Citation Nr: 20071476 Decision Date: 11/05/20 Archive Date: 11/05/20 DOCKET NO. 08-08 075 DATE: November 5, 2020 ORDER The claim of entitlement to service connection for a respiratory disability, claimed as chronic obstructive pulmonary disease (COPD), is denied. The claim of entitlement to service connection for a central neurological disability, to include Meniere’s disease, is denied. FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam and is presumed to have been exposed to herbicides including Agent Orange and other chemicals; interstitial lung disease and mild ataxia with impaired balance are not recognized by VA as causally related to such exposure. 2. The most probative evidence of record indicates that the Veteran’s interstitial lung disease was first manifested many years after service and does not demonstrate that this condition began during or is etiologically related to his honorable active duty service. 3. The most probative evidence of record indicates that the Veteran’s mild ataxia with impaired balance first manifested many years after service and does not demonstrate that this condition began during or is etiologically related to his honorable active duty service. CONCLUSIONS OF LAW 1. The criteria for service connection for a respiratory disability, diagnosed as interstitial lung disease, have not been met. 38 U.S.C. §§ 1110, 1132, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.311 (2019). 2. The criteria for service connection for a central neurological disability, diagnosed as mild ataxia with impaired balance, have not been met. 38 U.S.C. §§ 1110, 1132, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.311 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1968 to November 1970, to include service in the Republic of Vietnam. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a November 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. The Veteran appeared and testified at a Board hearing held at the RO before the undersigned Veterans Law Judge in August 2010. A transcript of this hearing is associated with the claim file. In May 2011, February 2014, and August 2017, the Board remanded the issues for additional development. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service or for aggravation of a preexisting injury suffered or disease contracted in line of duty. 38 U.S.C. §§ 1110 (wartime), 1131 (peacetime) (2012). In general, to establish a right to compensation for a present disability, a Veteran 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 the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service establishes that the disability was incurred in service. 38C.F.R. §3.303(d) (2019). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clear-cut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “Chronic.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2019). Service connection may be established on a presumptive basis for certain disabilities resulting from herbicide exposure. A veteran who, during active military service, served in Vietnam during the period beginning in January 1962 and ending in May 1975, is presumed to have been exposed to herbicides. See 38 C.F.R. §§ 3.307, 3.309 (2019). Herbicide exposure is also presumed for veterans of certain units that served in or near the Korean DMZ anytime between April 1, 1968 and August 31, 1971. 38 C.F.R. § 3.307(a)(6)(iv) (2019). VA has also determined that a special consideration of herbicide exposure on facts found or direct basis should be extended to those veterans whose duties placed them on or near the perimeters of Thailand military bases. After the evidence is assembled, it is the Board’s responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a) (2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2019). A veteran need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Initial Considerations The Veteran alleges, in part, that he has Meniere’s disease and COPD due to in-service chemical and Agent Orange exposure. (Further details below.) He served in Vietnam during the Vietnam Era and so Agent Orange exposure in service is presumed. 38 C.F.R. § 3.307 (2019). He also alleges that he has COPD due to in-service exposure to cleaning chemicals, diesel and gasoline, and welding fumes. Service personnel records show the Veteran as having a military occupational specialty of 51B20, carpenter, in service. The Board will accept that he was exposed to cleaning chemicals, diesel and gasoline, and welding fumes in service. The Veteran alleges that he was initially treated for a respiratory disorder and for Meniere’s disease during service. Service treatment records (STRs) show treatment for an upper respiratory infection (URI) in April 1968. Bronchitis was diagnosed. He was seen for otitis as well as for dizziness and weakness in April 1970. VA records show that the Veteran was suspected or found to have COPD or reactive airways disease in November 2005, and Meniere’s disease in September 2005 and March 2007. As previously noted, the claims on appeal were remanded in May 2011, February 2014, and August 2017 for evidentiary development. Due to the long histories of the appeals and complexity of the claims at hand, the Board will repeat the Board’s August 2017 summarization of the pertinent medical evidence of record under the heading, Additional Background. Moreover, the reasons given by the Board for additional evidentiary development will be noted. Then, the pertinent evidence received subsequent to that remand will be summarized in detail in that same section. Finally, an Analysis section will address whether service connection may be warranted for either claim. Additional Background Respiratory Disorder In a VA medical addendum opinion of May 2014, the examiner stated that the Veteran did not have a diagnosis of COPD. However, VA chest X-rays of September 2005 done at the time of an Agent Orange examination, showed a diagnosis of mild hyperextension of the lungs consistent with COPD. The May 2014 examiner did not discuss these findings and did not explain why the Veteran did not have a diagnosis of COPD despite the 2005 findings. Therefore, the Board found that the opinion was inadequate, and a new opinion was needed. Moreover, the Board noted that in the June 2011 VA medical opinion (from the same examiner who provided the May 2014 addendum), the examiner seemed to have based his conclusion on an inaccurate factual premise. Indeed, in June 2011, the examiner stated the Veteran had a diagnosis of only shortness of breath (SOB)which he attributed to the Veteran’s physical deconditioning which resulted from neurological problems which started the year before. However, the examiner appeared not to have considered the reports of difficulty with breathing which existed years before such as those reported at the time of the September 2005 Agent Orange examination. Furthermore, it did not appear that the VA examiner reviewed the VA treatment records added to the claim file before providing the May 2014 addendum medical opinions. VA treatment records added to the claims file in January 2012 included a November 2011 Pulmonary consultation for the Veteran’s dyspnea on exertion. The Veteran was noted to have Velcro-like rales in the lower lobes from the bases to about four inches up from the diaphragm, although his pulmonary function tests (the one just taken in June for the VA examination) was essentially normal. It was unclear what the etiology of his