Citation Nr: 21000289 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 17-03 711 DATE: January 5, 2021 ORDER Entitlement to a rating in excess of 20 percent for a thoracolumbar spine disorder is denied. Entitlement to a rating in excess of 10 percent for a left knee disorder is denied. Entitlement to a rating in excess of 10 percent for a right knee disorder is denied. REMANDED Entitlement to service connection for a traumatic brain injury (TBI) is remanded. Entitlement to service connection for chronic fatigue syndrome (CFS), to include as due to an undiagnosed illness or a medically unexplained multisymptom illness. is remanded. Entitlement to service connection for neuropathy of the left upper extremity, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, is remanded. Entitlement to service connection for neuropathy of the right upper extremity, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, is remanded. Entitlement to service connection for neuropathy of the left lower extremity, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, is remanded. FINDINGS OF FACT 1. During the course of the appeal, the Veteran’s thoracolumbar spine disorder has not manifested forward flexion limited to 30 degrees or less even when considering motion loss during flares or on repetitive use; favorable ankylosis; or incapacitating episodes of at least four weeks for a 12-month period during the course of the appeal. 2. During the course of the appeal, the Veteran’s left knee has manifested painful but noncompensable motion loss even when considering motion loss during flares or on repetitive use with no other ratable symptomology. 3. During the course of the appeal, the Veteran’s right knee has manifested painful but noncompensable motion loss even when considering motion loss during flares or on repetitive use with no other ratable symptomology. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 20 percent for a thoracolumbar spine disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5235-5243. 2. The criteria for entitlement to a rating in excess of 10 percent for a left knee disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DCs 5014-5260. 3. The criteria for entitlement to a rating in excess of 10 percent for a right knee disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DCs 5014-5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 2004 to June 2010. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Schedule). 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify various disabilities and the criteria for specific ratings. Relevant regulations do not require that all cases show all findings specified by the Schedule; however, findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. §§ 4.7, 4.21. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In establishing an appropriate initial assignment of a disability rating, the proper scope of evidence includes all medical evidence submitted in support of the veteran’s claim. Fenderson v. West, 12 Vet. App. 119 (1999). In cases where an assigned disability rating has been challenged or appealed, it is possible for a veteran to receive a staged rating. A staged rating is an award of separate percentage evaluations for separate periods, based on the facts found during the appeal period. Id. at 126-28; see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (in determining the present level of a disability for any increased evaluation claim, the Board must consider staged ratings). If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45 but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). In Sharp v. Shulkin, the United States Court of Appeals for Veterans Claims (Court) decision addressed what constitutes an adequate explanation for an examiner’s inability to estimate motion loss in terms of degrees during periods of flare-ups. 29 Vet. App. 26 (2017). The Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. 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. 38 C.F.R. § 4.59. 1. Entitlement to a rating in excess of 20 percent for a thoracolumbar spine disorder The Veteran’s thoracolumbar spine disorder is currently rated as 20 percent disabled under DC 5299-5243. The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent disability rating for forward thoracolumbar flexion not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine 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. 38 C.F.R. § 4.71a, DCs 5235-5243. A 20 percent disability rating is warranted upon evidence of forward thoracolumbar flexion 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. Id. Forward thoracolumbar flexion to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine is rated as 40 percent disabling. Unfavorable ankylosis of the entire thoracolumbar spine is evaluated as 50 percent disabling. Id. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. See 38 C.F.R. § 4.71a, Plate V. Further, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a, DCs 5235-5243. Note 1 to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note 2 reads that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. 