Citation Nr: 21068151 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 17-37 517 DATE: November 9, 2021 ORDER Entitlement to a 10 percent rating for lumbosacral spondylosis with degenerative disc disease, intervertebral disc syndrome and degenerative arthritis for the appeal period prior to April 1, 2016 is granted. Entitlement to a 40 percent rating for lumbosacral spondylosis with degenerative disc disease, intervertebral disc syndrome and degenerative arthritis beginning on April 1, 2016 is granted. FINDING OF FACT 1. For the appeal period prior to April 1, 2016, the Veteran's lumbosacral spondylosis with degenerative disc disease, intervertebral disc syndrome and degenerative arthritis was manifested as forward flexion up to 90 degrees, at worst, in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups with X-ray evidence of arthritis without abnormal gait, abnormal spinal contour, ankylosis, incapacitating episodes or associated bowel or bladder impairments. 2. For the appeal period beginning April 1, 2016, the Veteran's lumbosacral spondylosis with degenerative disc disease, intervertebral disc syndrome and degenerative arthritis was manifested as forward flexion to 15 degrees, at worst in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups without ankylosis, incapacitating episodes or associated bowel or bladder impairments. CONCLUSIONS OF LAW 1. The criteria for a 10 percent rating for lumbosacral spondylosis with degenerative disc disease, intervertebral disc syndrome and degenerative arthritis for the appeal period prior to April 1, 2016 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5242. 2. The criteria for a 40 percent rating for lumbosacral spondylosis with degenerative disc disease, intervertebral disc syndrome and degenerative arthritis for the appeal period beginning on April 1, 2016 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from June 21, 1984 to March 10, 1992 and December 15, 2013 to December 21, 2013. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2015 rating decision issued by a Department of Veterans Affairs Regional Office (RO). This matter previously came before the Board in April 2019 whereupon it was remanded back to RO for additional development, to include obtaining any outstanding records and providing the Veteran with a VA examination to ascertain the current nature and severity of his lumbosacral spondylosis. Updated VA treatment records have been associated with the record and an April 2019 letter requested that the Veteran complete an authorization form to allow VA to obtain treatment records on his behalf. A VA examination was conducted in July 2021 to determine the current severity of the Veteran's lumbosacral spondylosis. The Board therefore determines that there has been substantial compliance with its previous remand. Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the Board confers the right to compliance with remand orders). The matter has now returned to the Board for further appellate action. A July 2021 rating decision granted the Veteran's claim for service connection for coronary artery disease w/stent placement and assigned an initial rating. As this decision represents a full grant of the benefits sought with respect to this claim for service connection, such issue is no longer before the Board for consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). In addition, the July 2021 rating decision awarded temporary total ratings for the Veteran's lumbosacral spondylosis for the periods from June 29, 2015 to September 1, 2015; June 8, 2018 to December 1, 2018; and June 11, 2021 to September 1, 2021. The Veteran is presumed to seek the maximum available benefit for a disability. As such, the Board will consider the periods for which a temporary total rating has not been awarded herein. See AB v. Brown, 6 Vet. App. 35, 38 (1993). 1. Entitlement to a 10 percent rating for lumbosacral spondylosis with degenerative disc disease, intervertebral disc syndrome and degenerative arthritis, for the appeal period prior to April 1, 2016 is granted. 2. Entitlement to a 40 percent rating for lumbosacral spondylosis with degenerative disc disease, intervertebral disc syndrome and degenerative arthritis, for the appeal period beginning on April 1, 2016 is denied. The Veteran asserts that he is entitled to an increased rating for his lumbosacral spondylosis, specifically because his symptoms are more severe than contemplated by the currently assigned ratings. The Veteran has contended that the limitations placed on him by his condition, such as difficulty walking, standing, and being in constant pain, warrant a higher evaluation. The Veteran's wife has also submitted statements in support of the Veteran's claim, indicating that the Veteran lays in bed for hours daily, relies heavily on Tylenol to deal with constant pain, and is unable to perform basic household chores. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered because of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Separate ratings can be assigned for separate periods based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. 