dyspnea on exertion was and he was to undergo a work-up with a CT with high resolution cuts and an echocardiogram to rule out pulmonary hypertension or cause. A December 2011 follow up note indicated the CT scan showed pulmonary peripheral and basilar fibrosis most consistent with IPF (interstitial pulmonary fibrosis), but the report of the CT scan was not in the claim file. The plan was to talk about further work-up at the next visit to include possibly a biopsy and NAC. However, the claims file did not contain treatment record from January 2012 to August 2013 from the Cheyenne VA Medical Center. Consequently, the follow up records were not available. In addition, a May 2015 Internal Medicine note stated “diag with ILD by Dr. Martin CHY after lung biopsy early 2014” indicating additional work-up, but those records were also not available in the claims file. Hence, remand was necessary to obtain those records to assist the VA examiner in understanding the Veteran’s proper diagnosis because it appeared that, subsequent to the May 2011 VA examination, the Veteran was diagnosed to have Interstitial Pulmonary Fibrosis and that this was confirmed by CT scan and biopsy (according to what the Veteran had said). As already noted, the Veteran contends that his current respiratory disorder is related to exposure to various chemicals and particles in service. Specifically, the Veteran has alleged exposure to cleaning chemicals, diesel, gasoline, welding, Agent Orange, creosote, asphalt, and rock dust. See November 2005 VA Form 21-4138. The Veteran has also contended that his current respiratory disorder is related to an episode upper respiratory infection/bronchitis that he had during basic training in service and that he was forced to leave the hospital and go on a march before he was fully recovered, thereby resulting his continued breathing problems. See August 2010 Board hearing testimony. Finally, the Board noted that the claims file contained private imaging from November 1995 (and associated with the claims file in July 2006) which showed the presence of “minimal linear fibrosis in the left costophrenic angle” of the Veteran’s lungs. Such record was to be considered in addressing whether the Veteran’s current respiratory disability was related to his military service. Consequently, the Board found that remand of this claim was warranted to obtain the missing VA treatment records that are clearly relevant to the Veteran’s claim and, once obtained, to obtain a new VA examination to obtain a his current diagnosis of all current respiratory disorders and medical nexus opinions. Central Neurological Disorder The Veteran initially claimed service connection for Meniere’s disease. His contention, in part, is that his symptoms were caused by head injuries he sustained in service as a result of hitting his head on six-by-six-inch timbers sticking out in unfinished bunkers multiple times without wearing a hard hat. See August 2010 BVA hearing. The Veteran also contends this could be due to Agent Orange exposure or other chemical exposures in service. The Board acknowledged that the current medical evidence failed to demonstrate that the Veteran had a current diagnosis of Meniere’s disease or that this was the etiology of his current symptomatology causing the issues for which he was seeking service connection. A review of the medical treatment records demonstrated that the Veteran was initially treated by his private primary care physician in April 1997 for complaints of vertigo and was treated with Meclizine for benign viral labyrinthitis. When it did not improve, he was referred to a specialist in May. The Veteran had stated that this specialist’s records were not available as they have been destroyed but that this physician diagnosed him to have Meniere’s disease. Thus, it would appear that the Veteran had at one time a diagnosis of Meniere’s disease. At the September 2005 Agent Orange examination, the Veteran reported his history of having Meniere’s disease, but no current symptoms. When he established care at VA in November 2005, the Veteran did not report any current problems with Meniere’s disease. In fact, he did not report a history of Meniere’s disease until February 2007, when he came in complaining of having blurred vision, ringing in his ears and dizziness. But no diagnosis of Meniere’s disease was rendered by his primary care physician until February 2008 at which time the Veteran had reported a one-month history of extreme episodes of dizziness. He was prescribed Meclizine. Although this helped somewhat, he still complained of significant episodes of dizziness. He was noted to also have hypotension, worsened since going on Prazosin, and he was put on medication for that to see if it improved his dizziness, but it did not seem to help. The Veteran’s primary care physician felt that the Veteran’s dizziness was due to Meniere’s disease and/or tinnitus given the Veteran complained of ringing in his ears all the time. He was given hearing aids to help with the tinnitus, but he did not use them constantly. In June 2008, the Veteran was sent for an ENT consultation at which time he reported a whole list of problems to include feeling fatigued to the point of falling asleep during the day, difficulty sleeping at night, chronic balance and dizziness problems, hearing loss, ringing in his ears, chronic anxiety, forgetfulness, and trouble concentrating. The physician conducted allergy testing and ordered a magnetic resonance imaging (MRI) scan of the Veteran’s brain. On follow-up in July, it was noted that a sleep scan showed mild sleep apnea with good oxygen saturations and the MRI of the brain showed some nonspecific white matter disease. The physician wondered about narcolepsy and referred the Veteran to Neurology. In November 2008, the Veteran underwent a Neurology consultation where he again had multiple complaints to include fatigue and falling asleep when he drove, poor sleep with dry mouth awakening him three times a night and awakening with sweats due to posttraumatic stress disorder (PTSD). Although he reported dizziness, the physician stated he was actually bothered by a visual sense of motion in that he might drift to the left or right. He also felt that his balance was bad in general and that he fell to one side or the other. He noted a tremor with action had started over the past few month. He complained his tinnitus was getting louder. He reported he was having trouble distinguishing the end of the stairs when he got to about the lower three and often tripped. He also reported losing his balance with neck extension in yoga. The physician’s impression after examining the Veteran and reviewing the diagnostic studies, including the sleep study and the brain MRI, was that the Veteran’s symptoms of dry mouth, drowsiness and tremor were usually seen as a cholinergic medication effect, especially of Bupropion which the Veteran had started taking for his PTSD. It was recommended the Veteran decrease or discontinue taking this medication, as well as discontinue taking the medication for his hypotension as he was not seeing a clinical benefit from it. In November 2008, the Veteran was seen for follow up in the ENT Clinic, and he reported that he stopped taking the medicines that the neurologist thought he might have been having a reaction to and that he was, in fact, “somewhat better,” although he was still having some dizzy spells. But he was better enough that he wanted