Citation Nr: 21030327 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 15-12 186 DATE: May 18, 2021 ORDER Entitlement to service connection for left upper extremity carpal tunnel syndrome, to include as secondary to service-connected disability, is denied. Entitlement to service connection for right upper extremity carpal tunnel syndrome, to include as secondary to service-connected disability, is denied. Entitlement to disability rating in excess of 30 percent prior to August 20, 2019, for service-connected major depressive and anxiety disorders is denied. Entitlement to disability rating in excess of 50 percent from August 20, 2019, for service-connected major depressive and anxiety disorders is denied. FINDINGS OF FACT 1. The Veteran's left upper extremity carpal tunnel syndrome is not secondary to service-connected disability, did not manifest during or within one year of separation from service, and is not otherwise related to an in-service injury or disease. 2. The Veteran's right upper extremity carpal tunnel syndrome is not secondary to service-connected disability, did not manifest during or within one year of separation from service, and is not otherwise related to an in-service injury or disease. 3. The severity, frequency, and duration of the Veteran's major depression and anxiety symptoms did not more closely approximate occupational and social impairment with reduced reliability and productivity during the period prior to August 20, 2019. 4. The severity, frequency, and duration of the Veteran's major depression and anxiety symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas for the period from August 20, 2019. CONCLUSIONS OF LAW 1. The criteria for service connection for left upper extremity carpal tunnel syndrome due to service or service-connected disability are not met. 38 U.S.C. §§ 1110, 1131, 5107(2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). 2. The criteria for service connection for right upper extremity carpal tunnel syndrome due to service or service-connected disability are not met. 38 U.S.C. §§ 1110, 1131, 5107(2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). 3. The criteria for a disability rating in excess of 30 percent for major depression and anxiety have not been met for the period prior to August 20, 2019. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9434 (2019). 4. The criteria for a disability rating in excess of 50 percent for major depression and anxiety have not been met for the period from August 20, 2019. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9434 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1979 to June 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran testified before the undersigned Veterans Law Judge (VLJ) during a April 2018 videoconference hearing. A transcript of that hearing is associated with the claims file. This case was previously before the Board in September 2018 and November 2020 when it was remanded for additional development. It has returned for adjudication. Service Connection To establish service connection for a disability, there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The currently diagnosed bilateral wrist carpal tunnel syndrome, as an organic disease of the nervous system, is a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service are applicable. For the showing of chronic disease, such as carpal tunnel, in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Under 38 C.F.R. § 3.303(b), service connection will be presumed where there are either chronic symptoms shown in service or continuity of symptomatology since service for diseases identified as "chronic" in 38 C.F.R. § 3.309(a). See Walker v. Shinseki,7 08 F.3d 1331, 1338-40 (Fed. Cir. 2013) (holding that continuity of symptomatology is an evidentiary tool to aid in the evaluation of whether a chronic disease existed in service or an applicable presumptive period). In addition, the law provides that, where a veteran served ninety days or more of active service, and certain chronic disease manifest to a degree of ten percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. In addition to the elements of direct service connection and presumptive service connection, service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either proximately caused by or proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). 1. Entitlement to service connection for left upper extremity carpal tunnel syndrome, to include as secondary to service-connected disability 2. Entitlement to service connection for right upper extremity carpal tunnel syndrome, to include as secondary to service-connected disability The Veteran contends his bilateral carpal tunnel syndrome is due to his service-connected neck or right wrist strain. Regarding the theory of entitlement to service connection on a secondary basis, the question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or was aggravated beyond its natural progress by, a service-connected disability. The Board concludes that, while the Veteran has a current bilateral upper extremity carpal tunnel disability, the preponderance of the evidence is against finding that the disability is proximately due to or the result of, or aggravated beyond its natural progression by, service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). In this regard, the Board notes that the Veteran was afforded a VA examination in October 2018. The examiner confirmed the Veteran's diagnosis of bilateral upper extremity carpal tunnel syndrome. However, the examiner opined that it is less likely than not that that the Veteran's carpal tunnel syndrome was caused by neck or wrist injuries. The examiner explained that carpal tunnel is caused by compression of the median nerve at