Citation Nr: 22013631 Decision Date: 03/10/22 Archive Date: 03/10/22 DOCKET NO. 16-15 975 DATE: March 10, 2022 ORDER Entitlement to service connection for a back condition, claimed as lumbar strain, is denied. For the period prior to October 2, 2015, entitlement to a rating of 30 percent, and no higher, for status post left acromioclavicular joint dislocation is granted. For the period prior to October 2, 2015, entitlement to a separate 20 percent rating for recurrent dislocation of the scapulohumeral joint associated with status post left acromioclavicular dislocation is granted. For the period starting February 1, 2016, entitlement to a rating in excess of 20 percent for status post left acromioclavicular joint dislocation is denied. REMANDED Entitlement to service connection for a neck condition, claimed as cervical strain, is remanded. Entitlement to service connection for hearing loss is remanded. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. It is less likely than not that the Veteran's current back condition was incurred in or aggravated by his active duty service. 2. Prior to October 2, 2015, the Veteran's left shoulder disability was characterized by arm motion limited to midway between the side and shoulder level and infrequent episodes of recurrent dislocation at the scapulohumeral joint. 3. Since February 1, 2016, the Veteran's left shoulder disability has not been characterized by arm motion limited to midway between the side and shoulder level. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a back condition have not been met. 38 U.S.C. §§ 1101, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2021). 2. For the period prior to October 2, 2015, the criteria for entitlement to a rating of 30 percent, and no higher, for status post left acromioclavicular joint dislocation have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.69, 4.71a, Diagnostic Code 5201 (2021). 3. For the period prior to October 2, 2015, the criteria for entitlement to a separate 20 percent rating, and no higher, for recurrent dislocation of the scapulohumeral joint associated with status post left acromioclavicular joint dislocation have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.69, 4.71a, Diagnostic Code 5202 (2021). 4. For the period starting February 1, 2016, the criteria for entitlement to a rating in excess of 20 percent for status post left acromioclavicular joint dislocation have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.69, 4.71a, Diagnostic Code 5201 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1978 to January 1982. He received the Army Service Ribbon, Expert Badge with M-16 rifle bar, Expert Badge with hand grenade bar, and Good Conduct Medal. In September 2018, the Veteran testified at a Central Office hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. This appeal was previously before the Board in April 2019. The Veteran's increased rating claim was remanded for an updated examination and his service connection claims were remanded for new nexus opinions. In the April 2019 decision, the Board also referred claims for service connection for impairments of muscle groups III, IV and V; slap syndrome; calcific tendonitis; removal of ligaments; and bursitis. Such claims have not yet been adjudicated by the Agency of Original Jurisdiction (AOJ) and are, once again, referred for adjudication. Service Connection for a Back Condition The Veteran contends that service connection is warranted for a back condition. Direct service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 C.F.R. § 3.303(a). Direct service connection generally requires credible and competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). The evidence shows that the Veteran has a current disability. At the January 2016 VA examination, the Veteran reported a history of lumbosacral strain (diagnosed in February 2000) but there are no treatment records showing a diagnosis of lumbosacral strain during the period on appeal. However, the Veteran's diagnosis of degenerative disc disease of the lumbar spine was confirmed with x-rays in December 2019. See December 2019 VA Examination, p. 1; January 2020 CAPRI, p. 458. Accordingly, the Board finds that the first element of service connection is established. See Holton, 557 F.3d at 1366. The Veteran has also presented sufficient evidence to establish the occurrence of an in-service injury or event. At the September 2018 hearing, the Veteran recalled experiencing a pulled low back muscle during his active duty service. See September 2018 Hearing Transcript, p. 13. His service treatment records corroborate his reports and show that he was treated for low back pain in March 1980. See January 1982 STR, p. 55. Accordingly, the Board finds that the second element of service connection is established. See Holton, 557 F.3d at 1366. However, there is insufficient evidence to establish the final element of nexus. In December 2019, VA obtained a nexus opinion that it is less likely than not that the Veteran's degenerative disc disease is related to his service. See December 2019 VA Examination, pp. 2-3. The examiner considered the in-service history of low back pain from a pulled muscle but noted that there were no other records of a back problem, including the Medical Evaluation Board examination which denotes a normal spine. See January 1982 STR, p. 18. The examiner reasoned that the single episode of a pulled muscle and the absence of any documentation of low back pain for many years following