to hold off on trying a stimulant medication, such as Ritalin, like the neurologist recommended. The Board notes that the Veteran had continued to have issues over the years with the various complaints of balance, “dizziness,” memory and daytime sleepiness since that time with varying efforts to diagnose and treat the problems. For example, a July 2009 Internal Medicine note indicated that he underwent vestibular therapy with improved balance and nausea, but no resolution. Another March 2010 note indicated that he continued to work on balance issues with a physical therapist, but still had issues with balance and memory, and drifted to the right while driving. The assessment at this time was disequilibrium rather than Meniere’s disease. In May 2010, the Veteran underwent screening for his balance issues for further testing, which was indicative of proprioceptive instabilities as well as central nervous system and vestibular conflict. He was referred for a full battery of balance tests, which were conducted in June 2010. Those tests indicated the Veteran had a central deficiency. The posturography indicated a somatosensory instability. The ocular flutter recorded during the ventrilography might be consistent with a brain stem lesion. The abnormal ocular motor tests are also consistent with central findings. A physical therapist was brought in during testing to observe the ocular flutter. He did a quick neurologic test with the Veteran’s hands. This was positive. The physical therapist indicated that it might be Parkinson’s or other neurological involvement. Further neurological testing was recommended, as well as physical therapy to improve his gait and posture. In August 2010, the Veteran was referred to the Neurology Clinic at the Denver VA Medical Center for additional evaluation of his balance issues. He reported having problems keeping his balance and feeling unsteady on his feet and falling multiple times per day. He denied vertigo but endorsed tinnitus (noted a history of Meniere’s disease). He reported having troubling nodding off and even falling asleep while doing activities during the day, including driving; blurred vision, impaired with depth perception; trouble with fine movement and coordination, especially writing and typing; bilateral action tremor; decreased hearing in his right ear; and memory difficulties. The impression was that the Veteran’s symptoms were suggestive of a progressive neurodegenerative disorder specifically affecting the frontal lobe and cerebellar functioning, but the diagnosis was unclear. He was to undergo additional testing and return. The attending physician agreed with the examining physician but stated that he suspected that this may be a multi-system atrophy, some of which have frontal lobe dysfunction. A September 2010 Occupational Therapy re-evaluation note indicated that the Veteran was demonstrating signs of a central nervous system issue due to right side neglect as evidenced by left posture when walking and step through gait. The assessment was that the Veteran would benefit from activities of crossing midline, bilateral movements, mirror tasks, and right sided weight bearing tasks to re-train the pathways in the brain so that he can be successful in retirement activities. He would also benefit from vestibular ocular response training. On Neurology follow up in September 2010, the results of his tests were reviewed. It was noted that the electroencephalogram (EEG) showed only mild slowing with increased beta activity, and it was noted that the Veteran was on a benzodiazepine, which could cause this. The sleep study was noted to reveal sleep apnea. The prior MRI was noted to be without significant cerebellar, pontine, or putamental atrophy, and no evidence of profound ventriculomegaly. Neuropsychological testing showed the Veteran was at low average IQ with more difficulties in non-verbal communication. He was noted to have been seen by physical, occupational and speech therapies. The assessment was that the Veteran’s symptoms of ataxia, excessive daytime somnolence, coordination issues on the computer, memory difficulties, urinary urgency (in setting of prostate cancer), questionable hallucinations, bradykinesia, and dizziness when standing up with notable examination positive for poor FAB score, impaired coordination and gait and hyper-reflexia raised the question of Multiple System Atrophy (MSA)-cerebellar type. Progressive supranuclear palsy (PSP) was less likely given extraocular motion intact. Idiopathic Parkinson ’s disease (PD) was still a consideration, however, symptoms onset seems less likely. He did endorse hallucinations at this appointment, so questionable LBD. Corticobasal degeneration (CBD) was less likely as he denied episodes of dystonia. Also could consider Fragile X associated ataxia, severe congenital anomaly (SCA) 2, 3, 17, and paraneoplastic syndrome. Normal Pressure Hydrocephalus (NPH) seemed less likely as his MRI did not show prominent ventriculomegaly. The physician noted that Meniere’s disease typically waxed and waned, and these symptoms were different than what he had experienced in the past. He was referred to the Movement Disorder Clinic for further work up, which was noted could include a paraneoplastic panel or a lumbar puncture. He had an appointment with the Movement Clinic in January 2011, but he did not keep it. The Veteran was next seen in the Denver Neurology Clinic in May 2011and was again assessed to most likely have a neurodegenerative disorder with motor and cognitive decline for the last two to three years. He was again referred to the Movement Disorder Clinic for further work up. Before the Veteran could be seen in the Denver Movement Disorder Clinic, he underwent VA examination in June 2011. At this examination, he reported that his primary problem was that he was unable to maintain his balance and, as a result, he fell to the ground. It was noted that he always falls forwards and to the left (although this was inconsistent with the treatment records that had shown he has reported fallen backwards multiple times). He denied having vertigo or a sense of spinning. He noted having difficulty with reading in that he was able to read a single line but then got lost when he moved his gaze to the next line. He reported that he was improving and having fewer falls, using only a single can now instead of a walker. As part of his history, it was noted that the onset of his symptoms was approximately one year ago (which was inconsistent with the records that showed he started complaining of dizziness and balance issues in 2007) and that he has been seen by his primary care physician and specialists and diagnosed to have Meniere’s disease (which was initially true, as previously indicated, but his current diagnosis by his primary care physician was disequilibrium). It was further noted that Parkinson’s disease was being considered and, to rule this out, the Veteran would need to have a spinal tap done, but he did not want to do that procedure yet. The Board noted that the treatment records were again inconsistent with this statement as MSA-cerebellar type was thought the most likely etiology although Idiopathic Parkinson Disease was still a possibility; however, the treatment records did not show that a lumbar puncture had been ordered despite the Veteran’s statements to the contrary, but rather such work up was left to the Movement Disorder Clinic’s physician to determine its necessity. The