Citation Nr: 21061294 Decision Date: 10/01/21 Archive Date: 10/01/21 DOCKET NO. 17-23 033 DATE: October 1, 2021 ORDER Entitlement to an increased evaluation in excess of 20 percent disabling for right lower extremity peripheral neuritis is dismissed. Entitlement to an increased evaluation in excess of 40 percent disabling for mechanical low back pain is dismissed. Entitlement to an initial evaluation of 50 percent disabling, but no higher, for posttraumatic stress disorder (PTSD) from September 18, 2007 to August 23, 2015 is granted. Entitlement to an evaluation in excess of 70 percent disabling for PTSD from August 24, 2015 is dismissed. FINDINGS OF FACT 1. In his June 2021 hearing, the Veteran testified that he desired to withdraw his claim for entitlement to an increased evaluation in excess of 20 percent disabling for right lower extremity peripheral neuritis. 2. In his June 2021 hearing, the Veteran testified that he desired to withdraw his claim for entitlement to an increased evaluation in excess of 40 percent disabling for mechanical back pain. 3. From September 18, 2007 to August 23, 2015, the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. 4. In his June 2021 hearing, the Veteran testified that he desired to withdraw his claim for entitlement to an evaluation in excess of 70 percent disabling for PTSD from August 24, 2015. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal by the Veteran have been met for the issue of entitlement to an increased evaluation in excess of 20 percent disabling for right lower extremity peripheral neuritis. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for withdrawal of an appeal by the Veteran have been met for the issue of entitlement to an increased evaluation in excess of 40 percent disabling for mechanical low back pain. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 3. The criteria for entitlement to an initial evaluation of 50 percent for PTSD from September 18, 2007 to August 23, 2015 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411. 4. The criteria for withdrawal of an appeal by the Veteran have been met for the issue of entitlement to an evaluation in excess of 70 percent disabling for PTSD from August 24, 2015. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from August 1988 to October 1991. This appeal comes to the Board of Veterans' Appeals (Board) from a rating decision dated October 2014 issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran timely appealed. The Veteran testified at a June 2021 Board virtual hearing before the undersigned Veterans Law Judge (VLJ). A transcript of this hearing has been reviewed and associated with the Veteran's claims file. Dismissals 1. Entitlement to an increased evaluation in excess of 20 percent disabling for right lower extremity peripheral neuritis is dismissed. 2. Entitlement to an increased evaluation in excess of 40 percent disabling for mechanical low back pain is dismissed. 3. Entitlement to an evaluation in excess of 70 percent disabling for PTSD from August 24, 2015 is dismissed. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the Veteran or by his authorized representative either in a signed statement or on record during a Board hearing. 38 C.F.R. § 20.204. In the present case, in his June 2021 hearing the Veteran explicitly withdrew his appeals of the claims for entitlement to an increased evaluation in excess of 20 percent disabling for right lower extremity peripheral neuritis, entitlement to an increased evaluation in excess of 40 percent disabling for mechanical low back pain, and entitlement to an evaluation in excess of 70 percent disabling for PTSD from August 24, 2015. In order for a claim to be properly withdrawn during a Board hearing, the Board member must explicitly ask a Veteran during the hearing whether he or she intends to withdraw the claim, and understands the consequences of withdrawing the claim. Acree v. O'Rourke, 891 F.3d 1009, 1015 (Fed Cir. 2018). The VLJ met these requirements. See Hearing Transcript pp. 2-3. Therefore, the Veteran has withdrawn the issues of entitlement to an increased evaluation in excess of 20 percent disabling for right lower extremity peripheral neuritis, entitlement to an increased evaluation in excess of 40 percent disabling for mechanical low back pain, and entitlement to an evaluation in excess of 70 percent disabling for PTSD from August 24, 2015. Hence, there remain no allegations of errors of fact or law for appellate consideration with regard to these issues and they are dismissed. Increased Rating The Veteran's PTSD is currently rated as 10 percent disabling under 38 C.F.R. § 4.130, Diagnostic Code 9411 from September 18, 2007 to August 23, 2015. The Veteran contends he is entitled to a higher rating. Upon review of the evidence, the Board finds that the Veteran's symptoms have most closely approximated the social and occupational impairment consistent with a 50 percent disability rating throughout the duration of the appeal period. A disability rating is determined by applying VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board may consider whether separate ratings may be assigned for separate periods of time - a practice known as "staged ratings," - whether or not the claim concerns an initial rating. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The schedule for rating psychiatric disabilities, to include PTSD and other acquired psychiatric disorders, provide that a 10 percent rating is warranted for 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 continuous medication. A 30 percent rating is warranted for 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 conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. The use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When there is an approximate balance of evidence for and against the issue, all reasonable doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. 3. Entitlement to an initial evaluation of 50 percent disabling for PTSD from September 18, 2007 to August 23, 2015 The Veteran's PTSD is rated as 10 percent disabling from September 18, 2007 to August 23, 2015 under Diagnostic Code 9411. The Veteran seeks a higher rating. Having reviewed the evidentiary record thoroughly, the Board finds that the evidence of record warrants the assignment of an evaluation of 50 percent disabling from September 18, 2007 to August 23, 2015. 38 C.F.R. § 4.7. The Board finds that the severity, duration, and frequency of PTSD symptoms during the appeal period resulted in occupational and social impairment with reduced reliability and productivity as he exhibited symptoms articulated by the 50 percent rating criteria throughout the appeal period. However, the PTSD did not produce deficiencies in most areas to warrant a 70 percent rating. In mental health treatment notes ranging from September 2007 to August 2015, the Veteran complained of isolating to get away from his family. He also complained of being angry for no reason and his wife complained of him thrashing about and shouting in his sleep. He had intrusive thoughts of the past. He complained of being distrustful in general, being easily scared, having an altered relationship with his wife, symptoms precipitated by helicopters, decreased sleep, being tired all the time, and having decreased concentration. He had no suicide attempts or violent behavior. He was well groomed and had good hygiene. His speech was normal. His mood was anxious and dysphoric and affect was congruent. He had no suicidal or homicidal ideation. In a December 2007 statement, the Veteran's brother wrote, The first year after he was discharged from the military, I noticed a change in his attitude. At first, I didn't think too much about it. I only thought, maybe he was going through a transition period. Years later, he still struggled with what sometimes seems like mood-swings. He does talk about his time over in the desert a lot. Some things he wants to say, and I can tell because he gets quiet. He seems to have been close to some of the guys over there as well. I've seen him apologize over and over because of a simple situation that he blew up...I did notice that he appears to be a lot less anxious during the times I've been around. The Veteran had a VA examination in October 2008 for PTSD. He described symptoms of difficulty sleeping with nightmares. He also had intrusive thoughts and recollections, irritability, social isolation, startle responses, and hypervigilance. The symptoms occurred as often as three to four times per week with each occurrence lasting one hour. He indicated that the symptoms affected his total daily functioning which resulted in him just doing his job and trying to stay by himself. He had no friends except his wife and he did absolutely no socializing. He had abandoned some of his hobbies and just wanted to be by himself. His wife confirmed that he thrashed around in his sleep and made noises during his dreams. He had worked as a Respiratory Therapist for the past 10 years. He did not socialize at work; he just did his job and wanted to be left alone. His relationship with his parents was good. He had three siblings and had good relationships with them. He communicated with them but not as much as before his service. He was married and noted that the relationship had been strained but she was trying to be understanding and supportive. She said he was different since he came back and the lack of socializing was difficult for her because she wanted to have friends and do things with them and he wanted to stay by himself. He had good relationships with his children and was involved with them although he was more irritable with them than he used to be. Since he developed his mental condition there had been major changes in his daily activities, such as playing community football and basketball. He used to go fishing with friends but now he did not. He read and stayed to himself. He also got nervous and irritable if one of his wife's friends dropped by the house. He went to church but left before anyone could speak to him. He had no friends at all and they did not socialize with any other couple at all. His relationship with his supervisor and coworkers was fair. He did not interact with his coworkers. He had not lost any time at work due to his PTSD. He stated he got scared and upset if a helicopter flew over him. At work, his boss had asked him to join the Transport Team which would mean he might have to fly in a chopper and he refused to do so. He did not trust people at all. He looked over his shoulder when out in public. There was a persistent, restricted range of affect. The restricted range of affect was noticeable as he only smiled on two occasions during