Citation Nr: 22040124 Decision Date: 07/13/22 Archive Date: 07/13/22 DOCKET NO. 17-63 067 DATE: July 13, 2022 ORDER Entitlement to service connection for sleep apnea is granted. Entitlement to a rating higher than 10 percent for loss of sense of taste is denied. Entitlement to service connection for compensation purposes for the loss of teeth, numbers one and two, is denied Entitlement to an effective date earlier than March 30, 2017, for the award of service connection for treatment purposes only, for the loss of teeth, numbers one and two, is denied. REMANDED Entitlement to service connection for high blood pressure is remanded. Entitlement to service connection for a vision disorder is remanded. Entitlement to an initial compensable disability rating for dysphagia for solids and liquids, prior to May 7, 2018, and a rating in excess of 30 percent thereafter, is remanded. FINDINGS OF FACT 1. There is probative medical evidence indicating that the Veteran's sleep apnea has been permanently aggravated by his service-connected major depressive disorder with anxious distress. 2. The Veteran has already been assigned the maximum rating allowed for loss of sense of taste. 3. The Veteran has replaceable missing teeth, which are not considered a disability for VA compensation purposes. The Veteran did not incur dental trauma, and he does not have any impairment of the bone or jaw. 4. The Veteran did not submit any correspondence prior to March 30, 2017, indicating an intent to claim entitlement to service connection for a dental disorder. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for sleep apnea have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 2. There is no legal basis for the assignment of a schedular evaluation higher than 10 percent for loss of sense of taste. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.87a, Diagnostic Code 6276. 3. The criteria for service connection for the loss of teeth, numbers one and two, for compensation purposes, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.381, 4.150. 4. The criteria for an effective date earlier than March 30, 2017, for the award of service connection for compensation purposes for the loss of teeth, numbers one and two, have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.151, 3.155, 3.158, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1966 to September 1969, including service in the Republic of Vietnam. This case comes to the Board of Veterans' Appeals (Board) from September 2016, February 2017, and October 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office. In a May 2019 decision and remand, multiple claims, including service connection for a psychiatric disorder and for sleep apnea, were decided by the Board, and the issues of entitlement to service connection for hypertension and for higher ratings for loss of taste and dysphagia were remanded. In September 2019, the Board's denial of the claims for service connection for a psychiatric disorder and sleep apnea were vacated, because additional evidence had been submitted by the Veteran and his attorney which had not been considered by the Board in making its decisions. In an April 2020 rating decision, entitlement to service connection for an acquired psychiatric disorder, to include major depression with anxious distress, was granted. This is a full grant of the Veteran's claim for service connection for a psychiatric disorder, and the issue is no longer part of the current appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Service Connection for Sleep Apnea The Board finds that there is sufficient evidence to find that entitlement to service connection for sleep apnea is warranted. Generally, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection requires evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). This permits service connection not only for a disability caused by a service-connected disability, but also for the degree of disability resulting from aggravation of a disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In this case, there is evidence that the Veteran's sleep apnea has been permanently aggravated by his service-connected psychiatric disorder, diagnosed as major depressive disorder with anxious distress. The evidence clearly shows that the Veteran has a current diagnosis of sleep apnea. The May 2021 VA examination found that the Veteran had been diagnosed with obstructive sleep apnea in April 2017, and he has reported that his condition began in 1997. The Veteran has reported having symptoms of snoring, restless sleep, morning headaches, and daytime sleepiness. The Veteran has also submitted an August 2018 Disability Benefits Questionnaire and evaluation from physician M.B. She wrote that the Veteran's depressive disorder caused him significant sleep impairment, and that medical research had shown than psychiatric disorders were commonly associated with sleep apnea. She cited a recent study that found that subjects with depression had a higher prevalence of sleep apnea, and that CPAP treatment reduced both sleep apnea and psychiatric symptoms. She wrote that the Veteran was treated with Citalopram, which is an anti-depressant, and which has been known to cause secondary effects on sleep. She explained that it was a selective serotonin reuptake inhibitor, and that this can cause increased sleep onset latency and/or increased number of awakenings and arousals, leading to an overall decrease in sleep efficiency. She concluded that it was her opinion that the Veteran's depressive disorder and anti-depressant medication more likely than not caused and permanently aggravated his sleep apnea. A medical opinion has therefore been provided by a competent physician who reviewed the Veteran's medical records and provided a thorough medical opinion that is consistent