Citation Nr: 21040152 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 14-41 086A DATE: July 2, 2021 ORDER Entitlement to service connection for peripheral neuropathy of the bilateral upper extremities is denied. REMANDED This issue of entitlement to service connection for chronic obstructive pulmonary disease (COPD) is remanded. This issue of entitlement to service connection for hypertension is remanded. The issue of entitlement to service connection for venous insufficiency is remanded. This issue of entitlement to service connection for anxiety disorder, to include for purposes of receiving Department of Veterans Affairs (VA) health care benefits under 38 U.S.C. Chapter 17, is remanded. This issue of entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDING OF FACT The Veteran is not shown to have a current diagnosis of peripheral neuropathy of the right or left upper extremities. CONCLUSION OF LAW The criteria for entitlement to service connection for peripheral neuropathy of the bilateral upper extremities, including residuals thereof, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran, who is the appellant in this case, served on active duty from May 1969 to August 1971, to include service in the Republic of Vietnam, with a discharge characterized as under honorable conditions. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2012 rating decision of a Department of Veterans' Affairs (VA) Regional Office, the agency of original jurisdiction (AOJ). In January 2018, the Veteran and his spouse testified during a video-conference hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record and has been reviewed. In June 2018, the Board remanded the Veteran's claims for service connection for bilateral hearing loss, COPD, venous insufficiency, hypertension, peripheral neuropathy of the bilateral upper and lower extremities, and anxiety disorder to afford the Veteran new VA examinations to determine the likely etiology of these disabilities. The Board deferred adjudication of the claim for entitlement to a TDIU pending development of the service connection claims on remand. Subsequent to the remand, the RO granted service connection in June 2019 for bilateral hearing loss and diabetic peripheral neuropathy of the right and left lower extremities, which is considered a full grant of the benefits on appeal for those claims. As such, these issues are no longer before the Board for appellate consideration. A.B. v. Brown, 6 Vet. App. 35 (1993). The examination reports and opinions requested by the Board in its June 2018 remand are of record and have been reviewed. The Board finds substantial compliance with its remand directives regarding the Veteran's claim for service connection for peripheral neuropathy of the bilateral upper extremities. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). However, as detailed in the remand section below, the Board finds that there has not been substantial compliance with its June 2018 remand directives regarding the service connection claims for COPD, venous insufficiency, hypertension, peripheral neuropathy of the bilateral upper extremities, and anxiety disorder. Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order). The Board notes that since the issuance of the August 2020 Supplemental Statement of the Case, additional evidence has been associated with the Veteran's electronic claims file, specifically VA treatment records. Having reviewed this evidence, the Board finds such evidence to be cumulative and redundant of previously submitted evidence regarding the issue of entitlement to service connection for peripheral neuropathy of the bilateral upper extremities, and, as such, a waiver of initial AOJ consideration of the evidence is not necessary. See 38 C.F.R. § 20.1305(c) (2020). Preliminary Matter 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 Veteran 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 Applicable Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed aggravation of a disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Generally, the degree of probative value which may be attributed to a medical opinion of record takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Also significant is whether the examiner had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). A Veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). Peripheral Neuropathy of the Bilateral Upper Extremities At the outset, the Board must determine whether the Veteran meets the criteria for the threshold element of a current disability. In other words, the Board must determine if the Veteran has been diagnosed with peripheral neuropathy of the upper extremities since the date of claim. See Shedden, 381 F.3d at 1167. The Board notes that the Veteran's service treatment records are silent as to symptoms, treatment, or diagnosis of peripheral neuropathy of the upper extremities. The post-service private and VA treatment records reference numbness and burning, polyneuropathy, and peripheral neuropathy of the lower extremities, including as due to diabetes mellitus. Private treatment records reflect neck and back injuries from a May 2008 vehicle accident and the Veteran's endorsement of numbness and tingling in his hands a week