Citation Nr: 20059661 Decision Date: 09/10/20 Archive Date: 09/10/20 DOCKET NO. 13-13 330 DATE: September 10, 2020 ORDER Entitlement to an earlier effective date prior to May 31, 2011 for the grant of an increased 30 percent rating for service-connected bilateral flat feet is denied. Entitlement to an increased rating for service-connected bilateral flat feet, rated as 30 percent disabling prior to August 23, 2019, and as 50 percent disabling from that date is denied. Entitlement to a disability rating greater than 30 percent for service-connected mood disorder (depression) is denied. Entitlement to a disability rating greater than 20 percent for service-connected left shoulder and arm strain with osteoarthritis and glenohumeral joint instability is denied. Entitlement to an increased rating for service-connected lumbosacral strain with degenerative arthritis and spinal stenosis, rated as 10 percent disabling prior to August 23, 2019, and as 20 percent disabling from that date, is denied. FINDINGS OF FACT 1. An unappealed January 2010 Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) decision denied an increase in a 10 percent rating for service-connected bilateral flat feet. 2. The claims file does not contain any subsequent formal or informal claim for an increased rating for bilateral flat feet prior to May 31, 2011. 3. During the period prior to August 23, 2019, the Veteran’s bilateral flat feet were manifested by no more than severe acquired flatfoot symptoms. 4. During the period from August 23, 2019, the Veteran’s bilateral flat feet are rated as 50 percent disabling, which is the maximum schedular rating permitted for bilateral acquired flatfoot. 5. The severity, frequency, and duration of the Veteran’s mood disorder (depression) symptoms did not more closely approximate occupational and social impairment with reduced reliability and productivity. 6. The Veteran's left shoulder and arm strain with osteoarthritis and glenohumeral joint instability is manifested by pain, weakness, and limitation of motion of the minor extremity no worse than to 75 degrees of flexion and 70 degrees of abduction, even with consideration of pain, and has not been manifested by limitation of the minor arm motion to 25 degrees from the side or less. 7. During the period prior to August 23, 2019, the Veteran's lumbosacral strain with degenerative arthritis and spinal stenosis was manifested by pain and limitation of motion but without evidence of forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; no ankylosis; no incapacitating episodes; and no other neurological abnormalities. 8. During the from August 23, 2019, the Veteran’s lumbosacral strain with degenerative arthritis and spinal stenosis was manifested by pain and limitation of motion but without evidence of forward flexion being limited to 30 degrees or less; no ankylosis; no incapacitating episodes; and no other neurological abnormalities. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to May 31, 2011 for the grant of an increased 30 percent rating for bilateral flat feet have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.151, 3.155, 3.400, 4.71A, Diagnostic Code 5276. 2. The criteria for a disability rating in excess of 30 percent prior to August 23, 2019, and in excess of 50 percent from that date for bilateral flat feet have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.71a, Diagnostic Code 5276. 3. The criteria for a disability rating in excess of 30 percent for mood disorder (depression) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9435. 4. The criteria for a rating in excess of 20 percent for left shoulder and arm strain with osteoarthritis and glenohumeral joint instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5201. 5. The criteria for a disability rating in excess of 10 percent prior to August 23, 2019, and in excess of 20 percent from that date for lumbosacral strain with degenerative arthritis and spinal stenosis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 1976 to November 1984. This case comes to the Board of Veterans’ Appeals (Board) on appeal from decisions of the Agency of Original Jurisdiction (AOJ) dated in January 2010, August 2011, December 2011, and August 2012. The Veteran testified before the undersigned Veterans Law Judge at an October 2015 hearing; a transcript of the hearing is of record. This case was previously remanded to the Agency of Original Jurisdiction (AOJ) in March 2016 and August 2018, for additional development. In an April 2020 rating decision, the AOJ granted an increased 50 percent rating for bilateral flat feet, effective August 23, 2019, granted a higher 20 percent rating for left shoulder and arm strain, effective May 31, 2011, and granted a higher 20 percent rating for lumbosacral strain, effective August 23, 2019. In a July 2020 written brief, the Veteran's representative stated that since increased ratings were granted for bilateral flat feet, a left shoulder disability, and lumbosacral strain, these issues were not before the Board. However, neither the representative nor the Veteran has explicitly withdrawn these appeals. 38 C.F.R. § 19.55. Since the increased ratings for bilateral flat feet, a left shoulder disability, and lumbosacral strain did not constitute a full grant of the benefits sought throughout the rating period on appeal, the increased rating issues remain in appellate status. See AB v. Brown, 6 Vet. App. 35, 39 (1993). 