Citation Nr: 21041649 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 18-22 001 DATE: July 9, 2021 ORDER Service connection for fibromyalgia is granted. REMANDED Entitlement to service connection for chronic fatigue syndrome, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for obstructive sleep apnea, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for a gastrointestinal disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for headaches, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for a respiratory disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for a left shoulder disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for a right shoulder disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for a left elbow disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for a right elbow disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for a left knee disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for a right knee disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for a left eye disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for a right eye disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. Entitlement to an initial disability rating greater than 50 percent for service-connected other specified trauma and stressor related disorder, claimed as posttraumatic stress disorder (PTSD) with dreams, sleep disturbances, cognitive dysfunction, memory loss, poor concentration, focus and mood problems, is remanded. Entitlement to an initial disability rating greater than 10 percent for service-connected right carpal tunnel, claimed as bilateral wrist condition and right arm nerve, is remanded. FINDING OF FACT The Veteran is a Persian Gulf Veteran, and the evidence is at least in equipoise as to whether he has fibromyalgia manifested to a compensable degree. CONCLUSION OF LAW The criteria for service connection for fibromyalgia have been met. 38 U.S.C. §§ 1110, 1117; 38 C.F.R. §§ 3.102, 3.303, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1986 to August 1991. This case is before the Board of Veterans' Appeals (Board) on appeal from a February 2016 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in Winston-Salem, North Carolina. The Veteran's notice of disagreement was received in November 2016. The RO issued a Statement of the Case in March 2018. The Veteran's Appeal To Board Of Veterans' Appeals (VA Form 9) was received in April 2018. In April 2021, the Veteran testified at a Board hearing over which the undersigned Veterans Law Judge presided. A transcript of the testimony is of record. 1. Entitlement to service connection for fibromyalgia. The Veteran asserts that he has fibromyalgia that is manifested as a result of his period of active service. During the April 2021 Board hearing, he explained that he had been diagnosed with fibromyalgia in 2016, and that exposure to certain elements during his service in the Southwest Asia Theater of Operations resulted in his current symptoms. The Veteran served in the Southwest Asia theater of operations during the Persian Gulf War and is a Persian Gulf Veteran. 38 C.F.R. § 3.317(e). Service connection can be established for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021; and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). A "qualifying chronic disability" includes an undiagnosed illness or a medically unexplained chronic multi symptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders. 38 C.F.R. § 3.317(a)(2)(i). A VA outpatient treatment record dated in February 2015 shows that the Veteran was shown to be experiencing fibromyalgia type pain. However, a diagnosis was not provided. A VA examination report dated in February 2016 shows that a VA examiner opined that the Veteran did not have a diagnosis fibromyalgia, but rather his reported symptoms of joint pain were associated with individual conditions, and that he did not meet the clinical criteria for a fibromyalgia diagnosis. A private medical record from Physicians East, P.A., dated in April 2016, shows that the Veteran was said to have progressively more noticeable symptoms of fibromyalgia. In June 2016, he was given an impression of fibromyalgia, and it was indicated that the Veteran's symptoms were responding to medication. Later in June 2016, he was given an assessment of fibromyalgia/polyarthralgias. In summary, the Veteran had a cluster of symptoms early on that did not meet the criteria for a diagnosis of fibromyalgia, but they ultimately progressed to the point of a diagnosis in 2016. The evidence suggests constant or nearly constant signs or symptoms attributable to fibromyalgia. The medical records include a diagnosis of fibromyalgia and note the use of medications for the diagnosed disability. In light of the foregoing, the evidence is at the very least in relative equipoise as to whether the Veteran has a current diagnosis of fibromyalgia manifested to a compensable degree. See 38 C.F.R. §§ 3.317, 4.71a, Diagnostic Code 5025. Resolving reasonable doubt in the Veteran's favor, service connection for fibromyalgia is warranted. See 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for chronic fatigue syndrome, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 2. Entitlement to service connection for obstructive sleep apnea, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. The Veteran asserts that he had the onset of chronic fatigue syndrome and obstructive sleep apnea during active service. During the April 2021 Board hearing, he endorsed that he had been having unexplained fatigue ever since his period of active service. He added that he had been exposed to open burn pits during service that resulted in his inhaling certain toxins that resulted in respiratory difficulties and snoring. A VA outpatient treatment record dated in April 2015 shows that the Veteran was said