Citation Nr: A25035997 Decision Date: 04/18/25 Archive Date: 04/18/25 DOCKET NO. 240925-476770 DATE: April 18, 2025 ORDER From July 3, 2024, entitlement to a disability rating greater than 70 percent for posttraumatic stress disorder (PTSD) with alcohol use disorder, in remission, is denied. REMANDED Entitlement to service connection for back disorder is remanded. FINDING OF FACT From July 3, 2024, the Veteran's PTSD with alcohol use disorder, in remission, was manifested by, at worst, occupational and social impairment with deficiencies in most areas, but without more severe manifestations more nearly approximating total occupational and social impairment. CONCLUSION OF LAW From July 3, 2024, the criteria for entitlement to a disability rating greater than 70 percent for PTSD with alcohol use disorder, in remission, are not met. 38?U.S.C. §§?1155; 5107; 38?C.F.R. §§?4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411.?? REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from June to August 2007, from November 2008 to December 2009, from March 2010 to May 2011, and from August 2012 to September 2013. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2024 rating decision, issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). In the September 2024 Decision Review Request: Board Appeal (Notice of Disagreement), VA Form 10182, the Veteran elected the Direct Review Docket. Therefore, for the PTSD claim the Board may only consider the evidence of record at the time of the August 2024 agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. If the Veteran would like VA to consider any evidence that was submitted the Board could not consider, he may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim(s), considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. For the back claim, because the Board is remanding the claim of entitlement to service connection for back disorder, any evidence the Board could not consider will be considered by the AOJ in the adjudication of the claim. 38 C.F.R. § 3.103(c)(2)(ii). From July 3, 2024, entitlement to a disability rating greater than 70 percent for servicePTSD with alcohol use disorder, in remission, is denied. The Veteran contends his current, 70 percent disability rating does not accurately reflect the severity of his service-connected psychiatric disability. Disability evaluations are determined by the application of the facts presented to VA's Schedule of Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment of earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38?U.S.C. §?1155; 38?C.F.R. §§?3.321(a), 4.1. VA adjudicators must consider whether to assign different ratings at different times during the rating period to compensate the Veteran for times when the disability may have been more severe than others. The Court has since extended this practice to established, as well as initial ratings. See Hart v. Mansfield, 21?Vet. App.?505, 509-10 (2007). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38?C.F.R. §?4.7. Except as otherwise provided, the effective date of an evaluation and award of compensation based on an increased rating claim will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The RO assigned an increased, 70 percent evaluation for the Veteran's service-connected psychiatric disability under the criteria of DC 9411, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders (General Formula). See 38?C.F.R. §?4.130. Under the General Formula, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29?Vet. App.?10, 22 (2017); 38?C.F.R. §?4.130. With respect to unlisted symptoms, the Board must determine whether such symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages and must determine whether the associated symptoms, listed and unlisted, rise to the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). Under DC 9411, a 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood.?? A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place; memory loss for names of close relatives, own occupation, or own name.??? See 38?C.F.R. §?4.130, DC 9411.? It is not enough for the Board to list the Veteran's symptoms, the Board must explain why the Veteran's symptoms, assessing their severity, frequency, and duration, support its assignment of a particular rating. In so doing the Board must consider the length of remissions, and the Veteran's capacity for adjustment during periods of remission. In rating disabilities, symptomatology from nonservice-connected disability should be considered symptomatology from service-connected disability in the absence of medical evidence that differentiates one from the other. In such cases, the reasonable doubt doctrine requires all symptoms be attributed to the service-connected disability. Mittleider v. West, 11?Vet. App.?181, 182 (1998) (per curiam). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be granted to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. To deny a claim on the merits, the evidence must clearly weigh against the claim. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). In August 2023, the Veteran underwent an initial VA examination. The examiner diagnosed PTSD and alcohol use disorder and indicated all symptoms and impairment were then attributable to PTSD as the alcohol use disorder was in sustained remission. See August 2023 VA Examination. The examiner noted PTSD symptoms of crowd avoidance, panic, anxiety, guilt, self-blame, passive suicidal ideation, distrust of others, irritability and anger with little to no provocation, including throwing things and yelling, low frustration tolerance, intrusive memories, nightmares, avoidance, persistent negative emotional state, feeling detached from others, persistent inability to experience positive emotions, hypervigilance, exaggerated startle response, problems concentrating, and sleep disturbance. Id. The examiner noted additional symptoms of depressed mood, anxiety, chronic sleep impairment, and difficulty establishing and maintaining effective work and social relationships. Id. Regarding social impairment, the Veteran then reported he was in a relationship with his partner for the past year and maintained a relationship with her two children. Id. He indicated he enjoyed working out but reported difficulty making new friends or connecting with non-veterans. Id. He indicated he was not close to his parents or siblings, despite having been close to them while growing up. Id. Regarding occupational impairment, he reported he then owned a wood working business with a partner and predominantly worked alone. Id. He denied difficulty completing jobs on schedule. Id. He indicated he had attended college and graduated with a chemistry major. Id. He reported he initially planned to become an optometrist but was unable to continue his schooling because he "had the shakes really bad." Id. On examination, he reported being in a "pretty good" mood, despite experiencing passive suicidal ideation. Id. The examiner noted his affect to be appropriate, his insight and judgement to be intact, and his thoughts to be linear and goal directed. Id. The examiner opined his psychiatric symptoms then resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation, consistent with the 30 percent rating criteria. Id. In a January 2024 periodic health assessment, the Veteran denied experiencing any nightmares, avoidance, exaggerated startle response, detachment, self-blame, loss of interest, and/or depressive symptoms. See January 2024 Service Periodic Health Assessment. Despite his psychiatric disability, he was found fully medically ready for deployment without limitation. Id. During a January 2024 VA mental health consult, he denied experiencing depressive symptoms over the prior 2 weeks, other than sleep disturbance nearly every day and denied experiencing anxiety symptoms other than irritability nearly every day and trouble relaxing more than half the days. See January 2024 Mental Health Consult. He then reported he was close to his mother and best friend, enjoyed a good relationship with his partner, and enjoyed golfing in his free time. Id. He indicated he then owned his own business and was starting up 2 other businesses as well which contributed some financial strain to his household. Id. He then denied experiencing any suicidal ideation. Id. In May 2024, the Veteran's PTSD was noted to be stable. See May 2024 VA Primary Care Note. He then reported ongoing sleep problems but denied experiencing depression or anxiety symptoms. Id. VA treatment records document an apparent worsening of psychiatric symptoms in or around June 2024, at which time the Veteran reported experiencing headaches, depression, sensitivity to noise, poor concentration, forgetfulness, irritability, poor frustration tolerance, and severe fatigue, loss of energy, and sleep impairment. See June 2024 TBI Note. In July 2024, the Veteran submitted the increased rating claim on appeal. In July 2024, he continued to report symptoms including severe fatigue/low energy and sleep impairment, moderate sensitivity to noise, poor concentration, forgetfulness, irritability, and low frustration tolerance, and mild headaches. See July 2024 Polytrauma Support Clinic Note. The Veteran then reported experiencing financial and work-related stressors (difficulty finding work and maintaining his small business) and increased conflict with his romantic partner related to his frustration that she did not clean up after herself and due to differences of opinion regarding how to parent her two children. See July 2024 Psychology Note. The Veteran's treating provider noted he was then also struggling with some adjustment issues due to the recent end of his military career. Id. He then denied experiencing any suicidal ideation. Id. In July 2024, the Veteran underwent a VA examination. See July 2024 VA Examination. The examiner diagnosed PTSD and alcohol use disorder, in remission. Id. The examiner noted PTSD symptoms of intrusive memories, nightmares, flashbacks, avoidance, persistent exaggerated negative beliefs, persistent negative emotional state, feelings of detachment/estrangement from others, survivor's guilt, persistent inability to experience positive emotions, irritable behavior and angry outbursts with little or no provocation, hypervigilance, exaggerated startle response, problems with concentration, and sleep disturbance. Id. The examiner opined PTSD symptoms caused clinically significant distress and impairment with social, occupational, or other important areas of functioning. Id. The examiner noted additional psychiatric symptoms of depressed mood, suspiciousness, chronic sleep impairment, mild memory loss, impairment of short- and long-term memory, flattened affect, disturbances of motivation and mood, and passive suicidal ideation. Id. The examiner noted the Veteran was diagnosed with traumatic brain injury but opined it was not possible to differentiate between his symptoms and impairment attributable to PTSD, alcohol use disorder, or traumatic brain injury because his traumatic brain injury and