the examination. His orientation was normal. His appearance, hygiene, and behavior were appropriate. His mood was abnormal. His speech and concentration were normal. Panic attacks were absent. There were signs of suspiciousness present. He did not have delusions or hallucinations. Obsessional rituals were absent. His thought processes were appropriate and judgment was not impaired. His thinking and memory were normal. Suicidal and homicidal ideation were absent. He isolated himself from friends and family. He stayed to himself at work but functioned adequately at his job. The effects of PTSD symptoms on his employment and overall quality of life included decreased socializing for himself and his wife. He was not social at all. He functioned adequately on his job but necessary interacting with supervisor and patients at his job created anxiety and irritability for him. The examiner concluded that the best description of the Veteran's current psychiatric impairment was symptoms causing occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks although generally functioning satisfactorily with routine behavior, self-care and normal conversation. The above statement is supported by the following symptoms: anxiety, suspiciousness, chronic sleep impairment, social withdrawal, and constricted affect. In a July 2009 correspondence, the Veteran's physician noted that the Veteran had chronic anxiety, depression, nightmares, and relationship issues due to his PTSD. In a statement from June 2010, the Veteran's wife wrote, [We've been] together now for 22 years and three kids later. When I first met [him] he was a very warm, easy going, and humble man. We always did a lot of activities and events together. [He] had a lot of friends that he enjoyed fishing, bowling, and simply hanging out with before he was sent to the Gulf War in 1990. After returning home I noticed a drastic change in him. His hugs weren't the same, he didn't have interest in family/friend entertainment, and the hobbies he once treasured subsided. Most, if not all of his leisure time was spent at home with long periods of silence and isolation. Until this day [he] is still withdrawn and he has almost caused us this marriage on many occasions. He has a flaring attitude that is unpredictable. In a December 2010 statement, one of the Veteran's coworkers wrote, I have known [him] for seven years, during these years he has portrayed signs of anxiousness and withdrawal. You can be talking to him and he seems to be somewhere else, it's like his focus is not there and sometimes it is hard to get him to refocus. We work in a noisy environment. I can see the irritation on his face when it gets over stimulating. [He] has this escape look on his face, his body language is that of I have to get out of here. [He] has continuous dreams of what happened in Iraq...it's hard for him to maintain his sanity, he will go off on you in a minute, he has had family problems because of his temper. He has problems at work because of this, he stays to himself most of the time at work. Whatever is going on with [him] does at times [a]ffect his employment, sometimes he will come to work without combing his hair and his clothes will be all wrinkled. Sometimes the behavior he presents on his jobs renders him ineffective on the job. In a March 2011 VA examination for PTSD, the Veteran said he averaged about five hours of sleep a night. He said, "I feel sluggish when I wake up; I fall asleep usually around 1 to 2 p.m.; that's not good; I'm on the job." He said he had nightmares "two or three times a week." He said, "I have flashbacks, maybe three times a month; if I'm on the road and a truck backfires, I feel like heart is coming out of the chest." He avoided loud celebrations and got anxious in crowds. He also avoided movies and ball games, and sat with his back to the wall in restaurants. He said he was on edge and "anytime, I hear noise, even from the kids, it gets me in a bad mood and I think something will happen." He said even "when friends come to visit, I might feel less anxious if I go outside." He said his "depression comes and goes; it sneaks up on me." He said he has never attempted suicide but "I often feel like I'd be better off not around." He said crowds will make me anxious; "I love to go to church but I want to leave right after church, groups bother me." He said anxiety comes and goes; situations make it more difficult. He had been working in respiratory at a hospital for the past 10 years. He noted, "I like my job but it's stressful...it makes me anxious and less competent in job performance; I was recently given a 'final' warning as I forgot certain tasks." He reported that he had been married for 22 years. However, they had been separated for the past six months. He had three children. He said, "I've been the main problem; nerves are bad; I yell and don't show affection." With regards to social adjustment, the Veteran said, "I enjoy being with myself not with others." He was a loner when he could be and noted, "I enjoy being alone and working in the yard or reading; better not dealing with people." He had hobbies, such as fishing and yard work but usually did these alone. He also read. He lived in the house with his children and his spouse lived with her mother. He went to her house when he was off work. He did not sleep well and woke up often