Citation Nr: 22008087 Decision Date: 02/11/22 Archive Date: 02/11/22 DOCKET NO. 17-41 753 DATE: February 11, 2022 ORDER Entitlement to service connection for a lumbar spine condition is granted. Entitlement to service connection for a cervical spine condition is granted. Entitlement to service connection for bilateral hearing loss is dismissed as withdrawn. Entitlement to service connection for tinnitus is dismissed as withdrawn. REMANDED Entitlement to service connection for radiculopathy of the left lower extremity is remanded. Entitlement to service connection for a left knee condition is remanded. Entitlement to service connection for a right knee condition is remanded. Entitlement to service connection for migraine headaches is remanded. FINDINGS OF FACT 1. The Veteran's lumbar spine condition manifested to a compensable degree within one year of his active-duty service. 2. The Veteran's cervical spine condition manifested to a compensable degree within one year of his active-duty service. 3. The Veteran withdrew the issue of service connection for bilateral hearing loss in October 2019. 4. The Veteran withdrew the issue of service connection for tinnitus in October 2019. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for the Veteran's lumbar spine condition have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for the Veteran's cervical spine condition have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 3. The criteria for withdrawal of entitlement to service connection for bilateral hearing loss have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 4. The criteria for withdrawal of entitlement to service connection for tinnitus have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1984 to August 1987. This case comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of September 2012 issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Guaynabo, Puerto Rico. The Board briefly clarifies the scope of the issues presently on appeal. Following the rating decision on appeal, the Veteran filed a Notice of Disagreement (NOD) in June 2013. In this NOD, the Veteran also asserted entitlement to service connection for a psychiatric condition and to a total disability rating based on individual unemployability (TDIU). See June 2013 NOD at 1-2. The RO issued a separate rating decision denying these claims in September 2014. The Veteran did not appeal this separate rating decision. Accordingly, the Board finds that these issues are not presently before it in this appeal. Entitlement to service connection for bilateral hearing loss and tinnitus. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision by the appellant or by his or her authorized representative. 38 C.F.R. § 19.55(a). The withdrawal must be filed with the Board and include the name of the veteran, the applicable VA file number, and a statement that the appeal is withdrawn. Id. at (b)(1). If the appeal involves multiple issues, the withdrawal must specify that the appeal is withdrawn in its entirety or list the issue(s) withdrawn from the appeal. Id. Withdrawal of an appeal will be deemed a withdrawal of the NOD and, if filed, the substantive appeal (VA Form 9), as to all issues to which the withdrawal applies. Withdrawal does not preclude filing a new NOD and, after a Statement of the Case (SOC) is issued, a new VA Form 9, as to any issue withdrawn, provided such filings would be timely under these rules if the appeal withdrawn had never been filed. Id. at (c). The Veteran attended a conference with a Decision Review Officer (DRO) in October 2019, at which he withdrew his claims for service connection for bilateral hearing loss and tinnitus. See October 2019 Correspondence; see also October 2019 VA Form 21-4138 (stating that "[the] claims of bilateral hearing loss and tinnitus [are] withdrawn from appeal"). This correspondence also identifies the Veteran's VA file number. The Board therefore finds that the applicable criteria for withdrawal of an appeal have been met. 38 C.F.R. § 19.55(b)(1). The Board therefore no longer has jurisdiction over these issues, which are dismissed. Id. at (c). Entitlement to service connection for lumbar and cervical spine conditions. Service connection requires the existence of a present disability, the in-service incurrence or aggravation of a disease or injury, and a causal relationship between the present disability and the disease or injury incurred or aggravated during service. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (2004). 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). Certain conditions, including arthritis, may be service-connected on a presumptive basis even in the absence of a direct nexus. See 38 C.F.R. §§ 3.307(a), 3.309(a). Generally, such a condition must have manifested to a compensable degree within one year following separation from service. 