with the evidence of record, and which was accompanied by adequate rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). While a May 2021 VA examiner provided a negative nexus regarding whether the Veteran's sleep apnea was aggravated beyond the natural progression by his psychiatric disorder, the Board finds that this opinion does not address the Veteran's specific contentions, or the evidence presented by the private examiner. It states that sleep apnea is multifactorial and that there is no direct causality of the psychiatric disorder medications aggravating the sleep apnea, but this rationale is found to be conclusory, and less persuasive than the more specific assertions, supported by medical evidence, of the private examiner. The Board therefore accepts that the weight of the more probative medical opinion is in favor of the claim. In sum, the Veteran currently has a diagnosis of sleep apnea, and there is persuasive and probative evidence which shows that the disorder was permanently aggravated by his service-connected psychiatric disorder. The claim is granted. Increased Rating for Loss of Sense of Taste The Veteran has also appealed the 10 percent rating that has been assigned for loss of sense of taste. The Veteran has attended VA examinations in May 2017 and July 2019 that confirm that he has loss of sense of taste. Diagnostic Code 6276 provides a maximum rating of 10 percent for complete loss of sense of taste. As such, the Veteran is currently in receipt of the maximum disability evaluation available for this disability under Diagnostic Code 6276. 38 C.F.R. § 4.89a. The symptoms of the claimant's loss of sense of taste are manifested by precisely that. May 2017 testing has found that he has a decreased ability to recognize numerous substances, including coffee, lemon, and salt, and he had no ability to recognize sugar. The July 2019 VA examiner found that loss of sense of taste was "complete." This indicates that the Veteran's symptoms are appropriately contemplated by the schedular rating criteria. Without any evidence reflecting that the Veteran's disability picture is not sufficiently contemplated by the rating schedule, referral for a determination of whether his disability picture requires the assignment of an extraschedular rating is not warranted. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). The Veteran has not indicated that he believes an extraschedular rating is warranted, nor is there any evidence raising this issue. The record before the Board does not suggest that loss of sense of taste requires frequent hospitalization or causes a marked interference with employment, nor does it indicate there is additional symptomatology that suggests that referral for an extraschedular consideration under 38 C.F.R. § 3.321 is indicated. The Board notes that the Veteran has already been assigned a separate 10 percent rating for loss of sense of smell, and this issue has not been appealed to the Board. The Board's prior May 2019 Board remand also requested that an examination be held to determine whether the Veteran had symptoms of facial paralysis that were separate from his already service-connected loss of sense of taste and dysphagia. While these remand instructions were not followed, the Board finds that this failure does not prevent the Board from deciding this issue at this time, as the Veteran is already in receipt of the maximum rating for loss of sense of taste, and the issue of entitlement to a higher rating for dysphagia, including any possible separate ratings for facial paralysis symptoms, is addressed in the remand below. There is therefore no legal entitlement to an initial rating in excess of 10 percent for loss of sense of taste. The Board has carefully reviewed the rating schedule and finds no other Diagnostic Code which would be appropriate for this issue. The Veteran currently has the highest possible schedular rating provided, and the claim is denied. See Sabonis v. Brown, 6 Vet. App. 426 (1994). Compensation for Dental Disorder The Veteran has also requested compensation for the loss of teeth, numbers one and two. In an October 2017 rating decision, the Veteran was granted service connection for dental treatment purposes, because it was found that his loss of teeth numbers one and two were secondary to his squamous cell cancer. He was assigned an effective date of March 30, 2017, the date that the claim was received. The Veteran submitted a Notice of Disagreement in October 2017 stating that he disagreed with the effective date of the award and the evaluation of the disability. While the Veteran has been awarded service connection for treatment purposes, missing teeth are not considered a "disability" for VA compensation purposes. Even though the Veteran's missing teeth have been medically linked to his service-connected tonsil cancer, they are not "disabilities" that can be evaluated under the same type of regulations that are used to determine whether physical disorders of the body are service connected. See, e.g., Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The requirements for service connection for dental disorders for compensation purposes are far more restrictive, and in this case, the law does not allow for service connection for compensation purposes to be granted. The law and regulations provide that treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are considered non-disabling conditions and may be considered service-connected solely for the purpose of determining entitlement to VA dental examination or outpatient dental treatment. See 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 17.161; see also Woodson v. Brown, 8 Vet. App. 352, 354 (1995). Generally, service trauma is defined as an injury or wound produced by an external physical force during a service member's