Citation Nr: 19136881 Decision Date: 05/13/19 Archive Date: 05/13/19 DOCKET NO. 17-46 587 DATE: May 13, 2019 ORDER Entitlement to a rating of 70 percent from February 10, 2014 to December 23, 2014 for other specified trauma and stressor related disorder (other specified trauma disorder) is granted. Entitlement to a rating in excess of 70 percent from for other specified trauma disorder is denied. Entitlement to a rating in excess of 30 percent from June 1, 2015 for Coronary Artery Disease (CAD), status post myocardial infarction, is denied. Entitlement to an effective date of February 1, 2015 for the assignment of a total disability rating based on individual unemployability due to service connected disabilities (TDIU) is granted. Entitlement to an effective date of February 1, 2015 for the award of basic eligibility for Dependents Educational Assistance (DEA) is granted. REMANDED Entitlement to a rating in excess of 0 percent (noncompensable) after February 1, 2012 for non-Hodgkin’s lymphoma with diffuse large B-Cell lymphoma (non-Hodgkin’s lymphoma) is remanded. FINDINGS OF FACT 1. For the entire period on appeal, other specified trauma disorder has been manifested by occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood; it has not been manifested by total occupational and social impairment. 2. CAD manifested in a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, and left ventricular dysfunction with an ejection fraction of 60 percent or greater. 3. The Veteran was unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities and was last gainfully employed prior to February 1, 2015, the date requested for entitlement. 4. The Veteran had a permanent and total service-connected disability as of February 1, 2015. CONCLUSIONS OF LAW 1. From February 10, 2014 to December 23, 2014, the criteria for a rating of 70 percent for other specified trauma disorder is granted. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1–4.7, 4.126, 4.130, Diagnostic Code (DC) 9410 (2017). 2. The criteria for a rating in excess of 70 percent for other specified trauma disorder have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1–4.7, 4.126, 4.130, Diagnostic Code (DC) 9410 (2017). 3. The criteria for an evaluation in excess of 30 percent for CAD have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1–4.7, 4.104, Diagnostic Code 7006 (2017). 4. The criteria for an effective date of February 1, 2015, but no earlier, for the grant of entitlement to TDIU have been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.400, 4.16, 4.18 (2017). 5. The criteria for basic eligibility for Dependents Educational Assistance benefits under 38 U.S.C. Chapter 35 was met on February 1, 2015. 38 U.S.C. §§ 3500, 3501 (2012); 38 C.F.R. § 3.807 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1968 to December 1969. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R., Part 4. The ratings are intended to compensate impairment in earning capacity due to a service-connected disease or injury. 38 U.S.C § 1155; 38 C.F.R. § 4.1. If the evidence for and against a claim is an equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinksi, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where there is question as to which of the two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Staged ratings, however, are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The determination of whether an increased evaluation is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows or fails to show. The Veteran should not assume that the Board has overlooked pieces of evidence that are not specifically discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). 1. & 2. Rating other specified trauma disorder The Veteran filed a claim for a mental disorder in February 2014. The RO granted an initial rating of 0 percent from February 10, 2014, which was increased to 70 percent on December 23, 2014. The Board notes that any psychiatric disorder is rated under the General Rating Formula for Mental Disorders, and the criteria under this formula shall be considered no matter what diagnostic code is assigned. Here, because DC 9410 contemplates the Veteran’s diagnosis of other specified stress disorder and his psychiatric symptoms, the Board concludes that the Veteran is appropriately rated under DC 9410. The General Rating Formula for Mental Disorders provides that mental disorders are to be rated under 38 C.F.R. § 4.130 as follows: A noncompensable (0 percent) rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. 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); inability to establish and maintain effective relationships. 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; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or name. The “such symptoms as” language of the diagnostic codes for mental disorders in 38 C.F.R. § 4.130 means “for example” and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The Veteran had a VA examination in August 2014. The examiner identified two disabilities, other specified trauma disorder and bipolar disorder. The examiner indicated the Veteran had non-service connected bipolar disorder, which caused periods of depressed mood and manic symptoms. The Veteran’s other specified trauma disorder caused distressing thoughts of military trauma, hypervigilance, startled reaction, and avoidance of things that remind him of his military trauma. The examiner indicated no significant social or occupational impairment was present due to other specified trauma and stressor related disorder. The examiner noted that records document depression and bipolar disorder well-controlled with medication since 2009. The Veteran had mildly depressed mood four hours a month, hypomania, anxiety, one instances of inpatient hospitalization for suicidal ideation in 2008 and had six months