38 C.F.R. § 3.307(a)(3). The Veteran asserts that these conditions, as well as the other conditions on appeal, are the result of a motor vehicle accident incurred during his active-duty service. See January 2010 Correspondence (asserting that accident occurred in April 1987 and that witness A.T. was driving behind the Veteran at the time). While this accident is not reflected in the Veteran's service treatment records (STR), the Veteran has submitted a corroborating lay statement from an alleged eyewitness. See September 2014 STR at 1-7 (providing May 1987 separation examination reflecting no injuries); cf. November 2020 Affidavit (providing assertion of A.P.L. regarding driving behind the Veteran at the time of the accident). The Veteran's medical records document the manifestation of symptoms of back, neck, and shoulder pain from November 1987 onward, as well as the Veteran's contemporaneous assertions that such symptoms manifested following a motor vehicle accident. See July 2012 Medical Treatment Records (II) at 1-24 (documenting periodic consultations from November 1987 to February 1995). The Board particularly notes the following treatment records: The patient... [presents in November 1987] with a history of severe pain in the chest, neck, back, and knee... These symptoms are the result of an automobile accident suffered in 1987... The car he was driving went off an embankment and rolled over. He suffered injuries in the chest, neck, back, and knee. The patient did not seek any medical attention... Upwards and backwards movements of the arms cause pain... He shows hypersensitivity in the shoulders and back which reflects on the arms and chest... Sensory examination shows nonstandard results. Touch, position, and vibration stimulation produce pain, at times severe. Coordination and [gait] show sign[s] of difficulty. Impression: chronic intermittent pain in the upper and lower cervical spine as well as the upper thoracic spine show signs of an inflammatory condition and possible damage to the spine. See July 2012 Medical Treatment Records (II) at 1-2. [The Veteran] continues to suffer from severe pain in the back (thoracic and cervical regions) and the shoulders [in April 1988]... The X-ray results reveal no significant injury. The cervical spine MRI results show a small protuberance in disk C5-C6. There is no presence of herniated disk or spinal stenosis. The thoracic spine MRI reveals the presence of a hernia in disks T4-T5 and T6-T7. Id. at 3-4. Rheumatoid results show no sign of a degenerative condition in the disks, nor do they point to an arthritis-related condition. As stated by previous results, the patient shows signs of possible lesion to the C5-C6 and that disks T4-T5 and T5-T6 are herniated. The damage is extensive enough to be the cause of the chronic pain in the cervical and thoracic segments. Id. at 9. Additional medical records from a separate consulting provider in August 1999 present an alternative etiology, noting that the Veteran sustained multiple spine injuries during his post-service civilian employment. These records do not mention the Veteran's asserted in-service motor vehicle accident: [The Veteran's] history of current illness dates back to his first injury which happened on February 1, 1994, when [he] was carrying a heavy metal box and slipped on the ice and fell in a sitting position. He complained of immediate pain in the back radiating to the abdomen... About 1998 he had a second injury. During this whole four years he would get occasional on and off neck pains which were easily manageable. While he was carrying a 150 pound pipe on [his] shoulder, he went to put it down and felt a sharp pain through the upper back and felt that it was a reaggravation of his same 1994 pain... ... the third injury happened on September 14, 1998. He was loading dry ice, and then he pulled on the cart and experienced severe sharp pain on the left side of the chest with severe pain in his mid-thoracic spine with numbness of the left hand and lower back pain... His fourth injury happened on May 18, 1999, when he was pushing a heavy cart at work and felt severe pain in the left scapular area, neck[,] and around the chest to back area... From the history it seems that the patient had incurred significant mechanical injury... [this] pain as we know has been a recurring problem since his 1994 injury... Walking is limited as the pain becomes sharp, but he has no history of neurogenic claudication. See April 2010 Medical Treatment Records at 14-15; see also id. at 18-19 (observing "mild degenerative disc disease" of cervical spine and "essentially unremarkable" thoracic and lumbar scans). The Veteran underwent a VA examination which addressed his cervical spine and knee conditions, but not his lumbar spine condition. The VA examiner diagnosed the Veteran with cervical spondylosis. See August 2012 VA Examination Report at 38; see also id. at 47-48 (documenting arthritis based on imaging studies). The VA examiner opined that the Veteran's cervical spine condition was less likely than not incurred in or a result of his active-duty service. Id. at 59. In reaching this conclusion, the examiner stated only that "[there is] no evidence in claim folder to show any complaints, treatments, or traumas in cervical area during service." Id. The Veteran has submitted a letter from a private physician describing the symptoms and treatment of his lumbar spine and left lower radiculopathy conditions. See July 2012 Correspondence (providing statement of Dr. G.C.). This statement does not address the etiology of either condition. The Veteran has also submitted disability benefits questionnaires (DBQ) prepared by a private physician in support of these claims. See November 2020 DBQ (Cervical); see also November 2020 DBQ (Lumbar). This physician diagnosed degenerative disc disease of the lumbar spine, as well as degenerative disc disease, foraminal or central stenosis, and radiculopathy of the cervical spine. This physician also opined that the Veteran's cervical and lumbar spine conditions were incurred in his active-duty service: [It] is my opinion that the [Veteran's] neck condition is more likely than not related to his military service... [He] was in a car accident on April 12, 1987. As a result of the accident [he] injured his back, neck, and knees... [He] was seen by [Dr. A.S.]... for severe pain in the chest, neck, back, and knee and burning feeling. [He] is currently diagnosed with cervical spondylosis/cervical degenerative disc disease. Whiplash (also called neck strain) is caused by an abrupt backward and/or forward jerking motion of the head, often as a result of a car accident or a backward fall. The sudden force stretches and tears the muscles and tendons in your neck. Spondylosis and cervical degenerative disc disease are a degenerative condition in the spine compromising the cushions between the spinal disks and the joins between the bones of the spine. When these discs are compromised, the bones of the spine lose their place, sometimes pressing on the nerve. A crack in the outer wall that causes degenerative disc disease can occur naturally with age, or it may stem from a traumatic accident. When the neck sustains an injury in a car accident, it may not be able to fully recover. Even minor injuries, such as a tear in the outer wall of the spine, can damage the nerves and make disc degeneration painful. See November 2020 DBQ (Cervical) at 11. [The] Veteran is currently diagnosed with lumbar degenerative disc disease. Lower back pain is one of the most common causes of back pain. The lower back and neck are particularly sensitive to injury after a car accident. The lower back and cervical spine are vulnerable to injury due to the whip-like nature of this violent snapping. While the thoracic spine and sacral area are most stable, the lower back and neck are mobile and will continue to move. Low back pain is a common disorder involving the muscles, nerves, and bones of the back. In most episodes of LBP, a specific underlying cause is not identified, with the pain believed to be due to mechanical problems such as muscle or joint strain. If the pain does not go away with conservative treatment or if it is accompanied by red flags such as unexplained significant problems with feeling or movement, further testing may be needed to look for underlying problem[s]. After listening to [the Veteran's] statement, [the corroborating lay statement], and reviewing the medical record, it is my opinion that [his] back condition is more likely than not... related to his military service. [His] back condition is consistent with an injury in service, [he] received medical treatment only 3 months after discharge from active duty and by that time [his] medical condition was chronic. A chronic back pain, like [the Veteran's], [is] not developed overnight or in a short period of time. See November 2020 DBQ (Lumbar) at 11. The Veteran's VA medical records note chronic lower back and neck pain among his conditions. See, e.g., September 2014 Medical Treatment Records at 99 (assessing "neck pain and low back pain exacerbation" during May 2013 treatment). These records also include July 2011 x-ray results showing "[mild] degenerative changes at L4-L5 and L5-S1." See September 2012 Medical Treatment Records at 24. The Veteran's VA medical records do not otherwise contradict the private records or examinations discussed above. The Board now turns to the analysis of the evidence of record. Based on the July 2011 x-ray results showing mild degenerative changes, the VA examiner's finding of cervical spondylosis, and the private physician's diagnosis of cervical and lumbar degenerative disc disease, the Board finds that the first Shedden factor has been met as to both of these conditions. While the motor vehicle accident asserted by the Veteran is not reflected in his