performance of military duties. See Nielson v. Shinseki, 607 F.3d 802 (Fed. Cir. 2010). The term dental trauma does not include, for example, the intended effects of treatment by VA. See VAOPGCPREC 5-97. Dental trauma also does not include intended results of proper medical treatment provided by the military. See Nielson, 607 F.3d 802. VA regulations distinguish between "replaceable missing teeth", or periodontal disease and teeth lost as a result of "loss of substance of body of maxilla or mandible." Simington v. West, 11 Vet. App. 41 (1998); 38 C.F.R. § 3.381. Dental disabilities that may be awarded compensable disability ratings are set forth under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. In this case, the evidence is very clear that the Veteran has not had a traumatic injury to his face, teeth, mandible, or maxilla. The Veteran has never indicated that he had such an injury, and the October 2017 VA examination found no anatomical loss or bony injury to mandible, maxilla, mouth, or any other part of the face. The evidence also shows that the Veteran does not have any of the bone loss disorders which are specified under 38 C.F.R. § 4.150. The evidence only indicates that the Veteran has dry mouth as a result of his service-connected tonsil squamous cell carcinoma, and that this contributed to the loss of these two teeth. The October 2017 VA examiner confirmed that the Veteran had loss of teeth related to dental deterioration caused by dry mouth, which was likely caused by his radiation treatment. Under 38 C.F.R. § 3.381, treatable or replaceable teeth, can be considered service-connected solely for the purpose of establishing eligibility for outpatient dental treatment as provided in 38 C.F.R. § 17.161, and not for compensation purposes. The October 2017 VA examiner found that the Veteran's lost teeth could be restored by suitable prosthesis, and they are, therefore, replaceable teeth which can only be service connected for treatment purposes. There is absolutely no evidence indicating that the Veteran has had any trauma to the mouth or jaw, or that he has any other dental disorder for which service connection for compensation purposes can be allowed. The law is therefore against allowing service-connected compensation for the Veteran's loss of teeth, numbers one and two. See 38 C.F.R. §§ 3.303, 3.381. The benefit of the doubt doctrine is inapplicable, and the claim must be denied. Earlier Effective Date for Dental Disorder The Board is also unable to award an effective date any earlier than March 30, 2017, for the award of service connection for treatment purposes for the loss of teeth numbers one and two. March 30, 2017, the date the Veteran submitted his claim for service connection for "dental issues due to radiation" is the appropriate effective date for his award of service connection for compensation purposes. The effective date for service connection is the day following separation from active service, or the date entitlement arose, if the claim is received within one year after separation from service; otherwise, it will be the date of receipt of the claim, or date entitlement arose, whichever is the later. 38 C.F.R. § 3.400(b)(2)(i). There is absolutely no correspondence that was received from the Veteran prior to March 30, 2017, that could be interpreted as a claim for benefits for a dental disorder, or as an Intent to File a Claim within one year prior to March 30, 2017. The Veteran also has not asserted that he actually submitted a claim prior to that date or that any claims had been pending. The Board acknowledges that the Veteran's tonsil squamous cell carcinoma has been service connected since June 22, 2010. When a veteran submits a claim, VA is required to consider all issues that are reasonably raised by the claimant or by the evidence of record. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009). Although the Veteran had these teeth removed prior to 2017, the Veteran did not report this to VA or indicate in any of his written correspondences or VA examinations that he had undergone this procedure, or that he believed he had a dental disorder related to his tonsil cancer or radiation. VA was therefore not on notice that any such related symptoms or disorder needed to be developed as part of the Veteran's claim for squamous cell carcinoma. See Talbert v. Brown, 7 Vet. App. 352 (1995) (While the VA should broadly interpret submissions from a Veteran, it is not required to conjure up claims not specifically raised.). The Veteran did not raise the issue of any secondary dental disorders until March 2017, and VA therefore had no way of knowing that this was a claim he wished to bring as a downstream issue from the claim for service connection for tonsil squamous cell carcinoma. There are no other documents submitted by the Veteran which could constitute a claim of entitlement to service connection for a dental disorder or would have raised the possibility of a dental disorder which was part of his prior claim for service connection for tonsil squamous cell carcinoma. In sum, the Board finds that there is no pending claim or valid claim that can allow for an effective date earlier than March 30, 2017, for the award of service connection for the loss of teeth numbers one and two. The Board is bound by applicable regulations regarding when an effective date may be assigned. In the absence of any claim, either formal or informal, of entitlement to service connection for a dental disorder prior to March 30, 2017, there is no basis under law to assign an earlier effective date, and the claim must be denied. See Sabonis, 6 Vet. App. 426. REASONS FOR REMAND High Blood Pressure The Veteran has also requested service connection for high blood pressure, or hypertension. He has reported that the condition began around 