for hepatitis C Pursuant to the Board's June 2013 remand instructions, the Veteran was afforded a VA examination in September 2013. The examiner noted a 2003 diagnosis of hepatitis C based on the Veteran's report and a 2005 diagnosis of cirrhosis of the liver, determining that it was at least as likely as not that the Veteran's current liver condition was related to his military service. For his rationale, he appeared to rely solely on the Veteran's report of medical history ("The Veteran states that all of his liver problems originated while he was in service and have continued to present.). Due to an inadequate opinion, a medical opinion was obtained from a different provider in August 2020. Her (unfavorable) opinion was also insufficient, so the VA sought another medical opinion, from a specialist. In an October 2020 report, the Board-certified internal medicine physician discussed various risk factors for the contraction of hepatitis C, to include shared razors and toothbrushes as claimed by the Veteran, but did not provide an assessment on the probability that the Veteran's risk factors led to the development of hepatitis C. Instead, the physician indicated that an opinion on etiology of the virus could not be given without resorting to mere speculation. The examiner did not explain the reason that an opinion could not be provided, as requested in the Board's remand. While the Board greatly regrets further delay, remand is required for an additional addendum medical opinion for full compliance with the Board's previous remand instructions. See Barr, 21 Vet. App. 303; see also Stegall, 11 Vet. App. 268. Accordingly, the matters are REMANDED for the following action: 1. Obtain an addendum opinion from the examiner of the August 2020 report, or another appropriate clinician if she is unavailable, addressing the etiology of the Veteran's diagnosed hiatal hernia and GERD. The claims file must be made available to and reviewed by the examiner. (a). For each gastroesophageal disability present during the period of the claim (between May 2004 and November 2013), the examiner should provide a separate opinion whether it is at least as likely as not (50 percent or greater probability) that the disability originated during the Veteran's period of active service from October 1965 to July 1977 or is otherwise etiologically related to his active service. (b). In providing rationale, the examiner should explain whether the Veteran's GERD was related to his in-service complaints of upper gastrointestinal symptoms. The examiner should also address the Veteran's claim that he had had symptoms of hiatal hernia since service and that he had been self-treating for it since service. (He received a diagnosis of hiatal hernia after service. See April 2005 VA treatment records.) The examiner should consider the Veteran's assertions of hiatal hernia and GERD as evidence of disability, to the extent the assertions are within the ambit of lay knowledge. (E.g., the Veteran would be competent to assert that he had heartburn for the past 20 years, or that his physician 20 years ago told him he had GERD, but he would not be competent to assert that he had GERD 20 years ago even though he had never been told so by any clinician.) Complete rationale for each opinion must be provided. If the examiner is unable to provide any required opinion, he or she should explain why the opinion cannot be provided. 2. Obtain an addendum opinion from the examiner of the October 2020, or another appropriate clinician (specialist in liver diseases) if the examiner is unavailable, addressing the etiology of the Veteran's hepatitis C. The claims file must be made available to and reviewed by the examiner. The examiner should opine whether the Veteran's hepatitis C was at least as likely as not (50 percent or greater probability) related to risk factors during his service from October 1965 to July 1977. The examiner should explain the likelihood of the Veteran having contracted hepatitis C in service through the sharing of razors and toothbrushes when on "mobility trips," which (according to the Veteran) required mobilization with little time for adequate preparation of packing of personal care items. (For example, relative to other known risk factors for hepatitis C infection, did the Veteran's asserted risk factors constitute a high or higher degree/likelihood of transmission?) The examiner should consider the Veteran's assertions of hepatitis C or symptoms thereof to the extent the assertions are within the ambit of lay knowledge. (E.g., the Veteran would be competent to assert that he had liver pain by indicating the location of the pain, and would be competent to assert that a physician told him 20 years ago that he had hepatitis, but he would not be competent to assert that he had hepatitis 20 years ago even though he had never been told this by any clinician.) If an opinion sought cannot be given without resort to speculation, (to satisfy legal requirements) the consulting provider should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts) or by a deficiency in the record or examiner (additional facts are required, or the provider does not have the requisite knowledge or training), in which case the further testing/specialist's opinion/other information that is needed to provide the requested opinion should be identified. The consulting provider must explain the rationale for all opinions, citing to supporting factual data and existing pertinent medical and scientific literature, as necessary. Debbie A. Breitbeil Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Ruddy, 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.