Citation Nr: 23055893 Decision Date: 10/12/23 Archive Date: 10/12/23 DOCKET NO. 19-27 826 DATE: October 12, 2023 ORDER Entitlement to service connection for hypertension, claimed as high blood pressure, is denied. Entitlement to service connection for an upper respiratory disability, claimed as allergic rhinitis and sinusitis, is denied. Entitlement to service connection for a right wrist disability, to include as secondary to a service-connected cervical spine/neck cephalgia, is denied. Entitlement to service connection for a gastrointestinal disability, other than irritable bowel syndrome (IBS), is denied. Entitlement to service connection for obstructive sleep apnea, to include as secondary to costochondritis, is denied. Entitlement to service connection for a right hip strain, to include as secondary to service-connected radiculopathy of the lower extremities, is denied. FINDINGS OF FACT 1. The Veteran's hypertension was not shown during active duty, was not diagnosed for many years post-service, and the evidence fails to establish an etiological relationship between the Veteran's claimed hypertension and her active service. 2. The evidence fails to establish an etiological relationship between the Veteran's upper respiratory disability, claimed as allergic rhinitis and sinusitis, and her active service. 3. The evidence fails to establish an etiological relationship between the Veteran's right wrist disability and her active service or her service-connected cervical spine/neck cephalgia. 4. The evidence fails to establish an etiological relationship between the Veteran's gastrointestinal disability, other than IBS, and her active service. 5. The evidence fails to establish an etiological relationship between the Veteran's obstructive sleep apnea and her active service or her service-connected costochondritis. 6. The evidence fails to establish an etiological relationship between the Veteran's right hip strain and her active service or her service-connected radiculopathy of the lower extremities. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension, claimed as high blood pressure, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for an upper respiratory disability, claimed as allergic rhinitis and sinusitis, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. A right wrist disability was not incurred in or aggravated by service, nor is it proximately due to or the result of the Veteran's service-connected cervical spine/neck cephalgia. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for entitlement to service connection for a gastrointestinal disability, other than IBS, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. Obstructive sleep apnea was not incurred in or aggravated by service, nor is it proximately due to or the result of the Veteran's service-connected costochondritis. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. A right hip strain was not incurred in or aggravated by service, nor is it proximately due to or the result of the Veteran's service-connected radiculopathy of the lower extremities. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1989 to July 1993, with additional periods of active duty training including from October 1988 to March 1989. The Veteran testified before the undersigned Veterans Law Judge in January 2022. A copy of the transcript is of record. This case was previously before the Board in June 2022. The Board granted service connection claims for IBS, a cervical spine disability, right knee disability, and left knee disability at that time; moreover, in addition to the claims listed above, the Board remanded a claim for service connection for blepharitis, claimed as blurred vision. In a March 2023 rating decision, the RO granted service connection for blepharitis and allergic conjunctivitis of the left and right eyes. These issues are no longer before the Board. Additional development was completed with respect to the remaining issues. A May 2023 supplemental statement of the case was issued and the claims are once again before the Board. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show: (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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden elements is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Service connection is also warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. Finally, 38 U.S.C. § 1154(a) requires that VA give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Specifically, lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). 1. Entitlement to service connection for hypertension, claimed as high blood pressure. 2. Entitlement to service connection for an upper respiratory disability, claimed as allergic rhinitis and sinusitis. 3. Entitlement to service connection for a right wrist disability, to include as secondary to a service-connected cervical spine/neck cephalgia. 4. Entitlement to service connection for a gastrointestinal disability, other than IBS. 5. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected costochondritis. 