KNEE IMPAIRMENT OF

M. C. GRAHAM · 2026 · Case ID: A26040509

MIXED

Summary

The veteran, who served in the Army from October 1967 to June 1970, including service in Vietnam, appeals the denial of service connection for bilateral knee and shoulder disabilities, and an increased rating for coronary artery disease. The Board denied service connection for the knee and shoulder claims, finding the evidence weighed persuasively against a service connection and that no duty-to-assist error occurred regarding examinations. For coronary artery disease, the Board found the evidence did not support a rating higher than the 30 percent already granted, as heart failure symptoms only manifested at workloads exceeding 5.0 METs. However, the Board granted a separate 10 percent rating for an implantable cardiac pacemaker, noting its placement in 2016 for atrial fibrillation, but found no higher rating warranted under other diagnostic codes. The claim for an increased rating for PTSD was remanded due to the AOJ's failure to obtain relevant private treatment records from Evers Psychological Associates, which constituted a pre-decisional duty-to-assist error.

Rationale

No competent medical evidence linking current disability to in-service event; No duty-to-assist error regarding cancelled VA examination; Record weighs against service connection

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

251009-587774

Full Decision Text

Citation Nr: A26040509
Decision Date: 04/30/26 Archive Date: 04/30/26

DOCKET NO. 251009-587774
DATE: April 30, 2026

ORDER

Entitlement to service connection for a left knee disability is denied.

Entitlement to service connection for a right knee disability is denied.

Entitlement to service connection for a left shoulder disability is denied.

Entitlement to service connection for a right shoulder disability is denied.

Entitlement to a disability rating in excess of 30 percent for coronary artery disease is denied.

Entitlement to a separate 10 percent rating for implantable cardiac pacemaker, but no higher, is granted.

REMANDED

Entitlement to a disability rating in excess of 30 percent for post-traumatic stress disorder (PTSD) is remanded.

FINDINGS OF FACT

1. The Veteran's left knee disability is not related to an in-service event, injury, or disease.

2. The record weighs persuasively against a finding that the Veteran had a right knee disability during the appeal period.

3. The record weighs persuasively against a finding that the Veteran had a left shoulder disability during the appeal period.

4. The record weighs persuasively against a finding that the Veteran had a right shoulder disability during the appeal period.

5. The Veteran experienced heart failure symptoms from a workload of 5.1-7.0 metabolic equivalents (METs), but no fewer.

6. The Veteran had an implantable cardiac pacemaker during the appeal period.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.304.

2. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.304.

3. The criteria for entitlement to service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.304.

4. The criteria for entitlement to service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.304.

5. The criteria for entitlement to a disability rating in excess of 30 percent for coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.21, 4.3, 4.7, 4.104, Diagnostic Code 7005.

6. The criteria for entitlement to a separate 10 percent rating for an implantable cardiac pacemaker have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.21, 4.3, 4.7, 4.104, Diagnostic Code 7018.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the Army from October 1967 to June 1970, including service in the Republic of Vietnam. The Board thanks the Veteran for his service.

The rating decisions on appeal were issued in March 2025 and July 2025 and constitute initial decisions; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

In the October 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran listed the notification dates of these rating decisions and elected the Hearing docket. A Board hearing was held on January 20, 2026 before the undersigned Veterans Law Judge and a transcript has been associated with the record.

Therefore, the Board may only consider the evidence of record at the time of the March 28, 2025 agency of original jurisdiction (AOJ) decision on appeal with respect to the issue of service connection for bilateral shoulder disabilities, and the evidence of record at the time of the July 17, 2025 rating decision with respect to the other issues on appeal, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing,
Judge and a transcript has been associated with the record.

Therefore, the Board may only consider the evidence of record at the time of the March 28, 2025 agency of original jurisdiction (AOJ) decision on appeal with respect to the issue of service connection for bilateral shoulder disabilities, and the evidence of record at the time of the July 17, 2025 rating decision with respect to the other issues on appeal, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran 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 claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

However, because the Board is remanding the claim for entitlement to an increased rating for PTSD, any evidence the Board could not consider will be considered by the AOJ in the adjudication of that claim. 38 C.F.R. § 3.103(c)(2)(ii).

The issues of entitlement to service connection for bilateral knee and shoulder disabilities were subject to prior denials in a November 2017 AOJ decision. In the rating decisions on appeal, AOJ found that the Veteran had submitted new and relevant evidence sufficient to readjudicate the claims. The Board is bound by these favorable findings. 38 CFR § 3.104(c).

As a final introductory matter, the Board notes that it is cognizant of the recent decision issued by the United States Court of Appeals for Veterans Claims (Court) in the case of Williams v. McDonough, 37 Vet. App. 305 (2024). There, the Court held, in essence, that the Board must refrain from deciding a case until the case proceeds to the point where a docket switch is no longer permitted under the terms of 38 C.F.R. § 20.202(c)(2). Id. at 310.