PTSD arise from the same event(s) and his alcohol use is a coping mechanism in relation to his PTSD symptoms. Id. The Veteran reported he continued to reside with his fiancée and her two children and continued to own and operate his own custom woodworking business. Id. The examiner did not otherwise specifically address instances of social and/or occupational impairment related to his service-connected psychiatric disability but opined his psychiatric disability then resulted in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, and/or mood, consistent with the 70 percent rating criteria. Id. Based on the foregoing, from July 3, 2024, the evidence of record documents psychiatric symptoms resulting in, at most, occupational and social impairment with deficiencies in most areas, but without more severe symptoms more nearly approximating total occupational and social impairment. The evidence of record does document a worsening of the Veteran's psychiatric symptoms around June 2024. However, it does not demonstrate resulting total occupational and social impairment. While the Veteran reported experiencing work-related stressors including difficulty finding work and maintaining his own business, he did not then attribute such difficulties to his psychiatric symptoms. The most recent relevant evidence of record indicates the Veteran continues to operate his own woodworking business and there is no evidence his psychiatric symptoms interfere with the performance of his work. Similarly, while the most recent relevant evidence of record indicates he was experiencing some conflict in his romantic relationship, he attributed this conflict to his fiancée's unwillingness to clean up after herself and to their different approaches to parenting, not to his psychiatric symptoms. The most complete description of his current psychiatric symptoms is documented in his July 2024 VA examination. While the examiner opined the psychiatric symptoms then caused clinically significant distress and impairment with social, occupational, or other important areas of functioning, the examiner did not indicate symptoms then resulted in total occupational and social impairment. No evidence of record indicates the Veteran experiences symptoms of gross impairment in thought processes or communication, persistent delusions, or hallucinations. There is no evidence he has engaged in any grossly inappropriate behavior. While he reported experiencing passive suicidal ideation, there is no indication he is in persistent danger of hurting himself or others. The evidence of record does not indicate he is unable to independently perform any activities of daily living due to his psychiatric symptoms. While he reported experiencing cognitive symptoms including impaired memory and difficulty concentrating, there is no evidence his cognitive symptoms result in disorientation to time or place and/or memory loss for the names of close relatives, his own occupation, or his own name. In sum, no evidence of record documents total social and/or occupational impairment due to the Veteran's psychiatric symptoms and, as such, the evidence of record documents psychiatric symptoms resulting in, at most, occupational and social impairment with deficiencies in most areas, consistent with the 70 percent rating criteria. Therefore, entitlement to a higher, 100 percent disability rating is not warranted. REASONS FOR REMAND Entitlement to service connection for back disorder is remanded. The Veteran contends he suffers from a back disorder that was incurred in or is otherwise related to an in-service event, injury, or illness. Under the AMA, remands are limited to correction of: (1) duty to assist errors occurring prior to the date of the RO decision on appeal, and (2) RO errors in satisfying a regulatory or statutory duty if correction of such error would have a reasonable possibility of aiding in substantiating the Veteran's claim. See 38 C.F.R. § 20.802(a). Remand is warranted to correct a duty to assist error. Specifically, remand is warranted to obtain an addendum VA medical opinion adequately addressing all theories of entitlement and evidence of record. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide an examination, such examination must be adequate). In August 2024, the Veteran underwent a VA examination. The examiner did not diagnose any back condition, pointing to imaging dated April 2011 and X-rays taken in conjunction with the examination, both normal. See August 2024 VA Examination. The Veteran reported the onset of back pain in 2008-2009 after falling down a hill about 75 feet and hitting his head. Id. He indicated he was also involved in multiple blasts. Id. He denied reporting any back injuries at the time of the accident and indicated he worked through his back pain for fear he would have to leave his duties if he reported it. Id. He reported current symptoms of mid-low back pain for which he reportedly sought emergency treatment on multiple occasions in the prior year. Id. He reported additional symptoms of pain after standing for long periods, with twisting, and with reaching above his shoulders. Id. He indicated his back pain resulted in functional impairment including difficulty sleeping and finding a comfortable sleeping position and pain with heavy lifting. Id. He indicated he also experienced pain in his right hip and thigh, and numbness from his right knee to toes due to which he must sleep with one leg off his bed. Id. He reported current treatment with lumbar support while sitting, stretching, NSAIDs, and