Citation Nr: 21070688 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 16-19 799 DATE: November 24, 2021 ORDER A disability rating of 100 percent for other specified trauma and stressor related disorder with posttraumatic stress disorder (PTSD) is granted, subject to the laws and regulations governing payment of monetary benefits. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, for the entire rating period, the Veteran's PTSD was manifested by symptoms resulting in total occupational and social impairment. CONCLUSION OF LAW The criteria for a maximum rating of 100 percent for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran, who is the appellant in this case, served on active duty from May 1971 to May 1973, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision of a Department of Veterans' Affairs (VA) Regional Office Regional Office (RO). In April 2021, the Board remanded the Veteran's claim for further development, to include a VA PTSD examination. In August 2021, the Board again remanded the claim requesting an addendum medical opinion to ensure compliance with its prior remand directives. An addendum obtained in October 2021 has been associated with the electronic claims file and reviewed. The Board finds substantial compliance with its remand terms. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). The Board observed in its August 2021 remand that the Veteran's representative was no longer accredited to represent claimants before the Board and directed the RO to so notify the Veteran and ascertain whether the Veteran wished to appoint a new representative. VA notified the Veteran of the foregoing, provided information about identifying accredited representatives, and provided contact information for VA for assistance. See VA Correspondence dated August 20, 2021. To date, the record does not reflect that the Veteran has appointed a new representative; therefore, he is considered to be pursuing his appeal unrepresented. Increased Ratings Applicable Laws and Regulations Disability evaluations are determined by comparing a veteran's present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 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. When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Where the veteran is appealing the rating for an already established service-connected condition, his or her present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 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). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him or her through the senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Rating Criteria for Psychiatric Disorders The AOJ has assigned a 50 percent disability rating from August 29, 2013 for the Veteran's Other Specified Trauma and Stressor Related Disorder with PTSD (hereinafter, "PTSD") under DC 9411 based on occupational and social impairment, with reduced reliability and productivity, and a 70 percent rating from May 14, 2021 for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood. 38 C.F.R. § 4.130, DC 9411; Rating Decisions dated March 22, 2016 and May 20, 2021. The Veteran claims that a higher rating is warranted. Under the General Rating Formula for Mental Disorders, a noncompensable rating is warranted where a mental condition has been diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. 38 C.F.R. § 4.130, DC 9411. 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 if the evidence establishes there is 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 work like setting); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating (total occupational and social impairment) is warranted 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 minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When determining the appropriate disability evaluation to assign, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact a Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The use of the term "such as" in the rating criteria 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). Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442. Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that a veteran's impairment must be "due to" those symptoms; a veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The Board recognizes that the United States Court of Appeals for Veterans Claims (Court) in Mauerhan, stated that the symptoms listed in VA's General Rating Formula for Mental Disorders is 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; however, the Court further indicated that, without those examples, differentiating between rating evaluations would be extremely ambiguous. Mauerhan, 16 Vet. App. at 442. In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that, given that the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) abandoned the Global Assessment of Functioning (GAF) scale and that VA has formally adopted the DSM-5, GAF scores are inapplicable to psychiatric rating cases where the DSM-5 applies, and the appeal was certified after August 4, 2014. Here, the Veteran's claim for an increased rating was submitted in October 2014, and his claim for an increased rating was certified to the Board in September 2016, and as such, only DSM-5 applies. Rating Analysis For the reasons set forth below, the Board finds that a disability rating of 100 percent is warranted for the Veteran's PTSD for the entire rating period. Turning to the evidence of record, in a statement received in September 2013, the Veteran said after returning home from his deployment to Vietnam, he learned more members of his unit who had remained in Vietnam were killed. He added, "I felt extremely guilty that I was spared, and they were not." The Veteran's spouse J.H. submitted a statement in September 2013, reporting that the Veteran often said that he would be better off dead and that he should have died in Vietnam. She added that a few months after retiring, the