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. According to the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, a 10 percent rating contemplates incapacitating episodes having a total duration of at least 1 week but less than 2 weeks during the past 12 months. A 20 percent rating contemplates incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating requires evidence of incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating requires evidence of incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. Note 1 reads that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. In pertinent part, VA clinic records in 2014 noted the Veteran to have thoracolumbar spine pain and lumbar radiculopathy. A December 2014 VA examiner diagnosed the Veteran with degenerative disc disease based on VA imaging, but the examiner did not perform range-of-motion testing. In February 2016, the Veteran contacted VA and reported that his thoracolumbar spine disorder was worsening. July, August, and October 2016 private medical records reflect he received treatment for his spine. During private treatment, range-of-motion measurements were at worst forward flexion of the back to 50 degrees with pain; extension to 15 degrees with pain; right lateral flexion to 20 degrees; and left lateral flexion to 20 degrees. November 2016 VA treatment records reflect that the Veteran was diagnosed with hypolordosis of the lumbar spine after seeking treatment for back pain. November and December 2016 private medical records reflect chiropractic treatment, and the Veteran reported back pain of three out of ten at that time; January 2017 private medical records reflect chiropractic treatment, and the Veteran reported back pain of five out of ten. During a March 2017 VA examination, the Veteran reported low back pain which radiated into his legs, and lasted about 15 minutes limiting movement until it subsided. He self-described “saddle anesthesia.” His pain was brought on by prolonged standing and sitting as well as yard work. The Veteran was diagnosed with degenerative arthritis of the thoracolumbar spine. Upon initial and repetitive use range-of motion assessments, forward flexion of the back was measured to 50 degrees; extension to 20 degrees; right lateral flexion to 30 degrees; left lateral flexion to 30 degrees; right lateral rotation to 30 degrees; and left lateral rotation to 30 degrees; for a combined range of motion of 190 degrees. The examiner found evidence of pain with weight bearing, passive, and non-weight bearing motion, but found no guarding, muscle spasms, radiculopathy, or ankylosis. Thereafter, VA clinic records reflect continued treatment for low back pain with findings significant for vertebral spasms. During a September 2019 VA examination, the Veteran was diagnosed with degenerative disc disease of the thoracolumbar spine. The Veteran described a progressive worsening since service with dull pain over the lower back, and numbness and tingling in both lower extremities. He symptoms worsened with prolonged sitting or standing. Upon initial and repetitive use range-of motion assessments, forward flexion of the back was measured to 90 degrees; extension to 30 degrees; right lateral flexion to 30 degrees; left lateral flexion to 30 degrees; right lateral rotation to 30 degrees; and left lateral rotation to 30 degrees; for a combined range of motion of 240 degrees. The Veteran manifested pain on forward flexion and extension. For repeated use over time and flare-ups, the examiner estimated forward flexion to 70 degrees; extension to 20 degrees; lateral flexion to 25 degrees bilaterally; and lateral rotation to 25 degrees bilaterally; for a combined range of motion of 190 degrees. The examiner found radiculopathy of the right lower extremity (which is currently service-connected), but found no guarding, muscle spasms, or ankylosis. The Veteran is currently rated as 20 percent disabled for his thoracolumbar spine disorder. The Veteran credibly describes low back pain exacerbated by activities such as prolonged walking or standing, and lifting. During the course of the appeal, his range of motion has been variable with forward flexion of the thoracolumbar spine measuring no worse than 50 degrees. The most recent VA examination measured 90 degrees of forward flexion and estimated forward flexion being limited to 70 degrees with repetitive use/flares. Thus, even with consideration of additional motion loss due to repetitive use and during flares, the Veteran’s forward flexion falls well short of flexion to 30 degrees or less. There is also no lay or medical evidence of ankylosis. Finally, there are no episodes of incapacitating episodes of IVDS, as defined by regulation, during any 12-month period under appeal. The Board notes that the Veteran has been provided a separate rating for right lower extremity radiculopathy, and he has not appealed the initial rating assigned nor the effective date of award. In the absence of evidence of forward thoracolumbar flexion to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine; or incapacitating episodes of IVDS having a duration of at least four weeks during any 12-month period, a rating in excess of 20 percent for a thoracolumbar spine disorder is not warranted. 