examiner concluded, after reviewing the Veteran’s claims file and interviewing and examining him, that there was insufficient clinical evidence to support a diagnosis of Meniere’s disease. Consequently, in rendering a medical opinion, the VA examiner stated that the Veteran has not been diagnosed with Meniere’s disease, he had a central neurological disorder that has not been diagnosed at this time despite numerous evaluations and diagnostic tests. The examiner remarked that the Veteran had been another diagnostic test, a lumbar puncture (the results of which had the potential to clarify his diagnosis), but he has refused to have that test performed. After the VA examination, in July 2011, the Veteran was initially seen in the Movement Disorder Clinic at the Denver VA Medical Center. After reviewing the Veteran’s complicated history and prior work up, the assessment was again that the etiology of the Veteran’s symptoms was unclear and additional work up was needed. However, the records of that work up were not in the claims file as there are no additional treatment records from the Denver VA Medical Center after October 2011. In February 2014, the Board remanded the Veteran’s claim for the June 2011 VA examiner to provide an addendum to clarify his medical opinion. Essentially, the Board requested that the VA examiner provide a medical nexus opinion as to whether the Veteran’s central neurological disorder that the VA examiner diagnosed was related to his military service, to Veteran’s active duty service, to specifically include ear problems, dizziness, and weakness shown in April 1970, and any in-service Agent Orange or chemical exposure. In response, in May 2014, the VA examiner provided an addendum in which he provided the following statement: Regarding his central neurological disorder to include Meniere’s disease, he has not been diagnosed with Meniere’s disease based on the result of the specific testing done by the audiologist on 06/24/2010. He has a central neurological disorder that has not been fully diagnosed. To establish this diagnosis, a specific test, a lumbar puncture with cerebrospinal fluid analysis needs to be done. [The Veteran] has refused to have this diagnostic test done. Without these test results, a more definitive diagnosis cannot be made. At this time, there is insufficient clinical evidence to support the diagnosis of a specific central neurological disorder. It was unclear whether the VA examiner considered the Denver Neurology notes that were associated with the claim file in January 2012 after his initial examination of the Veteran when he provided the May 2014 addendum medical opinion. Furthermore, without all of the VA treatment records, it was impossible for the Board to determine what the outcome of the neurological work up was and whether the VA examiner’s statements are consistent with the findings by the Denver Neurologists at the Movement Clinic. Moreover, the Board noted that additional VA Neurology treatment records from the Cheyenne VA Medical Center were associated with the Veteran’s claim file after the May 2014 VA examiner’s medical opinion that appear to place into question what, if any, neurological disorder the Veteran may have. These treatment records, associated with the claims file in May 2015, covered the period of June 2014 to May 2015 and contained a Neurology consultation note from September 2014. This treatment note indicated that, since the last Neurology note of record, the Veteran had taken a balance class using Feldenkrais therapy and a tai chi class that helped him to the point that he did not need a cane except for long distance walking. His last fall was a month before, but he reported falls now occur rarely although he lost his balance daily. He continued to have sleep issues with awakenings during the night, and problems with daytime sleepiness; however, he had been diagnosed with sleep apnea resulting in hypoxia. He denied dizziness but reported a feeling of a rocking side-to-side sensation in his head. He also reported continued poor memory. The impression was that he had significant complaints of balance problems with a feeling of movement but no true vertigo. Examination and work-up were non-diagnostic. The physician noted that the Veteran was actually walking better than he was when seen the year before. The physician opined that the Veteran’s balance problems “may be due to mild physical problems and lack of attention when he is walking.” Further work-up for his balance issues was not recommended. Consequently, the Board noted that this Neurology note raised the question of whether the Veteran’s balance issues were, in fact, due to a central neurological disorder as previously thought. Given this question and the lack of an actual diagnosis of the cause of the Veteran’s problems, the Board found that remand was warranted for a new VA examination to determine, if possible, a diagnosis or, if not possible to do so, at least to assist the Board in clarifying the Veteran’s disability picture given that he has had many complaints but the treatment records did not specifically identify the specific diagnosis to which they are related. For example, the Veteran complained of fatigue, daytime somnolence and sleep impairment. However, he was diagnosed with PTSD and sleep apnea. It was not really clear from the treatment records whether these symptoms had been wholly related to his PTSD and/or sleep apnea or whether they were also a manifestation of the claimed disorder, which was initially thought to be Meniere’s disease and then a central neurological disorder. The Board noted that the June 2011 VA examination was an ear disease examination because of the Veteran’s complaints of Meniere’s disease and dizziness. However, given the findings of a (now questionable) neurological disorder, prior neurological work up with continued follow up by Neurology, and the records showing that the Veteran’s main issue had been and continued to be balance problems without dizziness or vertigo, it appeared that a neurology examination was more appropriate. Consequently, the Board found that remand was appropriate to obtain the Veteran’s VA treatment records from the Denver VA Medical Center from November 2011 to the present and then to obtain a VA neurology examination to determine what, if any, neurological disorder the Veteran may have and to obtain a medical nexus opinion. The August 2017 remand directives called for the obtainment of pertinent treatment records and VA examinations to address the medial questions raised. Subsequently added to the record following the August 2017 Board remand were Cheyenne, Colorado, VAMC treatment records from January 2012 to August 2013, and Denver Colorado, VAMC treatment records from January 2012 to May 2014. Also added to the record were private treatment records from the Healing Warriors Program dated from 2015 through 2017. Also, in accordance the Board’s August 2017 remand, the Veteran was scheduled for a VA examination to determine the nature and etiology of his claim for a respiratory disability. In the January 2018 report, the examiner noted that all records in the claims file were reviewed, and an in-person examination was conducted. Interstitial lung disease was diagnosed. As to history of the disease, the Veteran stated that he first noted symptoms of dyspnea in approximately 2012 while hiking uphill at high elevations. He said that during his normal work or walking