Citation Nr: 22018154 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 16-29 649 DATE: March 28, 2022 ORDER Service connection for a back condition is denied. REMANDED Entitlement to service connection for a joint condition, diagnosed as fibromyalgia, is remanded. Entitlement to service connection for vertigo is remanded. Entitlement to service connection for a sinus condition, to include sinusitis and rhinitis, is remanded. Entitlement to service connection for a headache condition, to include migraines, is remanded. Entitlement to service connection for a disability manifesting as fatigue is remanded. Entitlement to service connection for a gastrointestinal disability, to include gastroesophageal reflux disease (GERD) and hiatal hernia, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include depression, anxiety, sleep problems, and posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for tinea pedis is remanded. FINDING OF FACT The evidence is persuasively against finding that the Veteran's back condition is attributable to his active service or any incident of service. CONCLUSION OF LAW The criteria for service connection for a back condition have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2021). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 2003 to May 2004. He also had a period of active duty for training (ACDUTRA) from September 1994 to March 1995. These matters are before the Board of Veterans' Appeals (Board) on appeal from April 2013 and April 2018 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). Regarding the issues of entitlement to service connection for a joint condition, vertigo, a sinus condition, a gastrointestinal disability, headaches, and an acquired psychiatric condition, a Board hearing was held before the undersigned in February 2019. A transcript of the hearing is of record. The Veteran did not request a hearing before the Board in his May 2020 VA Form 9, Appeal to Board of Veterans' Appeals, on the other issues addressed in this decision. The matters addressed at the February 2019 hearing were previously before the Board in May 2019 when they were remanded for further development. All of the matters were previously before the Board in November 2020 when they were remanded for further development. An October 2021 rating decision granted service connection for hemorrhoids with anemia. As the decision constitutes a full grant of the claims previously before the Board, the matters are no longer before the Board and will not be discussed further. Service Connection Service connection for a back condition is denied. The Veteran generally contends that his back condition is related to his active service. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the current disability and an in-service precipitating disease, injury, or event. 38 C.F.R. § 3.303(a). Service connection may be granted for a Persian Gulf veteran with objective indications of a qualifying chronic disability. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). Objective indications of a qualifying chronic disability include both signs and symptoms, in the medical sense of objective evidence perceptible to an examining physician, and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs and symptoms include, but are not limited to, fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 C.F.R. § 3.317(b). Non-medical indicators include evidence such as time lost from work, the veteran having sought treatment for his symptoms, and change in the veteran's appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in approximate balance, with the claimant prevailing in either event, or whether the weight of the evidence is persuasively against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37307 (Fed. Cir. Dec. 17, 2021). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. In this case, the record shows the Veteran has a current back condition as private treatment records note diagnoses including an acute lumbar strain and mild degenerative disc disease. Thus, the first element of service connection has been established. The remaining issues are whether there is evidence of an in-service incurrence and a nexus linking the Veteran's back condition and the in-service incurrence. Regarding whether there is evidence of an in-service incurrence, the Veteran's service treatment records do not show that the Veteran has complaints, diagnoses, or treatment for a back condition during his service. He also has not otherwise indicated that the condition had its onset during service or that he began experiencing symptoms related to the condition during service. Therefore, the Board finds that there is no in-service injury, disease, or event that meets the second element of service connection. Shedden v. Principi, 381 F.3d 1167 (Fed. Cir. 2004). As there is no evidence of an in-service disease, event, or injury, it is not necessary to reach the third element of service connection (whether there is a relationship between an in-service event and his currently diagnosed condition). Thus, service connection for a back condition is denied. The Board has considered whether the Veteran is entitled to service connection under the presumption for Persian Gulf War Veterans. However, the Board finds the Veteran is not a Persian Gulf War Veteran for presumptive purposes. See 38 C.F.R. § 3.317. While the Veteran had active duty service during the Persian Gulf War era, he did not serve in the Southwest Asia Theater of Operations. The