2. Entitlement to a rating in excess of 10 percent for a left knee disorder 3. Entitlement to a rating in excess of 10 percent for a right knee disorder The Veteran’s left and right knees are currently rated as 10 percent disabled, respectively. Included within 38 C.F.R. § 4.71a are multiple DCs that evaluate impairment resulting from service-connected knee disorders, including DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum). Under DC 5260, a noncompensable rating is assigned when flexion of the leg is limited to 60 degrees; a 10 percent rating is assigned when flexion is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, a noncompensable rating is assigned when extension of the leg is limited to 5 degrees; a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Under DC 5257, which evaluates recurrent subluxation or lateral instability of a knee, and assigns a 10 percent disabling for a slight impairment, 20 percent disabling for a moderate impairment, and 30 percent disabling for a severe impairment. Under DC 5258, a maximum 20 percent rating is warranted for semilunar cartilage, dislocated, with frequent episodes of “locking”, pain, and effusion into the joint. Lastly, under DC 5259, a maximum 10 percent rating is warranted for removal of semilunar cartilage that is symptomatic. Separate ratings under DCs 5260 and 5261 may be assigned for disability of the same knee joint. See VAOPGCPREC 9-2004. Additionally, for a knee disability already rated under DCs 5260 and/or 5261, a claimant would have additional disability justifying a separate rating if there is instability and/or subluxation of the knee joint under DC 5257. See generally VAOPGCPREC 23-97. Furthermore, the rating criteria do not preclude separate ratings for meniscal injury under DCs 5258 and 5259 where there are separate ratings for limitation of motion under DCs 5260 and/or 5261, or instability under DCs 5257. Lyles v. Shulkin, 29 Vet. App. 107 (2017). The normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. The terms “slight,” “moderate,” “moderately severe,” and “severe” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The use of terminology such as “slight” or “moderate” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. Historically, the Veteran was evaluated for right knee pain during service with a magnetic imaging resonance (MRI) scan showing osteoid osteoma of the distal medial femoral cortex. He subsequently underwent radiofrequency ablation of the right femoral osteoid osteoma. Thereafter, there were recorded complaints of locking, swelling and painful knees. During a July 2014 VA examination, the Veteran was diagnosed with bilateral knee strain and left knee osteogenic fibroma. The Veteran reported bilateral knee pain and limitation of motion either a few times a day or week. He described an intermittent “ice pick” sensation under the knee caps and into the joint which occurred a couple of times a day or week. He worked as an emergency medical technician, and his knee pain limited his lifting ability. He reported that certain movements caused his knee to pop out of place which he self-reduced. Bilateral knee range of motion was zero degrees to 120 degrees, with pain on movement after repetitive use testing. The knees manifested no instability, subluxation, or meniscus issues. There was 5/5 strength in flexion and extension bilaterally. Imaging reflected left knee osteogenic fibroma and benign bone island. During a March 2017 VA examination, the Veteran was diagnosed with bilateral knee strain. Bilateral knee range of motion was zero degrees to 110 degrees with no additional motion loss with repetitive testing. While the Veteran described snapping and popping, objective testing reflected no instability, subluxation, or meniscus issues in either knee. Imaging reflected bilateral knee arthritis. The examiner determined that there was evidence of pain on passive and non-weight bearing motion. During a September 2019 VA examination, the Veteran was diagnosed with bilateral knee strain and right knee osteoid osteoma. The Veteran described worsened pain with movement and exertion. He had difficulty walking or running for long due to pain and fatigue. Bilateral knee range of motion was zero degrees to 140 degrees, with pain on flexion and extension bilaterally. The examiner estimated that range of motion during repetitive use over time and flare-ups is zero to 120 degrees bilaterally. Objective testing reflected no instability, subluxation, or meniscus issues in either knee. During the course of the appeal, flexion of the knees has been limited to, at worst, 110 degrees bilaterally; and extension of the knees has been normal. The medical record also reflects no ankylosis of the knees, and objective testing has consistently reflected no subluxation or instability. The Veteran has credibly reported symptoms of painful motion, intermittent ice pick sensation, snapping and popping out of joint requiring self-reductions. However, the Veteran has not reported motion loss to the extent of flexion limited to 60 degrees or extension limited to 