over the counter topical medication. Id. He did not report any functional loss or impairment after repeated use over time but reported flareups of back pain once per month which persist for one day, precipitated by weather changes and alleviated by rest, time, stretching, and medication. Id. He rated his flareup back pain as an 8 out of 10 and indicated his flareups result in functional impairment including difficulty reaching, bending, lifting, and twisting. Id. On examination, the Veteran exhibited normal active range of motion. Id. The examiner did not perform passive range of motion testing because the Veteran exhibited normal active range of motion. Id. While he did not exhibit any limitation of motion, he reported experiencing pain on forward flexion, extension, left lateral flexion, and left lateral rotation. Id. The Veteran further reported pain with weightbearing, non-weightbearing, in active motion, and on rest/non-movement. Id. The Veteran was able to perform repetitions with no functional loss. Id. The examiner opined pain would result in functional impairment during flareups with estimated forward flexion to 80 degrees, extension to 20 degrees, right lateral flexion to 25 degrees, left lateral flexion to 20 degrees, right lateral rotation to 25 degrees, and left lateral rotation to 25 degrees. Id. The Veteran reported stiffness when sitting for long periods or on soft surfaces and indicated he had missed up to 5 weeks work time during the prior 12-month period due to back pain and difficulty bending, twisting, and lifting. Id. The examiner noted the Veteran complained of right lower extremity symptoms that could be consistent with radiculopathy but opined his reported lower extremity symptoms are likely related to his hip condition. Id. The evidence of record documents diagnosed disorders affecting the Veteran's left hip, knee, and ankle; however, the examiner did not explain how his diagnosed left lower extremity disorders relate to his reported right lower extremity symptoms. In a corresponding August 2024 VA medical opinion, the examiner opined it is less likely than not the Veteran has a current, chronic back condition that was incurred in or is otherwise related to an in-service event, injury, or illness. See August 2024 VA Medical Opinion. As a rationale, the examiner pointed to: (1) his service treatment records which the examiner indicated are silent for complaint, diagnosis, or treatment for a back condition during service; (2) the Veteran's denial of "muscle, joint, or low back pain" on an in-service periodic health assessment dated January 8, 2021; (3) an April 2011 CT of his spine which was normal; and (4) August 2024 X-rays of his lumbar and thoracic spine which were normal. Id. Based on the foreogoing, the examiner opined there is not enough objective medical evidence of record, to include the results of his August 2024 VA examination, to render a chronic diagnosis. Id. The examiner further opined the Veteran's reported subjective back pain is acute in nature, given the lack of evidence documenting any evaluation, treatment, or diagnosis of a back condition either during or after his separation from service-which the examiner indicated demonstrates a lack of chronicity or continuity of care such as would be seen with a chronic condition. Id. To the extent the examiner indicated the Veteran's service treatment records are silent for complaints of back pain, the opinion is inaccurate and, therefore, inadequate. See Reonal v. Brown, 5?Vet. App.?458, 461 (1993) (a medical opinion based upon an inaccurate factual premise has no probative value). The Veteran's service treatment records contain several complaints of back pain. In January 2011, the Veteran was seen for a possible traumatic brain injury after an IED went off on his right side, resulting in corneal pain and possible loss of consciousness. See January 2011 Service Treatment Note. He then further complained of experiencing "low back pain that is similar to his previous chronic low back pain." Id. He was then diagnosed with corneal irritation and mild traumatic brain injury, but no diagnosis was made concerning his complaints of low back pain and reported previous chronic low back pain. Id. In a July 2013 post-deployment health assessment after his deployment to Afghanistan from October 2012 through June 2013, he reported being "bothered a little" by back pain and pain in the arms, legs, or joints. See July 2013 Post-Deployment Health Assessment. In an October 2014 post-deployment health assessment after his deployment to Afghanistan beginning in July 2013, he again reported being a little bothered by back pain and pain in the arms, legs, or joints. See October 2014 Post-Deployment Health Assessment. He then received a referral for pain in the low back. See October 2014 Chronological Record of Medical Care. In a January 2021 periodic health assessment, he reported experiencing recurring muscle, joint, or low back pain for which he did not seek medical care since his last annual periodic health assessment. See January 2021 Periodic Health Assessment. It is unclear whether his reported recurring pain related to his lower back. He then denied receiving any civilian treatment or taking any prescription or over the counter medication. Id. In a January 2022 periodic health assessment, he again reported experiencing recurring muscle, joint, or low back pain for which he did not seek medical care since his last annual periodic health assessment. See January 2022 Periodic Health