6. Entitlement to service connection for a right hip strain, to include as secondary to service-connected radiculopathy of the lower extremities. The Veteran asserts that she has hypertension, an upper respiratory disability (claimed as allergic rhinitis and sinusitis), right wrist disability, gastrointestinal disability (other than IBS), obstructive sleep apnea and a right hip disability related to service. She alternatively asserts that her right wrist disability is secondary to her service-connected cervical spine/neck cephalgia and her right hip strain is secondary to her service-connected radiculopathy of the lower extremities. She has additionally vaguely asserted that her obstructive sleep apnea is secondary to her service-connected costochondritis. See July 2020 Substantive Appeal. The Board will first consider the right wrist, right hip, and obstructive sleep apnea disabilities on a secondary service connection basis. A May 2018 VA examination and secondary opinion was initially obtained regarding the Veteran's right hip. As noted in the initial June 2022 BVA Remand, the May 2018 secondary opinion regarding the Veteran's right hip did not address secondary aggravation as required by 38 C.F.R. § 3.310(b). This opinion is accorded little probative value as to the question of secondary service connection. December 2022 VA examinations were subsequently completed regarding the Veteran's right wrist and right hip disabilities. The Veteran was diagnosed with a right ganglion cyst, right triangular fibrocartilaginous complex (TFCC) injury, and right wrist strain. The Veteran was additionally diagnosed with right trochanteric pain syndrome (right hip). In December 2022 opinions, the VA examiner opined that the Veteran's claimed right hip disorder is less likely than not proximately due to or the result of the Veteran's radiculopathy of the right lower extremities. The examiner noted that lumbar radiculopathy is a separate unrelated condition to a right hip trochanteric pain syndrome. He noted that lumbar radiculopathy affecting the leg is due to nerve impingement, in this case the sciatic nerve. The examiner noted that trochanteric pain syndrome is a lateral hip pain involving inflammation and irritation at the bursa of the lateral hip. The hip bursa and sciatic nerve are anatomically distinct and as a result a hip trochanteric pain syndrome (bursitis) could not be due to or the result of lumbar radiculopathy. The examiner additionally noted that the current diagnosed right hip disability was less likely than not aggravated beyond its natural progression by the Veteran's lower radiculopathy. He noted that the hip bursa and sciatic nerve are anatomically distinct and as a result a hip trochanteric pain syndrome (bursitis) could not be aggravated by lumbar radiculopathy. With respect to the Veteran's right wrist disability, the examiner opined that the disorder is less likely than not proximately due to or the result of the Veteran's cervical spine/neck cephalgia. He noted that a right wrist sprain, right wrist ganglion cyst and right wrist TFCC injury are conditions caused by anatomical problems specifically in the right wrist. He noted that a cervical spine/neck cephalgia pain are conditions in the cervical spine and neck that are distinct, unrelated and anatomically separate from the wrist. The examiner stated that there is no medical evidence in the case or literature to support a wrist strain, wrist cyst formation or wrist TFCC type injury being due to a cervical spine issue or neck pain. Moreover, the examiner stated that the Veteran's diagnosed right wrist disabilities are less likely than not aggravated beyond its natural progression by the Veteran's cervical spine/neck cephalgia. He explained how the right wrist conditions were anatomically separate from her cervical spine/neck cephalgia pain. The examiner stated that there is no medical evidence in the case or literature to support wrist strain, wrist cyst formation or wrist TFCC type injury being aggravated beyond its natural progression by a cervical spine issue or neck pain. The Board finds that the examinations together are adequate for evaluation purposes. Significantly, the examiner considered the Veteran's history. Together, these opinions provide evidence against these claims, making it less than likely such a connection exists. The Board further finds compelling the fact that no probative medical evidence is of record to support a conclusion that the Veteran's right hip disorder was caused or aggravated by her service-connected radiculopathy of the lower extremities or that her right wrist disorder was caused or aggravated by her service-connected cervical spine/neck cephalgia. After weighing the pertinent evidence of record, the Board concludes that the persuasive weight of the evidence is against entitlement to service connection for either a right hip disability as secondary to her service-connected radiculopathy of the lower extremities or right wrist disability as secondary to her service-connected cervical spine/neck cephalgia. With respect to her secondary service connection claim for obstructive sleep apnea, the Board has closely reviewed the medical and lay evidence in the Veteran's claims file and finds no evidence that may serve as a medical nexus between the Veteran's obstructive sleep apnea and service-connected costochondritis. No medical professional has established a relationship between the Veteran's obstructive sleep apnea and service-connected costochondritis. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, the etiology of obstructive sleep apnea, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Other than a bare assertion that her obstructive sleep apnea might be related to her service-connected costochondritis, without any reason or explanation as to how such relationship might occur, neither the bare assertion nor the evidence in this case indicates that the obstructive sleep apnea may be associated with the costochondritis. For this reason, not even the low standard to trigger a secondary nexus opinion is triggered. See Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (a conclusory generalized lay statement alleging nexus between a current disability and service does not meet the standard to warrant a VA examination); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In light of the above discussion, the Board concludes that the evidence weighs against the claim for service connection for obstructive sleep apnea on a secondary basis, and there is no doubt to be otherwise resolved. Regarding the claims for service connection on a presumptive basis, the Board has also considered that where a veteran served continuously for ninety days or more during a period of war, or during peacetime service after December 31, 1946, and certain disabilities become manifest to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1131, 1133; 38 C.F.R. §§ 3.307, 3.309. However, the Veteran's treatment records do not reflect a diagnosis of or treatment for hypertension for many years following separation from service. Thus, this presumption is not available to the Veteran. Id. The Board also considers the theory of entitlement to service connection on a direct basis. Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). However, the evidence does not show a causal relationship between any of the claimed disabilities (hypertension, upper respiratory, right wrist, gastrointestinal disorder other than IBS, obstructive sleep apnea, or right hip) and any other incident of active service, as will be discussed below. The Veteran testified at her January 2022 BVA hearing that she was first treated for blood pressure issues in service and continues to be treated to this day and is on several medications. See BVA Hearing T. at 7. The Veteran explained in her notice of disagreement that she had had preeclampsia while pregnant in service. She stated that she also started experiencing respiratory issues in service and continues to suffer from this same symptomatology. See BVA Hearing T. at 3, 22. In her notice of disagreement, submitted in March 2018, the Veteran alleged being treated for sinusitis and allergic rhinitis during service at Ft. Hood. The Veteran testified that she hurt her wrist in service and throughout the years her right hand has just gotten weaker and weaker. See BVA Hearing T. at 10. She testified that it is probably an overuse injury caused by all the lifting she did in service. With respect to the Veteran's gastrointestinal disability, the Board notes that the Veteran was recently awarded service connection for IBS by the Board in June 2022. The decision below determines whether service connection for an additional gastrointestinal disability, separate and distinct, from her already service-connected disability, is warranted. The Veteran additionally testified that she began having sleep issues, specifically snoring, while in service. See BVA Hearing T. at 16. With respect to her right hip, the Veteran asserts that she has a right hip disability stemming from an in-service injury. See BVA Hearing T. at 20. A September 1987 entrance examination noted a normal clinical evaluation of her lungs and chest, heart, abdomen, musculoskeletal system, upper and lower extremities. Service treatment records noted abdominal pain in August 1990, November 1991, January 1992, and February 1992. An August 1990 service treatment record additionally noted fatigue. A September 1992 service treatment record noted a pulled muscle in the upper right thigh. A March 1993 service treatment record noted viral conjunctivitis. A May 1993 separation examination reflects similar normal findings to her entrance examination. Specific to her hypertension, the statements of the Veteran reporting a history of continued symptomatology since active service have been considered but are not found to be accurate. In making this determination, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is not required to accept an appellant's uncorroborated account of her active service experiences. Wood v. Derwinski, 1 Vet. App. 190 (1991). The mere absence of medical records does not contradict a Veteran's statements about her symptom history. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, if it is determined based upon reliable evidence that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). This period without problems weighs against the claim. Additionally weighing against the claim is the fact that the Veteran did not have a diagnosis related to hypertension for many years following separation from service. Records first note hypertension around 2007. See February 2007 private treatment record. Moreover, in a February 2018 private treatment record, the Veteran self-reported being diagnosed with hypertension about fifteen years prior. Specific to her upper respiratory (sinusitis/allergic rhinitis), right wrist, gastrointestinal (other than IBS), obstructive sleep apnea, and right hip claims, the Board has also considered the statements of the Veteran regarding continuity of symptoms since service. See for example BVA Hearing Testimony. However, the Federal Circuit has held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). As the Veteran's claimed upper respiratory (sinusitis/allergic rhinitis), right wrist, gastrointestinal (other than IBS), obstructive sleep apnea, and right hip disabilities are not listed under 3.309(a), continuity of symptomatology is simply not applicable in the present case. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board nevertheless notes that treatment records do not note complaints of upper respiratory (sinusitis/allergic rhinitis), right wrist, gastrointestinal (other than IBS), obstructive sleep apnea, or right hip issues for many years following separation from service. See April 2013 private record (rhinitis); July 2008 private treatment record (right wrist); June 2010 private treatment record (sleep apnea); and May 2012 private treatment record (right hip). While private treatment records as early as June 1994 reflect complaints of abdominal discomfort, the Veteran has already been awarded service connection for IBS, and as will be shown below the Veteran does not have another intestinal disability, separate from IBS, that is related to service. The Board next considers that service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. Here, however, the service and post-service evidence provides negative evidence against these claims. With respect to her hypertension claim, the Veteran was provided a December 2022 VA examination. She was diagnosed with hypertension. The examiner opined that the claimed condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that it was less likely than not that any high blood pressure or hypertension had its clinical onset during the Veteran's active duty or within 1 year of service separation. The examiner noted that there is inadequate medical evidence that the Veteran's hypertension was incurred in or caused by service. He acknowledged the Veteran's reports of having had preeclampsia during the birth of her child, but noted that this is a temporary condition. He noted that the Veteran's blood pressure was normal in the next 3 days post-delivery as documented and all blood pressure readings during service were reviewed with no clear evidence of hypertension. There are no contradictory medical opinions of record. With respect to her upper respiratory claim, the Veteran was provided a respiratory conditions VA examination and a separate sinusitis/rhinitis VA examination. She was diagnosed with benign pulmonary lung nodules and allergic rhinitis. The examiner opined that the claimed condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that it was less likely than not that any upper respiratory disability had its clinical onset during the Veteran's active duty or is otherwise etiologically related to her active service. The examiner noted that there is inadequate medical evidence that the Veteran's allergic rhinitis was incurred in or caused by service. It was noted that a service treatment record in March 1993 had noted viral conjunctivitis, which is a virus and not an allergy condition. The examiner noted no evidence of chronic allergic rhinitis in the service treatment records and a negative separation examination. The examiner noted that an October 2020 treatment record had noted allergy symptoms present for 15 years which would be 2005. The examiner additionally considered that chronic sinusitis had not been diagnosed. While the examiner acknowledged that the Veteran had benign pulmonary lung nodules that were diagnosed in 2020, the examiner opined that they were not due to service as they were diagnosed over 25 years following separation. There are no contradictory medical opinions of record. With respect to the Veteran's right wrist, a May 2018 VA examination and opinion were initially provided. In a June 2022 Board remand, it was noted that the examiner had provided a negative opinion because the Veteran did not have a diagnosis. The Board noted that the medical opinion was inadequate and a new VA examination and opinion were requested. As such, little probative value is accorded to this May 2018 medical opinion. The Veteran was most recently afforded a December 2022 VA examination and opinion. She was diagnosed with a right ganglion cyst and right TFCC injury. The examiner opined that the claimed condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that it was less likely than not that any right wrist disability had its clinical onset during the Veteran's active duty or is otherwise etiologically related to service. The examiner considered that the Veteran states her right wrist condition is due to service related overuse but did not remember any specific traumatic wrist injuries. He noted that there was a notation of a right thumb fracture in the service treatment records, but that a right wrist injury had not been noted. The examiner considered that the Veteran was first treated chronically for a right wrist condition in 2013. The examiner noted that if the right wrist condition had had its onset in service, it would be expected that the Veteran would have been evaluated and treated before 2013, 20 years after discharge. There are no contradictory medical opinions of record. Specific to her gastrointestinal disability, other than IBS, claim, the Board reiterates that the Veteran is already in receipt of service-connected for irritable bowel syndrome (IBS). The claim was remanded by the Board in June 2022 to determine if the Veteran