5 degrees required for even a noncompensable rating under either DC 5260 or DC 5261. Additionally, the Veteran does not describe ankylosis or instability, and the medical evidence shows no ankylosis and no instability on clinical testing. The Veteran has a past history of reporting locking and swelling, but there is no medical evidence of any meniscal abnormality of either knee. See July 2014, March 2017, and September 2019 VA Examinations. The Veteran, while having some medical training, has not alleged a meniscal disability. In the absence of evidence of any ratable disorders under DCs 5256 – 5261, the knees are appropriately individually rated as 10 percent disabled for painful motion under 38 C.F.R. § 4.59. Entitlement to a rating in excess of 10 percent for either knee is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for TBI is remanded. Unfortunately, there has not been substantial compliance with the Board’s previous remand directives regarding the issue of entitlement to service connection for TBI. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). In a November 2018 remand, the Board instructed the Agency of Original Jurisdiction to obtain a VA examination regarding TBI in which the examiner “consider the VA clinic records which include an assessment of short-term memory loss probably due to (d/t) mild TBI….” See December 2011 VA Treatment Records. The AOJ obtained an August 2019 VA examination in which a VA physiatrist determined that the Veteran did not have a diagnosis of TBI during the course of the appeal. The examiner did not, however, address VA clinic records indicating mild TBI. A remand is needed to obtain an addendum opinion that addresses these records. 2. Entitlement to service connection for CFS, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, is remanded. 3. Entitlement to service connection for neuropathy of the left upper extremity, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, is remanded. 4. Entitlement to service connection for neuropathy of the right upper extremity, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, is remanded. 5. Entitlement to service connection for neuropathy of the left lower extremity, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness, is remanded. The Veteran currently has a diagnosis of chronic fatigue syndrome that requires continuous use of Aleve to control and includes symptoms that wax and wane without causing periods of incapacitation. See September 2019 VA Examination. The claims file also contains evidence that the Veteran has neuropathy of the left and right upper extremities and left lower extremity. See, e.g., July 2016 Private Medical Records; May 2014 VA Treatment Records. Additionally, during service, the Veteran indicated that he experienced numbness and tingling in his hands and feet, muscle aches, and painful joints. See, e.g., October 2007 Post-Deployment Assessment. The September 2019 VA examiner diagnosed the Veteran with neuropathy of the right lower extremity, which is currently service-connected. The examiner determined there was no objective evidence to support a diagnosis of neuropathy of the left and right upper extremities and left lower extremity. While the examiner noted that service-connected right lower extremity had a clear and specific etiology and diagnosis, the examiner did not address the subjective symptoms of neuropathy of the other extremities. An addendum opinion is needed to address whether diagnosed chronic fatigue syndrome and symptoms of neuropathy in the extremities are symptoms of an undiagnosed illness or a medically unexplained multisymptom illness. The matters are REMANDED for the following action: 1. Obtain VA treatment records since August 2017 and associate them with the claims file. 2. Forward the Veteran’s claims file to the August 2019 VA physiatrist or another appropriate examiner for an opinion addressing the Veteran’s claimed TBI. The examiner should answer the following questions: (a) Does the Veteran currently or at any time during the course of the appeal manifested residuals of TBI? In answering this question, the examiner must specifically address December 2011 VA Treatment Records indicating possible mild TBI. (b) If the answer to (a) is yes, is it at least as likely as not that any diagnosed TBI is etiologically related to the Veteran’s service? If an examination is needed, one should be scheduled. A complete medical rationale for all opinions expressed must be provided. 3. Forward the Veteran’s claims file to an appropriate examiner to obtain an opinion that addresses the Veteran’s CFS and subjective symptoms of neuropathy of the left and right upper extremities and lower left extremity. The examiner should opine as to whether it is at least as likely as not (i.e., probability of 50 percent or greater) symptoms that constitute an undiagnosed illness or medically unexplained chronic multi-symptom illness. If an examination is needed, one should be scheduled. A complete medical rationale for all opinions expressed must be provided. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Howell, 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.