on flat ground, he had no symptoms of dyspnea. He stated that he was evaluated by a pulmonologist but did not remember the diagnosis. Currently, he was on an inhaler that he used daily. The VA examiner reviewed the claims file and summarized pertinent findings in the record. He noted the Veteran’s single episode of treatment for dyspnea during service with diagnosis of an URI with bronchitis. He also noted that the record was silent for additional treatment or diagnosis, to include upon separation examination. He further noted that initial pulmonary function testing (PFT) in May 2011 was normal, and that the Veteran was diagnosed with idiopathic pulmonary fibrosis in December 2011, and with interstitial lung disease following biopsy in September 2012. The VA examiner further noted that subsequently dated records attributed the lung disease to the taking of sertraline which resolved with the cessation of sertraline. This was corroborated in the record by computerized tomography (CT) scan of the lungs in January 2014 which showed near resolution of the Veteran’s lung disease. As a result, it was the examiner’s opinion that the Veteran’s interstitial lung disease was less likely than not (less than 50 percent probability) incurred in or caused by claimed in-service injury, event, or illness. Central Neurological Disorder As reported in August 2017, the Board acknowledged that the current medical evidence failed to demonstrate that the Veteran had a current diagnosis of Meniere’s disease or that this was the etiology of his current symptomatology causing the issues for which he was seeking service connection. A review of the medical treatment records demonstrates that the Veteran was initially treated by his private primary care physician in April 1997 for complaints of vertigo and was treated with Meclizine for benign viral labyrinthitis. When it did not improve, he was referred to a specialist in May. The Veteran has stated that this specialist’s records were not available as they have been destroyed but that this physician diagnosed him to have Meniere’s disease. Thus, to the Board, it appeared that he had at one time had a diagnosis of Meniere’s disease. At the September 2005 Agent Orange examination, the Veteran reported his history of having Meniere’s disease, but no current symptoms. When he established care at VA in November 2005, the Veteran did not report any current problems with Meniere’s disease. In fact, he did not report a history of Meniere’s disease until February 2007, when he came in complaining of having blurred vision, ringing in his ears and dizziness. But no diagnosis of Meniere’s disease was rendered by his primary care physician until February 2008 at which time the Veteran had reported a one-month history of extreme episodes of dizziness. He was prescribed Meclizine. Although this helped somewhat, he still complained of significant episodes of dizziness. He was noted to also have hypotension, worsened since going on Prazosin, and he was put on medication for that to see if it improved his dizziness, but it did not seem to help. The Veteran’s primary care physician felt that the Veteran’s dizziness was due to Meniere’s disease and/or tinnitus given the Veteran complained of ringing in his ears all the time. He was given hearing aids to help with the tinnitus, but he did not use them constantly. In June 2008, the Veteran was sent for an ENT consultation at which the Veteran reported a whole list of problems to include feeling fatigued to the point of falling asleep during the day, difficulty sleeping at night, chronic balance and dizziness problems, hearing loss, ringing in his ears, chronic anxiety, forgetfulness, and trouble concentrating. The physician conducted allergy testing and ordered a magnetic resonance imaging (MRI) scan of the Veteran’s brain. On follow-up in July, it was noted that a sleep scan showed mild sleep apnea with good oxygen saturations and the MRI of the brain showed some nonspecific white matter disease. The physician wondered about narcolepsy and referred the Veteran to Neurology. In November 2008, the Veteran underwent a Neurology consultation where he again had multiple complaints to include fatigue and falling asleep when he drove, poor sleep with dry mouth awakening him three times a night and awakening with sweats due to posttraumatic stress disorder (PTSD). Although he reported dizziness, the physician stated he was actually bothered by a visual sense of motion in that he may drift to the left or right. He also felt that his balance was bad in general and that he falls to one side or the other. He noted a tremor with action had started over the past few month. He complained his tinnitus was getting louder. He reported he was having trouble distinguishing the end of the stairs when he got to about the lower three and often tripped. He also reported losing his balance with neck extension in yoga. The physician’s impression after examining the Veteran and reviewing the diagnostic studies, including the sleep study and the brain MRI, was that the Veteran’s symptoms of dry mouth, drowsiness and tremor is usually seen as a cholinergic medication effect, especially of Bupropion which the Veteran had started taking for his PTSD. It was recommended the Veteran decrease or discontinue taking this medication, as well as discontinue taking the medication for his hypotension as he was not seeing a clinical benefit from it. In November 2008, the Veteran was seen for follow up in the ENT Clinic and he reported he stopped taking the medicines that the neurologist thought he might have been having a reaction to and that he was, in fact, “somewhat better,” although he was still having some dizzy spells. But he was better enough that he wanted to hold off on trying a stimulant medication, such as Ritalin, like the neurologist recommended. The Veteran has continued to have issues over the years with the various complaints of balance, “dizziness,” memory and daytime sleepiness since that time with varying efforts to diagnose and treat the problems. For example, a July 2009 Internal Medicine note indicated he underwent vestibular therapy with improved balance and nausea, but no resolution. Another March 2010 note indicated that he continued to work on balance issues with a physical therapist, but still had issues with balance and memory, and drifted to the right while driving. The assessment at this time was disequilibrium rather than Meniere’s disease. In May 2010, the Veteran underwent screening for his balance issues for further testing, which was indicative of proprioceptive instabilities as well as central nervous system and vestibular conflict. He was referred for a full battery of balance tests, which were conducted in June 2010. Those tests indicated the Veteran had a central deficiency. The posturography indicated a somatosensory instability. The ocular flutter recorded during the ventrilography might be consistent with a brain stem lesion. The abnormal ocular motor tests were also consistent with central findings. A physical therapist was brought in during testing to observe the ocular flutter. He did a quick neurologic test with the Veteran’s hands. This was positive. The physical therapist indicated that it may be Parkinson’s or other neurological involvement. Further neurological testing was recommended, as well as physical therapy to improve his gait and posture. In August 2010, the Veteran was referred to the Neurology