Veteran her "he 'hears' voices that guide his decision-making and he has even claimed to see 'dead people' who have come back to life in solid form. He is so convinced that this is real that I cannot reason with him logically and it has even frightened me many times." Similarly, in a September 2013 statement, the Veteran's brother J.A. said the Veteran's PTSD symptoms include withdrawal from society, intense emotions, hypersensitivity to loud noises, short-term memory loss, nightmares, and insomnia. Notably, J.A. said the Veteran on more than one occasion "has reported having hallucinations of seeing deceased family members." VA treatment notes dated September 2013 reflect that the Veteran reported having "spiritual experiences" that the counselor referenced as hallucinations. On examination, the Veteran was oriented to person, place, and time. He was clean and well groomed. His mood and affect were depressed. He denied suicidal and homicidal intent. The Veteran again endorsed hallucinations he characterized as "spiritual experiences" in October 2013. He endorsed short term memory deficits. He denied suicidal and homicidal ideation. During a January 2014 VA mental health biopsychosocial assessment, the Veteran reported sporadically seeing people who died in Vietnam, that he had also seen his deceased father and grandfather, and that he has heard voices he characterized as a guardian angel, "like his own voice in telepathy." During a March 2014 VA outpatient appointment, the Veteran was alert and oriented. He endorsed nightmares even with taking sleep medication. He denied hallucinations. He said he remained vigilant and occasionally was depressed. He denied suicidal ideas or thoughts of harming others. In March 2014, the Veteran was afforded a VA examination. The diagnosis was PTSD. The examination report shows that the Veteran met all diagnostic criteria for a PTSD diagnosis. In terms of social impairment, the examiner noted that the Veteran was previously married, which lasted 20 years and produced two children, but the Veteran rarely had contact with his children. He Veteran remained married to his second wife, a schoolteacher, and they had no children. The Veteran had four brothers and sisters but did not have ongoing contact with his siblings and only rare contact with his mother. His father was deceased. The Veteran said he had lost most of his friends and he avoided being around people. He said he enjoyed having intellectual conversations. He avoided family functions. In terms of occupational impairment, the examiner noted that the Veteran graduated from high school and during high school he wrestled. After high school he attended barber school and started working as a barber when he was drafted into the Army in 1971. He said he was deployed to Vietnam and earned the Combat Infantryman Badge. After his separation from the Army, owned a hair salon from the late 1970s to the 1990s. He then worked as a stuntman in the movie industry in California for about 16 years. He had not worked over the past 10 years. He said he earned college degrees. On examination, the Veteran endorsed problems with anger and survivor's guilt, chronic sleep problems, bad dreams up to three times a week, memory and concentration problems. The examiner identified PTSD symptoms of depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; and difficulty in establishing and maintaining effective work and social relationships. The examiner concluded that the Veteran's PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The examiner determined that the Veteran was capable of handling his financial affairs. See VA PTSD examination report dated March 24, 2014. October 2014 correspondence from a VA social worker notes that the Veteran "isolates daily, struggles to engage with others, has nightmares which impede his ability to rest and recover from the internal daily stress of the traumas recalled. He has daily recall of combat trauma, which causes anger, lack of sleep, distancing from others, lack of trust, poor focus and memory, and paranoia." In February 2015, the Veteran underwent a VA examination, at which time the examiner rendered the following diagnoses: (1) Other specified trauma and stressor-related disorder, a continuation or progression of the previously diagnosed PTSD in the context of alcohol use disorder; and (2) Alcohol use disorder, moderate. The examiner noted that it was not possible to differentiate what symptoms are attributable to each mental disorder due to extensive overlap of symptoms. In terms of social impairment, the examiner noted that the Veteran said he and his wife of eleven years resided on the same property as his wife but that she lived in their home alone and he stayed in a camper on the property. He said they were contemplating divorce, although he was interested in preserving their marriage. He said he had an adult daughter and son who resided in another state, and they had little contact. The Veteran said he did not associate with his siblings, and he described himself as "pretty much antisocial." In terms of occupational impairment, the examiner noted that the Veteran said he had not worked in eleven years after working as a stuntman in the movie industry. He said he was doing a lot of dangerous stunts and that "my wife made me quit," and that his wife provided for the family after he stopped working. He said they raised horses to sell. On examination, the Veteran was alert and oriented to person, place, and time. No psychomotor agitation or retardation was observed. His mood was neutral, and his affect was initially depressed, at times tearful. His speech was of regular rate, amount, rhythm and volume. The Veteran was negative for suicidal and homicidal ideation. There were no active hallucinations, delusions, or obsessions. The Veteran's thought process was logical, and goal directed, and his memory, attention and concentration were grossly intact. His