of therapy in 2006. No other symptoms were identified as due to other specified trauma disorder. A VA contractor examination occurred in May 2015. The examiner diagnosed other trauma related anxiety disorder and unspecified bipolar disorder by history. The examiner indicated that it was not possible to differentiate the symptoms attributable to each. The examiner found occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The examiner indicated that there was little change since the prior examination. The examiner noted that the Veteran was not presently working. Symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, impaired judgment, disturbances of motivation and mood, difficulty in adapting to stressful circumstances, including work or a work-like setting, and inability to establish and maintain effective relationships. Another VA examination occurred in November 2015. Examiner found occupational and social impairment due to mild or transient symptoms which decrease work efficiency, inability to perform occupational tasks only during periods of significant stress, and symptoms controlled by medication. The examiner identified that the service-connected mental health disorder was responsible for recurrent and intrusive memories of traumatic events, distress when exposed to trauma reminders, attempts to avoid trauma memories, hypervigilance, exaggerated startle response, and nightmares. The non-service connected bipolar disorder caused depressed mood, anhedonia, and low motivation. The examiner stated there does not appear to be any association between the two diagnoses. The examiner stated that both bipolar and other specified trauma disorder caused occupational and social difficulties, but it would not possible to say which portion of these difficulties is due to which mental health disorder. The examiner noted that the overall severity and frequency of symptoms had been unchanged since the May 2015 examination in areas of social, marital, and family history and in the mental health history section. The Veteran had few friends, socialized one day per week, and attended religious services weekly. He did chores around the house but had recent decreased motivation. He took medication to reduce anger and isolation and was in counseling. Symptoms were depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work-like setting. Behavioral observations were largely normal or appropriate, excepting the Veteran sometime gave vague answers and had shaking hands. The examiner remarked that the Veteran’s symptoms, their frequency, and intensity remained unchanged. Symptoms would cause intermittent difficulties with attendance, lowered productivity, and social functioning. There was an additional examination in February 2017. The examiner found occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The Veteran’s symptoms were noted to be the same since the last examination. The examiner stated other specified trauma disorder caused symptoms of avoidance, depression, social isolation, anger, irritability, anxiety, and somatic symptoms including vomiting. The Veteran took Xanax daily and Depakote for bipolar disorder. Both disabilities were well-controlled with medication. The Veteran continued to be happily married and was the primary care giver for his wife, who had had a stroke. The Veteran had friends, could go out to eat, and the Veteran enjoyed fishing and camping. The Veteran was estranged from his family and his wife’s family, but he did not understand why. He attended religious services weekly when possible and was a member of a veterans’ association. He did not prefer to do activities and instead preferred to stay home due to depression as well as vomiting. The Veteran reported being unemployed due to painkiller he takes for chronic pain, which prevented him from being able to drive. The examiner identified symptoms as depressed mood, anxiety, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner’s behavioral observations reported the Veteran responses were adequate, normal, or intact in all relevant areas. Private treatment records show the Veteran has diagnosis of major depressive disorder, PTSD, generalized anxiety disorder, nicotine use disorder, and other specified personality disorder. An August 2018 private treatment note reports the Veteran stopped fishing but was still able to do yard work. He reported no trouble with others and the Veteran did not feel his anxiety was too bad. He had no nightmares or outbursts. Mental status examination(s) were normal or intact, except for reports of being depressed. Other private treatment record note the Veteran had low energy and motivation, but overall was stable. Additional records indicate depression, either severe or moderate. A November 2015 letter from a private doctor, A. L., reported one suicide attempt in October 2000 and hospitalization for depression. A. L. reported the Veteran had some dysfunction, including marital strife, due to depression and that currently depression was well-controlled on medication. Regarding the date of the 70 percent rating, the current effective date for the 0 percent rating is the date of claim, February 10, 2014. The 70 percent rating is based on a May 2015 VA contractor examination. See June 2015 rating decision. There appears to have been no sign of worsening between February 2014 and May 2015, much less one that would justify a 70 percent change in rating. The August 2014 VA examination shows more-or-less the same level of symptomology as the next examination in May 2015. The May 2015 VA contractor examination specifically states that the Veteran’s mental disorder symptoms had not worsened in the last twelve months. Therefore, given a 70 percent rating has been warranted based on the May 2015 VA contractor examination and the factual findings do not show distinct time periods