1997. This issue was remanded in May 2019, and the Board remand instructed that a VA medical opinion be obtained which would address whether it was at least as likely as not that the Veteran's hypertension was related to his presumed exposure to herbicide agents in the Republic of Vietnam. The examiner was instructed to specifically comment on the National Academy of Science's Agent Orange: Update 11 (2018), which upgraded hypertension from the category of "limited or suggestive" evidence of an association with herbicide exposure the category of "sufficient" evidence. A VA medical opinion was obtained in July 2019. The examiner wrote that the condition was less likely than not incurred in or caused by service, and as explanation, she wrote that the Veteran's medical records were silent for hypertension during military service, and there was no chronicity of care. The Board finds that this medical opinion is wholly inadequate. The VA examiner clearly did not read the Board's remand instructions, as she made no mention of herbicide agents or the National Academy of Science's Agent Orange: Update 11. The April 2020 Supplemental Statement of the Case also made no mention of the Board's remand instructions or whether the Veteran's hypertension was related to herbicide agents. The Board finds that there has not been substantial compliance with the prior remand, and this issue is again remanded. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Vision Disorder The Veteran has also claimed that he has a vision disorder, which he reports has manifested as double vision, and which he believes is related to service or to his service-connected squamous cell carcinoma. The Veteran attended a VA examination in September 2017. He was diagnosed with right upper eyelid ptosis, bilateral cataracts, and bilateral dry eyes. The examiner noted the Veteran's reports of having intermittent double vision and blurred vision. The examiner wrote that these symptoms were covered by the diagnoses of cataracts and dry eyes. The examiner then wrote that the Veteran's eye disorders were less likely than not proximately due to or the result of the service-connected loss of taste residuals or tonsil squamous cell cancer. She wrote that tonsil squamous cell cancer was not related to the ocular structure nor connected to the eyes to produce the ocular pathology, and that the dry eyes were due to the exposure of the cornea to dry conditions and a minimal area of coverage of the interior conjunctiva and cornea. She wrote that cataracts were due to the natural aging of the lens. The Board appreciates the VA examiner's opinion, but finds that it is not adequate to decide the claim at this time. The Veteran has indicated that one of his residuals from his tonsil cancer is an inability to produce saliva, and that at the same time this began he had to start using eye drops more than 3 times a day. The Board finds that these assertions need to be specifically addressed, and it is insufficient for the examiner to simply say that tonsil cancer was not related to the ocular structures, as it does seem possible that the function of the salivary glands is connected in some way to the function of the lacrimal and meibomian glands, or that the radiation that affected the function of the salivary glands could affect other glands as well. The Veteran also has asserted that his exposure to herbicide agents, such as Agent Orange, led to his cancer and its residuals, and the Board finds that a medical opinion must be obtained which also addressed the impact of herbicide agents on his current eye disorders. Dysphagia In the May 2019 Board remand, the Board requested that an examination be held to evaluate all of the Veteran's residuals of his tonsil squamous cell cancer, to specifically include consideration of whether he has paralysis of any of the facial nerves, and whether this paralysis resulted in symptomatology which overlapped with his dysphagia and loss of taste, or whether they had distinct symptoms which would warrant their own, separate rating/s. The Veteran attended VA examinations in July 2019 to evaluate his loss of sense of taste and his dysphagia, but no evaluation was made of his facial nerve paralysis. In December 2021, the Veteran also attended a VA examination for esophageal conditions. The examiner found no change in the Veteran's dysphagia and noted complete loss of taste and smell, but made no discussion or evaluation of his facial paralysis. The Board finds that its prior Board remand instructions have been completely disregarded, and no attempt was made to evaluate his facial paralysis, nor was this addressed at all in the April 2020 Supplemental Statement of the Case. This is a total lack of compliance with the prior remand, and the issue is again remanded in order to obtain an appropriate examination and medical opinion about the Veteran's facial paralysis symptoms. See Stegall, 11 Vet. App. at 271. The matters are REMANDED for the following action: 1. Obtain all VA treatment records since February 2022. 