later. However, the treatment records do not attribute these symptoms, which were noted in the context of the Veteran's 2008 vehicle accident, to the Veteran's military service or diabetes mellitus. Furthermore, such symptoms and/or diagnosis of upper extremity peripheral neuropathy are not reflected in treatment records or VA examinations during the current claim period. The Veteran was afforded a VA general medical examination in February 2011, during which the Veteran endorsed paresthesias and loss of sensation of the bilateral lower extremities. See VA general medical examination dated February 16, 2011. During a February 2012 outpatient appointment with his treating doctor W.J.C., it was noted that the Veteran had uncontrolled Type II diabetes mellitus; however, he denied neurologic symptoms including tinging and numbness. During the January 2018 Board hearing, the Veteran said he experienced neuropathy in both arms and indicated that he was formally diagnosed as such in 2014 by his doctor, W.J.C. However, as noted above, the post-service treatment records, including those of Doctor W.J.C., generally reference peripheral neuropathy and reflect specific diagnoses of lower extremity peripheral neuropathy, but not upper extremity peripheral neuropathy. The Veteran underwent a VA examination in April 2019 at which time the VA examiner rendered diagnoses of diabetic sensory peripheral neuropathy of the right and left lower extremities based on the Veteran's lay description of symptoms, testing of muscle strength, reflexes, and sensory perception testing. The examiner opined that the Veteran's lower extremity neuropathy was likely due to his service-connected diabetes mellitus. Notably, the examination report reflects that the Veteran endorsed lower extremity neuropathy symptoms, but denied pain, paresthesias, dysesthesias, and numbness of the upper extremities, and diagnostic testing was also negative for upper extremity symptoms. The VA examiner diagnosed only diabetic sensory peripheral neuropathy of the lower extremities. See VA examination dated April 23, 2019. Thus, the Veteran's assertions in support of his claim are inconsistent with objective evidence of record. Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (Board decision properly assigned more probative value to a private hospital record that included lay history that was made for treatment purposes than to subsequent statements made for compensation purposes). In the absence of a diagnosed current disability, it follows that service connection for peripheral neuropathy of the bilateral upper extremities cannot be granted as the threshold element of the claim has not been met. Shedden, supra. In analyzing this claim, the Board also considered the Veteran's claim as to a current disability. While the Veteran may genuinely believe that he has peripheral neuropathy of the bilateral upper extremities, the Board finds that the question as to whether the Veteran has peripheral neuropathy requires substantiation through diagnostic findings, requiring specialized training for a determination, and is not susceptible of lay opinion. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). There being no competent evidence that the Veteran has been diagnosed with the claimed disability, analysis of the remaining elements of a service connection claim is unnecessary. Based on this body of evidence, the appeal must be denied. In reaching this determination, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application here. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Although the Board regrets the additional delay, a remand is again necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38C.F.R. § 3.159(c) (2020). Once VA undertakes the effort to provide an examination or medical opinion when developing a service-connection claim, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr, 21 Vet. App. at 312. COPD In its June 2018 remand, the Board requested an opinion as to the etiology of the Veteran's COPD, to include as to whether it was caused by his in-service exposure to gas and chemical fumes as an automobile mechanic for the Marine Corps, or caused or worsened by his service-connected diabetes mellitus. Three separate opinions were obtained. The first one, dated April 2019, concludes that the Veteran's COPD was not related to exposure to contaminants in southwest Asia. As the record does not reflect that the Veteran had service in southwest Asia, the April 2019 VA opinion is of no probative value. Second, in July 2020, the same VA examiner declared prior private medical opinions in error, emphasized that there are "no significant medical articles" that indicate that Type II diabetes mellitus causes COPD, and opined, "I have worked in respiratory medicine for 15 years and I have found that there is no evidence that COPD is at least as likely as not caused by or aggravated by [Type II diabetes mellitus]." See VA medical opinion dated July 16, 2020. The VA examiner's statement is not found to constitute an adequate rationale, as the rationale provided amounts to little more than "I've come to this conclusion; trust me, I'm an expert." See Nieves-Rodriguez, 22 Vet. App. at 304 (noting that most of the probative value of a medical opinion comes from its reasoning and that it must be clear that the medical expert applied valid medical analysis to the significant facts of a particular case). To be clear, the record does not reflect that this examiner is an expert or that he possesses the universe of knowledge as to possible COPD etiologies. For the foregoing reasons the July 16, 2020 VA opinion is inadequate. Third, the same VA examiner again opined in July 2020 that "There is not a good temporal relationship between onset of his current COPD diagnosis and military exposure to gas and fumes." See VA medical opinion dated July 28, 2020. A "good temporal relationship" is not the standard by which service connection is granted. The posited correlation or etiology need only be an "as likely as not" possibility. Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (indicating a "definite" or "obvious" etiology is not a condition precedent to granting service connection). Additionally, the examiner emphasized that the record includes "no nexus letter of support from a medical provider indicating a relationship between his military service and later onset of COPD." See VA medical opinion dated July 28, 2020. Applicable law does not require a threshold showing of a nexus upon which a favorable VA opinion must rest. If such were required, the need for an opinion from a VA examiner would not be necessary. For these reasons the July 28, 2020 VA opinion is inadequate. Barr, supra. Accordingly, remand is necessary to obtain an adequate opinion addressing the etiology of the Veteran's COPD. Stegall, supra. Hypertension In its June 2018 remand, the Board requested an opinion as to the etiology of the Veteran's hypertension, specifically whether it was caused or worsened beyond normal progression by his service-connected diabetes mellitus. Two separate opinions were obtained from the same VA examiner. In an April 2019 opinion, the VA examiner declared: "By his own admission, the veteran's [hypertension] began before his [Type II diabetes mellitus]. Therefore, [Type II diabetes mellitus] could not be the cause of his [hypertension]. The Veteran's [hypertension] is most likely due to ... morbid obesity." See VA medical opinion dated April 23, 2019. It has not been shown that the Veteran is competent to determine the onset of hypertension. Moreover, the VA examiner has not indicated whether such onset is reflected in the treatment records, which is suggestive that the VA examiner's review of the claims file was cursory at best. See Nieves-Rodriguez, supra. As such, the April 23, 2019 VA opinion is inadequate. Barr, supra. In August 2019, the same VA examiner again reiterated his April 2019 opinion that the Veteran's hypertension was not caused by his diabetes mellitus, declaring, in part: "If this Veteran was not obese, he would not have [Type II diabetes mellitus] or [hypertension]. Because his [Type II diabetes mellitus] did not cause obesity, his [Type II diabetes mellitus] could not be a substantial factor in causing [hypertension]." See VA medical opinion dated August 5, 2019. While the VA examiner was requested to consider evidence suggesting that the Veteran's hypertension may be related to his obesity, the examiner addressed whether the Veteran's diabetes mellitus aggravated his weight, not whether his diabetes aggravated his hypertension, the question posed by the Board. See Stegall, supra; El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (holding that an opinion will be considered inadequate unless it addresses both the caused by and aggravation avenues for secondary service-connection under 38 C.F.R. § 3.310(b)). The Board cannot rely on a negative VA opinion that does not provide the requested information. For these reasons the August 5, 2019 VA opinion is inadequate. Barr, supra. Accordingly, remand is necessary to obtain an adequate opinion addressing the etiology of the Veteran's hypertension. Stegall, supra. Venous Insufficiency In its June 2018 remand, the Board requested an opinion as to the etiology of the Veteran's venous insufficiency, to include whether it was caused or worsened beyond normal progression by his service-connected diabetes mellitus. Two separate opinions were obtained from the same VA examiner. In an April 2019 opinion, the VA examiner opined: "Although [Type II diabetes mellitus] does affect the arterial vascular system, it is not common for [diabetes mellitus] to affect the venous vascular system." See VA medical opinion dated April 23, 2019. In essence, the VA examiner concluded that it is possible that diabetes mellitus may cause venous insufficiency. Conjectural or speculative opinions which suggest no more than some remote possibility of an etiological relationship are afforded little probative value. 