Assessment. It is unclear whether his reported recurring pain related to his lower back. He then denied regularly taking any prescription or over the counter medication. Id. In a January 2023 periodic health assessment, he denied experiencing any recurring muscle, joint, or low back pain. See January 2023 Periodic Health Assessment. Despite the foregoing, he reported experiencing chronic low back pain he was treating with self-care. Id. In addition to the foregoing service treatment records documenting complaints of back pain, the examiner did not address relevant lay evidence of record. In January 2010, the Veteran submitted an initial claim for service connection for a back disorder he reported began in November 2009. See January 2010 VA Form 21-526. In a January 2010 written statement, he reported experiencing frequent pain and stiffness in his back and neck which he then attributed to being tossed and banged into the sides of a turret while wearing ill-fitting body armor due to rough roads while serving as an armored vehicle gunner. See January 2010 Statement in Support of Claim. In April 2023, the Veteran attributed his back disorder to multiple IED explosions, heavy lifting, and bodily twisting during his active service. See April 2023 VA Form 21-526EZ. He then reported the onset of his back condition in 2009. Id. In the absence of evidence of a current disability, there can be no grant of service connection under the law. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In general, pain alone is not a current disability. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). However, the term "disability" refers to functional impairment of earning capacity, rather than the underlying cause of the impairment. Thus, pain may be considered a disability if it results in functional impairment. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). In his August 2024 VA examination, the Veteran reported functional impairment including difficulty sleeping, difficulty standing for long periods, stiffness with sitting for long periods or on soft surfaces, and difficulty with twisting and lifting above his shoulders. Moreover, the examiner opined he would suffer limitation of motion during flareups. Considering Saunders, on remand the examiner should provide an opinion as to whether it is at least as likely as not the Veteran's reported back pain results in a functional impairment of earning capacity, i.e., constitutes a disability for VA purposes. The Board notes that after the August 2024 rating decision on appeal, VA treatment records dated December 2009 documenting complaints of back pain and stiffness were added to the claims file. See VA Treatment Records, Received March 2025. Based on the foregoing, remand is warranted to obtain a further VA medical opinion adequately addressing all theories of entitlement and evidence of record. The matter is REMANDED for the following action: 1. In remanding this matter, the Board makes no credibility determination, express or implied at this juncture. 2. Obtain any outstanding VA treatment records and associate them with the claims file. 3. Forward the claims file to the August 2024 VA examiner or to an appropriate substitute clinician. The need for a further in-person or telehealth examination of the Veteran is left to the discretion of the clinician selected to write the opinion. After reviewing the claims file, including this Remand, the clinician is asked to opine on the following: (a.) Whether it is at least as likely as not (likelihood is in at least approximate balance or nearly equal, if not greater) the Veteran's back pain results in a functional impairment of earning capacity? (b.) If so, whether it is at least as likely as not (likelihood is in at least approximate balance or nearly equal, if not greater) the Veteran's back pain resulting in a functional impairment of earning capacity was incurred in or is otherwise related to an in-service event, injury, or illness? In answering the above questions, the clinician is requested to consider the following: (1) service treatment records documenting complaints of: (i) low back pain similar to previous chronic low back pain in January 2011 (See January 2011 Treatment Note, Received May 8, 2023); (ii) being bothered a little by back pain in July 2013 and October 2014 (See July 2013 Post Deployment Assessment; October 2014 Post Deployment Assessment); and (iii) chronic low back pain for which he was self-treating in January 2023 (See January 2023 Annual Periodic Health Assessment); (2) Tomah VAMC treatment records dated December 2009 documenting complaints of back pain and stiffness (See Tomah VAMC Treatment Records, Received March 2025); and (3) lay evidence of record in which the Veteran discusses his back pain (See January 2010 VA Form 21-526; January 2010 Written Statement; April 2023 VA Form 21-526EZ). Note: The Veteran is competent to report his lay observable symptoms and the onset of symptoms. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions requested. The clinician should further identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical literature, ect., relied upon in reaching the conclusion(s). If the clinician cannot provide an opinion to one or more of the above questions without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the clinician shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to one or more questions. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Given, R. A. 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.