2. Schedule the Veteran for a VA examination to address the etiology of the Veteran's hypertension. All necessary tests and studies should be accomplished, and the examiner should provide a complete rationale for all conclusions reached. The examiner should provide an opinion as to whether it is at least as likely as not that hypertension is related to the Veteran's presumed exposure to herbicide agents during active service. In rendering the requested opinion, the examiner must specifically comment on the National Academy of Science's Agent Orange: Update 11 (2018), which upgrades hypertension from the category of "limited or suggestive" evidence of an association with herbicide exposure the category of "sufficient" evidence; and whether the Veteran has other risk factors that are more likely the cause of hypertension given his complete medical history. A complete and fully explanatory rationale must be provided. If the opinion cannot be rendered without resorting to speculation, the examiner must explain why. 3. Schedule the Veteran for a VA eye examination to address the nature and etiology of the Veteran's current eye disorders, including cataracts, dry eyes, and double vision. All necessary tests and studies should be accomplished, and the examiner should provide a complete rationale for all conclusions reached. The examiner should then address: a) What are the Veteran's current eye diagnoses? For the Veteran's reports of having blurry vision and double vision, what diagnoses most likely account for these symptoms? b) For all disorders found, is it at least as likely as not that the disorder is related to the Veteran's presumed exposure to herbicide agents during active service? c) For all disorders found, is it at least as likely as not that the disorder has been either i) caused or ii) aggravated by the Veteran's service-connected tonsil squamous cell cancer residuals? Please discuss the Veteran's assertions that since his cancer, he has been unable to produce saliva and has difficulty swallowing, and at the same time began having very dry eyes and needing to use eye drops. Please also discuss the October 2017 dental evaluation which found that the Veteran's radiation treatment had irritated the soft tissue of his mouth, causing dry mouth, and whether the radiation treatment could also have irritated the glands of the eyes. A complete and fully explanatory rationale must be provided. If the opinion cannot be rendered without resorting to speculation, the examiner must explain why. 4. Schedule the Veteran for a VA examination with an appropriate physician or specialist to evaluate the current severity of his dysphagia and facial paralysis associated with his tonsil squamous cell carcinoma residuals. All necessary tests and studies should be accomplished, and the examiner should provide a complete rationale for all conclusions reached. The examiner is asked to identify and clarify all residuals of the Veteran's service-connected tonsil squamous cell cancer, including all overlapping symptomatology. For instance, the Veteran is currently service-connected for loss of taste and dysphagia; however, it is unclear whether the bilateral incomplete moderate paralysis of the Veteran's cranial nerve V (trigeminal), cranial nerve VII (facial), and cranial nerve IX (glossopharyngeal), identified upon VA cranial nerves examination in April 2017, results in overlapping symptomatology including loss of taste or dysphagia, or distinct residuals which would potentially be compensable under an alternate diagnostic code regarding disease of the cranial nerves. The examiner must specifically indicate whether the Veteran has any facial paralysis which manifests in symptoms separate from his loss of taste and dysphagia. The examiner should consider and discuss all relevant evidence of record; however, to assist the examiner with his/her review of the record, the Board provides the following relevant evidence, with citations to the record: An April 22, 2011, VA examination documents that the Veteran's squamous cell cancer of mouth had been in full remission for six years with the residual of loss of saliva production, loss of taste, scarring of the throat, and difficulty swallowing. See VBMS entry with document type, "VA Examination," receipt date 04/22/2011. An April 2017 VA loss of taste examination documents diagnoses of hyposmia and hypogeusia. The examiner documented that the Veteran's cancer residuals included a constant runny nose, loss of sense of taste, difficulty swallowing, some loss of sensation in the face, and partial loss of sense of smell. See "VA Examination," receipt date 05/25/2017. A concurrent April 2017 VA cranial nerves examination documents diagnoses including olfactory nerve damage, glossopharyngeal nerve damage, and facial agnosia (facial and trigeminal nerve damage). The VA examiner identified the Veteran's cranial nerve impairment as: bilateral incomplete moderate paralysis of cranial nerve V (trigeminal), cranial nerve VII (facial), and cranial nerve IX (glossopharyngeal). See "VA Examination," receipt date 05/25/2017. A concurrent April 2017 VA sinusitis/rhinitis examination documents the Veteran's diagnosis of rhinitis, residual of tonsil squamous cell, which the examiner concluded was a correction of a prior diagnosis of difficulty swallowing. See "VA Examination," receipt date 05/25/2017. A May 2018 VA esophageal conditions examination report documents a diagnosis of dysphagia for solids and liquids. The Veteran reported extreme difficulty with swallowing meats, pasta, and breads, and intermittent dysphagia for liquids. He noted the disability was difficult to manage as he no longer made saliva. The examiner noted that the Veteran's service-connected disability had progressed to not only involve difficulty with swallowing solids, but also difficulty with swallowing liquids. See "VA Examination," receipt date 05/07/2018. A July 2019 VA esophageal conditions examination at which the Veteran reported having occasional trouble consuming liquids and difficulty with nasal discharge during eating. See "C&P Exam," receipt date 07/22/2019. A December 2021 VA esophageal conditions examination found that the Veteran had symptoms of choking and difficulty swallowing solids and liquids. See "C&P Exam," receipt date 12/06/2021. A complete and fully explanatory rationale must be provided. If the opinion cannot be rendered without resorting to speculation, the examiner must explain why. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mary E. Rude, 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.