and felt tired the next day. He said he frequently checked doors and windows during the night. He was appropriately dressed and groomed. He was alert and oriented to all spheres. His speech was normal. No hallucinations or delusions were noted or reported. There was no noted impairment of long term memory. He had mild difficulty with recall. He displayed no concentration deficits. His mood was anxious and mildly depressed and affect was congruent. He seemed to be fatigued. He expressed negative thoughts about his condition and future. He seemed tense and passive at times. He denied suicidal and homicidal ideation or plans. Judgment and insight were good. There was no impairment in thought processes. The examiner concluded that there were PTSD signs and symptoms that were transient or mild, such as anxiety, chronic sleep deficits with fatigue, agitation, depressed mood, and periodic poor concentration. He was seen as usually able to work satisfactorily and relate adequately to others in the work setting. A January 2012 mental health note provided that the Veteran had periods of plummeting moods, survivor guilt, and alienation. He accepted his need to be isolating to get away from his family. He had just one friend. He had less thrashing about and shouting in his sleep, but still had nightmares. He complained of being distrustful in general, easily scared, having an altered relationship with his wife, symptoms precipitated by helicopters, decreased sleep, still feeling tired all the time, decreased concentration, and nightmares. He did not have suicidal or homicidal ideation. His mood was anxious/dysphoric and affect was congruent. He did not have psychotic processes. In a November 2013 mental health note, the Veteran noted that he was experiencing depressive symptoms that included sleep problems. A suicide risk assessment showed that he was not an imminent suicide risk. During the Veteran's June 2021 hearing, he contended that his PTSD during this period more closely approximated a 70 percent rating. His representative contended that the AOJ appeared to assign the initial 10 percent rating based on a GAF score, but given the evidence of the severity of his condition, the Veteran's functioning should have been given greater weight than the GAF score for the same reasons the DSM-5 rejected it. He contended that, based on the Veteran's October 2008 psychological examination, the Veteran should be rated as 70 percent disabling for the entirety of the appeal period. He also discussed several lay statements and other medical evidence of record. The Veteran testified that he did not have many friends and when he was around people with his wife, he was chastised for not being talkative or friendly towards other people. This also caused problems at work. He consistently felt himself losing control of a lot of things. He had a hard time controlling his emotions. He used to be a practitioner and his job was to run life support machines for babies and there would be times where he had to log in information on a timely basis and there would be times when he would forget or when he was not really paying attention and the babies would get into trouble such as desaturations or the tube accidentally coming out of their mouth. He also said there were several occasions where he got into pretty big arguments with his neighbor. He did not really have any friends. He had two brothers and a lot of times, he spent time speaking with his mom over the phone but she died several months prior. He enjoyed being by himself and noted that when he was alone, he could not really hurt anyone verbally. He used to love playing basketball and fishing and he did not do that anymore. He was not interested in those activities like he used to be. The Veteran noted that he lost his job after the period on appeal, but that the types of difficulties he was having with coworkers were the same prior to him losing his job. He stated that his supervisors felt he was a risk on the job around others and how he responded at times to them. This was described as difficulty with impulse control. His inability to focus severely affected his work performance and his difficulty communicating with his superior affected his retention of work. He said that during the appeal period, his wife would sometimes remind him to take care of himself in terms of showering, shaving, and brushing his teeth. The evidence shows that the Veteran's symptoms were consistent with a 50 percent rating from September 18, 2007 to August 23, 2015, because they produced occupational and social impairment with reduced reliability and productivity. The Veteran had reports of flattened, diminished, or restricted affect and descriptions of loss of interest, anhedonia, sleep disturbance and nightmares, isolating, difficulty maintaining romantic and work relationships, and exaggerated startle response. These symptoms are contemplated by the 50 percent rating criteria. In a December 2010 lay statement, one of the Veteran's coworkers noted that sometimes he would come to work without combing his hair and his clothes were wrinkled. During his hearing, the Veteran reported that he experienced neglect of personal appearance and hygiene in the form of his wife sometimes reminding him to take care of himself in terms of showering, shaving, and brushing his teeth. Additionally, in his