Clinic at the Denver VA Medical Center for additional evaluation of his balance issues. He reported having problems keeping his balance and feeling unsteady on his feet and falling multiple times per day. He denied vertigo but endorsed tinnitus (noted a history of Meniere’s disease). He reported having troubling nodding off and even falling asleep while doing activities during the day, including driving; blurred vision, impaired with depth perception; trouble with fine movement and coordination, especially writing and typing; bilateral action tremor; decreased hearing in his right ear; and memory difficulties. The impression was that the Veteran’s symptoms were suggestive of a progressive neurodegenerative disorder specifically affecting the frontal lobe and cerebellar functioning, but the diagnosis was unclear. He was to undergo additional testing and return. The attending physician agreed with the examining physician but stated that he suspected that this may be a multi-system atrophy, some of which have frontal lobe dysfunction. A September 2010 Occupational Therapy re-evaluation note indicated that the Veteran was demonstrating signs of a central nervous system issue due to right side neglect as evidenced by left posture when walking and step through gait. The assessment was that the Veteran would benefit from activities of crossing midline, bilateral movements, mirror tasks, and right sided weight bearing tasks to re-train the pathways in the brain so that he can be successful in retirement activities. He would also benefit from vestibular ocular response training. On Neurology follow up in September 2010, the results of his tests were reviewed. It was noted that the electroencephalogram (EEG) showed only mild slowing with increased beta activity, and it was noted that the Veteran was on a benzodiazepine, which could cause this. The sleep study was noted to reveal sleep apnea. The prior MRI was noted to be without significant cerebellar, pontine, or putamental atrophy, and no evidence of profound ventriculomegaly. Neuropsychological testing showed the Veteran was at low average IQ with more difficulties in non-verbal communication. He was noted to have been seen by physical, occupational and speech therapies. The assessment was that the Veteran’s symptoms of ataxia, excessive daytime somnolence, coordination issues on the computer, memory difficulties, urinary urgency (in setting of prostate cancer), questionable hallucinations, bradykinesia, and dizziness when standing up with notable examination positive for poor FAB score, impaired coordination and gait and hyper-reflexia raised the question of Multiple System Atrophy (MSA)-cerebellar type. Progressive supranuclear palsy (PSP) was less likely given extraocular motion intact. Idiopathic Parkinson ’s disease (PD) was still a consideration, however, symptoms onset seemed less likely. He did endorse hallucinations at this appointment, so questionable LBD. Corticobasal degeneration (CBD) was less likely as he denied episodes of dystonia. Also could consider Fragile X associated ataxia, severe congenital anomaly (SCA) 2, 3, 17, and paraneoplastic syndrome. Normal Pressure Hydrocephalus (NPH) seemed less likely as his MRI did not show prominent ventriculomegaly. The physician noted that Meniere’s disease typically waxed and waned and these symptoms are different than what he has experienced in the past. The Veteran was referred to the Movement Disorder Clinic for further work up, which was noted could include a paraneoplastic panel or a lumbar puncture. He had an appointment with the Movement Clinic in January 2011, but he did not keep it. He was next seen in the Denver Neurology Clinic in May 2011 and was again assessed to most likely have a neurodegenerative disorder with motor and cognitive decline for the last two to three years. The Veteran was again referred to the Movement Disorder Clinic for further work up. Before the Veteran could be seen in the Denver Movement Disorder Clinic, the Veteran underwent VA examination in June 2011. At this examination, the Veteran reported that his primary problem is that he is unable to maintain his balance and, as a result, he fell to the ground. It was noted that he always falls forwards and to the left (although this is inconsistent with the treatment records that have shown he has reported fallen backwards multiple times). He denied having vertigo or a sense of spinning. He noted having difficulty with reading in that he was able to read a single line but then gets lost when he moves his gaze to the next line. He reported that he was improving and having fewer falls, using only a single can now instead of a walker. As part of his history, it was noted that the onset of his symptoms was approximately one year ago (which is inconsistent with the records that showed that he started complaining of dizziness and balance issues in 2007), and that he had been seen by his primary care physician and specialists and diagnosed to have Meniere’s disease (which was initially true, as previously indicated, but his current diagnosis by his primary care physician was disequilibrium). It was further noted that Parkinson’s disease was being considered and, to rule this out, the Veteran would need to have a spinal tap done, but he did not want to do that procedure yet. Again the treatment records are inconsistent with this statement as MSA-cerebellar type was thought the most likely etiology although Idiopathic Parkinson Disease was still a possibility; however, the treatment records did not show that a lumbar puncture had been ordered despite the Veteran’s statements to the contrary, but rather such work up was left to the Movement Disorder Clinic’s physician to determine its necessity. The examiner concluded, after reviewing the Veteran’s claims file and interviewing and examining him, that there was insufficient clinical evidence to support a diagnosis of Meniere’s disease. Consequently, in rendering a medical opinion, the VA examiner stated that the Veteran has not been diagnosed with Meniere’s disease, he had a central neurological disorder that has not been diagnosed at this time despite numerous evaluations and diagnostic tests. The examiner remarked that the Veteran had been another diagnostic test, a lumbar puncture (the results of which have the potential to clarify his diagnosis) but had refused to have that test performed. After the VA examination, in July 2011, the Veteran was initially seen in the Movement Disorder Clinic at the Denver VA Medical Center. After reviewing the Veteran’s complicated history and prior work up, the assessment was again that the etiology of the Veteran’s symptoms was unclear and additional work up was needed. However, the records of that work up were not in the claims file as there are no additional treatment records from the Denver VA Medical Center after October 2011. In February 2014, the Board remanded the Veteran’s claim for the June 2011 VA examiner to provide an addendum to clarify his medical opinion. Essentially, the Board requested that the VA examiner provide a medical nexus opinion as to whether the Veteran’s central neurological disorder that the VA examiner diagnosed is related to his military service, to Veteran’s active duty service, to specifically include ear problems, dizziness, and weakness shown in April 1970, and any in-service Agent Orange or chemical exposure. In response, in May 2014, the VA examiner provided an addendum in which