STR, the Board finds that the July 2012 medical treatment records discussed above, which document treatment for neck and back pain from November 1987 onwards and which include the Veteran's contemporaneous assertion of a motor vehicle accident, corroborate his assertion. The Board therefore finds it at least as likely as not that the second Shedden factor has been met as to both of these conditions as well. 38 U.S.C. § 5107. The Board now turns to the third Shedden factor. The Board notes that an adequate medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions... Relevant points that can be discussed in an examination report include, but are not limited to, why the examiner finds cited studies persuasive or unpersuasive, whether the veteran has other risk factors for developing the claimed condition, and whether the claimed condition has manifested itself in an unusual way." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). "[Most] of the probative value of a medical opinion comes from its reasoning. Neither a VA medical examination report nor a private medical opinion is entitled to any weight... if it contains only data and conclusions." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also id. at 302 (providing that "[the] first inquiry is whether the medical expert is informed of sufficient facts upon which to base an opinion relevant to the problem at hand") (internal citation omitted). Generally, the Board may not consider the absence of evidence as substantive negative evidence when adjudicating a claim. See Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); see also id. (contrasting with Federal Rule of Evidence 803(7) for the proposition that the absence of a record may be substantive negative evidence if such a record would ordinarily be recorded). As noted above, the Veteran has not undergone a VA examination specifically addressing his lumbar spine condition. The Board assigns the VA examiner's opinion as to the Veteran's cervical spine condition no probative weight because it appears to be based solely on the absence of corroborating STR, without discussing the July 2012 medical records showing treatment for back and neck pain within a year of the Veteran's active-duty service. However, the Board also assigns the private physician's opinions no probative weight because they do not address the extensive history of post-service spine injuries discussed in the April 2010 medical records. As noted above, "whether the veteran has other risk factors for developing the claimed condition" is among the most relevant factors to be discussed in a medical opinion, and "[the] first inquiry is whether the medical expert is informed of sufficient facts upon which to base an opinion relevant to the problem at hand." Stefl, 21 Vet. App. at 124; see also Nieves-Rodriguez, 22 Vet. App. at 302. The Board assigns moderate probative weight to the November 1988 finding of Dr. A.S. that "[the] damage is extensive enough to be the cause of the chronic pain in the cervical and thoracic [spine] segments." See July 2012 Medical Records at 9. However, because this finding predates the Veteran's extensive history of post-service spine injuries, it too is inadequate to fully address the relevant medical history. The Board has therefore considered whether to remand these issues for an adequate VA medical opinion. However, the Board is also mindful of regulatory constraints on its ability to remand for further development, which "should not be undertaken when [the] evidence present is sufficient for this determination." 38 C.F.R. § 3.304(c). As noted above, service connection for arthritis may be assigned on a presumptive basis where the condition has manifested to a compensable degree within one year of active-duty service. 38 C.F.R. §§ 3.307, 3.309(a). The July 2012 medical records include findings supporting the inference that the Veteran's spine conditions were not diagnosable as arthritis within that specific period. See July 2012 Medical Treatment Records at 9 (indicating that "[rheumatoid] results show no sign of a degenerative condition in the disks, nor do they point to an arthritis-related condition" and instead finding herniated discs) (emphasis added). The applicable regulations provide that "[no] condition other than one listed in [38 C.F.R.] § 3.309(a) will be considered chronic." 