to be experiencing chronic fatigue, achiness, and general pain, the symptoms of which overlap with depression and obstructive sleep apnea. He was said to meet the criteria for unspecified depressive disorder. A VA examination report dated in February 2016 shows that the examiner opined that the Veteran did not have a diagnosis of chronic fatigue syndrome. The examiner noted that the Veteran had not had a work-up for chronic fatigue syndrome, had not been diagnosed with chronic fatigue syndrome, and did not meet the clinical criteria for diagnosis of chronic fatigue syndrome. His fatigue was felt to be a symptom of his mental health complaints and not a separate diagnosable complaint. A private medical record from Physicians East dated in June 2015 shows that the Veteran reported a history of chronic fatigue since the 1990's. Service connection may be established on a secondary basis for a disability that 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 (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). VA will not concede aggravation unless a baseline for the claimed disability can be established with evidence created prior to any aggravation. 38 C.F.R. § 3.310(b). In light of the foregoing, it remains unclear, whether the Veteran, in fact, has a diagnosis of chronic fatigue syndrome and/or obstructive sleep apnea, in addition to his service-connected psychiatric disorder, and if so, which symptoms are attributed to which diagnosis. As such, the Board finds that an additional development is required to clarify whether the Veteran has more than one diagnosed disorder, and if so, whether the respective symptoms may be differentiated. See Mittleider v. West, 11 Vet. App. 181, 182 (1998); Waddell v. Brown, 5 Vet. App. 454, 456-57 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 3. Entitlement to service connection for a gastrointestinal disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. The Veteran seeks service connection for diverticulitis, as well as irritable bowel syndrome. During his April 2021 Board hearing he testified that his symptoms have manifested as a result of exposure to environmental toxins in the Southwest Asia Theater of Operations. He also attributed his symptoms to an episode of food poisoning experienced during active service. The Veteran's service treatment records confirm that in September 1987 he was treated for food poisoning. Following service, VA and private outpatient treatment records show that the Veteran has been variously diagnosed with rectal bleeding, generalized abdominal pain, gastroesophageal reflux disease, fatty liver disease, and diverticulitis. The February 2016 VA examiner stated that the Veteran had a diagnosis of diverticulitis, but opined that it was unrelated to active service. The examiner, however, did not address any of the other diagnosed gastrointestinal disorders of the Veteran, nor any potential relationship to the in-service food poisoning experienced by the Veteran. As such, an additional opinion must be obtained. When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin, 1 Vet. App. at 175; Hatlestad, 3 Vet. App. at 216; see also Barr, 21 Vet. App. at 311. 4. Entitlement to service connection for headaches, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. 5. Entitlement to service connection for a respiratory disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. The Veteran seeks service connection for headaches and a respiratory disability. During the April 2021 Board hearing he testified that he began having symptoms during service, and that they were manifested by head pain, sinus congestion, rhinitis, and breathing difficulties. He attributed his symptoms to exposure to open burn pits and to asbestos. The Veteran's service treatment records reveal that in February 1987, he was treated for reported headache associated with sinusitis versus strep. In February 1991, he was treated for a three-week history of runny nose with headache. The assessment was upper respiratory infection. Following service, he has been intermittently treated for headaches, bronchitis, rhinitis, and pneumonia. The Veteran has not yet undergone a VA examination so as to determine whether he has a headache and/or respiratory disability as a result of his period of active service. As such, he should be afforded a VA examination to assess the current nature and etiology of his asserted disabilities. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 (c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). 6. Entitlement to service connection for a left shoulder disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 7. Entitlement to service connection for a right shoulder disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 8. Entitlement to service connection for a left elbow disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 9. Entitlement to service connection for a right elbow disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 10. Entitlement to service connection for a left knee disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 11. Entitlement to service connection for a right knee disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. The Veteran asserts that he has left and right shoulder, elbow, and knee symptoms that are manifested as a result of active service. During his April 2021 Board hearing he described that his symptoms were not the result of a particular injury, but rather, they developed over time as a result of exposure to environmental toxins in the Southwest Asia Theater of Operations. The February 2016 VA examiner stated that the asserted disabilities were unrelated to active service because they were each first manifested after separation from service. However, manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness includes muscle and joint pain. See 38 C.F.R. § 3.317 (b). Thus, the reasoning of the VA examiner does not account for the possibility that the symptoms may have developed as a manifestation of an undiagnosed illness or medically unexplained chronic multi-symptom illness. As such, an additional opinion is required. When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin, 1 Vet. App. at 175; Hatlestad, 3 Vet. App. at 216; see also Barr, 21 Vet. App. at 311. 