he provided the following statement: Regarding his central neurological disorder to include Meniere’s disease, he has not been diagnosed with Meniere’s disease based on the result of the specific testing done by the audiologist on 06/24/2010. He has a central neurological disorder that has not been fully diagnosed. To establish this diagnosis, a specific test, a lumbar puncture with cerebrospinal fluid analysis needs to be done. [The Veteran] has refused to have this diagnostic test done. Without these test results, a more definitive diagnosis cannot be made. At this time, there is insufficient clinical evidence to support the diagnosis of a specific central neurological disorder. The Board noted that it was unclear whether the VA examiner considered the Denver Neurology notes that were associated with the claim file in January 2012 after his initial examination of the Veteran when he provided the May 2014 addendum medical opinion. Furthermore, without all of the VA treatment records, it was impossible for the Board to determine what the outcome of the neurological work up was and whether the VA examiner’s statements were consistent with the findings by the Denver Neurologists at the Movement Clinic. Moreover, the Board noted that additional VA Neurology treatment records from the Cheyenne VA Medical Center were associated with the Veteran’s claim file after the May 2014 VA examiner’s medical opinion that appeared to place into question what, if any, neurological disorder the Veteran might have. These treatment records, associated with the claims file in May 2015, covered the period of June 2014 to May 2015 and contained a Neurology consultation note from September 2014. This treatment note indicated that, since the last Neurology note of record, the Veteran had taken a balance class using Feldenkrais therapy and a tai chi class that helped him to the point that he did not need a cane except for long distance walking. His last fall was a month before, but he reported falls now which occurred rarely although he lost his balance daily. He continued to have sleep issues with awakenings during the night, and problems with daytime sleepiness; however, he had been diagnosed with sleep apnea resulting in hypoxia. He denied dizziness but reported a feeling of a rocking side-to-side sensation in his head. He also reported continued poor memory. The impression was that he had significant complaints of balance problems with a feeling of movement but no true vertigo. Examination and work-up were non-diagnostic. The physician noted that the Veteran was actually walking better than he was when seen the year before. The physician opined that the Veteran’s balance problems “may be due to mild physical problems and lack of attention when he is walking.” Further work-up for his balance issues was not recommended. Consequently, the Board noted that this Neurology note raised the question of whether the Veteran’s balance issues were, in fact, due to a central neurological disorder as previously thought. Given this question and the lack of an actual diagnosis of the cause of the Veteran’s problems, the Board found that remand was warranted for a new VA examination to determine, if possible, a diagnosis or, if not possible to do so, at least to assist the Board in clarifying the Veteran’s disability picture given that he had had many complaints but the treatment records did not specifically identify the specific diagnosis to which they were related. For example, the Veteran complained of fatigue, daytime somnolence and sleep impairment. However, he was diagnosed with PTSD and sleep apnea. It was not really clear from the treatment records whether these symptoms had been wholly related to his PTSD and/or sleep apnea or whether they were also a manifestation of the claimed disorder, which was initially thought to be Meniere’s disease and then a central neurological disorder. The Board noted that the June 2011 VA examination was an ear disease examination because of the Veteran’s complaints of Meniere’s disease and dizziness. However, given the findings of a (now questionable) neurological disorder, prior neurological work up with continued follow up by Neurology, and the records showing that the Veteran’s main issue has been and continues to be balance problems without dizziness or vertigo, it appeared that a neurology examination was more appropriate. Consequently, the Board found that remand was appropriate to obtain the Veteran’s VA treatment records from the Denver VA Medical Center from November 2011 to the present and then to obtain a VA neurology examination to determine what, if any, neurological disorder the Veteran might have and to obtain a medical nexus opinion. Subsequently added to the record following the August 2017 Board remand were Cheyenne, Colorado, VAMC treatment records from January 2012 to August 2013, and Denver Colorado, VAMC treatment records from January 2012 to May 2014. Also added to the record were private treatment records from the Healing Warriors Program dated from 2015 through 2017. Also, in accordance the Board’s August 2017 remand, the Veteran was scheduled for a VA examination to determine the nature and etiology of his claim for a central neurological disability, to include Meniere’s disease. The requested VA examination was conducted in January 2018. The VA examiner noted that the claims file was reviewed, and an in-person examination was conducted. The diagnosis was mild ataxia with impaired balance. It was his opinion that the condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. For rationale, the examiner summarized pertinent evidence in the file to include that the service treatment records (STRs) which showed treatment for a single episode of “feeling dizzy” with diagnosis of mild flu in 1970. There was no further documentation in the STRs for evaluation of a dizziness condition, to include upon separation examination report which was silent for any neurologic findings. There was no documentation found in the records for complaints of, evaluation, diagnosis, or treatment for dizziness following military service until February 2008, 38 years after military service, which did not satisfy continuity of care and concern for the condition. The examiner further noted that initial neurology consult for symptoms of stumbling in November 2008 were thought to be secondary to medication reaction. Extensive workup was done for a central nervous system (CNS) condition from November 2008 to August 2016 and included cardiology with diagnosis of syncope, Holter monitor with diagnosis of sinus arrhythmia associated with dizziness, tilt table test (negative for vestibular condition), and comprehensive balance evaluation times 2, with suggestion of possible CNS cause, but no vestibular condition with 2 magnetic resonance imaging (MRI) tests which showed no brain stem abnormality. Diagnosis was eventually mild ataxia with impaired balance in August 2016. The Veteran was diagnosed with tremor and dizziness in early November 2008, but this was reported as resolved with normal physical exam that day. The examiner’s review of current medical literature did not support a causal relationship between a single episode of dizziness and later development of ataxia. It was the examiner’s opinion also that it was less likely than not that the Veteran’s mild ataxia with impaired balance was causally related to or aggravated by reported “hitting his head” on timber multiple