had a separate gastrointestinal disability, other than IBS. The Veteran underwent a December 2022 VA examination. She was diagnosed with irritable bowel syndrome. The examiner opined that the claimed condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that it was less likely than not that any gastrointestinal disorder, other than IBS, had its onset during the Veteran's active duty or is otherwise related to the Veteran's service. The examiner noted that the Veteran was service connected for IBS and there were no other intestinal conditions diagnosed. The examiner stated that the Veteran's other gastrointestinal issues (cholecystectomy surgery, and GERD) were beyond the scope of an intestinal examination. There are no contradictory medical opinions of record. With respect to her obstructive sleep apnea claim, the Veteran was provided a VA examination. She was diagnosed with obstructive sleep apnea. The examiner opined that the claimed condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that it was less likely than not that any obstructive sleep apnea had its clinical onset during the Veteran's active duty or is otherwise etiologically related to her active service. The examiner noted that there is inadequate medical evidence that the Veteran's obstructive sleep apnea was incurred or caused by service. The examiner noted that a June 2010 sleep study was negative for obstructive sleep apnea, but there was evidence that it started sometime between 2010 and 2015, well after her discharge from service in 1993. The examiner considered that a service treatment record noted a day of fatigue in August 1990. He stated that this is nonspecific for obstructive sleep apnea. The examiner considered that the Veteran has chronic insomnia, but noted that the Veteran is service-connected for depression and anxiety with chronic sleep impairment as part of that rating. The examiner noted that a chronic sleep impairment is a separate unrelated condition from obstructive sleep apnea, which is caused by an anatomical oral airway blockage. There are no contradictory medical opinions of record. Specific to her right hip disability, the Veteran was initially provided a September 2018 VA examination and opinion. A negative etiological opinion was provided. In the June 2022 Board remand, inadequacies in this medical opinion were noted and little probative value is accorded to this opinion. The Veteran was most recently afforded a December 2022 VA examination. She was diagnosed with trochanteric pain syndrome of the right hip. The VA examiner opined that the Veteran's claimed disability is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran's right hip disorder less likely than not had its clinical onset during the Veteran's active duty service, or is otherwise etiologically related to her active service. The examiner noted that there is inadequate medical evidence that the Veteran's right hip trochanteric pain syndrome was incurred in or caused by service. The examiner noted that the Veteran had been seen for one day of acute right hip strain in September 1992. He noted that the current diagnosis is a different hip condition, right hip trochanteric pain syndrome (bursitis). The examiner stated that an acute one day muscular strain does not result in or predispose to development of right hip trochanteric pain syndrome over 25 years later. There are no contradictory medical opinions of record. The most recent opinions, most recently obtained on remand, when reviewed together, are considered highly probative, as they are shown to have been based on a review of the Veteran's claims file, and are accompanied by a sufficient explanation and findings on these highly complex medical questions. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board has closely reviewed the medical and lay evidence in the Veteran's claims file and finds no evidence that may serve as a medical nexus between the Veteran's service and her claimed hypertension, upper respiratory condition, right wrist, gastrointestinal disorder (other than IBS), obstructive sleep apnea or right hip disabilities. Although the Board recognizes that the Veteran is competent to report pain, snoring and stomach issues, the evidence in this case clearly demonstrates that her claimed disabilities developed many years following separation from service. Additionally, the Veteran does not have a separate gastrointestinal issue distinct from her already service-connected IBS. The weight of the evidence of record simply does not support a finding that her hypertension, upper respiratory condition, right wrist, gastrointestinal disorder (other than IBS), obstructive sleep apnea or right hip disorders are in any way related to service. In any event, the probative value of the statements of the Veteran is outweighed by the most recent opinions of record. (Continued on next page) In sum, the competent evidence does not establish that the Veteran's hypertension, upper respiratory condition, right wrist, gastrointestinal disorder (other than IBS), obstructive sleep apnea or right hip are related to her period of active duty in any way. The most probative medical evidence of record has demonstrated that the Veteran's claimed disabilities are less likely than not related to service. The claims are denied. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. M. Clark, 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.