Board acknowledges that the Veteran's service personnel records reflect that he was ordered to active duty in support of Operation Enduring Freedom from October 2003 to May 2004 and that he was scheduled to go to Southwest Asia. However, the evidence of record persuasively indicates that he did not actually deploy to Southwest Asia. Specifically, his service personnel records do not list any foreign service. At his February 2019 hearing the Veteran reported his locations of service and did not indicate any service in Southwest Asia. Board Hearing Tr. at 3-4. Additionally, the Veteran consistently reported that he did not end up deploying to Southwest Asia. (See, e.g., a February 2018 Statement in Support of Claim for PTSD in which the Veteran indicated that he was supposed to deploy but could not deploy due to a complication with his wife's pregnancy and that he suffered a tremendous amount of guilt after his unit was struck by a major mortar attack shortly after they arrived in Iraq.) Therefore, the Board finds the evidence is persuasively against a finding that the Veteran is a Persian Gulf War Veteran pursuant to 38 C.F.R. § 3.317 and the presumption cannot apply. The Board acknowledges that the Veteran has not been provided a VA examination in conjunction with this claim. Significantly, however, one is not required. The Board notes that while there is competent medical evidence of a current disability, there is no indication in the record to suggest that the Veteran's back condition is related to service. Accordingly, a VA examination regarding the Veteran's claim is neither necessary nor warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). In summary, the Board finds that the evidence is persuasively against a finding that the Veteran's current back condition is related to his service. Therefore, the benefit of the doubt doctrine is inapplicable and service connection for a back condition is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch, 2021 U.S. App. LEXIS 37307. REASONS FOR REMAND 1. Entitlement to service connection for a joint condition, diagnosed as fibromyalgia, is remanded. In December 2020, the Veteran underwent a VA examination and was diagnosed with fibromyalgia of the bilateral knees and shoulders. The examiner then provided an opinion indicating that the Veteran's right knee condition was not related to his service, noting that medical records were silent for right knee pain during service. The examiner also addressed the Veteran's report of right knee pain during service due to a lot of exercising but indicated that there were no further complaints of knee pain until 2019, which does not establish chronicity of his condition. The examiner then noted that service treatment records were silent for knee or joint pain, that there was no evidence of any other causative condition noted to lead to fibromyalgia, and that there was no evidence in medical literature showing a relationship between fibromyalgia and vaccinations; however, the examiner indicated there was "unconfirmed evidence and case reports" that suggest vaccinations may trigger fibromyalgia or chronic pain. Another December 2020 medical opinion indicates that the Veteran's right shoulder condition was not related to his service as his in-service right shoulder pain was acute. Additionally, it was noted that there were no complaints of joint pain until 2019 and no evidence of complaints of joint pain or right shoulder pain in service treatment records. The examiner noted that there was no evidence of chronicity of care and that the Veteran's condition was not related to vaccinations received during service. However, the Board finds neither opinion adequately addresses whether the Veteran's diagnosed fibromyalgia is related to his service as they address the Veteran's right knee and right shoulder conditions separately. Additionally, a September 2019 VA treatment record reflects that the Veteran reported his joint pain onset shortly after the death of his newborn child and this contention has not been addressed. Therefore, remand for a new medical opinion is required. 2. Entitlement to service connection for vertigo is remanded. In December 2020, a VA examiner opined that the Veteran's vertigo was not related to his service as there was no chronic diagnosis, the objective examination was normal, and the Veteran's symptoms were subjective. In November 2021, another VA medical opinion was obtained, and the examiner opined that the Veteran's vertigo was not related to his service. In support of the opinion, it was again noted that the Veteran's objective examination was normal and that his symptoms were only subjective. Additionally, the examiner noted that the Veteran's vertigo was not related to vaccines, noting that side effects of vaccines are mild and not chronic. However, the record reflects that the Veteran was diagnosed with vertigo and a peripheral vestibular disorder, as noted on the January 2013 VA examination report. As the examiners' rationales essentially indicate that the Veteran does not have a current diagnosis, it is unclear whether the noted diagnoses were adequately considered. Therefore, remand for a new medical opinion is necessary. 