38 C.F.R. § 3.307(a). The Board notes that herniated discs are not among the conditions listed at 38 C.F.R. § 3.309(a). However, these regulations also provide that: For the showing of chronic disease... there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic" ... Continuity of symptomatology is required only where the condition noted... in the presumptive period... is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. See 38 C.F.R. § 3.303(b) (emphasis added); see also 38 C.F.R. § 3.307(b) (providing that "[the] chronicity and continuity factors outlined in § 3.303(b) will be considered" in evaluating the applicability of presumptive service connection). Because the Veteran's spine conditions are now diagnosable as arthritis on the basis of x-rays showing degenerative changes, because the symptoms of these conditions manifested to a compensable degree within a year of his active duty service, and because the evidence of record discussed above supports the inference that they have manifested with continuous symptomatology from that point, the Board concludes that service connection on a presumptive basis for these conditions is therefore warranted. 38 C.F.R. §§ 3.307, 3.309. In other words, the Board does not find the absence of a diagnosis of arthritis made within a year of the Veteran's active-duty service dispositive, because the symptoms of the Veteran's spine conditions have proceeded continuously from his active-duty service and these conditions have subsequently been identified as chronic conditions. 38 C.F.R. § 3.303. REASONS FOR REMAND Entitlement to service connection for radiculopathy of the left lower extremity. The Veteran has not undergone a VA examination specifically addressing this issue. As discussed above, the evidence of record supports the inference that the Veteran's spine conditions did not initially manifest with any associated radiculopathies, but that such radiculopathies may have manifested subsequently. See July 2012 Medical Records at 22 (providing February 1992 treatment observing that "straight leg raising is painless and peripheral pulsations are normal in all the extremities"); see also id. at 23 (observing that "[sensory] examination is normal to touch, pain, position, vibration and double simultaneous stimulation" and noting no radiculopathies among diagnostic impressions); see also April 2010 Medical Records at 18 (providing August 1999 treatment note observing "[essentially] unremarkable" neurological examination) cf. id. at 25 (providing July 2010 letter from Dr. G.C. observing "pain of the lumbar spine radiating to the left lower extremity"). The evidence of record reflects that the Veteran has non-service-connected diabetes mellitus. See September 2014 Medical Treatment Records at 1. Peripheral nerve conditions are among the symptoms of diabetes. See "Diabetes Symptoms," Centers for Disease Control and Prevention (obtained via https://www.cdc.gov/diabetes/basics/symptoms.html). Neither the July 2010 letter from Dr. G.C. discussed above, nor the DBQ submitted by Dr. R.M.D. in November 2020, address the Veteran's diabetes or explain how a nerve condition of the extremities is determined to be attributable to a spine condition as opposed to diabetes. See Stefl, 21 Vet. App. at 124 (providing that "whether the veteran has other risk factors for developing the claimed condition" is among the most relevant factors to be discussed in a medical opinion"). The Board is not competent to make such a determination on its own. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). Generally, the VA must provide a medical examination "when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service... and (3) an indication that the disability... may be associated with the veteran's service... but (4) insufficient competent medical evidence on file... to make a decision on the claim." McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The third McLendon element "requires only that the evidence 'indicates' that there 'may' be a nexus between the two." McLendon, 20 Vet. App. at 83. "This is a low threshold... [and includes] credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation." Id. The Veteran has provided competent evidence of symptoms of a peripheral nerve condition, his spine conditions are now service-connected, there is an indication that such a peripheral nerve condition may be associated, and there is otherwise insufficient competent medical evidence to fully adjudicate this issue. The Board therefore finds that each of the McLendon factors has been met. Entitlement to service connection for bilateral knee conditions. The Veteran has undergone a VA examination addressing these conditions. The VA examiner diagnosed bilateral knee arthralgia. See August 2012 VA Examination Report at 21. The VA examiner opined that these conditions were less likely than not incurred in the Veteran's active-duty service. In reaching this conclusion, the examiner stated that there was "[no] evidence in [the] claim folder of any knees conditions [sic] during service or [in the] year thereafter." Id. at 53. The Board finds that this is not consistent with the evidence of record. The Veteran's STR reflect treatment for left knee pain in May 1985. See September 2014 STR at 53. Additionally, the July 2012 medical records discussed above include the Veteran's November 1987 and April 1988 complaints of knee pain. See July 2012 Medical Records at 1; see also id. at 3. The Board