38 C.F.R. § 3.102; Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992). Accordingly, the April 23, 2019 opinion is inadequate. Barr, supra. In July 2020, the same VA examiner concluded that the Veteran's obesity aggravated his venous insufficiency, but emphasized that "because his [obesity] is not due to [Type II diabetes mellitus], his venous insufficiency is not aggravated due to [Type II diabetes mellitus]." See VA medical opinion dated July 16, 2020. The entire opinion hinges on the examiner's finding that the Veteran developed obesity prior to the onset of diabetes, i.e. "obesity came first." Id. However, March 2012 correspondence from the Veteran's treating doctor notes that the Veteran's "diabetes mellitus has contributed to [the Veteran]'s weight gain[.]" See Correspondence from W.J.C., D.O. dated March 13, 2012. While the Veteran may have gained weight prior to the onset of symptoms of venous insufficiency, W.J.C.'s correspondence indicates that the Veteran continued to gain weight after the onset of diabetes, and the VA examiner failed to consider the Veteran's post-diabetes weight gain in his opinion in the context of the Veteran's development of venous insufficiency. Furthermore, the examiner did not reconcile his July 2020 opinion with his April 2019 opinion in which he acknowledged the possibility that diabetes mellitus may cause venous insufficiency. See Nieves-Rodriguez, supra. For these reasons the July 2020 VA opinion is inadequate. Barr, supra. Accordingly, remand is necessary to obtain an adequate opinion addressing the etiology of the Veteran's venous insufficiency. Stegall, supra. Anxiety Disorder In its June 2018 remand, the Board requested that a VA examiner determine the nature and etiology of the Veteran's anxiety disorder. However, the VA mental disorders examination received by VA in April 2019 appears to be incomplete and reflects neither the name nor the professional credentials of the examiner. See VA mental disorders examination received April 22, 2019. Furthermore, the examiner diagnosed "Specific Phobia Disorder" and ruled out generalized anxiety disorder. The examiner opined that the "Veteran's diagnosis of Specific Phobia Disorder is unlikely (less than 50%) to be caused by, incurred in, secondary to or permanently aggravated by his military service." Id. at pg. 1. However, the examiner provided no rationale for the opinion. See Nieves-Rodriguez, supra. Furthermore, the examiner did not reconcile the examination findings with the March 2012 correspondence from the Veteran's doctor, W.J.C., D.O., which reflects that the Veteran was diagnosed with "severe anxiety." Id. Notably, recent private treatment notes reflect a diagnosis of generalized anxiety disorder. See Private treatment notes dated April 24, 2020 from M.M., M.D. For these reasons the April 2019 VA mental disorders examination and opinion are inadequate. Barr, supra. Accordingly, remand is necessary to obtain an adequate opinion addressing the nature and etiology of the Veteran's anxiety disorder, and to ensure that the complete April 2019 VA mental disorders examination is associated with the Veteran's claims file or, if the complete report is unavailable, that the Veteran is afforded a new VA mental disorders examination. Stegall, supra. TDIU The Board finds that the issue of entitlement to a TDIU is inextricably intertwined with the above development such that a decision on the claim for a TDIU would be premature. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined). The claim of entitlement to a TDIU is therefore also remanded pending resolution of the intertwined claims. The matters are REMANDED for the following action: 1. Ensure that all outstanding VA treatment records are associated with the claims file. 2. Associate with the Veteran's electronic claims file the complete VA mental disorders examination report dated April 22, 2019. At present, an incomplete copy of the examination report is of record (see VBMS entry with document type "VA Examination," receipt date 04/21/2019). If the complete examination report is unavailable, ensure that the Veteran is provided with a new VA mental disorders examination in association with the Board's request for an etiology opinion specified under Number 6, below. 3. Then, obtain an opinion as to the nature and etiology of the Veteran's COPD with an appropriately qualified VA physician (M.D.). The claims file, and a copy of this Remand, must be made available to and be reviewed by the examiner. The examiner's review of the body of this Remand is recommended to assist in avoiding errors that have rendered the previous VA opinions inadequate. * The need for another examination(s) is left to the discretion of the medical professional offering the opinion. Should an examination(s) be necessary, all indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a complete review of the claims file, the examiner shall: (a) Provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's COPD began in service, was caused by service, or is otherwise related to service, including reported exposure to gas and chemical fumes during service. *Reconcile the opinion with the Veteran's Military Occupational Specialty (MOS) as an automobile mechanic. (b) Provide a medical opinion as to whether it is at least as likely as not (50 percent probability or greater) that COPD was: (i) caused by service-connected diabetes mellitus; or, (ii) aggravated beyond the normal progression as a result of the Veteran's service-connected diabetes mellitus. * Any increase/aggravation is sufficient, permanent aggravation is NOT required. See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019) (permanent worsening is not a requirement for secondary service connection of a non-service-connected injury or disease). In making this determination, the examiner should consider the December 2010 and January 2011private opinions from W.J.C., D.O. that COPD is secondary to diabetes and the Veteran's lay statements. A rationale for all opinions expressed should be provided. * The examiner shall identify all occupational impairment due to the Veteran's COPD. * The examiner shall define any abbreviations used in the opinion(s). A rationale for all opinions expressed should be provided. 