3. Entitlement to service connection for a sinus condition, including sinusitis and rhinitis, is remanded. In December 2020, a VA examiner opined that the Veteran's sinus condition was not related to his service, noting that there was no diagnosis for a chronic condition, objective examination was normal, and the Veteran's symptoms were only subjective. It was also noted that there was no medical evidence indicating vaccines can cause sinusitis or rhinitis. In November 2021, another VA medical opinion was obtained, and the examiner opined that the Veteran's sinus condition was not related to his service. It was again noted that objective examination was normal and that the Veteran's symptoms were normal. The examiner also indicated that the Veteran's conditions were not related to vaccinations he received during service as side effects of vaccines are mild and resolve on their own in a few days and that there is no medical literature linking vaccination administration to sinusitis. However, the Board finds the opinions inadequate and remand for a new medical opinion is necessary. In this regard, the Board notes that the examiners' rationales both essentially indicate that the Veteran does not have a chronic condition and his symptoms are subjective, thereby indicating he does not have a current diagnosis. However, the record reflects that the Veteran was diagnosed with chronic sinusitis and nonallergic rhinitis during an October 2019 VA examination; thus, it is unclear whether this evidence was considered. Additionally, on his November 2019 VA Form 21-526EZ, Fully Developed Claim (Compensation), the Veteran reported exposure to dust during service. On remand, the examiner should also address whether the Veteran's sinus condition is caused by or otherwise related to his alleged exposure to dust during service. 4. Entitlement to service connection for a headache condition, including migraines, is remanded. In December 2020, a VA examiner opined that the Veteran's headache condition was not related to his service as he did not have a chronic diagnosis, objective examination was normal, and the Veteran's symptoms were only subjective. In November 2021, another VA examiner opined that the Veteran's headache condition was not related to his service again noting that the Veteran's objective examination was normal, and the Veteran's symptoms were subjective. The examiner also indicated that the Veteran's headaches were not related to vaccinations he received during service. The examiner noted that headaches are a mild side effect associated with vaccinations but resolve on their own within a few days and that medical literature does not link vaccine administration to headaches. However, the Board finds the opinions inadequate and remand for a new medical opinion is necessary. In this regard, the Board notes that the examiners' rationales both essentially indicate that the Veteran does not have a chronic condition and his symptoms are subjective, thereby indicating he does not have a current diagnosis. However, the record reflects that the Veteran was diagnosed with migraines during October 2019 and November 2021 VA examinations. Therefore, remand is required. 5. Entitlement to service connection for a disability manifesting as fatigue is remanded. The record reflects that the Veteran has consistently reported feeling fatigue, as noted in his private treatment records. However, it is unclear whether the Veteran's fatigue is a separate condition or is a symptom associated with identified disabilities. As this is a medical determination, remand for a medical opinion is required. 6. Entitlement to service connection for a gastrointestinal disability, including GERD and hiatal hernia, is remanded. In December 2020, a VA examiner opined that the Veteran's gastrointestinal disability was not related to his service, including the claimed in-service injury, but no further rationale was provided. In another December 2020 opinion, a VA examiner indicated that the Veteran's statement (that he did not go to sick call for his gastrointestinal symptoms during service because he did not want to lose eligibility to deploy but sought treatment as soon as he separated from service) was considered. The examiner then indicated that the Veteran was not diagnosed with GERD until August 2005, which was more than one year after separation, and that he had no symptoms prior to August 2005. Additionally, regarding the hiatal hernia, the examiner noted that it was not diagnosed until 10 years after separation. Thus, the examiner concluded that chronicity and disability could not be established. However, the Board finds the opinions inadequate as the examiners failed to provide adequate rationales. Specifically, the Veteran's contention that his gastrointestinal disability was caused by injury he sustained while lifting heavy tires at Fort Hood was not adequately addressed. Therefore, remand for a new medical opinion is required. 