finds that the VA examination of record is not adequate to adjudicate these claims. However, the DBQ submitted by the Veteran only address his spine conditions and are not otherwise sufficient to adjudicate these claims. The Board has considered whether the evidence of record is sufficient to grant these claims on a presumptive basis as discussed above. However, the Board notes that the July 2012 medical records appear to support the inference that the Veteran's knee pain at that time was not chronic, because they cease to reflect complaints of knee pain following November 1988. See July 2012 Medical Records at 3 (noting in April 1988 that the Veteran sustained injuries to the knee and elsewhere during his motor vehicle accident and that "[he] still feels pain in those areas"); see id. at 8 (providing same in November 1988); cf. id. at 10-25. In other words, the evidence of record supporting continuous symptomatology of the Veteran's spine symptoms is significantly stronger than that addressing his knee conditions. The Board therefore concludes that additional competent medical evidence is needed to fully adjudicate these claims. McLendon, 20 Vet. App. at 83. "[Once] the Secretary undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, he must provide an adequate one[.]" Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Entitlement to service connection for a migraine headache condition. The Veteran has not undergone a VA examination addressing this issue. The November 2020 DBQ addressing the Veteran's cervical spine condition states that "[the] Veteran gets migraine headaches," among other symptoms, during flare-ups of that condition. See November 2020 DBQ (Cervical) at 2. However, this DBQ does not otherwise provide any explanation or reasoning for how the physician diagnosed migraine headaches or attributed them to the Veteran's cervical spine condition. The Veteran's STR reflect treatment for "pharyngitis, and [headache] [for] 2 days" in January 1987. The Veteran's medical treatment records do not otherwise provide a diagnosis of migraine headaches or associate such migraines with the Veteran's active-duty service or cervical spine condition. Because that condition is now service-connected, remand for a VA examination addressing migraine headaches is therefore warranted. McLendon, 20 Vet. App. at 83. Finally, the Board notes that the Veteran has asserted receipt of disability benefits from the Social Security Administration (SSA) "since May 2011 due to injuries and disabilities resulting from a motor vehicle accident." See January 2010 Correspondence. These SSA records are logically relevant to the Veteran's remaining claims and do not appear to be associated with the evidence of record. These matters are therefore REMANDED for the following action: 1. Obtain the Veteran's disability benefits records from the Social Security Administration and associate them with the Veteran's claims file. If such records cannot be obtained or are determined not to exist, document all efforts to obtain such records. 2. Provide the Veteran's claims file to an appropriately-qualified examiner. The examiner shall review the claims file, including this remand, and provide the following opinions: (a.) Is it at least as likely as not that the Veteran has any radiculopathies which are associated with his service-connected spine conditions? If the examiner concludes that any radiculopathies are more likely than not due to non-service-connected conditions such as diabetes mellitus, the examiner shall clearly explain the medical evidence and reasoning supporting such conclusions. (b.) Is it at least as likely as not that the Veteran's bilateral knee conditions were incurred in or a result of his active-duty service, to include the motor vehicle accident described in the July 2012 medical treatment records? If the examiner concludes that such knee conditions are more likely than not due to non-service-connected factors, such as age or the history of non-service-connected injuries discussed in the April 2010 medical records, the examiner shall clearly explain the medical evidence and reasoning supporting such conclusions. (c.) Is it at least as likely as not that the Veteran has a migraine headache condition which was incurred in or a result of his active-duty service; or which is proximately due to or the result of his service-connected cervical spine condition? If the examiner concludes that such a migraine headache condition cannot be diagnosed or is more likely than not due to non-service-connected factors, the examiner shall clearly explain the medical evidence and reasoning supporting such conclusions. If the examiner is unable to provide any of these opinions without personally examining the Veteran, schedule the Veteran for such an examination. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Blore, 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.