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, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that "[t]he joints involved should be 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." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. Mitchell v. Shinseki, 25 Vet. App. 32 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claim. The Veteran's lumbar spondylosis is rated under Diagnostic Code 5242-5237, which assigns ratings based upon the General Rating Formula for Diseases and Injuries of the Spine (General Formula). 38 C.F.R. § 4.71a. In regard to the General Rating Formula for Diseases and Injuries of the Spine as applied to the lumbar spine disability, a 10 percent rating is assigned 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 under the General Rating Formula for Diseases and Injuries of the Spine. A 20 percent rating is assigned 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 assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees; extension is 0 to 30 degrees; left and right lateral flexion and 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. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 2. Any associated objective neurologic abnormalities, including, but not limited to bowel or bladder impairment, should be evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 1. The Board notes that effective February 7, 2021, the criteria for schedule of ratings for the musculoskeletal system was revised. See 86 Fed. Reg. 8142 (Feb. 4, 2021) (codified at 38 C.F.R. pt. 4). In the instant case, the diagnostic criteria for Diagnostic Codes 5242 and 5243 were unchanged in the revised rating criteria. Therefore, the February 2021 musculoskeletal criteria do not apply to the Veteran's claims on appeal; and the appropriate criteria is discussed below. VA law additionally provides for higher rating considerations on additional factors such as further limitation on motion due to pain on use and x-ray findings. A 10 percent evaluation is to be granted upon a showing of x-ray findings of arthritis accompanied with pain upon motion of the affected joint or body part. See DeLuca v. Brown, 8 Vet. App. 202 (1995); See also VAOPGCPREC 9-98; Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). "Although pain may cause a functional loss, pain itself does not constitute functional loss." Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Painful motion is deemed to be limitation of motion and warrants the minimum compensable rating for the joint, even if there is no actual limitation of motion. 38 C.F.R. § 4.59; Lichtenfels v. Derwinski; 1 Vet. App. 484, 488 (1991). The provisions of 38 C.F.R. § 4.59 relating to painful motion are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). The Veteran was granted service connection for degenerative arthritis of the lumbosacral spine disorder, effective June 18, 2014. The Veteran's condition has been assigned the following ratings: zero percent disabling (noncompensable) from June 18, 2014 to June 28, 2015; 100 percent disabling (for convalescence) from June 29, 2015 to August 31, 2015; zero percent disabling (noncompensable) from September 1, 2015 to April 5, 2016; 40 percent disabling from April 6, 2016 to June 7, 2018; 100 percent disabling (for convalescence) from June 8, 2018 to November 30, 2018, 40 percent disabling from December 1, 2018 to June 10, 2021; 100 percent disabling (for convalescence) from June 11, 2021 to August 31, 2021; and 40 percent disabling thereafter. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). As such, the Board will review evidence from each of these periods on appeal to determine whether the Veteran's disability has been properly rated. A treatment note from November 2013 noted moderate to severe back pain. Radiating pain was not found. The note also described the Veteran's back as "tight, very tender." Muscle spasm was noted. A VA treatment note from December 2013 notes the Veteran's low back pain and lists findings of lumbar spine disc space narrowing and incidence of spondylosis. Notes from 2013 and 2014 document the Veteran's pain but do not specifically mention range of motion findings. No incidence of guarding, spasms, abnormal spinal contour, localized tenderness, and fractures were noted. The Veteran was provided a VA examination for his back in January 2015. The examination confirmed the Veteran's diagnosis of lumbosacral spondylosis and made X-ray findings of degenerative arthritis of the spine. Recurrent daily pain upon motion was noted; with the Veteran self-medicating by taking four to five Tylenol per day. Flareups were not noted. The examiner did not find functional loss or functional impairment upon examination. Range of motion findings were all listed as normal, with full range of motion observed. The Veteran was also found able to perform repetitive use testing with at least three repetitions. Guarding and muscle spasms were also not found. The Board has also reviewed a handwritten private medical opinion and note dated April 1, 2016, from a private provider, Dr. N.M. The note states that the Veteran suffered from increased back pain and abnormal posture. The note described the condition causing functional limitations such as difficulty standing or walking for more than two