Citation Nr: 21005178 Decision Date: 01/29/21 Archive Date: 01/29/21 DOCKET NO. 10-20 202 DATE: January 29, 2021 ORDER Prior to January 28, 2009, a rating in excess of 30 percent for the service-connected asthma is denied. Since January 28, 2009, a rating higher than 60 percent for the service-connected asthma is denied. FINDINGS OF FACT 1. Prior to January 28, 2009, the Veteran’s asthma was manifested by FEV-1 of 56 to 70 percent of predicted value; FEV-1/FVC of 56 to70 percent of predicted value, and daily inhalational or oral bronchodilator therapy. 2. Since January 28, 2009, the service-connected asthma is generally manifested by FEV-1 is 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. CONCLUSIONS OF LAW 1. Prior to January 28, 2009, the criteria for a rating higher than 30 percent for the service-connected asthma are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.97, Diagnostic Code 6602 (2019). 2. Since January 28, 2009, the criteria for a rating higher than 60 percent for the service-connected asthma are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.97, Diagnostic Code 6602 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a veteran (the Veteran) who had active duty service from November 1985 to October 1995. This appeal comes before the Board of Veterans’ Appeals (Board) from a June 2020 Order of the United States Court of Appeals for Veterans’ Claims (Veterans Court). The appeal originated from a December 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In March 2014, the Veteran presented testimony at a Board hearing, chaired via videoconference by the undersigned Veterans Law Judge and accepted such hearing in lieu of an in-person hearing before a Member of the Board. See 38 C.F.R. § 20.700(e). At the Board hearing, the Veteran was informed of the basis for the RO’s denial of his claim and he was informed of the information and evidence necessary to substantiate the claim. 38 C.F.R. § 3.103. A transcript of the hearing is associated with the claims file. In a March 2017 decision, the Board denied this appeal. The Veteran appealed that decision to the Veterans Court. In a June 2020 memorandum decision, the Veterans Court vacated the Board’s decision and remanded this issue to the Board for additional adjudication. Increased Ratings—Law and Regulations Disability ratings are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran’s condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Entitlement to an increased disability rating for the service-connected asthma, currently rated at 30 percent prior to January 28, 2009, and 60 percent since January 28, 2009. Respiratory disorders are rated under Diagnostic Codes 6600 through 6817 and 6822 through 6847. Ratings under those diagnostic codes will not be combined with each other. Rather, a single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher rating only where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.96(a) (2019). Effective October 6, 2006, VA added provisions that clarify the use of pulmonary function tests in evaluating respiratory conditions. See 71 Fed. Reg. 52459 (Sept. 6, 2006) (codified at 38 C.F.R. § 4.96(d)). That is, 38 C.F.R. § 4.96(d) was added to the Rating Schedule, applicable to all applications for benefits received by VA on or after October 6, 2006. In the present case, the Veteran filed his claim on October 3, 2006, just prior to the effective date. Moreover, the amended regulation does not include Diagnostic Code 6602 for bronchial asthma, which is the most appropriate diagnostic code for the Veteran’s service-connected disability. Thus, the provisions of 38 C.F.R. § 4.96(d)(1)-(7) do not specifically apply here. As such, there are no regulations identifying whether pre- or post-bronchodilator results should be used when determining disability ratings under Diagnostic Code 6602. Under Diagnostic Code 6602, asthma is given a rating of 100 percent if FEV-1 is less than 40-percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. A rating of 60 percent is assigned if FEV-1 is 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A rating of 30 percent is assigned with FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication. A rating of 10 percent is assigned with FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of 71 to 80 percent, or; intermittent inhalational or oral bronchodilator therapy. Note: In the absence of clinical findings of asthma at time of examination, a verified history of asthmatic attacks must be of record. 