time during service. For rationale, he noted that is was known that head injuries could cause ataxia, but that symptoms occurred within the first year following the injury and either improved with time or remained stable, but were not known to develop nearly 38 years following head injury. Moreover, there was no documentation for in-service head injury. As to the Veteran’s presumed exposure to chemicals during service, to include Agent Orange, cleaning liquids, diesel, gasoline, and welding materials, (as opposed to any post service occupational exposure as an inspector with the city government, with exposure to concrete, soils, and asphalt as reported in 1999, it was less likely than not that the Veteran’s mild ataxia with impaired balance was causally related to Agent Orange exposure, cleaning chemicals, diesel, gasoline, and welding material during military service. For rationale, it was noted that ataxia was not known to be causally related to such exposure to Agent Orange. Moreover, although it was known that poisoning from hydrocarbons (cleaning materials, diesel, gasoline) could cause ataxia, it was noted that symptoms of acute poisoning would be sufficient to cause hospitalization and that full recovery was expected. Symptoms were not known to develop 38 years after possible exposure. The examiner also noted that welding fumes were known to cause bronchiolitis with prolonged exposure but were not known to cause symptoms over 38 years after potential exposure. In conclusion, the VA examiner noted that the findings and history were also reviewed by a VA neurologist at the Cheyenne VAMC who had examined the Veteran on numerous occasions and felt that the only CNS diagnosis that could be supported was mild ataxia with impaired balance. Analysis The Board will first address the Veteran’s contentions that he has a respiratory disorder and/or a central neurological disability that is due to his exposure to herbicides or chemicals. Records in his claim file reflect that the Veteran served in Vietnam. As such, exposure to herbicides is presumed. Despite his presumed exposure to an herbicide agent, presumptive service connection under 38 C.F.R. § 3.307(a)(6) (2019) is still not for application. Service connection is only warranted on this basis for a specific list of diseases set forth under 38 C.F.R. § 3.309(e) (2019). As the Veteran’s diagnosed conditions of interstitial lung disease and mild ataxia with impaired balance are not among those listed under 38 C.F.R. § 3.309(e) (2019) an award of presumptive service connection based on herbicide exposure is not warranted. Next, where the evidence does not warrant presumptive service connection, the United States Court of Appeals for the Federal Circuit has determined that an appellant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). However, the evidence does not show a causal relationship between the Veteran’s lung disease or his mild ataxia with impaired balance and in-service herbicide exposure or to any other incident of active service, to include exposure to other chemicals or as due to head injuries. As noted by the January 2018 examiner, while the Veteran was treated during service for a single episode of dyspnea, diagnosed as URI with bronchitis and for “feeling dizzy” with diagnosis of mild flu in 1970, there was no further documentation in the STRs for evaluation of a respiratory disorder or for a dizziness condition, to include upon separation examination report which was silent for any respiratory or neurologic findings. There was no documentation found in the records for complaints of, evaluation, diagnosis, or treatment for associated disabilities following military service for many, many years. Thus, continuity of care and concern for either condition is not satisfied. Thus, any allegation that there was continued symptomatology after since active service has also been considered but is 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 his active service experiences. Wood v. Derwinski, 1 Vet. App. 190 (1991). Notably, records do not reflect chronic problems related to the Veteran’s respiratory or central neurological system for many years following separation from service. The mere absence of medical records does not contradict a Veteran’s statements about his 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 long period without problems weighs against the claims. The value of the Veteran’s assertions are additionally diminished, given that there is no clinical evidence indicating a chronic respiratory disorder (interstitial lung disease) or a central neurological condition (mild ataxia with impaired balance) until many years post service. Accordingly, the Board finds that any argument of record asserting continuity of symptomatology of a central neurological disability since service lacks credibility and is without probative value. See, e.g., Madden v. Gober, 125 F.3d 1477, 1481 (1997) (the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration a veteran’s statements, it may consider whether self-interest may be a factor in making such statements). Continuity of symptomatology has not here been established, either through the competent evidence or through the statements submitted by the Veteran or the appellant. Having determined that the Veteran’s alleged clinical history regarding onset and continuity of a respiratory disorder or a central neurological disability is not consistent with the evidence, the Board next considers that service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. The most probative evidence of record as to both claims are the January 2018 opinions. The resulting reports included review of the claims file and examination of the Veteran. As reflected above, these reports are not favorable to the Veteran’s claims. The probative value of a medical opinion comes from the factually accurate, fully articulated, and sound reasoning for the conclusion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The VA examiner provided rationale for the conclusions reached. The Board finds that the January 2018 VA opinions are adequate because the examiner thoroughly reviewed the claims file and discussed the relevant evidence, considered the contentions of the Veteran, and provided a thorough supporting rationale for the conclusions reached. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (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 his respiratory disorder (diagnosed as interstitial lung disease) and central neurological disorder (diagnosed as mild ataxia with impaired gait). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issues in this case, the etiology of any respiratory or central neurological disability found, 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). Interstitial lung disease and mild ataxia with impaired balance are not the type of conditions that are readily amenable to mere lay diagnosis or probative comment regarding their etiology, as the evidence shows that specific findings are needed to properly assess and diagnose these disorders. Jandreau; Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). In light of the above discussion, the Board concludes that the preponderance of the evidence is against the claims for service connection and there is no doubt to be otherwise resolved. As such, the appeals are denied. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Hal Smith, 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.