hours; difficulty getting in and out of bed; and being unable to do any yard work. The doctor also noted radicular pain from the Veteran's lower back down his left leg. The note also contained the following range of motion findings: forward flexion to 15 degrees and extension to 4 degrees. The Veteran was provided another VA examination for his back in April 2016. Range of motion findings were forward flexion to 15 degrees and extension to 40 degrees. Functional loss was noted; specifically difficulty getting out of bed, difficulty walking or standing for prolonged periods, and difficulty with house-work. Ankylosis was not found. The record also contains an unsigned private Disability Benefits Questionnaire (DBQ) report, dated July 2019. The report lists range of motion findings of forward flexion to 20 degrees and extension to 10 degrees. The examination also made findings of abnormal spinal contour. However, the Board notes that an unsigned DBQ is inherently due limited, if any, probative value because it cannot be authenticated or verified as to whether a medical professional has made the assessment, given that no medical professional has actually signed their name to the DBQ. Therefore, the Board accords this DBQ little, if any, probative value. Prejean v. West, 13 Vet. App. 444 (2000). Magnetic Resonance Imaging (MRI) scan findings of August 2018 reveal changes at the lumbar spine. A May 2019 questionnaire notes the Veteran suffering from ongoing back pain that radiates to his legs. Functional limitations are noted as difficulty walking, standing, or sitting for prolonged periods. Range of motion findings are not provided. Medical notes are silent for ankylosis. Treatment notes from September 2018 and June 2021 document back surgeries. A July 2021 private treatment lists the Veteran's lower back symptoms as recurrent pain and difficulty walking, sitting, or standing. The note mentions "incapacitating" pain due to flareups but later explains that the "incapacitation" means laying in bed for a day or two. The Veteran was provided a new VA examination for lumbar spine in July 2021 in compliance with Correia (pursuant to the Board's April 2019 remand). Active range of motion testing revealed findings of forward flexion to 35 degrees and extension to 10 degrees. The examiner provided an explanation for why passive range of motion testing could not be conducted; i.e. because it would cause inordinate pain to the Veteran. The examiner also discussed flareups with the Veteran; with the Veteran reporting severe occasional flareups lasting 2-8 weeks per occurrence. The flareups are precipitated by prolonged standing, walking, climbing stairs, or bending over. The Board find that this examination is in compliance with the Correia and Sharp holdings. The examiner confirmed diagnoses of degenerative arthritis, intervertebral disc syndrome, and lumbosacral spondylosis. Pain was noted upon range of motion testing, in forward flexion, extension, and rotation. Functional loss was noted, with difficulty in lifting items, bending over to pick things up, walking, sitting, standing, and climbing stairs. No incidence of ankylosis was found. A review of the evidence prior to April 1, 2016 reveals that a 10 percent rating is warranted. The Veteran's January 2015 examination revealed X-ray findings of arthritis, along with pain upon motion. Such symptomatology warrants a 10 percent rating. Deluca v. Brown, supra; See also Degmetich v. Brown, supra. A rating higher than 10 percent requires forward flexion limited to be limited to 60 degrees or less, muscles spams or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A January 2015 VA examination found the Veteran's forward flexion to be to 90 degrees and that there was no guarding or muscle spasm of the thoracolumbar spine. Therefore, a higher rating is not warranted for this appeal period. 38 C.F.R. §§ 4.40, 4.45, 4.59. Accordingly, a compensable 10 percent rating is granted for the appeal period of prior to April 1, 2016. A review of the evidence reveals that a 40 percent rating is warranted for the appeal period beginning on April 1, 2016. This is supported by the April 1, 2016 private note documenting range of motion findings of forward flexion to 15 degrees; which aligns with the 40 percent rating under 38 C.F.R. § 4.71a. More severe symptomatology such as unfavorable ankylosis of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine are not indicated by the record. Indeed, no incidence of ankylosis is indicated at any time in the Veteran's clinical records and has not been alleged by the Veteran. Thus, a higher rating in excess of 40 percent is not warranted. The Board has also considered the lay evidence of record, including the statements of the Veteran and his wife submitted in support of the instant claim. Although laypersons are competent to report on observable symptoms, diagnosing the severity of a lumbar spine disorder according to the appropriate diagnostic codes is a complex medical matter reserved for the purview of qualified medical professionals; such matters fall outside the realm of common knowledge of a layperson. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (laypersons not competent to diagnose cancer). Thus, while the Veteran and his wife, are competent, as laypersons, to report observable symptomatology as it comes to them through their senses, they do not possess the requisite medical knowledge and are not competent to diagnose the specific level of disability of a lumber spine condition according to the appropriate and applicable diagnostic codes. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). As such, the Board finds the statements of medical personnel as to the severity of the Veteran's back disability to be the most competent evidence of record. The Board has also considered the effects of repeated use over time and flare-ups along with the adequacy of the VA examinations in light of the Court's holdings in Correia and Sharp. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016), and Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Correia decision provides that VA orthopedic examinations should include testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing. Additionally, the Sharp holding outlines VA examiners' obligation to elicit information regarding flare-ups of a musculoskeletal disability if the examination is not conducted during such a flare-up, and to use this information to characterize additional functional loss during flare-ups. The Board notes that the spine is not a paired joint and there is no paired joint to test. Regarding repeated use over time, the Board notes that the January 2015 VA examiner conducted repetitive-use testing and concluded that no additional functional loss or range of motion after three repetitions. Although the January 2015 VA examiner did not address passive range of motion, the Board notes that active range of motion testing usually results in further limitation than passive range of motion testing. See Massie v. Shinseki, 25 Vet. App. 123, 131 (2011); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). Therefore, although the Board notes that the January 2015 VA examination did not complete all the testing required under Correia v. McDonald, supra, the range of motion findings are still the most probative evidence concerning the Veteran's functional limitation at such times. The Veteran did not report flare-ups in the January 2015 VA examination. He did report flare-ups that occurred four to eight times in a July 2021 VA examination report and the examiner found that the Veteran's forward flexion would be limited to 30 degrees during flare-ups. Therefore, the range of motion findings are still the most probative evidence concerning the Veteran's functional limitation at such times. Moreover, the January 2021 VA examiner determined that passive range of motion testing was medically contraindicated as it may cause the Veteran further injury due to his recent spinal fusion surgery in June 2021. Therefore, the examinations of record are adequate for VA purposes. The Board has separately considered whether an additional rating is warranted for nerve impairments to include bladder or bowel impairment. However, neither bladder nor bowel impairment is indicated by the record. A gastrointestinal exam from a private provider, dated December 2012 made findings of "normal bowel" function. The Board also notes that the Veteran is already in receipt of separate ratings for right and left lower extremity radiculopathy. Thus, a separate rating for bladder or bowel impairment is not warranted. In addition, the Board has additionally considered whether a higher rating may be granted under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes (Diagnostic Code 5243), given that the Veteran was diagnosed with IVDS upon examination in July 2021. However, the Veteran has not alleged, and the record does not suggest, that there has been doctor prescribed bedrest. Therefore, a higher rating for IVDS is not warranted. The Board has also considered whether a further staged rating under Hart, supra, is appropriate for the Veteran's service-connected lumbar spine disorder; however, the Board finds that his symptomatology has been stable throughout each appeal period. Therefore, assigning a further staged rating for this disability is not warranted. Further, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, with regard to such claim. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). The Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a TDIU rating, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. The Veteran reported that he worked with special needs children at an alternative school center in a May 2020 VA treatment note and his current employment situation is not clear. Therefore, a TDIU has not been raised. A comprehensive review of the evidence of record leads the Board to the conclusion that a 10 percent rating is warranted for the Veteran's lumbosacral spondylosis with degenerative disc disease, intervertebral disc syndrome and degenerative arthritis for the appeal period prior to April 1, 2016 and a 40 percent rating beginning on April 1, 2016. The benefit of the doubt has been applied in favor of the Veteran wherever it can be applied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kashif I. Ali, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.