insight and judgment were fair. The examiner identified symptoms of depressed mood; anxiety; and suspiciousness. The examiner concluded that the Veteran's mental disorders resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner determined that the Veteran was capable of handling his financial affairs. See VA PTSD examination report dated February 23, 2015. The Veteran's VA psychiatrist, Doctor G.H., M.D., reported in June 2015 correspondence that the Veteran continued to experienced PTSD symptoms that resulted in intrusive memories of Vietnam, outbursts of anger, and nightmares. G.H. said the Veteran attempts to cope by drinking alcohol, takes his PTSD medication only occasionally, and has "suicidal ideas." In a July 2015 statement, the Veteran's cousin C.A. said the Veteran's PTSD symptoms have worsened with time and the Veteran has become unsociable, rarely attends family functions, and has destroyed his relationships with friends and neighbors. He added, "On occasion I have witnessed him be[ing] quick tempered and has taken his anger out physically on others when provoked. In May 2016, the Veteran's VA psychiatrist G.H. again submitted correspondence (dated April 2016) in support of the Veteran's claim. Doctor G.H. said, "He suffers from what we in the medical field would consider hallucinations. He suffers rage, panic, and severe anxiety. He has thoughts of suicide[.]" She added, "It is my opinion all of these are his PTSD symptoms as a direct result of his time in the military." A letter (dated April 2016) from the Veteran's VA social worker P.P. received in May 2016 reflects that P.P. provided counseling to the Veteran. She said the Veteran's hygiene was poor, he had noticeable memory lapses, and he endorsed "frequent hallucinations of deceased comrades, which is consistent with symptoms he had reported three years ago." He endorsed continuing sleep disturbances, drinking heavily to cope with sleeplessness and anxiety, and increased social isolation and deterioration. A May 2016 statement from a friend J.B. notes, in part, "On a few occasions he has related to me his thoughts of suicide. His memory in my opinion has been affected by his lack of sleep and his abuse of alcohol that he uses to cope with his PTSD." J.B. added that the Veteran's wife recently took him to see an Apache medicine man to help him with his PTSD. The Veteran's wife submitted a statement in May 2016, asserting, in part, that the Veteran had recently had two serious physical altercations with family members due to his inability to control his anger, which made him more depressed and unable to function in a social setting. She said he failed to get out of bed or bathe for a week and had thoughts of suicide. During a July 2016 VA outpatient appointment, the Veteran said that lately he had had experienced no hallucinations. He denied ideas of harming himself or others. October 2016 VA treatment records reflect that the Veteran endorsed problems with his memory and concentration. He continued to be irritable and experience nightmares. He said he had suicidal thoughts and thoughts of harming another person, but that he would not be around that person again. He said he walked around his ranch at thee o'clock in the morning to help feel secure. The Veteran said he experienced seeing his deceased father "in real form." During a January 2017 VA appointment, the Veteran reported problems sleeping, noting that he might go up to two days without sleep. He said he kept to himself at home and was hypervigilant, he continued to have trouble with concentration and memory, and was irritated easily and unable to get along with others. The Veteran denied hallucinations but endorsed previous thoughts of suicide. The Veteran was seen during a VA outpatient appointment in July 2017, at which time he said he would occasionally see people "who have passed on ... mostly family members[.]" He said he was unable to work because of his irritability, lack of concentration, and inability to embrace the concept that customers are always right. He endorsed periods of violence, episodes of neglect of personal hygiene, panic attacks, and anxiety. During a January 2018 VA appointment, the Veteran endorsed thoughts of hopelessness and suicidal ideation. In May 2021, the Veteran underwent a VA examination, at which time the examiner confirmed the diagnosis of PTSD and also diagnosed persistent depressive disorder. In terms of social impairment, the examiner noted that the Veteran has been married twice, and is currently separated from his second wife, and he currently lives in a camper while his wife lives in their home. He said divorce was possible. He has two grown children and six grandchildren he "rarely ever sees" due to his PTSD and depression, and because he is withdrawn and isolated. He said he experienced anhedonia and no longer played music or taught martial arts because of his PTSD symptoms. In terms of occupational impairment, the examiner noted that the Veteran said he retired in 2003 after working 17 years in California as a stunt man. He said he was engaging in reckless behaviors, doing dangerous stunts, but was forced to retire because of multiple injuries and reckless behaviors and verbal outbursts. He said he owned a barber business after his discharge from service but lost the business because of anger outbursts and throwing out customers to the point of physical assault and aggressive behavior. On examination, the Veteran was well groomed, his speech was appropriate, and his mood and affect were depressed and anxious. His thought process was linear and goal-directed, and his thought content was appropriate. He denied passive suicidal ideation and he denied current audio and visual hallucinations. His insight and judgment were described as fair. The examiner noted that the Veteran's ability to carry out activities of daily living was intact, but moderately compromised due to the severity of his