warranting distinct ratings, a 70 percent rating is awarded from February 2014 onwards. Regarding a higher rating, the Veteran’s symptomatology is consistent with a 70 percent rating. A higher evaluation of 100 percent is not warranted unless the evidence shows total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. For the most part, he did not have the symptoms outlined for a higher rating or symptoms of equal severity. In the last relevant treatment record, a private mental status examination dated in August 2018, the Veteran denied practically any symptoms, except for inability to fish for an unknown reason, anxiety (described as not too bad), and some depression. He was appropriate dressed, alert, with normal affect, speech, attention, concentration, intellectual functioning, thought process, judgment, and insight. No hallucinations, delusions, or suicidality were noted. Based on the above evidence, the Veteran continues to have some social relationships. He had some friends, was still married, and undertook at least weekly social activities, specifically going to religious services and occasionally eating out at restaurants. He is also able to take care of another person, his wife. The Veteran was generally found to have adequate memory and thought processes on mental status examinations and in VA examinations, and did not forget his own name or the names of close relatives. The other symptoms noted above do not rise to the level of total disability. This supports the conclusion that the Veteran is not 100 percent disabled according to the relevant criteria. The Board does note that the Veteran expressed suicidal ideation, which is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. There are medical record showing one or perhaps two hospitalizations due to suicidal ideation. However, these were years before the claim was filed and no evidence or statements from the Veteran report suicidal ideation, self-harm, or alike symptoms during the period on appeal, much less that these symptoms are of the severity contemplated by a 100 percent disability rating. The Board notes that the private treatment records contain additional acquired psychiatric diagnoses but these records did not indicate overall severity of symptoms due to any of these diagnoses that would warrant a higher rating. In conclusion, the Board finds that, throughout the appeal period, a disability rating of 70 percent is warranted. The Board finds the Veteran’s stress disorder symptoms and disability picture are not on par with the level of severity contemplated by the 100 percent disability rating criteria, which contemplates total occupational and social impairment. The preponderance of the evidence is against a rating in excess of 70 percent. Neither the Veteran nor the representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 3. Rating for CAD Since June 1, 2015, the Veteran’s CAD is assigned a rating of 30 percent under Diagnostic Code (DC) 7006. 38 C.F.R. § 4.104. He contends a higher rating is warranted. Diagnostic Code 7006, a 10 percent rating is warranted for history of documented myocardial infarction, resulting in a workload of greater than 7 METs but not greater than 10 METs causing in dyspnea, fatigue, angina, dizziness, or syncope, or; when continuous medication is required. Id. A 30 percent rating is warranted for a history of myocardial infarction resulting in a workload of greater than 5 METs but not greater than 7 METs causing dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. Id. A 60 percent rating is warranted for a history of myocardial infarction resulting in more than one episode of acute congestive heart failure in the past year, or; a workload of greater than 3 METs but not greater than 5 METs causing dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Id. Finally, a 100 percent rating is warranted for a history of myocardial infarction resulting in chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. For rating diseases of the heart, one MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for rating, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2. In February 2015, the Veteran had a myocardial infarction. The Veteran filed the claim in April 2015 and the Veteran was granted a 100 percent disabling effective April 7, 2015 to June 1, 2015. The 30 percent rating was assigned the first day of the month following the initial three-month period after the myocardial infarction. An April 2015 Heart Conditions Disability Benefits Questionnaire (DBQ) noted myocardial infarction and CAD diagnosed in February 2015 and had percutaneous coronary intervention the same month. The Veteran took medications (ASA, Nitrostat, and metoprolol). The Veteran had an echocardiogram showing left ventricular ejection fraction of 60 percent and normal wall motion and thickness. The Veteran had interview-based METs test, reported as the Veteran denied experiencing symptoms attributable to a cardiac condition with any level of physical activity. A second VA Heart Conditions Disability Benefits Questionnaire (DBQ) was completed in December 2016. This report noted a new exercise stress test from July 2015 in addition to other records available. An ejection fraction of 67 percent was provided. The Veteran required use of medications for control. An EKG in January 2016 was also referenced. The examiner indicated the Veteran have a METs level of 7. Applying the appropriate diagnostic codes to the facts in this case, the assessment of the Veteran’s present impairment does not suggest that he has sufficient symptoms so as to a warrant an evaluation in excess of 30 percent. Neither the medical evidence of record, nor the Veteran’s statements indicates that he meets the higher criteria. The award of a 30 percent evaluation was based on the VA examination report of 7 METs. The evidence discloses no record of acute congestive heart failure or that a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Therefore, a higher rating is not warranted. 