38 C.F.R. § 4.97, Diagnostic Code 6602. An August 19, 2005, report from Sharp Healthcare Urgent Care notes a prescription for Albuterol (inhaled bronchodilator). An August 21, 2005, report notes the Veteran returned with shortness of breath and was diagnosed with acute pneumonia. A March 1, 2006, report notes complaint of wheezing and shortness of breath, and a diagnosis of an upper respiratory infection (Record 07/25/2007). A February 26, 2007, Emergency Department Note from Pomerado Hospital reveals complaint of cough and fever. The examiner assessed bronchitis, pneumonia, and asthma exacerbation. The prescription was Levaquin (oral antibiotic), Albuterol (inhaled bronchodilator), and Prednisone Taper (inhaled corticosteroid) (Record 08/02/2007). A July 9, 2007, pulmonary function test reveals a pre-bronchodilator FEV-1 of 108.7 percent predicted and FEV-1/FVC of 97.4 percent predicted. Post-bronchodilator results for FEV-1 are 110.3 percent predicted. FEV-1/FVC was 98.7 percent predicted (Record 01/08/2008). An October 30, 2007, pulmonary function test reveals initial testing (2:53 pm) of pre-bronchodilator FEV-1 at 47 percent predicted. FEV-1/FVC was 82 percent predicted. Post bronchodilator (3:09 pm) FEV-1 was 59 percent predicted. Post bronchodilator FEV-1/FVC was 77 percent predicted. The examiner noted that there was possibly poor initial effort and a retest was conducted at 3:23 pm. Retest values reveal a FEV-1 value of 89 percent predicted. FEV-1/FVC was 87 percent predicted (Record 08/06/2008). Contrary to the quotation agreed to by the parties that this pattern would be “difficult to fake,” the report actually says: “HARD TO FAKE” and would be due to an unusual restrictive pattern of reactive lung disease seen in some patients with exercise-induced symptoms and is always intrinsic, i.e. not allergen associated or triggered. According to the examiner, it does not fit a strict definition of asthma because there is no bronchospasm, but does respond to beta-agonist therapy (Record 08/06/2008). A January 2, 2008, Gulf War Registry examination notes the Veteran was using an Albuterol inhaler and had occasional shortness of breath. He was initially diagnosed as having asthma, but a recent pulmonary function test was more consistent with reactive airway disease (Record 01/08/2008 at 3). A January 30, 2008, VA Allergy Consult notes the Veteran was using an inhaler before exercise or he would have shortness of breath. An October 2007 chest X-ray revealed lungs were clear and moderately expanded with sharp costophrenic sulci (Record 12/22/2016 at 205). The report of a VA examination dated in October 2008 reveals the Veteran was on Flovent (inhaled corticosteroid), 1 puff daily, which controlled his symptoms. Since January, he had not had any periods of incapacitation. However in the few months prior to January, he did have 3 days of incapacitation. Pre-bronchodilator FEV-1 was 103.6 percent predicted and FEV-1/FVC was 94.7 percent predicted. Post-bronchodilator results included FEV-1 of 110.6 percent predicted and FEV-1/FVC of 100 percent predicted (Record 10/24/2008). A January 28, 2009, outpatient report reveals complaint of trouble breathing for the past couple days. It was noted he takes Flovent (inhaled corticosteroid) and Albuterol (inhaled bronchodilator) with no relief. He was discharge home on Prednisone Burst (Record 05/08/2009). A private April 10, 2009, outpatient report reveals complaint of shortness of breath, but a normal examination. Prescriptions were Prednisone and PROAIR HFA (inhaled bronchodilator) (Record 5/08/2009). A November 25, 2009, prescription slip identifies a Methylprednisolone Dose Pack (oral corticosteroid). A November 25, 2009, walk-in urgent care note reveals complaint of shortness of breath for 4 days. He reported he was often treated with steroid burst (Record 12/18/2009). The report of a VA examination dated December 2009 reveals the Veteran had been treated with bronchodilators and intermittent topical steroids over many years. Seven months ago he ran out of steroids (Flovent) and had not been able to refill the prescription, but he was using Albuterol on a daily basis using 2-3 puffs every morning and occasionally during the day when he notes chest tightness. He reported it does not interfere with his ability to do his work. However on 3 occasions this year, he has been treated in urgent care for exacerbations of asthma, being treated with Aero Meds and steroid burst with good results. He responds to the bronchodilator as well. He has occasional dry cough. He will have intermittent dyspnea on exertion such as running upstairs but usually is able to exercise. He has not been incapacitated with asthma, defined as requiring bedrest and treatment by a physician, in the past year. He would, l to 2 times per month, go in late to work because of asthma symptoms. Pulmonary function test results were normal. Pre-bronchodilator values for FEV-1 were 124 percent predicted and FEV-1/FVC were 101.3 percent predicted. Post-bronchodilator results showed FEV-1 of 123.2 percent predicted and FEV-1/FVC of 101.3 (Record 12/30/2009). A December 2009 Independent Pulmonary Examination from J. Vevaina, MD, refers to the October 2007 pulmonary function test results as indicating moderately severe asthma. Dr. Vevaina noted that his other pulmonary function studies do not show such severe impairment, but as most pulmonologists know, asthma can vary from completely normal function studies to severe bronchospasm within days and minutes. A second pulmonary function test in October 2007 showed a mild restrictive pattern of lung disease that responded to bronchodilators. This is unusual for asthma, but is found in 5 percent of the patients with reactive airway