7. Entitlement to service connection for an acquired psychiatric disorder, to include depression, anxiety, sleep problems, and PTSD, is remanded. In the November 2020 Board remand, the Board requested the Veteran undergo a VA psychiatric examination to determine the nature and etiology of any acquired psychiatric disorder. Following examination of the Veteran, the examiner was asked to provide an opinion as to whether each diagnosed disorder was related to service, including vaccinations received on active duty. The examiner was specifically asked to address each vaccination, including the anthrax vaccination. In February 2021, the Veteran underwent a VA examination and was diagnosed with adjustment disorder with mixed anxiety and depression (it was determined that he did not meet criteria for a PTSD diagnosis). The examiner then opined that the Veteran's condition was not related to his service and, in support of the opinion, indicated that the Veteran's symptoms were related to many life events, including a dysfunctional marriage, and losing his job. The examiner indicated that an opinion as to whether his disorder was related to vaccinations received could not be provided by a psychologist. In October 2021, another VA examiner opined that the Veteran's acquired psychiatric disorder was not related to his service as his service treatment records did not show any evidence of the diagnosis, treatment, or symptoms suggestive of adjustment disorder during service or within one year of separation from service. The examiner then indicated that current medical literature did not support any vaccine causing or permanently aggravating any mental health condition. However, each vaccination, including anthrax, was not specifically addressed as requested in the Board remand order. Therefore, the Board finds remand is required to ensure substantial compliance with the Board's prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that where the remand orders of the Board are not substantially complied with, the Board errs as a matter of law when it fails to ensure substantial compliance). Additionally, the Board notes that the Veteran has reported his symptoms onset during service following the death of his child, as noted in a February 2020 VA treatment record. On remand, this evidence should be addressed. 8. Entitlement to service connection for tinea pedis is remanded. In December 2020, the Veteran underwent a VA examination and was diagnosed with tinea corporis and tinea pedis. The examiner then opined that the Veteran's conditions were not related to his service. In support of the opinion, the examiner referenced medical literature that explains the causes of the conditions and explained that one of the key determinants of diagnosing tinea pedis is visual inspection. The examiner then explained that attempting to diagnose the Veteran's reports of the condition during service would require speculation because one of the main ways to diagnose is visual inspection. In another December 2020 opinion, a VA examiner explained that the Veteran's condition was not related to his service as there is no evidence of skin rashes in the Veteran's medical records and on a 2004 anthrax immunization questionnaire, he denied experiencing skin rashes. The examiner then explained that, even taking into account the Veteran's self-reported statement regarding jock itch and foot infection, there is no method to determine what the diagnosis is for those conditions without resorting to speculation. However, the Board finds remand for a new medical opinion is required as the examiner did not adequately consider the Veteran's lay statements, namely that his condition started as jock itch and a foot condition during service. While the examiners did acknowledge the reports, they essentially indicated that his actual diagnosis during service cannot be determined without speculation without further explaining why the Veteran's reports of his condition are insufficient. Therefore, remand for a new medical opinion is required. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician addressing the etiology of the Veteran's fibromyalgia. The electronic claims file, including this remand, must be made available to the examiner for review. An examination should only be scheduled if the examiner deems one is necessary for providing the requested opinions. Following a review of the Veteran's claims file, the examiner should provide an opinion as to whether it is at least as likely as not (approximately a 50 percent or greater probability) the Veteran's fibromyalgia is related to his service, including (i) his reports of joint pain due to a lot of exercising; (ii) his reports that his joint pain onset shortly after the death of his newborn child; and (iii) vaccinations received while on active duty in October and November 2003 and March and May 2004. Any opinion provided should not be based on a finding that the Veteran's condition is related to exposures in the Southwest Asia Theater of Operations as the Veteran is not a Persian Gulf War Veteran. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 2. Obtain an addendum opinion from an appropriate clinician addressing the etiology of the Veteran's vertigo and headache condition (including migraines). The electronic claims file, including this remand, must be made available to the examiner for review. An examination should only be scheduled if the examiner deems one is necessary for providing the requested opinions. Following a review of the claims file, the examiner(s) must separately opine as to whether the Veteran's vertigo and headache condition (including migraines) are at least as likely as not (approximately a 50 percent or greater probability) related to an in-service injury, event, or disease, including vaccinations received while on active duty in October and November 2003 and March and May 2004. In providing the opinions, the examiner(s) must specifically address each vaccination, including the anthrax vaccination. Any opinion provided should not be based on a finding that the Veteran's condition is related to exposures in the Southwest Asia Theater of Operations as the Veteran is not a Persian Gulf War Veteran. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 3. Obtain an addendum opinion from an appropriate clinician addressing the etiology of the Veteran's sinus condition, to include sinusitis and rhinitis. The electronic claims file, including this remand, must be made available to the examiner for review. An examination should only be scheduled if the examiner deems one is necessary for providing the requested opinions. Following a review of the claims file, the examiner(s) must separately opine as to whether the Veteran's sinus conditions are at least as likely as not (approximately a 50 percent or greater probability) related to an in-service injury, event, or disease, including (i) vaccinations received while on active duty in October and November 2003 and March and May 2004 and (ii) alleged exposure to dust during service. In providing the opinion, the examiner(s) must specifically address each vaccination, including the anthrax vaccination. Any opinion provided should not be based on a finding that the Veteran's condition is related to exposures in the Southwest Asia Theater of Operations as the Veteran is not a Persian Gulf War Veteran. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 4. Obtain an addendum opinion from an appropriate clinician addressing the etiology of the Veteran's fatigue. The electronic claims file, including this remand, must be made available to the examiner for review. An examination should only be scheduled if the examiner deems one is necessary for providing the requested opinions. Following a review of the claims file, the examiner is asked to respond to the following: (a) State whether the Veteran has a disability manifested by fatigue that is separate and distinct from any currently diagnosed disability or whether the fatigue is a symptom of the identified disabilities. (b) If the fatigue is a manifestation of a separate and distinct disability, then opine as to whether the identified disability was at least as likely as not (approximately a 50 percent or greater probability) incurred in or is otherwise related to the Veteran's active service, including vaccinations received while on active duty in October and November 2003 and March and May 2004. The examiner must specifically address each vaccination, including the anthrax vaccination. Any opinion provided should not be based on a finding that the Veteran's condition is related to exposures in the Southwest Asia Theater of Operations as the Veteran is not a Persian Gulf War Veteran. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, then he or she must provide the reasons why an opinion would require speculation. 5. Obtain an addendum opinion from an appropriate clinician addressing the etiology of the Veteran's gastrointestinal disability, to include GERD and hiatal hernia. Following a complete review of the electronic claims file, including this remand, the examiner must opine as to whether it is at least as likely as not (approximately a 50 percent or greater probability) the Veteran's gastrointestinal disability is related to his active service, including an injury incurred while lifting heavy tires while stationed at Fort Hood. In providing the requested opinion, the examiner should consider the Veteran's lay statements, namely that he did not go to sick call for the condition because he did not want to lose eligibility to deploy but sought treatment as soon as he separated from service. Any opinion provided should not be based on a finding that the Veteran's condition is related to exposures in the Southwest Asia Theater of Operations as the Veteran is not a Persian Gulf War Veteran. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 6. Obtain an addendum opinion from an appropriate clinician addressing the etiology of any acquired psychiatric disorder. The examiner must opine whether each diagnosed disorder is at least as likely as not (approximately a 50 percent or greater probability) related to an in-service injury, event, or disease, to include (i) vaccinations received while on active duty in October and November 2003 and March and May 2004; and (ii) complications with his wife's pregnancy during service that resulted in the loss of his child. In providing the opinion, the examiner must specifically address each vaccination, including the anthrax vaccination. Any opinion provided should not be based on a finding that the Veteran's condition is related to exposures in the Southwest Asia Theater of Operations as the Veteran is not a Persian Gulf War Veteran. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion, without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 7. Obtain an addendum opinion addressing the etiology of the Veteran's tinea pedis and tinea corporis. Following a complete review of the electronic claims file, including this remand, the examiner must opine as to whether it is at least as likely as not (approximately a 50 percent or greater probability) the Veteran's condition is related to his active service, including his report of in-service jock itch/foot infection. Any opinion provided should not be based on a finding that the Veteran's condition is related to exposures in the Southwest Asia Theater of Operations as the Veteran is not a Persian Gulf War Veteran. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. (Continued on the next page) A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion, without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. M. SORISIO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Jiggetts 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.