12. Entitlement to service connection for a left eye disability. 13. Entitlement to service connection for a right eye disability. The Veteran seeks service connection for a bilateral eye disability. During the April 2021 Board hearing he testified that he began having symptoms following a fall during service wherein he sustained a head injury. He added that he gradually developed symptoms over time that his eye doctor had attributed to a possible head injury. The Veteran's service treatment records reveal that in his August 1991 separation report of medical history, he indicated that he had experienced eye trouble. The examiner elaborated that he had mild myopia (20/40) in each eye. Following service, private outpatient treatment records from East Carolina Retina Consultants show treatment for a retinal break without detachment and retinoschisis of the right eye. The Veteran has not yet undergone a VA examination so as to determine whether he has a left or right disability etiologically related to his period of active service. As such, he should be afforded a VA examination to assess the current nature and etiology of his asserted disabilities. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 (c)(4); see also McLendon, 20 Vet. App. at 79. 14. Entitlement to an initial disability rating greater than 50 percent for service-connected other specified trauma and stressor related disorder. The Veteran asserts that his service-connected psychiatric disorder is more disabling than reflected by the currently assigned 50 percent disability rating. The Veteran was most recently evaluated in a February 2018 VA examination wherein the examiner, in part, based his assessment of the Veteran's condition on his reported good relationships with his wife and children. During the April 2021 Board hearing, the Veteran indicated that his family life was not as positive as suggested and that his psychiatric symptoms had contributed to his first divorce. In light of the Veteran's assertion that the examination does not accurately reflect the extent of his symptoms, and as it has been more than three years since the most recent VA examination, the Board finds that an updated examination is warranted. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also Allday v. Brown, 7 Vet. App. 517, 526 (1995). As such, on remand, the Veteran should be afforded a new VA examination to determine the current nature and severity of his service-connected psychiatric disability. 15. Entitlement to an initial disability rating greater than 10 percent for service-connected right carpal tunnel syndrome. The Veteran asserts that his service-connected carpal tunnel syndrome is more disabling than reflected by the currently assigned 10 percent disability rating. The Veteran was most recently evaluated in a February 2016 VA examination. During the April 2021 Board hearing, the Veteran indicated that he had been experiencing increased symptoms of pain, weakened grip strength, and various neurological deficits. In light of the Veteran's assertion of an increase in the level of impairment since the most recent examination, and as it has been more than five years since the most recent VA examination, an updated examination is warranted. See Snuffer, 10 Vet. App. at 403; Allday, 7 Vet. App. at 526. As such, on remand, the Veteran should be afforded a new VA examination to determine the current nature and severity of his service-connected right carpal tunnel syndrome. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for his asserted chronic fatigue syndrome. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is requested to opine whether it is at least as likely as not that the Veteran's asserted chronic fatigue syndrome had its inception during his period of active service or is otherwise causally related to an in-service disease or injury, to include exposure to open burn pits in service? The examiner is requested to explain whether the Veteran, in fact, has a diagnosis of chronic fatigue syndrome in addition to his service-connected psychiatric disorder, and if so, which symptoms are attributed to which diagnosis. The examiner is asked to opine whether the Veteran's asserted chronic fatigue syndrome is diagnosable, but medically unexplained chronic multi-symptom illness of unknown etiology. The examiner is also requested to answer the following questions as definitively as possible: (a) Is it at least as likely as not that the Veteran's asserted chronic fatigue syndrome is caused (in whole or in part) by the service-connected psychiatric disorder, to include any medically prescribed treatment of such disability? (b) Is it at least as likely as not that the Veteran's asserted chronic fatigue syndrome is aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by the service-connected psychiatric disorder, to include any medically prescribed treatment of such disability? If the Veteran's chronic fatigue syndrome is aggravated by the service-connected psychiatric disorder, the examiner should, to the extent possible, also indicate the level of such aggravation by identifying a baseline level of disability. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. The absence of evidence of treatment for chronic fatigue syndrome in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. 2. Schedule the Veteran for a VA examination for his asserted obstructive sleep apnea. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is requested to opine whether it is at least as likely as not that the Veteran's asserted obstructive sleep apnea had its inception during his period of active service or is otherwise causally related to an in-service disease or injury, to include exposure to open burn pits in service? The examiner is requested to explain whether the Veteran, in fact, has a diagnosis of obstructive sleep apnea in addition to his service-connected psychiatric disorder, and if so, which symptoms are attributed to which diagnosis. The examiner is asked to opine whether the Veteran's asserted obstructive sleep apnea is diagnosable, but medically unexplained chronic multi-symptom illness of unknown etiology. The examiner is also requested to answer the following questions as definitively as possible: (a) Is it at least as likely as not that the Veteran's asserted obstructive sleep apnea is caused (in whole or in part) by the service-connected psychiatric disorder, to include any medically prescribed treatment of such disability? (b) Is it at least as likely as not that the Veteran's asserted obstructive sleep apnea is aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by the service-connected psychiatric disorder, to include any medically prescribed treatment of such disability? If the Veteran's obstructive sleep apnea is aggravated by the service-connected psychiatric disorder, the examiner should, to the extent possible, also indicate the level of such aggravation by identifying a baseline level of disability. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. The absence of evidence of treatment for obstructive sleep apnea in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. 3. Schedule the Veteran for a VA examination for his asserted gastrointestinal disability. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is requested to opine whether it is at least as likely as not that the Veteran's asserted gastrointestinal had its inception during his period of active service or is otherwise causally related to an in-service disease or injury, to include documented food poisoning during service and exposure to open burn pits in service? The examiner is asked to opine whether the Veteran's asserted gastrointestinal disability is diagnosable, but medically unexplained chronic multi-symptom illness of unknown etiology. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. The absence of evidence of treatment for a particular gastrointestinal disorder in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. 4. Schedule the Veteran for a VA examination for his asserted headache and respiratory disabilities. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is requested to opine whether it is at least as likely as not that the Veteran's asserted headaches and respiratory disabilities had inception during his period of active service or are otherwise causally related to an in-service disease or injury, to include documented headaches, sinusitis, and upper respiratory infection, as well as the asserted exposure to asbestos and/or open burn pits in service? The examiner is asked to opine whether the Veteran's asserted headaches and/or respiratory symptoms are diagnosable, but medically unexplained chronic multi-symptom illnesses of unknown etiology. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. The absence of evidence of treatment for a particular headache or respiratory disorder in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. 5. Schedule the Veteran for a VA examination for his asserted left and right shoulder, elbow, and knee disabilities. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is requested to opine whether it is at least as likely as not that the Veteran's asserted respective joint disabilities had their onset during his period of active service or are otherwise causally related to an in-service disease or injury, to include exposure to open burn pits in service? In this regard, the examiner is also asked to opine whether the Veteran's joint pain is part and parcel of the diagnosed fibromyalgia, or whether the joint pain of the shoulders, elbows and/or knees is separate and apart from the diagnosed fibromyalgia. The examiner is asked to opine whether the Veteran's asserted respective joint disabilities are diagnosable, but medically unexplained chronic multi-symptom illness of unknown etiology. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. The absence of evidence of treatment for a particular asserted respective joint disability in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. 6. Schedule the Veteran for a VA examination for his asserted left and right eye disabilities. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is requested to opine whether it is at least as likely as not that the Veteran's asserted left and right eye disabilities had inception during his period of active service or is otherwise causally related to an in-service disease or injury, to include documented myopia during active service? If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. The absence of evidence of treatment for a particular eye disorder in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. 7. Schedule the Veteran for a psychiatric examination to determine the current severity of his service-connected psychiatric disorder. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to his service-connected psychiatric disorder. 8. Schedule the Veteran for an examination to determine the current severity of his service-connected right carpal tunnel syndrome. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. In so doing, the examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, the examiner must explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Orfanoudis, 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.