service makes it less likely than not that the Veteran's current degenerative disc disease of the lumbar spine is related to his service. The VA opinion is based on the evidence of record and sets forth an adequate rationale. As such, the Board finds it to be probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board acknowledges the Veteran's reports that his back pain progressed after separation while working as a laborer. See December 2019 VA Examination, p. 1. The Veteran's statement is credible but is ultimately outweighed by the more probative December 2019 opinion. The Board finds there is insufficient evidence to establish a nexus between the Veteran's current degenerative disc disease and his in-service pulled muscle. See Holton, 557 F.3d at 1366. In the absence of a nexus, the evidence preponderates against the claim and there is no reasonable doubt to be resolved. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection for a back condition is not warranted. Increased Rating for Status Post Left Acromioclavicular Joint Dislocation During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Because there is no evidence submitted on or after the effective date of the revised criteria that pertains to the disability on appeal, the Board will evaluate the Veteran's disability under the former version. The Veteran's status post left acromioclavicular joint dislocation has been rated as 20 percent disabling prior to October 2, 2015 and as of February 1, 2016 under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5201. The Veteran was in receipt of a total rating from October 2, 2015 to February 1, 2016 and this period is not on appeal. The criteria of DC 5201 assign different ratings for impairments of the major (or dominant) extremity and impairments of the minor extremity. Handedness for the purpose of a dominant rating will be determined by the evidence of record and only one hand will be considered dominant. 38 C.F.R. § 4.69. For ambidextrous individuals, the injured or most severely injured extremity will be considered the dominant extremity for rating purposes. See id. The Veteran is ambidextrous, see December 2020 VA Examination, p. 4, and his left upper extremity is the more severely injured extremity. As such, it will be evaluated as the major extremity. Under DC 5201, a 20 percent rating is assigned when the arm motion is limited to the shoulder level. A 30 percent rating is assigned when such motion is limited to midway between the side and shoulder level. A 40 percent rating is assigned when the arm is limited to 25 degrees from the side. Prior to October 2, 2015 Turning to the evidence, the Veteran underwent a VA examination in August 2014. See August 2014 VA Examination, pp. 1-9. On initial range of motion testing, the Veteran's left shoulder flexion was to 90 degrees with objective evidence of painful motion at 50 degrees. His left shoulder abduction was limited to 75 degrees with objective evidence of painful motion at 60 degrees. The Veteran was able to perform repetitive-use testing with at least three repetitions. His post-test flexion was to 90 degrees and his post-test abduction was to 75 degrees. Following repeated use over time, the examiner estimated pain and weakness would limit the left arm flexion to 50 degrees and abduction to 60 degrees. The examiner indicated that the Veteran's disability produced less movement than normal, weakened movement, and pain on movement. There was also localized tenderness and guarding. On muscle strength testing, the Veteran exhibited slightly reduced strength (4/5) on flexion and abduction. The Veteran's Hawkins' impingement test, external rotation/infraspinatus strength test, and lift-off subscapularis test all produced positive results indicating rotator cuff conditions. The examiner also indicated that there was a history of instability/dislocation as indicated by a positive history of mechanical symptoms and infrequent episodes of dislocation of the glenohumeral (scapulohumeral) joint. There was also tenderness on palpation of the acromioclavicular joint and a positive cross-body adduction test. The Veteran underwent a second VA examination in July 2015. See August 2015 VA Examination, pp. 1-17. His initial range of motion showed arm flexion to 160 degrees, abduction to 150 degrees, external rotation to 60 degrees, and internal rotation to 60 degrees. There was pain noted on both flexion and abduction, but the examiner did not indicate at what point in the range of motion the pain began. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion. Following repetitive use over time, the examiner noted that neither pain, weakness, fatigability nor incoordination significantly limited functional ability. The Veteran had normal muscle strength testing (5/5) and the examiner noted an absence of any left shoulder rotator cuff conditions. The examiner further noted that the Veteran's clavicle or scapula condition did not affect the range of motion of the shoulder and there was no tenderness on palpation or other impairment of the humerus. Treatment records from the period prior to October 1, 2015 show that the Veteran complained of persistent left shoulder pain that increased with elevation of the arm and repetitive movements. See December 2014 CAPRI, pp. 2-3; August 2015 VA Treatment Records, pp. 1-10. Active range of motion testing in August 2015 revealed flexion to 101 degrees, abduction to 78 degrees, external rotation to 22 degrees, and internal rotation to 52 degrees. See