5. Effective date - TDIU The current effective date is March 5, 2015. The Veteran’s representative, on a March 2019 response to the 90-day letter, stated an effective date of February 1, 2015 should be granted. The effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(a)(1). The effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date. Id. § 5110(b)(3). TDIU can be awarded where the scheduler rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R § 4.16. Provided that if there is only one disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. Id. The Veteran met the requirements for schedular TDIU prior to February 1, 2015, the requested date for entitlement. The issue here is when the Veteran last worked. The evidence of record is unclear. VA Forms 21-8940 submitted in March 2014, August 2015, and October 2015 show dates last worked in June 2012, June 2013, December 2014, January 2015, and March 2015. The October 2015 form indicates the Veteran worked full-time as a self-employed driver until March 2015. He did not list any income from the period up to March 2015. The current effective date is based on this form. Employment information received in September 2015 from the truck driving company that the Veteran worked for indicates the Veteran worked as a truck driver from May 2001 until December 2013. This document states the Veteran last worked on May 30, 2013 and the date of the last payment was June 7, 2013. The employer indicated the Veteran ended employment due to health problems and medication. According to the representative’s March 2019 response to the 90-day letter, the Veteran meant to indicate on the October 2015 VA Form 21-8940 that his commercial driver’s license was rescinded in March 2015, not that that he was employed up to March 2015. The representative indicated the Veteran attempted further employment as a truck driver, a delivery driver, and at a grocery store after May 2013, but these were all before February 2015. Based on the other evidence of record, it seems the Veteran had several periods of not working due to medical treatment, which explains some of the conflicting dates. For example, VA treatment notes and Disability Benefits Questionnaires (DBQs) state the Veteran was on medical leave from his job in June 2012, was working in November 2012, but was no longer working by February 2014, having last worked in 2012. The evidence of record does establish that the Veteran was no longer employed by February 1, 2015. The only evidence of employment after this date is the Veteran’s October 2015 VA Forms 21-8940, but even this document does not establish gainful employment in February 2015, as the Veteran indicated no income. The representative explained this submission was based on a misunderstanding. This is accepted as probable. An effective date of February 1, 2015 is therefore granted. In regard to any possible earlier date, the information provided by the Veteran has been wildly inconsistent and not credible. 6. DEA The issue of entitlement to an earlier effective date for Dependents’ Educational Assistance benefits pursuant to 38 U.S.C. Chapter 35 necessarily is dependent on the effective date of the permanent total service-connected disability. 38 C.F.R. 3.807(a). The current effective date is March 3, 2015, same as the prior grant of TDIU above. The Board granted an effective date for TDIU of February 1, 2015. It follows that that DEA benefits should also be granted as of February 1, 2015. Prior to this date, the Board finds that the Veteran does not meet the criteria for DEA benefits as a matter of law and basic eligibility is not established. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Therefore, an effective date of February 1, 2015 for DEA benefits is granted. REASONS FOR REMAND 1. Rating for non-Hodgkin’s lymphoma The Veteran seeks a higher rating for non-Hodgkin’s lymphoma with diffuse large B-Cell lymphoma, which is rated as noncompensable since February 2015. The rating codesheet gives diagnostic codes (DC) as 7715-7703, leukemia and non-Hodgkin’s lymphoma. There are three VA Hematologic and Lymphatic Conditions Disability Benefits Questionnaires (DBQs), dated in February 2014, November 2014, and December 2016. In the February 2014 DBQ, the examiner checked yes for continuous medication, reporting medications for nausea and diarrhea, but also contains a mention of medication for pain elsewhere in the examination report. A November 2014 DBQ noted no continuous medication but did report pain. A December 2016 DBQ likewise reported no for continuous medication. However, letters from a Dr. A. L. dated in March 2014 and March 2015 report use of medications for pain associated with non-Hodgkin’s lymphoma. A November 2016 private treatment notes a variety of medications, but nothing specific to pain associated with lymphoma. An August 2015 VA treatment note also contains some type of vague report of ongoing treatment from a private provider. Treatment records from Dr. A. L. have not been obtained. A remand is required to allow VA to obtain authorization and request these records. The matter is REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for Dr. A. L. or other providers who treated the Veteran for non-Hodgkin’s lymphoma with diffuse large B-Cell lymphoma. 2. Obtain any outstanding VA treatment records. 3. Obtain an opinion regarding the Veteran’s non-Hodgkin’s lymphoma. An additional examination is discretionary. The opinion provider must clarify whether the Veteran requires continuous medication for non-Hodgkin’s lymphoma. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. Yoffe, Associate 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.