In the present case, as noted above, the Veteran appeared at a Board hearing and provided testimony in support of his appeal pursuant to 38 C.F.R. § 20.302. As such, a docket switch is no longer possible. See 38 C.F.R. § 20.202(c)(2) ("Requests to modify a Notice of Disagreement will not be granted if the appellant has submitted evidence or testimony as described in 20.302 and 20.303."). Under the circumstances, the Board may proceed with adjudication of the Veteran's appeal without further delay.

As to the increased rating claims on appeal, the appeal period runs from November 20, 2024, the date of receipt of the Veteran's VA Form 20-0995, Decision Review Request: Supplemental Claim, to July 21, 2025, the notification date of the rating decision on appeal.

Service Connection

Generally, to establish service connection for a claimed disorder, the following must be shown: (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, 1167 (Fed. Cir. 2004).

Secondary service connection can be established when a disability is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. To be awarded secondary service connection, there must be evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). To be service connected on a secondary basis under a causation theory, the primary disability need not be service-connected, or even diagnosed, at the time the secondary condition is incurred. Frost v. Shulkin, 29 Vet. App. 131,
the result of a service-connected disease or injury. 38 C.F.R. § 3.310. To be awarded secondary service connection, there must be evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). To be service connected on a secondary basis under a causation theory, the primary disability need not be service-connected, or even diagnosed, at the time the secondary condition is incurred. Frost v. Shulkin, 29 Vet. App. 131, 138 (2017) (holding that there was not a temporal requirement inherent in 38 C.F.R. § 3.310 (a) for claims for service connection on a secondary basis). A service-connected disability need only be a contributing cause, not the sole contributing cause, to establish secondary service connection. See Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (holding that 38 U.S.C. § 1110 employs only but-for causation in direct and secondary service connection claims, not proximate causation).

VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay testimony is competent to prove that a claimant exhibited certain lay-observable symptoms and the time that those symptoms appeared. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board can find lay statements competent and sufficient to establish that a condition existed if the lay statements are used to support a later diagnosis. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson, 581 F.3d at 1316.

When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in approximate balance, with the veteran prevailing in either event, or whether the evidence weighs persuasively against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990).

1. Entitlement to service connection for a left knee disability.

The Veteran contends that he is entitled to service connection for a left knee disability incurred on active duty. He reports that his knees "blew up" in service, which he attributes to heavy lifting. See January 2026 Board hearing transcript.

VA treatment records near the appeal period do not show a formal diagnosis of a left knee disability.

According to May 2025 and June 2025 VA emergency department treatment records, the Veteran was treated for low back pain radiating to his left knee. While no diagnosis was rendered, the Board will resolve all reasonable doubt in the Veteran's favor to find that this pain, for which he was seen at the emergency department during the pendency of the claim, caused a functional impairment of earning capacity and thus constituted a disability for VA purposes. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). The first element of service connection is met.

While the Veteran was scheduled for a VA knee examination, this examination was cancelled at the Veteran's request in April 2025. As such, the Board finds that there was no pre-decisional duty-to-assist error on which a remand to obtain a new examination or medical opinion may be based. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (VA's duty to assist is "not always a one-way street.") The record does not otherwise contain any competent medical evidence linking this current left knee disability to an in-service event, injury, or disease.

To the extent that his left knee disability is secondary to a low back condition, the Board has considered whether the record indicates that the Veteran's low back condition itself might be related to an in-service event or injury
request in April 2025. As such, the Board finds that there was no pre-decisional duty-to-assist error on which a remand to obtain a new examination or medical opinion may be based. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (VA's duty to assist is "not always a one-way street.") The record does not otherwise contain any competent medical evidence linking this current left knee disability to an in-service event, injury, or disease.

To the extent that his left knee disability is secondary to a low back condition, the Board has considered whether the record indicates that the Veteran's low back condition itself might be related to an in-service event or injury so as to raise a claim for service connection for a low back disability as a primary disability. DeLisio v. Shinseki, 25 Vet. App. 45, 55 (2011).

In this regard, an August 1969 service treatment record (STR) notes complaints of low back pain and weakness that were assessed as a fever of unknown origin. A November 1967 STR noted back pain that was assessed as a muscle strain. However, the Veteran's spine was clinically normal upon examination according to his June 1970 separation examination report. No low back condition was noted and the Veteran reported that his condition was "excellent." Further, the Veteran has not contended that he has suffered from continuous back symptoms since service. As such, a claim for a left knee disability secondary to a low back disability was not reasonably raised by the record.