4. Obtain an opinion as to the nature and etiology of the Veteran's venous insufficiency with an appropriately qualified VA physician (M.D.). The claims file, and a copy of this Remand, must be made available to and be reviewed by the examiner. The examiner's review of the body of this Remand is recommended to assist in avoiding errors that have rendered the previous VA opinions inadequate. * The need for another examination(s) is left to the discretion of the medical professional offering the opinion. Should an examination(s) be necessary, all indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a complete review of the claims file, the examiner shall: (a) Provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that any current venous insufficiency began in service, was caused by service, or is otherwise related to service. (b) Provide a medical opinion as to whether it is at least as likely as not (50 percent probability or greater) that venous insufficiency was: (i) caused by service-connected diabetes mellitus; or, (ii) aggravated beyond the normal progression as a result of the Veteran's service-connected diabetes mellitus. * Any increase/aggravation is sufficient, permanent aggravation is NOT required. See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019) (permanent worsening is not a requirement for secondary service connection of a non-service-connected injury or disease). In making this determination, the examiner should consider the January 2011 private opinion from W.J.C., D.O. that venous insufficiency was secondary to diabetes and the Veteran's lay statements. * The examiner shall identify all occupational impairment due to the Veteran's venous insufficiency. * The examiner shall define any abbreviations used in the opinion(s). A rationale for all opinions expressed should be provided. 5. Obtain an opinion as to the nature and etiology of the Veteran's hypertension with an appropriately qualified VA physician (M.D.). The claims file, and a copy of this Remand, must be made available to and be reviewed by the examiner. The examiner's review of the body of this Remand is recommended to assist in avoiding errors that have rendered the previous VA opinions inadequate. * The need for another examination(s) is left to the discretion of the medical professional offering the opinion. Should an examination(s) be necessary, all indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a complete review of the claims file, the examiner shall: (a) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that hypertension was (a) caused by service-connected diabetes mellitus; or, (b) aggravated beyond the normal progression as a result of service-connected diabetes mellitus. * Any increase/aggravation is sufficient, permanent aggravation is NOT required. See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019) (permanent worsening is not a requirement for secondary service connection of a non-service-connected injury or disease). In making this determination, the examiner is asked to consider the February 2011 VA diabetes examination report, March 2012 medical opinion, and the private statements from W.J.C., D.O. on the relationship between hypertension and diabetes. * The examiner shall identify any occupational impairment due to the Veteran's hypertension. * The examiner shall define any abbreviations used in the opinion(s). A rationale for all opinions expressed should be provided. 6. Obtain an opinion as to the nature and etiology of the Veteran's anxiety disorder with a VA psychiatrist or psychologist, preferably the same practitioner who completed the April 22, 2019 VA mental disorders examination. The claims file, and a copy of this Remand, must be made available to and be reviewed by the examiner. The examiner's review of the body of this Remand is recommended to assist in avoiding errors that have rendered the previous VA opinions inadequate. * The need for another examination(s) is left to the discretion of the medical professional offering the opinion. Should an examination(s) be necessary, all indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a complete review of the claims file, the examiner shall: (a) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's anxiety disorder arose during his Vietnam service or is otherwise related to service. * The examiner shall identify any occupational impairment due to the Veteran's anxiety disorder. A rationale for all opinions expressed should be provided. 7. Thereafter, ensure that the examiners have substantially responded to the questions posed by the Board, and if not, take corrective action. 8. Then, readjudicate the remanded claims. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Farrell, 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.