depression and lack of motivation. The examiner identified symptoms of depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect; circumstantial, circumlocutory or stereotyped speech; impaired judgment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; suicidal ideation; obsessional rituals which interfere with routine activities; impaired impulse control, such as unprovoked irritability with periods of violence; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner concluded that the Veteran's PTSD and depressive disorder resulted in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The examiner determined that the Veteran was capable of handling his financial affairs. See VA PTSD examination report dated May 14, 2021. Pursuant to the Board's August 2021 remand, a VA examiner addressed the April 2016 correspondence from a VA psychiatrist G.H., M.D. and VA social worker P.P. regarding the Veteran's PTSD symptoms, noting that the examiner reviewed the letters and concluded, in part, that they "appear to be consistent with the [VA examination] from 2021 overall, which is consistent with the recent mental health records." See VA Medical Opinion dated October 5, 2021. On review of all the evidence, both lay and medical, the Board finds that a 100 percent rating for PTSD is warranted for the entire period on appeal. In so finding, the Board notes that the Veteran's treatment records show persistent hallucinations throughout the rating period as well as intermittent inability to maintain his personal hygiene. Additionally, the Veteran has consistently endorsed suicidal ideation throughout the rating period. The Veteran's VA psychiatrist and social worker, as well as family members and friends, have consistently described the Veteran's tendency to hallucinate and neglect his hygiene. The psychiatrist and social worker are professionally qualified to make such observations, and the Veteran's family members and friends are capable of reporting these symptoms as lay persons. See Layno, 6 Vet. App. at 469. In terms of occupational impairment, the Board specifically considered evidence suggestive that the Veteran's psychiatric symptoms have impacted his ability to function in an occupational setting, including anxiety, irritability, and memory impairment. In terms of social impairment, credible statements from the Veteran, his spouse, family members, and a friend, as well as statements from the Veteran's VA psychiatrist G.H. and social workers reflect persistent hallucinations, irritability, anger, physical anger, and intermittently poor hygiene that have resulted in his tendency to remain socially withdrawn and isolated. While the March 2014, February 2015, and May 2021 VA examinations reflect less severe occupational and social impairment variously due to the Veteran's service-connected PTSD and related disorders, in this regard the VA examiners' conclusions are inconsistent with the record and the history of the Veteran's symptoms credibly related by the Veteran, his spouse, family members and a friend, as well as his VA psychiatrist and VA social worker as reflected in the treatment records and correspondence of record. In regard to the October 2021 addendum VA opinion, as it is inconsistent with the April 2016 correspondence the examiner was asked to review as well as the record as a whole, especially the Veteran's treatment records, the Board assigns the addendum no probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion). While it appears that the Veteran's symptoms may have fluctuated in severity throughout the pendency of the appeal, he overall continued to endorse these symptoms, which are contemplated by the criteria for a 100 percent rating. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that a rating of 100 percent for PTSD is warranted for the entire rating period on appeal. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. The Veteran has been granted entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU), effective May 14, 2021. See Rating Decision dated October 7, 2021. However, the issue of entitlement to a TDIU may be raised by the record as part of a claim for increased compensation. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). A TDIU is provided where the combined schedular rating for service-connected diseases and disabilities is less than total (less than 100 percent). 38 C.F.R. § 4.16(a). As TDIU is considered a lesser benefit than the 100 percent rating, the grant of a 100 percent rating generally renders moot the issue of entitlement to a TDIU for the period when the 100 percent schedular rating is in effect, here, for the entire rating period prior to May 14, 2021. However, the Court has held that the receipt of a 100 percent schedular rating for a service-connected disability does not necessarily render moot the issue of entitlement to a TDIU. Bradley v. Peake, 22 Vet. App. 280 (2008). Although no additional disability compensation may be paid when a total schedular disability rating is already in effect, the Court's decision in Bradley recognizes that a separate award of a TDIU predicated on a single disability other than the disability for which a 100 percent rating is in effect may form the basis for an award of special monthly compensation (SMC). Id. at 293. The Bradley case, however, is distinguishable from the instant case. Here, the Veteran is not seeking SMC at the housebound rate, and the record does not otherwise reasonably raise that matter. The Veteran's only service-connected disability other than PTSD is tinnitus, rated as 10 percent disabling. The basis for the Veteran's TDIU claim was his PTSD, and he does not contend that he is unemployable due solely to tinnitus. As such, the grant of a 100 percent rating for PTSD has rendered moot the issue of any further entitlement to a TDIU. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Farrell, 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.