August 2015 VA Treatment Records, pp. 4-5. A May 2015 Family and Medical Leave Act form also notes left shoulder instability. See May 2015 Fax Cover Sheet, p. 3. For the period prior to October 2, 2015, the Board finds that the evidence preponderates in favor of a finding of entitlement to a rating of 30 percent, and no higher, for status post left acromioclavicular joint dislocation. To warrant a higher rating, the evidence must show that the Veteran's left arm movement was limited to 25 degrees from his side. The evidence does not show this level of impairment. Instead, the evidence shows that the Veteran's left arm flexion was limited by pain and weakness to 50 degrees, at worst, and his left arm abduction was limited to 60 degrees, at worst. The Board finds that this level of impairment closely approximates arm motion that is limited to midway between the side and shoulder level. Accordingly, a rating of 30 percent, and no higher, is warranted for status post left acromioclavicular joint dislocation. The Board further finds that a separate rating for left shoulder recurrent dislocation of the scapulohumeral joint is warranted for this stage of the rating. See 38 C.F.R. § 4.71a, DC 5202. Separate ratings may be assigned for distinct disabilities from the same injury if the symptomatology for the conditions is not duplicative or overlapping; however, the evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009); 38 C.F.R. § 4.14. DC 5201 evaluates limited motion of the arm but does not contemplate joint instability/dislocation. Therefore, a rating under DC 5201 does not preclude a separate additional rating for recurrent dislocation under DC 5202. See Esteban v. Brown, 6 Vet. App. 259 (1994). Under DC 5202, which evaluates other impairment of the humerus, a 20 percent rating is assigned for recurrent dislocation of the humerus at the scapulohumeral joint, with infrequent episodes and guarding of movement only at shoulder level. A 30 percent rating is warranted when there are frequent episodes of dislocation and guarding of all arm movements. After careful consideration, the Board finds that the evidence preponderates in favor of a finding of entitlement to a separate 20 percent rating, and no higher, for recurrent dislocation of the scapulohumeral joint. In the August 2014 examination report, the examiner noted that there was a history of mechanical symptoms, infrequent but recurrent episodes of dislocation of the glenohumeral (scapulohumeral) joint, and guarding of the shoulder. See August 2014 VA Examination, pp. 4-6. These manifestations most closely approximate the disability picture contemplated by the 20 percent rating. Accordingly, a separate rating of 20 percent, and no higher, for left shoulder recurrent dislocation of the scapulohumeral joint is warranted for the period prior to October 2, 2015. After February 1, 2016 The Veteran's first examination following his operation occurred in November 2016. See November 2016 VA Examination, pp. 1-12. On initial range of motion testing, the Veteran had flexion to 130 degrees, abduction to 90 degrees, external rotation to 30 degrees, and internal rotation to 25 degrees. There was pain noted on all motions and the Veteran described his functional impairment as an inability to work with his arm above shoulder height. There was no additional loss of function or range of motion following repetitive use testing. The Veteran was not examined following repetitive use over time, but the examiner estimated that pain and lack of endurance would limit the Veteran's flexion to 80 degrees and his abduction to 75 degrees. The Veteran denied flare-ups at this time. There was slightly reduced muscle strength (4/5) on both flexion and abduction which the examiner attributed to the Veteran's condition. The Veteran's Hawkins' impingement test, empty-can test, external rotation/infraspinatus strength test, and lift-off subscapularis test all produced positive results indicating a rotator cuff condition. The examiner was unable to perform the crank apprehension and relocation test but indicated that there was no history of mechanical symptoms or recurrent dislocation. The examiner noted that there was shoulder instability, dislocation or labral pathology suspected but did not specify which of the three symptoms was present. The Veteran had a positive cross-body adduction test which indicates acromioclavicular joint pathology. The examiner indicated that the Veteran's disability renders him unable to work with his arm above shoulder height, including limiting his ability to lift objects off of high shelves. In December 2019, the Veteran underwent a VA examination for his right shoulder; however, the examiner conducted initial range of motion testing on the left shoulder. See December 2019 VA Examination, p. 3. The Veteran's flexion was to 85 degrees, abduction to 70 degrees, external rotation to 20 degrees, and internal rotation to 5 degrees. There was pain noted on all motions which caused functional loss. The examiner did not conduct any other testing on the Veteran's left shoulder at this examination. Most recently, the Veteran was examined in December 2020. See December 2020 VA Examination, pp. 1-23. At the time, the Veteran reported pain under his arm, at his collarbone, and on the posterior and anterior acromioclavicular joint. He further indicated that it hurts when he drives, and he experiences muscle cramps and intermittent tingling in the upper arm. The Veteran denied flare-ups of his