Citation Nr: 1301201 Decision Date: 01/11/13 Archive Date: 01/16/13 DOCKET NO. 10-35 615 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased rating for a mood disorder associated with a medial meniscectomy of the right knee, currently evaluated as 50 percent disabling. 2. Entitlement to an increased rating for a medial meniscectomy of the right knee, currently evaluated as 30 percent disabling. 3. Entitlement to an increased rating for instability of the right knee associated with medial meniscectomy of the right knee, currently evaluated as 30 percent disabling. 4. Entitlement to an increased rating for degenerative joint disease of the left knee, currently evaluated as 20 percent disabling. 5. Entitlement to an increased rating for instability of the left knee associated with degenerative joint disease of the left knee, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD D. Rogers, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1953 to August 1954. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied entitlement to a TDIU, and granted increased ratings for a medial meniscectomy of the right knee, degenerative joint disease of the left knee, and a mood disorder (previously evaluated as an adjustment disorder). In a July 2009 rating decision, the RO in Cleveland, Ohio, reconsidered and confirmed the denial of entitlement to a TDIU and continued the assigned evaluations for all service-connected disabilities. In September 2012, the Veteran and his wife testified at a Videoconference hearing before the undersigned Veterans Law Judge. A transcript of this hearing has been reviewed and is of record. From the date of the hearing, the record was help open for 30 days to allow for the submission of additional evidence for consideration. Additional evidence was submitted in November 2012, accompanied by a waiver of initial RO consideration. This evidence will be considered by the Board in adjudicating this appeal. See 38 C.F.R. § 20.1304 (2012). A review of the Veteran's Virtual VA electronic claims file is negative for any additional information or evidence pertinent to the claims on appeal. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. At the September 2012 Videoconference hearing, the Veteran withdrew his appeal as to the issues of entitlement to increased ratings in excess of: 30 percent for a medial meniscectomy of the right knee; 30 percent for instability of the right knee associated with a medial meniscectomy of the right knee; 20 percent for degenerative joint disease of the left knee due to a medial meniscectomy of the right knee, and; 30 percent for instability of the left knee associated with degenerative joint disease of the left knee. 2. For the entire appeal period, the Veteran's mood disorder associated with a medial meniscectomy of the right knee is productive of total social and occupational impairment. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a substantive appeal by the Veteran concerning the issues of entitlement to increased ratings in excess of: 30 percent for a medial meniscectomy of the right knee; 30 percent for instability of the right knee associated with a medial meniscectomy of the right knee; 20 percent for degenerative joint disease of the left knee due to a medial meniscectomy of the right knee, and; 30 percent for instability of the left knee associated with degenerative joint disease of the left knee, have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 2. After resolving all reasonable doubt in the Veteran's favor, the criteria for an increased rating of 100 percent for a service-connected mood disorder associated with a medial meniscectomy of the right knee have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002& Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9435 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all the evidence in the Veteran's claims file, his Virtual VA file, his contentions, and hearing testimony of he and his wife. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Veterans Claims Assistance Act of 2000 (VCAA) The requirements of the Veterans Claims Assistance Act of 2000 (VCAA) have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in notices dated in January 2008 and January 2010, of the information and evidence needed to substantiate and complete his claims for increase, to include information regarding how disability evaluations and effective dates are assigned. VA fulfilled its duty to assist the claimant in obtaining identified and available evidence needed to substantiate the claims, and as warranted by law, providing VA examinations and obtaining a medical opinions. Review of the record shows, in relevant part, that the claims file contains the Veteran's service treatment records, records obtained from the Social Security Administration, and identified VA treatment records. The Veteran was provided a VA mental disorders examination in July 2008 pertaining to his claim for increase for a mood disorder. The examiner performed a complete and thorough examination and interview of the Veteran. Although the Veteran subsequently stated that his mood disorder had worsened (see February 2009 request for reconsideration) and he requested to undergo an additional examination if necessary to determine the nature and severity of his disability, the Board declines to remand the claim for obtainment of an additional examination. Specifically, the July 2008 examiner opined Veteran's mood disorder resulted in total occupational and social impairment at that time, which is supported by the additional evidence of record dating as recent as September 2012. The Board is satisfied that the July 2008 examination report and VA treatment records dating through September 2012 adequately describe the severity of the Veteran's mood disorder and support the favorable determination reached herein. Thus, the Board declines to remand the claim for obtainment of an additional VA examination. The July 2008 examination and opinion is adequate for the purpose of adjudication of the claim. The examination report reflects that the examiner reviewed the claims file, the Veteran's contentions, and rendered an appropriate diagnosis and opinion consistent with the remainder of the evidence of record. The Board, therefore, concludes that the examination in combination with the other evidence of record is adequate for purposes of rendering a decision as to the claim for increase for a mood disorder. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran has also been afforded the opportunity to testify at the September 2012 Videoconference hearing. In accordance with the Veteran's request, the record was held open for 30 days to allow the Veteran to submit documentation of an upcoming psychiatric evaluation. The evidence alluded to during the hearing was received in November 2012, accompanied by a waiver of RO consideration. In sum, there is no evidence of VA error in notifying or assisting the claimant that reasonably affects the fairness of this adjudication. See 38 C.F.R. § 3.159(c). Analysis Withdrawal Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. A substantive appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. §§ 20.202, 20.204(b). At the September 2012 Videoconference hearing, the Veteran testified that he wished to withdraw his appeal as to all issues except for an increased rating for a mood disorder. In light of that fact, there remains no allegation of error of fact or law for appellate consideration with respect to the claims for increased ratings in excess of: 30 percent for a medial meniscectomy of the right knee; 30 percent for instability of the right knee associated with a medial meniscectomy of the right knee; 20 percent for degenerative joint disease of the left knee due to a medial meniscectomy of the right knee, and; 30 percent for instability of the left knee associated with degenerative joint disease of the left knee, and the appeal is withdrawn as it pertains to those issues. Accordingly, the Board does not have jurisdiction to review the appeal as to those issues and it is dismissed as it pertains to the same. Increased Rating - Mood Disorder Historically, service connection for an adjustment disorder associated with a medial meniscectomy of the right knee was granted in a May 2005 rating decision; the RO assigned a 30 percent evaluation pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9440. The current appeal stems for a January 2008 claim for increased compensation based on unemployability. In December 2008, the RO granted a 50 percent evaluation for a mood disorder pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9435, and noted that the disorder had been previously rated as an adjustment disorder. In July 2009, the Cleveland RO reconsidered the claim and the 50 percent evaluation currently assigned was continued. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate Diagnostic Codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods based on the facts found - a practice known as "staged" ratings. The Veteran contends that the current 50 percent rating does not accurately depict the severity of his mood disorder associated with a medial meniscectomy of his right knee. His mood disorder is currently rated as 50 percent disabling under Diagnostic Code 9435. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2012). Under Diagnostic Code 9435, which is governed by a General Rating Formula for Mental Disorders, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and/or difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9435 (2012). A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and/or memory loss for names of close relatives, own occupation, or own name. Id. In evaluating psychiatric disorders, it must be shown that industrial impairment is the result of actual manifestations of the service-connected psychiatric disorder. The severity of a psychiatric disability is based upon actual symptomatology, as it affects social and industrial adaptability. Two of the most important determinants of disability are time lost from gainful employment and decrease in work efficiency. 38 C.F.R. § 4.130 (2012). The Secretary, acting within his authority to "adopt and apply a schedule of ratings," chose to create one general rating formula for mental disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet. App. 128 (1997). The evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the Diagnostic Code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (1992). In assessing the evidence of record, it is important to note that the GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A score of 41-50 is assigned where there are, "Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. A score of 51-60 is assigned where there are moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflict with peers or co-workers). Id. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). For reasons that will be described below, the Board finds that for the entire appeal period, the Veteran's mood disorder associated with a medial meniscectomy of his right knee is most appropriately evaluated as 100 percent disabling. In July 2008, the Veteran, accompanied by his wife, was afforded a VA mental disorders examination. Treatment of his mood disorder at that time included medication and individual psychotherapy. He remained depressed, however, his wife indicated that the medication "made him a little calmer." The Veteran reported feeling sad and depressed "a lot" related to his inability to do things that he used to do (e.g. fix the lawnmower). He experienced nonspecific suicidal thoughts twice per month without attempts, difficulty falling and staying asleep nightly, a preference to be alone, impaired appetite, reduced motivation, and feelings of hopelessness that he would never get better. He described such symptoms as continuous in frequency and variable in degree. Socially, he was married to his second wife with whom he had a good relationship with unless he is depressed which causes him to become irritable at which times he typically prefer to stay in his room. He had friends, but not too many, and preferred to spend time alone. At the time of examination in July 2008, the Veteran appeared causally dressed, somewhat disheveled, and wheelchair bound. His psychomotor activity was restless and tense and his speech was irrelevant and soft or whispered. His attitude toward the examiner was cooperative, irritable, and guarded. His affect was flat and his mood was anxious, depressed, and dysphoric. His mind wandered a lot. He was easily distracted and had problems with concentration and word finding difficulties. His wife indicated that he has a hard time communicating his thoughts in a meaningful way. He often forgot things he fetched, phone numbers, and to complete tasks. He was unable to spell a word forward and backward and he completed two iterations of serial 7s. Recent and remote memory was moderately impaired and immediate memory was slightly impaired. His orientation was intact to person and place but not time - his date was two days off. His thought process was rambling, circumstantial and tangential. His thought content included suicidal ideation, preoccupation with one or two topics, and ruminations. His insight was impaired in that he did not understand that he has problem. He experienced moderate difficulty performing most of his activities of daily living and personal hygiene tasks which he wife stated was largely due to his medical problems and pain. Following an interview of the Veteran and his wife, the examiner diagnosed a chronic mood disorder secondary to bilateral knee conditions, limited mobility, and chronic pain, and a GAF score of 40 was assigned. Occupationally, the Veteran had been retired since the late 1980s due to limited mobility, medical problems, and chronic pain. In light of the Veteran's report that he would be able to work if he were physically fit, the examiner opined it is not likely that his current inability to work is due to his mood disorder. Notwithstanding, however, the examiner stated that signs and symptoms of the Veteran's mood disorder resulted in total occupational and social impairment. Thereafter, the Veteran intermittently sought VA individual psychotherapy for his mood disorder. He continued to be discouraged and irritable and frustrated due to his medical problems and limitations and his dependency on his wife. His wife was frequently noted to have accompanied him to his VA medical and psychiatric appointments. In May 2008, a depression screen indicated that in the two weeks prior, there were several days where the Veteran experienced little pleasure or interest in doing things and felt down, depressed, or hopeless. In June 2008, he continued to endorse passive suicidal ideations and difficulty sleeping. He often stayed awake all night and slept all day. His antidepressant medication was working "as well as it could given his chronic pain," which resulted in irritability, frustration, and depression. Since December 2009, the Veteran's VA individual psychotherapy was provided by F.M., RN, MSN. In January 2011, the Veteran's wife had recently completed chemotherapy. The Veteran was a worrier and depressed due to his inability to do activities that he used to be able to do. His reaction to stressors was chronic anxiety. He was coping but needed more assistance. His mobility was very restricted due to his impaired knees. F.M. stated that the Veteran is totally disabled socially and industrially for gainful employment due to his service-connected physical and mental conditions. In April 2011, difficulty coping with continued anxieties, focusing, and concentrating was reported. M.F. again stated that the Veteran is totally disabled socially and industrially for gainful employment due to his service-connected physical and mental conditions. In September 2012, the Veteran and his wife presented testimony during a Videoconference hearing. They stated that he experiences difficulty remembering everything (e.g. phone numbers or tasks that his wife had asked him to complete) and frequently looses his place in conversation and needs to be reminded what he is talking about. His representative stated that his memory alone prevents him from functioning in any kind of employment with regard to simply answering a phone. Although his wife assisted him with hygiene-related activities and his activities of daily living due to his physical limitations, if she did not perform these activities for him or remind him to do them, he would simply forget or not do them (e.g. bathing). His wife reported that he is obsessive about organization of materials in the recycle bin which recently resulted in an angry outburst when his daughter explained that only paper needed to be separated. When being driven by someone, he becomes anxious about getting pulled over and constantly checks the driver's speed. During periods of stress or when he is nervous or anxious, he picks at his hands and fingernails until they bleed without realizing it. He does not like to leave his home and becomes nervous around others and crowds. He has difficulty seeing people leave his home, especially his wife, which results in panic-like symptoms. The Veteran stated that he does not like to be left alone and he feels afraid to lose his wife. His wife indicated that she must take him with her wherever she goes. She is unable to leave his room without