the wrist. She outlined the risk factors, including repetitive stress activities such as typing, diabetes, alcoholism, hypothyroidism, family history, age, obesity, and hypertension. The examiner reasoned that though the Veteran has carpal tunnel in both wrists, he injured only his right wrist in service, rendering the in-service injury of his carpal tunnel a less likely etiology. Furthermore, it was noted that the Veteran's risk factors for carpal tunnel include obesity, history of computer and clerical work, and hypertension. The examiner referenced documentation from the American Association of Orthopedic Surgeons in formulating her opinion. Pursuant to November 2020 Board remand instructions, further development was conducted in the form of a December 2020 addendum opinion addressing the question of aggravation of the Veteran's carpal tunnel by his cervical or wrist strain. The examiner opined that it is less likely than not that the Veteran's bilateral carpal tunnel syndrome was caused by or otherwise related to his period of active service, to include injuries to his neck and right wrist. After reiterating the definition and risk factors of carpal tunnel syndrome, the examiner reasoned that there is no mechanism by which cervical spine conditions or injuries would or could contribute to the focal and localized wrist compression that characterizes carpal tunnel syndrome. Furthermore, the examiner noted that there is no radiographic evidence of bony deformity or nonvascular soft tissue calcifications to support a chronic inflammatory condition in the wrist related to military service. The examiner also indicated that the Veteran's acute right wrist injury in service had resolved prior to separation in 1988, as well as prior to the development of carpal tunnel, diagnosed in 2013 nearly 30 years later. Finally, the examiner reasoned that the bilateral nature of Veteran's carpal tunnel syndrome negates a unilateral injury or trauma as a likely etiology of his carpal tunnel, but rather, supports systemic or occupational use (i.e., accountant/computer based work) as an underlying cause. The December 2020 examiner also opined that it is less likely than not that the Veteran's bilateral carpal tunnel was caused by his service-connected cervical spine strain. It was reasoned that local compression of the median nerve at the wrist is required for the diagnosis of carpal tunnel, and a cervical strain of the neck does not cause or contribute to local nerve compression within the wrist or the carpal tunnel. Finally, the examiner also reasoned it is less likely than not that Veteran's bilateral carpal tunnel was aggravated by his service-connected cervical spine strain. The examiner reasoned that compression of the median nerve within the carpal tunnel of the wrists can only be caused by structures in proximity to the wrist/carpal tunnel. Further, it was noted that there is no physiologic mechanism by which strained muscles along the cervical spine would or could directly compress the median nerve within the wrists, and as such, a worsening of carpal tunnel from a cervical strain is not medically viable. There are no competent medical opinions to the contrary. While the Veteran's arguments have focused on entitlement to service connection secondary to a service-connected disability, the Board will address direct service connection to cover all theories of entitlement. To establish service connection for a claimed disability on a direct basis, there must be evidence of a current disability, an in-service incurrence or aggravation of a disease or injury, and a nexus between the two. See Shedden, 381 F.3d at 1167. The first Shedden element has been met as there is a current diagnosed bilateral carpal tunnel disability. The second Shedden element is also met, as there is an in-service incident involving injury to the Veteran's right wrist, as well as testimony by the Veteran that he strained his wrists by engaging in significant typing and other strenuous clerical duties in service. The question for the Board, then, is whether there is a nexus between the current diagnosis and the in-service incurrence. The Board finds that the competent medical evidence does not reach this threshold, and the claim thus fails on Shedden element three. In this regard, the Board notes that review of the Veteran's service records shows that the separation examination of May 1988 clinically evaluated the Veteran's upper extremities and neurologic system as normal. It was not until an April 2014 EMG test that the Veteran was diagnosed with carpal tunnel syndrome bilaterally, over 26 years after separation from service. In addition, as previously noted, both the October 2018 and December 2020 VA examiners opined that the Veteran's bilateral carpal tunnel is less likely than not incurred in or caused by an in-service injury, event, or illness. In reaching these conclusions, the VA examiners reviewed the Veteran's complete claims file, including his STRs and subsequent treatment. The Veteran has not advanced a competent argument as to why the VA examiner's opinions are inadequate or incorrect, and there is no contrary competent medical opinion of record. Furthermore, review of the Veteran's post service treatment records does not suggest an onset in service or near the time of separation. The Board acknowledges that the Veteran's carpal tunnel syndrome has been described as severe and longstanding, but there is simply no contemporaneous evidence or sufficient evidence of chronicity to alter the weight of the evidence in favor of granting the claim. The Board acknowledges that a layman is competent to report what he or she experiences through one of the senses. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Under certain circumstances, a lay person is competent to identify a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In the instant case, there are no Jandreau exceptions regarding the Veteran's contentions concerning his carpal tunnel syndrome. While competent to report problems with his wrists, the Veteran is not competent to associate these symptoms with a particular underlying disability. That is, the Veteran's carpal tunnel syndrome is not a simple medical condition he is competent to identify or relate to another disability or to service. As such, the Board finds that the weight of the evidence demonstrates that symptoms of carpal tunnel syndrome have not been continuous since service separation in May 1988. Similarly, the Board finds that the evidence does not show that the carpal tunnel syndrome manifested to a compensable degree (i.e., at least 10 percent) within one year of service separation. As previously discussed, the evidence of record demonstrates that carpal tunnel syndrome was diagnosed approximately 26 years after service separation. As such, presumptive service connection under 38 C.F.R. § 3.309(a) does not apply. Probative value is given to the opinions of the October 2018 and December 2020 VA examiners because they were based on a review of the record and consideration of the disability. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("[M]ost of the probative value of a medical opinion comes from its reasoning" and the Board "must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion."). There are no competent opinions of record indicating a relationship between the bilateral carpal tunnel syndrome and the Veteran's service or a service-connected disability. For these reasons, the Board finds that the preponderance of the lay and medical evidence that is of record weighs against the claim of service connection for bilateral upper extremity carpal tunnel syndrome, both as secondary to service connected disabilities, and directly incurred in service and presumptively as a chronic disease. The preponderance of the evidence is against all the theories of the claim; therefore, the benefit of the doubt doctrine does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The claim must be denied. Increased Rating A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as staged ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 3. Entitlement to disability rating in excess of 30 percent prior to August 20, 2019, for service-connected major depressive and anxiety disorders 4. Entitlement to disability rating in excess of 50 percent from August 20, 2019, for service-connected major depressive and anxiety disorders The Veteran seeks a higher rating for his service-connected major depressive disorder and anxiety. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-18 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 50 percent or higher for the period prior to August 20, 2019, and the level of impairment required for a disability rating of 70 percent or higher thereafter. The Board concludes that the Veteran's symptoms did not cause the level of impairment required for higher disability ratings during either appellate period. The General Rating Formula provides that a 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. The Veteran was afforded a VA examination in January 2015 to assess the nature and etiology of his psychiatric disability. The Veteran was diagnosed with panic disorder with features of anxiety and depression that was noted to be productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. His symptoms were noted to include depressed mood; anxiety; panic attacks that occur weekly or less often; and chronic sleep impairment. In terms of behavioral observations, the examiner's evaluation was largely normal, including but not limited to grooming, dress, engagement, eye contact, speech, thought form, thought content, mood, orientation, attention, concentration, comprehension, judgment, insight and perception. Nonetheless, the Veteran appeared somewhat nervous and guarded at times; and he expressed his belief that compared to same-aged peers that his memory is okay for his age which testing corroborated though his children tell him that he forgets things like names too much. In March 2015, the Veteran underwent a private evaluation by a licensed psychologist, who diagnosed depression and anxiety. It was noted that the Veteran suffers from the classic symptoms of depression, panic disorder and anxiety per the DSM-5. An August 2019 private disability benefits questionnaire was associated with the record in November 2019. The examiner indicated that the Veteran's records were reviewed, and he was assessed through video telehealth interview. The Veteran was noted to have diagnoses of major depressive disorder and generalized anxiety disorder. The Veteran reported work performance deficiencies, fear of job loss and decline in social interactions. The Veteran's psychological disability was assessed to be productive of occupational and social impairment with reduced reliability and productivity. His symptoms were noted to include depressed mood; anxiety; panic attacks more than once a week; mild memory loss, such as forgetting names, directions or recent events; disturbances of motivation and mood; and difficulty establishing and maintaining effective work and social relationships. Other symptoms included reduced activity; social withdrawal; irritability; fatigue; reduced concentration; reduced self-confidence; feelings of inadequacy; less interest in sex; relationship problems; helplessness; hopelessness; medication abuse; persistent guilt/shame; loss of employment opportunities; reduced reliability, productivity and drive. The Veteran was afforded another VA examination in March 2020. At that time, his diagnosis was confirmed as major depressive disorder with anxiety. The Veteran's psychological disability was assessed to be productive of occupational and social impairment with reduced reliability and productivity. His symptoms were noted to include depressed mood; anxiety; panic attacks more than once a week; chronic sleep impairment; disturbances of motivation and mood; and difficulty establishing and maintaining effective work and social relationships. In terms of behavioral observations, the examiner noted the Veteran appeared casually dressed and appropriately groomed; maintained appropriate eye contact and was cooperative and pleasant while being engaged in the interview; speech appeared at a normal rate, rhythm and volume; mood was anxious and affect was congruent and appropriate to the situation and discussion. The Veteran was afforded a hearing before the undersigned in April 2018. He testified that he has day to day problems with his anxiety, including consulting and traveling. He also noted having less of a social life, avoiding crowds, and generally avoiding certain interactions. For the period prior to August 20, 2019, the Board finds that the VA and private treatment records, the January 2015 VA examination, and the Veteran's lay statements all show that the Veteran's acquired psychiatric disability was manifested by symptoms associated with a 30 percent rating: weekly panic attacks, anxiety, chronic sleep impairment. The Veteran experienced occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but was generally functioning satisfactorily, with routine behavior, self-care, and normal conversation. Mental status examinations in VA and private treatment records and the January 2015 VA examination confirmed the aforementioned level of impairment, consistent with a 30 percent disability rating. Within this appellate period, review of the relevant medical record does not show the Veteran had such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; or difficulty in establishing and maintaining effective work and social relationships productive of occupational and social impairment with reduced reliability and productivity. The evidence overall does not demonstrate the level of impairment associated with a 50 percent rating for the period prior to August 20, 2019. The Veteran's symptoms were either contemplated by or more consistent with a 30 percent rating. While an October 2013 mental health treatment note indicates that the Veteran was not working at the time due to anxiety, a September 2014 treatment note shows he got a new work contract, and a January 2015 note reflects that the Veteran reported his work was going fine indicative that he was generally performing well at work. For the period from August 20, 2019, the Board concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 70 percent or higher. The Veteran's symptoms more closely approximated the symptoms associated with a 50 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating. VA and private treatment records, the March 2020 VA examination, and the Veteran's lay statements show that the Veteran's acquired psychiatric disability was manifested by symptoms associated with a 50 percent rating (panic attacks more than once per week, disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships). He also had symptoms that are not listed with a specific rating, such as reduced activity; social withdrawal; irritability; fatigue; reduced concentration; reduced self-confidence; feelings of inadequacy; less interest in sex; relationship problems; helplessness; hopelessness; medication abuse; persistent guilt/shame; loss of employment opportunities; reduced reliability, productivity and drive. The Board finds the level of impairment caused by these symptoms more closely approximates occupational and social impairment with reduced reliability and productivitythe level associated with a 50 percent rating. Mental status examinations in VA and private treatment records, including the August 2019 private disability benefits questionnaire and the March 2020 VA examination, indicate that the Veteran had the level of impairment contemplated by the 50 percent evaluation. Indeed, both the private DBQ and the VA examination are consistent in the assessment that the Veteran's psychiatric disability is productive of occupational and social impairment with reduced reliability and productivity. The evidence overall does not demonstrate the level of impairment associated with a 70 percent rating. As noted above, the Veteran's symptoms are more consistent with a 50 percent rating. While the August 2019 private examiner noted that the Veteran's psychiatric disability can impact his work, including reduced employment opportunities, the same provider noted the Veteran was currently working full time as an accountant, has held the same job for two years, and has never been fired or suspended. Further, review of the record does not indicate, nor does the Veteran testify that he has suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. In fact, suicidal ideation was explicitly denied, and no provider, VA or private, has identified obsessional rituals, speech problems, near-continuous panic, spatial disorientation, neglect of appearance or spatial disorientation of any kind. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran's symptoms resulted in the level of impairment required for a 50 percent rating for the period prior to August 20, 2019, nor did they result in a level of impairment warranting a 70 percent or higher rating thereafter. The appeal must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Comninos, Georgio 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.