condition. On initial range of motion testing, he had flexion to 90 degrees, abduction to 75 degrees, external rotation to 30 degrees, and internal rotation 20 degrees. The Veteran exhibited pain on all motions and there was also pain on palpation of the shoulder. The examiner noted that his range of motion renders him unable to perform overhead work. The Veteran was able to perform repetitive-use testing with at least three repetitions and no additional loss of function or range of motion. Following repetitive-use over time, the examiner estimated that pain would limit the Veteran's flexion to 90 degrees, abduction to 75 degrees, external rotation to 30 degrees, and internal rotation to 20 degrees. The examiner observed decreased normal muscle strength on testing (3/5 on both flexion and abduction) and the examiner attributed the reduction to the Veteran's disability. The Veteran was unable to perform the Hawkins' impingement, external rotation/infraspinatus strength, and lift-off subscapularis tests because of a suspected rotator cuff condition. The examiner indicated that there was no suspected instability, dislocation, or labral pathology and did not observe any guarding of arm movement. Treatment records from this stage of the appeal show that the Veteran complained of pain and weakness that are accentuated with overhead activities, abduction and pushing. See November 2016 CAPRI, pp. 23, 32, 50; November 2016 CAPRI, p. 2; January 2020 CAPRI, pp. 49-50, 67, 71, 92, 115-116, 135, 357, 373, 379; December 2020 CAPRI, pp. 98-99. An October 2019 imaging study showed recurrent partial tears of the rotator cuff and suspected labral tear. See January 2020 CAPRI, p. 49. At that time, the Veteran's left shoulder flexion was to 120 degrees and abduction to 130 degrees with painful internal and external rotation. Id. at p. 71. In a February 2019 treatment record, the Veteran had significantly reduced muscle strength (2/5) and flexion to 78 degrees, abduction to 92 degrees, external rotation to 48 degrees, and internal rotation to 62 degrees. Id. at p. 115. At the September 2018 hearing, the Veteran described having decreased endurance and pain in the shoulder that is exacerbated by repetitive movements and movements of the arm away from the body or in front of his body. See September 2018 Hearing Transcript, pp. 3, 9, 31, 34. The Veteran also described flare-ups marked by increased pain. After careful consideration of the evidence, the Board finds that the weight of the evidence preponderates against a finding of entitlement to a rating in excess of 20 percent for the period starting February 1, 2016. To warrant a higher rating, the evidence must show that the Veteran's arm motion is limited to midway between the side and shoulder level. The evidence does not show this level of impairment but instead shows that pain and weakness limit the Veteran's arm motion to 78 degrees of flexion and 70 degrees of abduction, at worst. The Veteran's limited motion, pain and weakness are adequately contemplated by the current assigned rating. Accordingly, a rating in excess of 20 percent for status post left acromioclavicular joint dislocation is not warranted. The Board has considered whether the Veteran would be entitled to a higher rating under a different diagnostic code for his left shoulder disability. To receive a higher rating, the evidence must show ankylosis of the scapulohumeral articulation (DC 5200) and there is no such evidence of record. The Board further notes that a separate rating for dislocation/instability or other impairment of the humerus under DC 5202 is not warranted for this stage of the rating because there is no evidence of such manifestations. The November 2016 examiner did not specify whether instability, dislocation or labral pathology was suspected. See November 2016 VA Examination, pp. 6-7. However, none of the evidence from this stage of the rating shows that there was instability or recurrent dislocation, and an October 2019 imaging study shows that there were suspected labral tears in the left shoulder. See January 2020 CAPRI, p. 49. Similarly, there is no evidence of malunion, nonunion or dislocation of the clavicle or scapula that would warrant consideration of DC 5203. Accordingly, the Board finds that neither an additional rating nor a higher rating is warranted under a different diagnostic code. REASONS FOR REMAND Service Connection for a Neck Condition The Veteran's claim for service connection for a neck condition, claimed as cervical strain, was previously remanded for an opinion that clarified a January 2016 opinion that related the Veteran's neck condition to a past injury. See January 2016 VA Examination, p. 42. It was unclear from the opinion whether the clinician was referring to the pre-service injury or the in-service operation. In December 2019, VA obtained a second nexus opinion. See December 2019 VA Examination, pp. 1-2. The clinician opined that the Veteran's neck condition is not related to his in-service operation because there is no relationship between the Mumford procedure and the development of degenerative joint disease of the cervical spine. The clinician further opined that the Veteran's neck condition is not secondary to his service-connected left shoulder condition. In support of the opinion, the clinician explained that the Veteran's inability to lift normal amounts of weight as a result of his shoulder disability would have a mitigating effect on the muscles and connective tissues at the base of the neck with the net effect of protecting those structures from normal wear and tear. However, the opinion does not appear to consider the impact of simple arm movement and radiating pain as noted in the literature submitted by the Veteran in August 2014. See August 2014 Private Treatment Records, p. 3. Accordingly, the Board finds that an additional opinion is needed that fully addresses whether the Veteran's service-connected shoulder disability aggravates his neck condition. See 38 C.F.R. § 3.310(b) (2021); see also September 2018 Hearing Transcript, pp. 10, 14, 21-22. Service Connection for Hearing Loss The Veteran's claim was remanded in April 2019 for a new nexus opinion. Specifically, the Board requested a nexus opinion that is not based on the absence of a hearing loss disability in service. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). In December 2019, the AOJ obtained an opinion that it is less likely than not that the Veteran's current hearing loss is related to his service because there was no significant permanent shift in hearing thresholds beyond test variability from entrance to separation. See December 2019 VA Examination, p. 5. The Court of Appeals for Veterans Claims has held that the proper inquiry in hearing loss claims is not whether hearing loss was demonstrated in service, but whether any current hearing disability can be related to in-service noise exposure. See Hensley v. Brown, 5 Vet. App. 155, 164 (1993). As the December 2019 opinion suffers from the same deficiencies that the Board identified in the August 2014 and February 2016 opinions, an additional remand is needed for a new opinion. TDIU The Veteran submitted his claim for TDIU in May 2015. See Veteran's Application for Increased Compensation Based on Unemployability, pp. 1-2. Shortly before submitting his claim, the Veteran took a short-term disability leave of absence from work for treatment of his service-connected left shoulder disability. See May 2015 Third Party Correspondence, p. 1. While the Veteran has informally referenced his employment status (whether he is employed and by whom) at various times during the period on appeal, his employment history since May 2015 is unclear. Specifically, it is unclear how long the Veteran was on short-term disability, at what point he resumed employment prior to or following his October 2015 surgery, and whether any employment held since May 2015 was gainful. Accordingly, the Board finds that a remand is necessary to obtain updated information on the Veteran's employment history. The matters are REMANDED for the following action: 1. Obtain an opinion on the etiology of the Veteran's cervical spine condition. If deemed necessary by the examiner designated to provide an opinion, schedule the Veteran for an examination. All indicated evaluations, studies and tests deemed necessary by the examiner should be accomplished. The entire claims file, to include a complete copy of this REMAND, should be made available to the examiner designated to provide the opinion, and the examination report should include a discussion of the Veteran's documented medical history and assertions. The examiner should offer comments, an opinion, and a supporting rationale that address whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's current cervical spine condition is caused by, aggravated by, or is otherwise etiologically related to his service-connected left shoulder disability. In providing this opinion, the examiner should discuss the Open Distal Clavicle Resection article which notes that patients with isolated acromioclavicular joint pathology often complain of radiating pain to the base of the neck resulting from trapezial spasms that are secondary to the joint condition. See August 2014 Private Treatment Records, p. 3. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered. If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so. 2. Obtain a VA opinion that addresses the nature and etiology of the Veteran's hearing loss. If deemed necessary by the examiner, schedule the Veteran for an examination. Any indicated evaluations, studies, and tests deemed necessary should be accomplished. The entire claims file, to include a complete copy of this REMAND, should be made available to the examiner designated to provide an opinion, and the examination report should include a discussion of the Veteran's documented medical history and assertions. After eliciting a history of the Veteran's disability, the examiner should offer comments, an opinion and a supporting rationale that address whether it is at least as likely as not that the Veteran's hearing loss was incurred in, aggravated by, or is otherwise etiologically related to his active duty service? In providing this opinion, the examiner should consider the Veteran's in-service exposure to hazardous noise, changes in his audiogram results in service, and his use of hearing protection in post-service occupations. See September 2018 Hearing Transcript, pp. 40-41; January 1982 STR, pp. 17, 35, 77. (Continued on the next page) The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered. If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so. 3. Provide the Veteran with the appropriate notification letter that informs him of the information needed to update his employment history in support of his application for TDIU, including a VA Form 21-8940. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board W.V. Walker, 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.