October 2008 VA examination, the examiner noted there was persistent irritability or outbursts of anger, which the Veteran described as getting irritated with anyone, including his children and his wife's children. The Veteran also testified that he experienced impaired impulse control in the form of difficulty controlling his emotions. He did not exhibit periods of violence during the appeal period. In a March 2011 VA examination, the Veteran stated that he had never attempted suicide but that he often felt like he would be better off not around. These three symptoms are articulated by the 70 percent rating criteria. However, there are a number of other medical treatment records spanning more than an eight-year period in which the Veteran did not have neglect of personal appearance and hygiene, did not experience impaired impulse control, and did not have suicidal ideation. As there are only a few reports of neglect of personal appearance and hygiene, impaired impulse control, and passive suicidal ideation over a long period, the frequency, duration, and severity of these symptoms alone are not sufficient to produce social and occupational impairment with deficiencies in most areas that is consistent with a 70 percent disability rating. Furthermore, the Veteran did not experience obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; and inability to establish and maintain effective relationships as articulated by the 70 percent rating criteria. The symptoms did produce a deficiency in the area of work. In his October 2008 VA examination, the examiner noted that the Veteran functioned adequately at his job, but that necessary interacting with his supervisor and patients at his job created anxiety and irritability for him. Additionally, in a December 2010 lay statement, the Veteran's coworker stated that sometimes the behavior the Veteran presented at his job rendered him ineffective. During his March 2011 VA examination, the Veteran noted that he liked his job but that it was stressful when he dealt with codes. At the time, he had been given a "final" warning as he had been forgetting certain tasks. The examiner noted that he was seen as usually able to work satisfactorily and relate adequately to others in the work setting. He did eventually lose his job, and a 70 percent rating is already assigned to compensate that stage. Prior to August 24, 2015, the evidence of record shows that the Veteran was able to keep his job but experienced a deficiency in the area of work. In the area of family/interpersonal relationships, the symptoms described above show difficulty establishing and maintaining relationships. He maintained a relationship with his wife, but noted that their relationship was strained. At the time of his March 2011 VA examination, they had been separated for six months, but his children stayed with him and this was temporary. He also only had one friend, and consistently expressed that his symptoms prevented him from maintaining effective work relationships. A 50 percent rating contemplated difficulty in this area and but the evidence does not show an inability to establish and maintain relationships as he maintained relationships with his parents, three siblings, children, a friend, and for most of this stage, his wife. In the areas of thinking and judgment, the evidence shows reports of decreased concentration but logical and coherent thought process, and normal judgment. His insight and judgment were consistently noted to be fair or good. His speech was consistently noted as within normal limits, there is no indication that it was intermittently illogical, obscure, or irrelevant. There is no indication of symptoms on par with obsessional rituals that interfere with routine activities or spatial disorientation that would be characteristic of a deficiency in these areas. The disturbances of motivation and mood shown by the evidence are contemplated by a 50 percent rating. The Veteran's anxiety and depression were occasionally described as chronic. The Veteran struggled with anger and irritability and expressed persistent irritability or outbursts of anger at points during the appeal period. He endorsed impaired impulse control in the form of having difficulty controlling his emotions. The Veteran described the feelings as coming and going. These are serious symptoms that affect the Veteran's life and warrant the higher 50 percent rating for disturbances of mood. However, the evidence does not show near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively that are the hallmarks of a deficiency in the area of mood warranting a 70 percent rating. The Board finds that the evidence does not show that the Veteran's psychiatric symptoms were productive of occupational and social impairment with deficiencies in most areas from September 18, 2007 to August 23, 2015. During this time, there was a deficiency in the area of work but he did not have deficiencies in the other areas of family, thinking, judgment, or mood as articulated by the 70 percent rating criteria. Therefore, the Board finds that the frequency, severity, and duration of the Veteran's symptoms are contemplated by a 50 percent disability rating, but no higher, from September 18, 2007 to August 23, 2015. LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Minock 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.