As the record weighs persuasively against a finding that the Veteran's left knee disability is related to an in-service event or disease or is otherwise related to any incident of his active service, the benefit-of-the-doubt rule is not applicable and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

2. Entitlement to service connection for a right knee disability.

3. Entitlement to service connection for a left shoulder disability.

4. Entitlement to service connection for a right shoulder disability.

The Veteran contends that he suffers from a right knee disability and bilateral shoulder disabilities incurred on active duty. See January 2026 Board hearing transcript.

At the January 2026 Board hearing, the Veteran reported having received treatment for shoulder and knee pain from VA providers at the East Orange VA Medical Center. However, VA treatment records are silent for complaints of or treatment for a right knee or shoulder disability during or near the pendency of the claim.

To the extent that the Veteran's claim can be construed as a competent report of right knee and bilateral shoulder pain, the Board notes that the record does not show that such pain results in any functional impairment of earning capacity so as to constitute a disability for VA purposes. Saunders, 886 F.3d 1356.

As noted above, the Veteran's VA knee examination was cancelled at his request and as such there was no duty-to-assist error in failing to obtain an examination or medical opinion.

While the Veteran was not scheduled for a VA examination for his shoulders, the record at the time of the May 2025 AOJ decision did not establish that the Veteran suffered an event, injury, or disease in service or indicate that the Veteran's claimed shoulder disabilities or symptoms may be associated with such an event or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). As such, there was no duty-to-assist error in failing to afford the Veteran an examination for these claimed disabilities. The Board acknowledges the Veteran's reports at the January 2026 Board hearing that he has experienced bilateral shoulder symptoms since service or shortly following service. However, such post-decisional evidence cannot serve as a basis for a remand in the AMA system.

As the record weighs persuasively against a finding that the Veteran had a right knee or left or right shoulder disability for VA purposes during the appeal period, the benefit-of-the-doubt rule is not applicable and the claims must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

Increased Ratings

Disability ratings are based on average impairment in earning capacity resulting from a particular disability and are determined by comparing symptoms shown with criteria in VA's Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities.

Where there is a question as to which of two ratings apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned
the benefit-of-the-doubt rule is not applicable and the claims must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

Increased Ratings

Where there is a question as to which of two ratings apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. An exception to this rule occurs when the rating criteria are successive. In such a case, all the requirements of the lower levels must be met before a higher level is awarded, so 38 C.F.R. §§ 4.7 and 4.21 do not apply. Johnson v. Wilkie, 30 Vet. App. 245 (2018).

With a claim for an increased initial rating, separate staged ratings may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In a claim for increase in a previously established rating, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007).

1. Entitlement to a disability rating in excess of 30 percent for coronary artery disease

The Veteran contends that a 30 percent disability is warranted for his service-connected coronary artery disease. In a March 2026 rating decision, the Veteran was granted a 30 percent rating under DC 7005, effective January 4, 2022. Thus, he is in receipt of a 30 percent rating for the entire period on appeal. The Board will therefore consider whether a rating in excess of 30 percent is warranted.

Under DC 7005, coronary artery disease is rated in accordance with the General Rating Formula for Diseases of the Heart. 38 C.F.R. § 4.104, Diagnostic Code 7005. A 30 percent rating is warranted where a workload of 5.1-7.0 METs results in heart failure symptoms, or where there is cardiac hypertrophy or dilatation confirmed by echocardiogram or equivalent (e.g., multigated acquisition scan or magnetic resonance imaging). A 60 percent rating is warranted where a workload of 3.1-5.0 METs results in heart failure symptoms. A 100 percent rating is warranted where a workload of 3.0 METs or less results in heart failure symptoms.

One MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2). When the level of METs at which breathlessness, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in those symptoms may be used. Id.

For purposes of the General Rating Formula for Diseases of the Heart, heart failure symptoms include, but are not limited to, breathlessness, fatigue, angina, dizziness, arrhythmia, palpitations, or syncope. Id. at Note (3).

The most recent VA examination of record for the Veteran's heart disability was conducted in January 2022. The Board affords the report of this examination only limited probative weight as it predates the period on appeal by
testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in those symptoms may be used. Id.

The most recent VA examination of record for the Veteran's heart disability was conducted in January 2022. The Board affords the report of this examination only limited probative weight as it predates the period on appeal by over two years. A VA examination in connection with this claim was cancelled at the Veteran's request in April 2025.

According to the January 2022 VA examination report, the Veteran held a diagnosis of coronary artery disease. An interview-based METs test was conducted and showed that the Veteran experienced fatigue at >5-7 METs, a level found to be consistent with activities such as walking 1 flight of stairs, golfing (without cart), mowing lawn (push mower), and heavy yard work (digging).

According to a February 2025 VA cardiology note, the Veteran can walk 1-2 miles on flat surfaces.

According to a March 2025 VA primary care note, the Veteran had non-obstructive coronary artery disease with no chest pains, shortness of breath, congestive heart failure, or palpitations.

According to a May 2025 VA cardiology note, the Veteran exercised regularly every morning, including stretching and a two-mile walk. He reported experiencing palpitations and shortness of breath when cutting the grass, which was quite heavy exertion for him.

At the January 2026 VA Board hearing, the Veteran reported difficulty climbing the stairs in his two-story home.

After careful consideration of the relevant evidence of record, the Board finds that the Veteran's coronary artery disease did not manifest by heart failure symptoms at a workload of 5.0 METs or less. The January 2022 VA examination report, VA treatment records, and the Veteran's own reports show an onset of heart failure symptoms with activities such as cutting grass and climbing 1 flight of stairs, activities associated with 5.1 to 7.0 METs.

As the record weighs persuasively against the assignment of a rating in excess of 30 percent under DC 7005, the benefit-of-the-doubt rule is not applicable and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

2. Entitlement to a separate 10 percent rating for implantable cardiac pacemaker.

VA treatment records show the placement of a cardiac pacemaker in July 2016.

DC 7018 provides that for one month, following hospital admission for implantation or reimplantation, a 100 percent rating is warranted. Thereafter, such is to be evaluated as supraventricular arrhythmias under DC 7010, ventricular arrhythmias under DC 7011, or AV block under DC 7015. Such further provides that a minimum rating of 10 percent is assigned for implantable cardiac pacemakers.

Under DC 7010, a 10 percent rating is warranted for supraventricular tachycardia confirmed by ECG, with one to four treatment interventions per year; or, confirmed by ECG with either continuous use of oral medications to control or use of vagal maneuvers to control. A 30 percent rating is warranted for supraventricular tachycardia confirmed by ECG with five or more treatment per year.

Examples of supraventricular tachycardia include, but are not limited to: Atrial fibrillation, atrial flutter, sinus tachycardia, sinoatrial nodal reentrant tachycardia, atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, atrial tachycardia, junctional tachycardia, and multifocal atrial tachycardia. Id. at Note (1).

A treatment intervention occurs whenever a symptomatic patient requires intravenous pharmacologic adjustment, cardioversion, and/or ablation for symptom relief. Id at Note (2).

The January 2022 VA examination reported noted the 2016 placement of the pacemaker in connection with his atrial fibrillation, a type of supraventricular tachycardia under DC 7010. This required the use of continuous oral medication (Eliquis) but not treatment interventions.

According to a
, atrioventricular reentrant tachycardia, atrial tachycardia, junctional tachycardia, and multifocal atrial tachycardia. Id. at Note (1).

A treatment intervention occurs whenever a symptomatic patient requires intravenous pharmacologic adjustment, cardioversion, and/or ablation for symptom relief. Id at Note (2).

According to a February 2025 VA cardiology pacemaker remote transmission note, the Veteran experienced a non-sustained ventricular tachycardia.

The Board finds that a minimum 10 percent rating, but no higher, is warranted DC 7018.

A 30 percent rating under DC 7010 is not warranted as the record weighs persuasively against a finding that the Veteran had supraventricular tachycardia with five or more treatment interventions per year.

While the Veteran experienced a non-sustained ventricular tachycardia in February 2025, the record does not show that he experienced sustained ventricular arrhythmias with hospital admission. Nor does it show that he experienced ventricular aneurysmectomy with inpatient hospital admission or had an automatic implantable cardioverter-defibrillator. As such, a 100 percent evaluation under DC 7011 is not warranted at any point during the appeal period.

Further, the rating criteria under DC 7015 for AV blocks is in effect identical to such provided in DC 7005, which governs the evaluation of his service-connected CAD. Thus, assigning a separate rating under DC 7015 for the same symptomatology already contemplated by the rating assigned under DC 7005 would result in impermissible pyramiding. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994).

Thus, based on the foregoing, the Board finds that the assignment of a separate 10 percent rating, but no higher, for implantation of cardiac pacemaker is warranted for the entire period on appeal.

REASONS FOR REMAND

1. Entitlement to a disability rating in excess of 30 percent for PTSD is remanded.

The Veteran contends that he is entitled to a 50 percent disability rating for his service-connected PTSD.

According to an October 2023 private treatment record, the Veteran received weekly psychotherapy at Evers Psychological Associates in Manasquan, New Jersey. The AOJ should have requested that the Veteran provide a release to obtain records of this relevant private treatment. 38 C.F.R. § 3.159(e)(2). Remand is necessary to correct this pre-decisional duty-to-assist error. 38 C.F.R. § 20.802(a).

The Board intimates no credibility findings at this time.

The matter is REMANDED for the following action:

1. After receiving necessary authorization from the Veteran, please make reasonable efforts to obtain records of mental health treatment the Veteran received at Evers Psychological Associates, P.C., in Manasquan, New Jersey, beginning in or around September 2023.

M. C. GRAHAM

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Alvarez, D.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.

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