1. Earlier effective date for a 30 percent rating for bilateral flat feet The Veteran contends that an earlier effective date prior to May 31, 2011 should be granted for the award of an increased 30 percent rating for bilateral flat feet. He essentially asserts that the severity of this disability had been unchanged for many years. This issue comes to the Board on appeal from an August 2012 rating decision that granted an increased 30 percent rating for bilateral flat feet, effective August 15, 2012. An earlier effective date of May 31, 2011 was assigned in a January 2014 rating decision, during the pendency of the appeal. In general, unless specifically provided otherwise, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final adjudication, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. The effective date for an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, provided a claim is received within one year from such date; otherwise, the effective date for an increased rating will be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 U.S.C. §§ 5110 (a), (b)(3); 38 C.F.R. § 3.400 (o); Swain v. McDonald, 27 Vet. App. 219, 224 (2015). Although the Veteran contended in October 2012 that it was a clear and unmistakable error (CUE) that his bilateral flat feet were rated as 10 percent disabling from March 1990 to August 15, 2012, the Board finds that he has not successfully alleged CUE, because he did not specify the date of any AOJ decision being challenged (see Mindenhall v. Brown, 7 Vet. App. 271, 275 (1994)), and did not describe the alleged error “with some degree of specificity” or explain why, but for the error, the result would have been “manifestly different.” See 38 C.F.R. § 3.105(a)(1)(vii); Pierce v. Principi, 240 F.3d 1348, 1355 (Fed. Cir. 2001). Each theory of CUE in an AOJ decision is a separate and distinct matter and must be separately appealed for the Board to have jurisdiction. Andre v. Principi, 301 F.3d 1354, 1361 (Fed. Cir. 2002); Jarrell v. Nicholson, 20 Vet. App. 326, 332-33 (2006). The Veteran did not file a timely notice of disagreement with a November 2013 rating decision that determined that there was no CUE in prior AOJ decisions. 38 U.S.C. § 7105; 38 C.F.R. §§ 19.20, 19.21 (2019). The issue of CUE is not in appellate status and will not be addressed by the Board. A claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) was received from the Veteran on May 31, 2011, which the AOJ construed as a claim for increased ratings for all of his service-connected disabilities. In a January 2014 rating decision, the AOJ granted an earlier effective date of May 31, 2011 for the award of a 30 percent rating. In that decision, the AOJ stated that in May 15, 2012, a new claim for a TDIU was received, and was construed to include a claim for increase in his service-connected disabilities. The AOJ determined that new and material evidence was received within the appeal period from a December 2011 decision that denied an increase in the 10 percent rating for flat feet, and the evidence was considered to have been filed in connection with the May 31, 2011 construed claim for an increase in the 10 percent rating for bilateral flat feet. A specific claim in the form prescribed by VA must be filed for benefits to be paid or furnished to any individual under the laws administered by VA. 38 U.S.C. § 5101 (a); 38 C.F.R. § 3.151 (a). Regulations governing what constitutes a claim were revised effective March 24, 2015, i.e., after the Veteran’s May 2011 claim. Prior to March 24, 2015, the VA administrative claims process recognized formal and informal claims. A formal claim is one that has been filed in the form prescribed by the Secretary. 38 C.F.R. § 3.151 (2014). Any communication or action, indicating an intent to apply for one or more benefits, under the laws administered by VA, from a claimant may be considered an informal claim. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within 1 year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. When a claim has been filed which meets the requirements of 38 C.F.R. § 3.151, an informal request for increase or reopening will be accepted as a claim. 38 C.F.R. § 3.155 (2014). Service connection has been in effect for bilateral flat feet since December 1, 1984. An unappealed January 2010 rating decision denied an increase in a 10 percent rating for service-connected bilateral flat feet. The Veteran was notified of this decision by a letter dated in January 2010, and he did not appeal the determination regarding bilateral flat feet. That decision is final and binding on him based on the evidence then of record. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104 (a), 3.160(d), 19.20, 19.52, 20.1103. The Board finds that the claims file does not contain any subsequent formal or informal claim from the Veteran for an increased rating for service-connected bilateral flat feet, or any request for an application for benefits or intent to file a claim for an increased rating for this disability, prior to May 31, 2011. 38 U.S.C. § 5101; 38 C.F.R. §§ 3.151, 3.155 (2014). The Board will now consider whether there is a report of examination or hospitalization on file that may be accepted as an informal claim for an increased rating for bilateral flat feet prior to May 31, 2011 (see 38 C.F.R. § 3.157 (2014)), or whether it is factually ascertainable, based on all evidence of record, that an increase in severity of bilateral flat feet to 30 percent occurred during the one year prior to the Veteran’s May 31, 2011 claim. 38 C.F.R. § 3.400 (o). The United States Court of Appeals for Veterans Claims (Court) has held that, when determining whether a particular VA medical record qualifies as a “report of examination” under 38 C.F.R. § 3.157 (b)(1) (2014), the medical record in question must describe the results of a specific, particular examination. Massie v. Shinseki, 25 Vet. App. 123, 133 (2011). In addition, “[a]lthough the language of § 3.157(b)(1) does not expressly require that a report of examination or hospitalization indicate that the Veteran’s service-connected disability worsened since the time it was last evaluated, any interpretation of § 3.157(b)(1) that does not include such a requirement would produce an absurd result. Without such a requirement, every medical record generated by the Veterans Health Administration and received by VA that could possibly be construed as a report of examination would trigger the provisions of § 3.157(b)(1). This would unnecessarily burden VA by requiring it to treat every such medical record as an informal claim for an increased disability rating, even where a particular medical record shows no change in the Veteran’s condition.” Id. at 134. Since the prior final January 2010 AOJ decision, additional VA and private treatment records have been received. However, such records relate to other medical conditions. After a review of all of the medical evidence submitted since the prior final January 2010 rating decision, the Board finds that there is no report of examination or hospitalization prior to May 31, 2011 that shows that the Veteran’s service-connected bilateral flat feet worsened since the time they were last evaluated, in order to be accepted as an informal claim for an increased rating under 38 C.F.R. § 3.157 (2014). Thus, the remaining question is whether the Veteran’s bilateral flat feet manifested symptoms sufficient to warrant an increase in his disability evaluation to 30 percent in the one year prior to his May 31, 2011 claim. The Veteran's flat feet are evaluated under Diagnostic Code 5276. Under this code, a 10 percent rating is warranted for moderate acquired flat foot; weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral. A 20 percent rating is assigned for severe unilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is warranted for severe bilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. The Board has considered all the evidence of record. However, the most probative evidence of the degree of impairment consists of records generated in proximity to and since the claim on appeal. There is no medical evidence of treatment for bilateral flat feet during the period from May 31, 2010 to May 31, 2011. A VA examination was conducted in February 2011 in connection with the Veteran’s January 2011 claims regarding other disabilities. The Veteran’s feet were examined, and there was no evidence of pain with manipulation, no calluses, and no eversion of heels. These findings do not show that the bilateral flat feet more nearly approximated the criteria for a higher 20 or 30 percent rating under Diagnostic Code 5276, as there was no pain on manipulation, characteristic callosities or marked deformity. It is not factually ascertainable that this disorder increased in severity on some date within the year preceding the claim. In sum, the most probative evidence indicates that the Veteran’s bilateral flat feet did not more nearly approximate the criteria for a 30 percent rating during the one-year period prior to May 31, 2011. 38 C.F.R. § 3.400 (o). Therefore, the effective date for the increased rating from 10 percent to 30 percent may be no earlier than the date of VA receipt of the claim, May 31, 2011, and the claim for an earlier effective date is denied. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Increased Ratings When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis, to include in situations where the disability at issue is not evaluated based on range of motion measurements. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011); Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). Additionally, in Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. 2. Increased rating for bilateral flat feet The AOJ has rated service-connected bilateral flat feet (pes planus) as 30 percent disabling prior to August 23, 2019, and as 50 percent disabling from that date, under Diagnostic Code 5276. The Veteran contends that during the period prior to August 23, 2019, his bilateral flat feet disability was more disabling than the assigned 30 percent rating. He reported that he had calluses and foot pain, and he used shoe inserts which had to be replaced every three months. He also said he had developed plantar fasciitis in addition to flat feet. See October 2015 Board hearing. The Veteran has not made any contentions with regard to this disability during the period after August 23, 2019. The Veteran’s bilateral flat feet are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5276, for acquired flatfoot. Under Diagnostic Code 5276, a noncompensable rating is warranted for mild acquired flatfoot; symptoms relieved by built-up shoe or arch support. A 10 percent rating is warranted for moderate acquired flat foot; weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral. A 20 percent rating is assigned for severe unilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is warranted for severe bilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is also warranted for pronounced unilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. A maximum 50 percent rating is warranted for bilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. Period prior to August 23, 2019 On VA examination of the feet in February 2011, there was no evidence of pain with manipulation, no calluses, and no eversion of heels. On VA examination in August 2011, the Veteran complained of regular pain in his feet that was gradually progressing, with pain on walking and at rest, and he sometimes had cramping of the feet at night. He used orthotics for his shoes. On examination, he had moderate flattening of the arches, no evidence of pain with manipulation, no calluses, no eversion of heels, and no hallux valgus or toe deformities. He was able to stand on his heels and toes. On VA examination in August 2012, the Veteran complained of constant pain in both feet; he said walking made it worse, and he also had pain at rest. His feet cramped at night, and he wore orthotics. On examination, the Veteran had pain on use, pain on manipulation, pain accentuated on manipulation, and swelling on use of both feet, and his symptoms were not relieved by arch supports. He had decreased longitudinal arch height on weight-bearing, no objective evidence of marked deformity of the feet, no marked pronation, the weight-bearing line did not fall over or medial to the great toe, no inward bowing of the Achilles tendon, no marked inward displacement and severe spasm of the Achilles tendon on manipulation. He used a cane constantly, and orthotics regularly. The examiner opined that there had been no significant change in the condition of pes planus since the last VA examination in August 2011. An October 2012 VA outpatient treatment record reflects that the Veteran reported that he wore boots because they have a steel shank that provided support for his fallen arches. In October 2013, he requested that VA provide him with custom cowboy boots to fit his ankle brace (for his service-connected left ankle disability), and stated that cowboy boots were part of his way of life. A February 2014 VA podiatry note reflects that the Veteran was diagnosed with multiple foot conditions, including xerosis, foot deformity with dropfoot on the left, flat foot deformity, and neuropathy. A June 2014 VA primary care note reflects that the Veteran complained of foot pain that started six weeks ago, as well as foot swelling, and pain that was worse in the morning. The assessment was plantar fasciitis. A June 2014 VA physical therapy consult reflects that the Veteran complained of acute insidious bilateral heel pain that was worse in the morning. On examination, there was bilateral pes planus. The diagnostic assessment was plantar fasciitis. Symptoms from the other service-connected or non-service-connected disabilities affecting the Veteran's feet will not be considered when rating the service-connected bilateral pes planus. See 38 C.F.R. § 4.14. The Board finds that prior to August 23, 2019, the preponderance of the evidence is against a rating in excess of 30 percent for bilateral flat feet. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain on use and at rest. However, even considering the Veteran’s lay reports of symptoms and functional loss, the degree of additional limitation reflected by the statements that he had constant foot pain would not result in symptoms more nearly approximating pronounced bilateral acquired flatfoot. The Veteran denied flare-ups of his pes planus on examination in August 2011. The evidence of record prior to August 23, 2019 does not show marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement or severe spasm of the tendo achillis on manipulation. The Board has also considered the other Diagnostic Codes pertaining to the foot. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also Lyles v. Shulkin, 29 Vet. App. 107 (2017). In Scott v. Wilkie, the Federal Circuit expressly adopted the Court’s holding that disabilities specifically listed in the rating schedule may only be rated under Diagnostic Codes which specifically pertain to them. Scott v. Wilkie, 920 F.3d 1375 (Fed. Cir. 2019) (citing Copeland v. McDonald, 27 Vet. App. 333, 336 (2015)). The Federal Circuit also expressly adopted the Court’s holding that unlisted conditions may be rated by analogy to Diagnostic Codes that may not describe the unlisted disability but addresses disabilities that may be productive of similar symptoms. Scott, 920 F.3d 1375 (citing Yancy v. McDonald, 27 Vet. App. 484, 493 (2016). Finally, the Federal Circuit concluded that the Board must also consider assigning separate ratings under analogous Diagnostic Codes, when rating an unlisted service-connected foot disability exhibiting distinct manifestations, even when service connection has also been granted for one of the eight conditions listed in the rating schedule. Id. Here, the Veteran’s disability of bilateral flat feet is specifically listed under the rating schedule and therefore cannot be rated under a different Diagnostic Code. Additionally, the evidence of record does not reflect that the Veteran has any other service-connected foot disabilities that would warrant a separate rating under a different Diagnostic Code. In conclusion, the Board finds that the preponderance of the evidence is a rating in excess of 30 percent for bilateral flat feet during the period prior to August 23, 2019. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Period from August 23, 2019 From August 23, 2019, the Veteran’s bilateral flat feet have been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5276, for acquired flatfoot. Under Diagnostic Code 5276, a maximum 50 percent rating is warranted for bilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. On VA examination of the Veteran’s bilateral flat feet on August 23, 2019, the Veteran complained of bilateral foot pain, which felt like needles, and also reported foot swelling and throbbing of the toes. He said he could not stand or walk for very long. On examination, the Veteran had pain on use, pain on manipulation, pain accentuated on manipulation, and swelling on use of both feet, and his symptoms were not relieved by arch supports, built-up shoes, or orthotics. He had extreme tenderness of the plantar surfaces of both feet and decreased longitudinal arch height on weight-bearing. He had no objective evidence of marked deformity of the feet, no marked pronation, the weight-bearing line did not fall over or medial to the great toe, no inward bowing of the Achilles tendon, no marked inward displacement and severe spasm of the Achilles tendon on manipulation. There was pain on physical examination of both feet, which contributed to functional loss, specifically, pain on weight-bearing and non-weight-bearing. He had reduced tolerance for weightbearing due to pain. He constantly used a cane and occasionally used a scooter if he needed to traverse longer distances such as from the parking lot to the store. He had bilateral foot pain with walking any distance or standing for any length of time. As the Veteran is in receipt of the highest schedular rating for acquired flat foot, there is no basis to award a higher rating. The Board has also considered the other Diagnostic Codes pertaining to the foot. As noted, other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also Lyles v. Shulkin, 29 Vet. App. 107 (2017); Scott v. Wilkie, 920 F.3d 1375 (Fed. Cir. 2019) (citing Copeland v. McDonald, 27 Vet. App. 333, 336 (2015)). Here, the Veteran’s disability is specifically listed under the rating schedule and therefore cannot be rated under a different Diagnostic Code. Additionally, the evidence of record does not reflect that the Veteran has any other service-connected foot disabilities that would warrant a separate rating under a different Diagnostic Code. The Veteran has not raised any other issues with respect to the increased rating claim, nor have any other assertions been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017). 3. Higher initial rating for mood disorder (depression) The Veteran contends that a higher rating should be assigned for his service-connected mood disorder. At his October 2015 Board hearing, he testified that his multiple physical conditions limited his ability to do things, which affected his mood. He reported memory impairment. His wife stated that he had a short fuse and was irritable and became upset when he could not do the things he wanted to do due to his physical limitations. He reported that his sleep was poor due to his back pain. He received VA individual therapy and medication for his mood disorder. He stated that his doctor had helped him a lot, and that a couple of years ago his symptoms were really bad, and he had 23 assaults because of his short fuse. He could not explain why other than that he was angry and in pain. Currently he tried to stay away from people. He tended to isolate himself, even from family and friends, and they rarely had guests at their home. Throughout the rating period on appeal, the AOJ has rated the service-connected mood disorder (depression) due to general medical condition associated with left tibia and fibula fracture residuals with traumatic left ankle arthritis as 30 percent disabling under Diagnostic Code 9435, pertaining to unspecified depressive disorder. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating of 50 percent or higher. The Board concludes that the Veteran’s symptoms did not cause the level of impairment required for a disability rating of 50 percent or higher. The Veteran’s symptoms more closely approximated the symptoms associated with a 30 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 30 percent rating. 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 assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such 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; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. VA and private treatment records, the July 2012 and August 2019 VA examinations, and the Veteran’s lay statements show that the Veteran’s mood disorder (depression) due to general medical condition was manifested by symptoms associated with a 30 percent rating (depressed mood, anxiety, chronic sleep impairment, panic attacks weekly or less often, and mild memory loss), and symptoms associated with a 50 percent rating (disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships). He also had symptoms that are not listed with a specific rating, such as crying spells, poor appetite, difficulty concentrating, irritability, and anger. The Board finds the severity, frequency, and duration of the Veteran’s unlisted symptoms more closely approximate the symptoms contemplated by a 30 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 50 percent rating. The Veteran reported that these symptoms were not present daily, but would increase in severity when prompted by life events. Further, crying spells, poor appetite, difficulty concentrating, irritability, and anger are similar to depressed mood, anxiety, suspiciousness, and mild memory loss, which are contemplated by the assigned 30 percent rating. The July 2012 and August 2019 examiners each opined that the Veteran's mood disorder (depression) due to general medical condition produced 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. This level of impairment is consistent with a 10 percent rating. The August 2019 VA examiner changed the diagnosis of the service-connected psychiatric disorder to depressive disorder due to another medical condition, and stated that the name change was prompted by the new Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), but stated that the symptoms remained the same. The Board also finds the level of impairment caused by the Veteran’s symptoms more closely approximates the level associated with a 30 percent rating. The Veteran experienced occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but was generally functioning satisfactorily, with routine behavior, self-care, and normal conversation. Mental status examinations in VA and private treatment records and the July 2012 and August 2019 VA examination indicate that the Veteran had normal speech, irritable mood, normal coherent thought processes, no unusual thought content, good insight and judgment and intact memory. See VA psychiatry notes dated in May 2012, September 2014 and October 2015. While the Veteran did experience symptoms contemplated by a 50 percent rating, namely disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, the evidence overall does not demonstrate the level of impairment associated with a 50 percent rating. As noted above, the Veteran’s other remaining symptoms were either contemplated by or more consistent with a 30 percent rating. Further, while the Veteran has reported that he could not work due to his service-connected disabilities, he has generally related this to his other service-connected and non-service-connected disabilities. The Board notes that a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) has been in effect throughout the rating period on appeal. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s symptoms resulted in the level of impairment required for a 50 percent rating. The criteria for a 50 percent or higher rating are not met and the appeal must be denied. 4. Increased rating for left shoulder and arm strain with osteoarthritis and glenohumeral joint instability The Veteran contends that he is entitled to a higher rating for his service-connected left shoulder and arm strain with osteoarthritis and glenohumeral joint instability because he has left shoulder pain and decreased ability to lift items weighing more than ten pounds. In November 2010, he said he could not carry groceries or mow the yard because of pain in his shoulders and back. See November 2010 AOJ hearing transcript, August 2011 VA examination. At the October 2015 Board hearing, he testified that he had extreme pain when lifting a gallon of milk with either arm. He also reported a popping feeling in his shoulder, and numbness around the left elbow when lifting. He reported pain in both shoulders when sleeping on his sides, and he had to sleep on his back. He stated that he was right-hand dominant but also ambidextrous. The Veteran’s left shoulder and arm strain with osteoarthritis and glenohumeral joint instability is rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5010 (pertaining to traumatic arthritis), and 5201, for limitation of motion of the arm. Arthritis due to trauma, substantiated by X-ray findings, is rated as degenerative arthritis, which will be rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5010. Under Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Normal shoulder forward elevation (flexion) and abduction is from zero to 180 degrees, with 90 degrees representing shoulder level; normal shoulder external and internal rotation is from zero to 90 degrees. See 38 C.F.R. § 4.71a, Plate I. Diagnostic Code 5201 “does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm.” Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for left shoulder and arm strain with osteoarthritis and glenohumeral joint instability. The evidence of record shows that the Veteran is right-handed. See August 2011 and August 2019 VA examinations. The left arm is therefore the minor extremity. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, weakened movement, excess fatigability, repetitive use, pain during flare-ups, and pain during repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he had daily flare-ups of pain with lifting and overhead motion for less than a minute (see August 2011 VA examination), or daily flare-ups with movement that lasted for varying amounts of time (see August 2019 VA examination) would not result in symptoms more nearly approximating limitation of motion of the arm to 25 degrees from the side of the minor extremity. On examination in December 2009, flexion was to 180 degrees, abduction to 160 degrees, and external and internal rotation were to 90 degrees. There was pain on motion and evidence of slight fatiguing on the left shoulder. On examination in February 2011, flexion was to 170 degrees, and abduction was to 160 degrees. Flexion of the left shoulder was, at worst, limited to 140 degrees on VA examinations in August 2011 and August 2012. Abduction was, at worst, limited to 100 degrees on VA examination in August 2011, and to 120 degrees on VA examination in August 2012, and external rotation was full (90 degrees) in August 2011. After repetitive motion testing in August 2012, there was no additional limitation of motion. On VA examination in August 2019, flexion of the left shoulder was, at worst, limited to 80 degrees on active or passive motion. The examiner opined that pain limited flexion to 75 degrees, and flare-ups limited it to 70 degrees. Abduction was limited to 75 degrees, pain limited it to 70 degrees, and flare-ups limited it to 65 degrees. External rotation was limited to 70 degrees, pain limited it to 65 degrees, and flare-ups limited it to 60 degrees. Internal rotation was full (90 degrees). Muscle strength was full on VA examination in August 2012, and in VA outpatient treatment records dated in January 2016, February 2017 and August 2017. A July 2019 VA outpatient treatment record reflects that range of motion of the left upper extremity was within full limits. Strength was 4/5 in left shoulder flexion due to pain. On VA examination in August 2019, muscle strength was 4/5 and there was no muscle atrophy. Even considering the Veteran’s complaints of weakness and fatigue, the disability rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a. See Thompson, supra. Even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he had flare-ups on use would not result in symptoms more nearly approximating limitation of motion of the arm to 25 degrees from the side of the minor extremity. Considering the foregoing, the Board finds that a rating higher than the 20 percent rating assigned for the Veteran’s left shoulder disability is not warranted based on functional impairment at any time during the appeal period. 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 204-06. The Board has considered whether any other Diagnostic Codes related to disabilities of the shoulder would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. There is no evidence of ankylosis of the scapulohumeral articulation, to warrant consideration under Diagnostic Code 5200. Although glenohumeral joint instability is shown, the Veteran is already in receipt of a 20 percent rating for this disability, and a higher rating is not warranted under Diagnostic Code 5202 as the evidence does not show nonunion or malunion of the humerus, or recurrent dislocation of the humerus at the scapulohumeral joint, or fibrous union of the humerus, or loss of head of the humerus. A higher rating is not warranted under Diagnostic Code 5203 as impairment of the clavicle or scapula is not shown and as the Veteran is already in receipt of the maximum rating under this code. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s appeal for a rating in excess of 20 percent for left shoulder and arm strain with osteoarthritis and glenohumeral joint instability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 5. Increased rating for lumbosacral strain with degenerative arthritis The Veteran contends that he is entitled to a higher rating for his lumbosacral spine disability because he has limitation of motion and back pain. In November 2010, he said he could not carry groceries or mow the yard because of pain in his shoulders and back. In October 2015, he reported that his sleep was poor due to his back pain. He stated that he could not bend over to put on his shoes, and his wife put them on for him. He reported back pain that radiated down both legs to his feet. His representative asserted that a 100 percent rating should be granted for bilateral radiculopathy of the lower extremities. See October 2015 Board hearing transcript. The AOJ has rated the Veteran's lumbosacral strain with degenerative arthritis and spinal stenosis as 10 percent disabling prior to August 23, 2019, and as 20 percent disabling from that date. The Veteran’s lumbosacral strain with degenerative arthritis and spinal stenosis is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. 38 C.F.R. § 4.71a. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. at Note 2; see also 38 C.F.R. § 4.71, Plate V. Ankylosis is defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Period prior to August 23, 2019 The Board finds that during the period prior to August 23, 2019, the preponderance of the evidence is against a rating in excess of 10 percent for lumbosacral strain with degenerative arthritis and spinal stenosis. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, excess fatigability, pain during flare-ups, and pain during repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that anything made it worse (see VA examination in August 2012) would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or the combined range of motion of the thoracolumbar spine not greater than 120 degrees. Additionally, the Veteran did not have muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis during this period. On VA examination in December 2009, the Veteran complained of low back pain. Forward flexion was to 70 degrees, with pain at 60 degrees, extension to 20 degrees, with pain at 15 degrees, left and right lateral flexion to 20 degrees with pain at 15 degrees, and left and right rotation to 30 degrees, with pain at 20 degrees. The examiner opined that the low back disability was a combination of degenerative arthritic changes myofascial pain syndrome without evidence of radicular symptoms or herniated intervertebral disc. The Veteran denied flare-ups. On examination in February 2011, forward flexion was to 80 degrees, extension to 30 degrees, left and right lateral flexion to 30 degrees, and left and right rotation to 45 degrees. On examination in August 2011, forward flexion was to 45 degrees, with pain at 30 degrees, extension to 20 degrees, with pain at 15 degrees, left and right lateral flexion to 20 degrees with pain at 15 degrees, and left and right rotation to 25 degrees, with pain at 20 degrees. There was normal curvature, no tenderness to palpation, and no guarding or spasm. On VA examination in August 2012, forward flexion was to 90 degrees with pain at 90 degrees, extension to 0 degrees, with pain at 0 degrees, left and right lateral flexion to 20 degrees with pain at 20 degrees, and left and right rotation to 30 degrees, with pain at 30 degrees. The examiner stated that after repetitive use, the Veteran had less movement than normal and pain on movement. There was muscle spasm and tenderness to palpation of the thoracolumbar spine paraspinal muscles. VA outpatient treatment records reflect treatment for low back pain. An August 2017 VA outpatient treatment record reflects that the Veteran reported that his back disability had worsened in the past 3-4 weeks, and he had difficulty walking and arising from sitting. There was pain over the lumbar spine to palpation, and hypertonicity of the paraspinal muscles. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS and the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. On VA examinations in August 2012 and August 2019, the examiner stated that the Veteran does not have IVDS of the thoracolumbar spine. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for lumbosacral strain with degenerative arthritis and spinal stenosis during the period prior to August 23, 2019. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Period from August 23, 2019 The Board finds that during the period from August 23, 2019, the preponderance of the evidence is against a rating in excess of 20 percent for lumbosacral strain with degenerative arthritis and spinal stenosis under the General Rating Criteria. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, excess fatigability, repetitive use, pain during flare-ups, and pain during repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he had daily severe flare-ups with movement, which lasted a varying amount of time would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. On VA examination on August 23, 2019, forward flexion was to 80 degrees, extension to 15 degrees, right lateral flexion and rotation to 15 degrees, and left lateral flexion and rotation to 20 degrees. Pain was noted on examination but did not result in or cause functional loss. After repetitive motion testing, and repeated use over time, flexion was to 70 degrees, and extension was to 10 degrees, due to pain. The examiner indicated that on flare-ups, there would be additional limitation of motion, with flexion to 60 degrees, extension to 5 degrees, right lateral flexion and rotation to 10 degrees, and left lateral flexion and rotation to 15 degrees. There was no guarding or muscle spasm of the thoracolumbar spine. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS and the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. On VA examinations in August 2012 and August 2019, the examiner stated that the Veteran does not have IVDS of the thoracolumbar spine. Regarding neurological impairment, the Veteran asserts that he has bilateral radiculopathy of the lower extremities, with pain radiating down his legs, related to his service-connected lumbosacral strain with degenerative arthritis and spinal stenosis. While the Veteran is competent to report symptomatology that he experiences, he has not shown that he has the medical experience or training to diagnose radiculopathy or to relate the leg symptoms to his service-connected lumbosacral spine disability, which is a medically complex determination that cannot be based on lay observation alone. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Instead, such a determination must be made by a medical professional with appropriate expertise. Id. Accordingly, the Veteran’s statements that he has bilateral radiculopathy of the lower extremities that is related to his spine condition are not competent evidence. The August 2012 and August 2019 VA examiners opined that the Veteran does not have radicular pain or any other signs or symptoms due to radiculopathy in either lower extremity. On examination of the lower extremities in August 2019, the examiner stated that muscle strength in the lower extremities was 5/5 (normal), there was no muscle atrophy, and deep tendon reflexes were normal. Straight leg raising tests were also normal. There were no other neurological abnormalities or findings related to the lumbosacral spine disability. (Continued on the next page)   The examiner opined that the decreased sensory findings of the left ankle and foot were related to non-service-connected diabetes and previous trauma and surgery to the left lower extremity. Decreased sensation of the right foot was related to diabetes and not the lumbar nerve root compression. As these symptoms are not related to the service-connected lumbosacral spine disability, they may not be considered when evaluating the service-connected disability. 38 C.F.R. § 4.14. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for lumbosacral strain with degenerative arthritis and spinal stenosis during the period from August 23, 2019. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. L. Wasser, 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.