disease. The review of the file shows that he has had continuous treatment for asthma with flare ups off and on. The diagnosis was moderate asthma based on VA criteria with moderately severe asthma in 2007. According to Dr. Vevaina, this supports a 60 percent disability (Record 12/09/2009). An August 14, 2010, Urgent Care Note reveals complaint of a dry cough for 1 week, shortness of breath, and feeling tired. The Veteran reported that he had an asthma exacerbation. He reported having some wheezing that was “not that bad,” and the examiner reported he was coughing. He was given a prescription Medrol Dosepak (oral corticosteroid) and Albuterol (inhaled bronchodilator). He reported these are what worked beautifully for him in the past. If he does not get better or if the cough continues, mucus develops, fevers then we will start Z-Pak (antibiotic) (Record 09/16/2010 at 4). A November 6, 2010, Urgent Care Note reveals complaint of shortness of breath for 3 days and asthma with poor control. A Handwritten note in the right margin says “FEV1 30%” (Record 12/10/2010). A 24-Hour Urgent Care Note dated February 27, 2011, shows the Veteran was given a Medrol Dosepak (Record 08/05/2011). A July 8, 2011, report reveals a complaint of shortness of breath, tightness in the chest for 3-4 days medications including Advair (inhaled corticosteroid), Medrol Dosepak, Zithromax (antibiotic), and Proventil (inhaled bronchodilator) (Record 03/29/2013). A November 2016 letter was submitted from Dr. Vevaina, who noted the Veteran had been treated with Albuterol, Fluticasone, and Mometasone Furoate (corticosteroids), but still needed courses of oral steroids to control his asthma. Apparently, on November 6, 2010, he sought care because Albuterol failed to control symptoms and a pulmonary function test showed an FEV-1 of 30 percent. He was prescribed oral steroids. Dr. Vevaina noted the pulmonary function test conducted on October 30, 2007, and acknowledged that his other pulmonary functions do not show such severe impairment, but as most pulmonary specialists know, asthma can vary (when in remission) from normal pulmonary function to severe airflow obstruction. According to Dr. Vevaina, when evaluating the Veteran’s disability, the following should be considered: (1) asthma is an episodic disease, and, in between exacerbations, the patient can feel normal and pulmonary function tests can show only small airway obstruction. It does not require post-bronchodilator studies to evaluate, although post-bronchodilator studies are helpful; (2), the standard therapy for mild to moderate asthma is inhaled bronchodilators, inhaled steroids and periodically oral steroids; (3), in 2010, the Veteran had an examination by a private doctor in Temecula where he was found to have moderately severe asthma and was prescribed 5 days-of oral steroids. His FEV-1 was 30 percent. According to Dr. Vevaina, in asthma, it is inadequate to only examine test results during remission in gauging the level of breathing impairment while ignoring tests done during an attack. This is why, in the Veteran’s case, a methacholine test was done. It is not by coincidence that the Veteran’s most impaired pulmonary function test happened during an asthma attack. Tests during asthma attacks are more informative in understanding impairment (Record 02/10/2017). In response to the Board’s remand instructions to address the stipulations of the parties to the Joint Motion, the Veteran was afforded a VA examination in December 2016. The report reveals that, since the initial diagnosis of asthma, he has had occasional Prednisone bursts for exacerbations. The first time was in 1996. Over the years, his maintenance medication has mainly been Albuterol alone. He also has been variously prescribed Fluticasone and Mometasone oral inhalers over the years, and most recently, in early 2016, was given Advair, but he stopped it because he says it did not prevent exacerbations and his insurance copay was expensive. His last Prednisone Burst was at the end of November 2016, with Prednisone 40 mg daily for 5 days. The prior episode was August 2016, and before that was January 2016 (both 60 mg daily for 5 days). Currently his maintenance regimen is Albuterol only, 1-2 puffs in the morning and later if needed. There have been no hospitalizations for asthma and no chest or lung surgery. He misses part of a workday when he goes to urgent care for asthma exacerbations, but then returns to work the next day. He recalls a pneumonia episode in 2012 that was treated with antibiotics and several days off from work, but no pneumonia since then. According to the December 2016 VA examiner, the Veteran’s respiratory condition requires intermittent courses or bursts of systemic (oral or parenteral) corticosteroids, totaling 3 courses or bursts in the past 12 months. The Veteran’s respiratory condition requires daily inhaled bronchodilator therapy. The condition does not require the use of oral bronchodilators, antibiotics, or oxygen therapy. There have been no asthma attacks with episodes of respiratory failure in the past 12 months. In 2016, he had 3 exacerbations (January, August, and November) that each involved an urgent care visit and prescription for 5-day course of oral Prednisone. Physician visits for required care of exacerbations were less frequently than monthly over the prior 12 months. Pulmonary function tests were performed. The examiner noted that the initial study on December 9, 2016, was considered invalid due to the Veteran not cooperating with instructions and giving variable efforts. Testing was repeated on December 22, 2016, and was satisfactory. These results were found to accurately reflect the Veteran’s current pulmonary function. Pre-bronchodilator testing showed FEV-1 of 121.0 percent predicted and FEV-1/FVC of 98.7 percent predicted. Post-bronchodilator testing showed FEV-1 of 124.8 percent predicted and FEV-1/FVC of 102.6 percent predicted. According to the examiner, the FEV-1/FVC test was assessed as most accurately reflecting the Veteran’s level of disability. Occupational impairment was assessed in terms of time missed in the prior year. The examiner noted that he had missed part of a workday on 3 occasions. The examiner opined that the Veteran’s pre-bronchodilator results should be considered in evaluating asthma functional impairment. The Veteran’s current pre-bronchodilator results are within normal limits, and improved slightly further with treatment. The examiner further opined that the November 6, 2010, Urgent Care Note represents an acute exacerbation. He based this on the note stating that the Veteran was short of breath for the previous 3 days, with increased use of his Albuterol during that period. Thus the symptoms over the previous 3-day period were a change from his baseline status. The examiner noted that Urgent Care notes provided by the Veteran showed 3 visits in the past year for asthma exacerbations: in January, August, and November of 2016. At each of the 3 visits, the Veteran was prescribed a short course of Prednisone, 40-60 mg daily for 5 days. Prednisone is a corticosteroid. Prednisone doses of 40-60 mg daily are usually considered “high dose”, but were given to the Veteran for only short bursts (each episode was for 5 days). During the intervals between the exacerbations the Veteran did not take corticosteroid medications. The examiner noted that Prednisone has both anti-inflammatory and immune-suppressive effects. However, for asthma exacerbations it is prescribed for its anti-inflammatory effects, and not for immune-suppression. The available records show that, in the past year, the Veteran was treated 3 times with a 5-day burst of Prednisone for asthma exacerbations. Generally corticosteroids must be taken for at least 2 weeks to be considered immunosuppressive. Between the exacerbations, the Veteran has been treated solely with an Albuterol inhaler (inhaled bronchodilator). Thus, the examiner concluded that the Veteran’s asthma has not been treated with medications for the purpose of immune suppression (Record 12/22/2016). After a review of all of the evidence, the Board finds that, prior to January 28, 2009, the criteria for a 60 percent are not more nearly approximated than are those for the currently assigned 30 percent rating. The Board finds that, during this period, there have not been monthly or more frequent visits to a physician for required care of exacerbations, or, intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. Regarding the period prior to January 28, 2009, the parties to the Joint Motion agreed that the Board must readjudicate whether the Veteran is entitled to a 60 percent rating under Diagnostic Code 6602 and specifically address Dr. Czer’s October 30, 2007, opinion that the pulmonary function test result showing an FEV-1 of 47 percent of predicted would be “difficult to fake” and was due to an unusual restrictive pattern on lung disease. The Board notes that the parties to the Joint Motion do not give an accurate quotation of Dr. Czer’s opinion (“HARD TO FAKE”) (Record 08/06/2008 at 5). In fact, he differentiated these findings from the service-connected asthma. Omitted from the description of the parties is the examiner’s finding that these results do not fit a strict definition of asthma, because there is no bronchospasm, but responds to beta-agonist therapy. While the Board may not differentiate between service-connected and nonservice-connected symptomatology in the absence of medical evidence which does, it would appear that the examiner has differentiated the test results from service-connected asthma. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). The Board does not contend or find that the Veteran was faking his test results. However, the Board may compensate the veteran only for service-connected disability. Here, the cited evidence adequately differentiates these results from the service-connected asthma/reactive airway disease. The Veteran bases his assertions regarding entitlement to a higher rating during this period on the cited test results. He asserts that, use of the pre-bronchodilator value for FEV-1 of 47 percent predicted supports entitlement to a 60 percent rating. However, the examiner who conducted that test was not satisfied with the Veteran’s initial effort and had to order additional testing. The examiner specifically questioned the Veteran’s initial effort. Retest values revealed substantially higher scores for FEV-1 of 89 percent predicted, and for FEV-1/FVC of 87 percent predicted. With the exception of the questioned initial test result, all other pulmonary function test results prior to January 28, 2009, fall clearly into the range of the 30 percent criteria whether pre-bronchodilator or post-bronchodilator results are used, and do not suggest entitlement to any higher rating. The parties to the Joint Motion found no other fault with the Board’s analysis. Regarding the period since January 28, 2009, the parties to the Joint Motion agreed that the Board must specifically address the November 2010 treatment record’s notation of an FEV-1 of 30 percent of predicted and determine whether the Veteran is entitled to a higher rating under Diagnostic Code 6602, which provides for a 100 percent rating when there is an “FEV-1 less than 40-percent predicted.” The Board finds that, since January 28, 2009, pulmonary function test results have not more nearly approximated the criteria for a 100 percent evaluation than they have for the 60 percent evaluation regardless of whether pre- or post-bronchodilator results are used. The Board acknowledges the urgent care visit in November 2010, where a finding of 30 percent predicted for FEV-1 was hand-written into the margin during an exacerbation of symptoms. In any event, the opinion of the December 2016 examiner was that such a result is best characterized as an exacerbation and does not represent his normal condition during this period. The Board finds that the rating schedule and criteria clearly and explicitly contemplate the presence of symptom exacerbation beyond the general level of impairment contemplated by a given rating. This is manifest at the 60 percent level by the alternative method for establishing the criteria of at least three exacerbations per year which require additional medications not needed for maintenance of the disability. While this is an independent route to a 60 percent rating, the presence of exacerbations is contemplated at that level. Symptom exacerbations represent the extremes, and not the overall disability picture or overall level of impairment caused by the disability. Establishing the overall level of impairment is of prime concern in establishing any disability rating as this describes the ability of an individual to function under the ordinary conditions of daily life including employment. See 38 C.F.R. § 4.10. The Board acknowledges the statement by Dr. Vevaina that it is inadequate to only examine test results during remission in gauging the level of breathing impairment while ignoring tests done during an attack. The Board has certainly not ignored any test results in this case. However, as acknowledged by Dr. Vevaina, there are a substantial number of tests conducted during low levels of symptomatology, and this is a factor to be considered in itself. In determining the overall disability picture, the Board must consider the frequency and duration of exacerbations, and compare this with the frequency and duration of periods of quiescent symptomatology. A single examination finding does not determine entitlement to a higher rating. There must be at least an approximate balance of the evidence for and against the claim. Here, to the extent there have been exacerbations, the Board must balance these exacerbations against a greater number findings of lesser severity. The Board finds that, on balance, the Veteran’s symptomatology is fully contemplated by the 60 percent rating and does not more nearly approximate a finding of total disability due to asthma. The Board also notes that the more severe initial finding in December 2016 was balanced by findings of lesser severity conducted on the same day. Moreover, the November 2010 result was found not be consistent with the service-connected asthma. Accordingly, the Board finds that staged ratings are not appropriate. The discussion of the November 2010 findings is the only fault found by the parties to the Joint Motion during this period. The Board also observes that, during this period, there have not been more than one attack per week with episodes of respiratory failure, or, requirement of daily use of systemic (oral or parenteral) high dose corticosteroids or immune-suppressive medications. In sum, the Board finds that, to the extent the Veteran has experienced exacerbations in symptoms which have reduced his pulmonary function below that generally contemplated for the 60 percent rating, these exacerbations are temporary, relatively few, and fully contemplated in the 60 percent rating. Accordingly the Board concludes that, since January 28, 2009, the criteria for a rating of 100 percent are not met and are not more nearly approximated that are those for the 60 percent rating. 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. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Cramp 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.