him calling for her - she needs to be within his eyesight at all times. She also stated that the Veteran frequently becomes very upset when seeing her do something that he thinks he should be able to do for her. For instance, he cried his heart out when she had to change a light bulb because he was unable to get up on a stepping stool. She stated that instances such as this occurred daily. Occupationally, the Veteran testified that he has not been employed since approximately 25 years prior. His employment history included working for two gas companies for longer than 25 years where he performed service on oil burners, gas stoves, and water heaters, however, he no longer remembers how to do those things. Upon being asked to describe his panic attacks, the Veteran indicated that he was experiencing one during the hearing. His wife stated that he becomes very emotional, cries, and picks at his hands, which occurs as much as once or twice a day. She stated that the Veteran has thoughts of suicide and he clarified that he only talks about it but that is it. In her final statement, the Veteran's wife emphasized that since approximately three years prior, she has not been able to leave the Veteran alone or be out of his sight due to his mood disorder. Later in September 2012, the Veteran underwent an evaluation for his mood disorder with F.M., RN, MSN. His wife appeared with him at that time. He continued to experience anxiety and a dysphoric mood which impacted his ability to function. He was irritable and ready to pick a fight with strangers. His cognitive function was mildly impaired and his short- and long-term memory was impaired. He was unable to cope with everyday stressors in life and his chronic pain and immobility exacerbated his anxiety and depression. At that time he was worried over his wife having lung cancer and her upcoming surgery. F.M. stated that the Veteran remains totally disabled both socially and industrially for gainful employment due to his service-connected conditions. The Board finds that during the entire appellate period, a 100 percent evaluation is warranted for the Veteran's mood disorder. The psychologist who examined the Veteran in July 2008 opined that the signs and symptoms of his mood disorder resulted in total social and occupational impairment at that time. That opinion is supported by the subsequent opinions noted above dated in January 2011 and September 2012 from F.M., a clinician who has provided individual psychotherapy to the Veteran since 2009. The opinions of the July 2008 examiner and F.M. satisfy the rating criteria for the assignment of a 100 percent evaluation for a mood disorder. See 38 C.F.R. § 4.130, Diagnostic Code 9435 (2012). Indeed, the Veteran's GAF scores ranged from 40 to 55, which is reflective of serious symptoms to some impairment in reality testing or communication or major impairment in several areas. The Board also observes that VA primary care notes occasionally quote the Veteran's statements and conversations with his VA medical providers. The quoted statements and conversations provide support that the Veteran's speech and thought processes are impaired as noted by the July 2008 VA examiner. (See VA treatment records dated December 12, 2007; February 7, 2008; May 13, 2008.) Furthermore, the Veteran and his wife have provided competent and credible lay testimony pertaining to the nature, duration, degree and type of symptoms experienced by the Veteran which VA mental health and medical professionals have consistently related to his service-connected mood disorder and associated knee disability. The Board acknowledges that the Veteran does not experience some symptoms outlined in the rating criteria for the assignment of a 100 percent disability rating such as persistent delusions or hallucinations, grossly inappropriate behavior, or persistent danger of hurting himself or others. See 38 C.F.R. § 4.130. As previously stated, however, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. Here, the evidence discussed demonstrates that the Veteran suffers symptoms and effects from his mood disorder that cause his occupational or social impairment equivalent to what would be caused by the symptoms listed in the Diagnostic Code for the assignment of a 100 percent evaluation. Thus, the appropriate, equivalent 100 percent rating will be assigned. See Mauerhan v. Principi, 16 Vet. App. 436 (1992). In light of the foregoing, the Board concludes the objective medical evidence and the Veteran's and his wife's competent and credible statements and testimony regarding his symptomatology show disability that by analogy more nearly approximates that which warrants the assignment of a 100 percent disability rating since January 29, 2008, the date his initial claim for increase was received. See 38 C.F.R. § 4.7 (2012). ORDER Entitlement to an increased rating of 100 percent for a mood disorder associated with medial meniscectomy of the right knee is granted, subject to the laws and regulations governing the payment of monetary awards. The appeal as to the denial of entitlement to an increased rating in excess of 30 percent for medial meniscectomy of the right knee is dismissed. The appeal as to the denial of entitlement to an increased rating in excess of 30 percent for instability of the right knee associated with medial meniscectomy of the right knee is dismissed. The appeal as to the denial of entitlement to an increased rating in excess of 20 percent for degenerative joint disease of the left knee due to medial meniscectomy of the right knee is dismissed. The appeal as to the denial of entitlement to an increased rating in excess of 30 percent for instability of the left knee associated with degenerative joint disease of the left knee is dismissed. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs