Citation Nr: 21071562 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 12-28 420 DATE: November 30, 2021 ORDER Entitlement to an initial compensable rating for service-connected bilateral hearing loss is denied. Entitlement to a rating greater than 10 percent for service-connected left hip bursitis is denied. Entitlement to a rating of 30 percent, but no higher, for service-connected residuals of a left knee injury, manifested by instability, is granted. Entitlement to service connection for a respiratory disorder is denied. REMANDED Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a coccyx disability is remanded. Entitlement to service connection for a cervical spine disability, to include neck strain, is remanded. FINDINGS OF FACT 1. Audiological evidence demonstrates that, for the period on appeal, the Veteran's service-connected bilateral ear hearing loss was manifested by hearing acuity of Level I at worst in his right ear and by Level I at worst in his left ear, with no exceptional hearing loss pattern shown in either ear. 2. Throughout the appeal period, the Veteran's left hip limitation of abduction was, at worst, 25 degrees. 3. Prior to April 26, 2014, the Veteran's left knee manifested to no greater than moderate instability; beginning April 26, 2014, the Veteran's left knee manifested as severe instability. 4. There is no evidence that a chronic lung illness or other respiratory condition was diagnosed during the appeal period. CONCLUSIONS OF LAW 1. The criteria for an initial compensable disability rating for the service-connected bilateral hearing loss have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100. 2. The criteria for a disability rating greater than 10 percent disabling for the service-connected left hip bursitis based on limitation of abduction have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.71a, Diagnostic Codes 5299-5019, 5253. 3. The criteria for a disability rating of 30 percent for the service-connected residuals of a left knee injury, manifested by instability, have been met from April 26, 2014. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.71a, Diagnostic Code 5257. 4. The criteria for service connection for a respiratory disorder are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 1968 to June 1972. Unfortunately, the Veteran died in January 2019, during the course of the appeal; the Appellant is his surviving spouse. In June 2019, VA granted her request to substitute in his appeal. The January 2019 videoconference hearing, scheduled as requested by the Veteran in his September 2012 substantive appeal, was rescheduled to August 2021 due to the Veteran's death. However, the Appellant did not appear for the hearing, and so the request is considered to be withdrawn. Increased Ratings Disability ratings are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Although a disability must be considered in the context of the whole recorded history, including service treatment records, the present level of disability is of primary concern in determining the current rating to be assigned. 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55 (1994); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). If a disability has undergone varying and distinct levels of severity throughout the claims period, staged ratings may be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. Hyphenated Diagnostic Codes are used when a rating under one Diagnostic Code requires the use of an additional Diagnostic Code to identify the basis for the rating assigned. The additional code is shown after the hyphen. 38 C.F.R. § 4.27. Bilateral Hearing Loss The Veteran contended that his bilateral hearing loss warranted a compensable disability rating. Evaluations for hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests in conjunction with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1,000, 2,000, 3,000, and 4,000 cycles per second. 38 C.F.R. § 4.85. "Pure tone threshold average" is the sum of the pure tone thresholds at 1000, 2000, 3000 and 4000 Hertz divided by four. This average is used in all cases (including those in § 4.86) to determine the Roman numeral designation for hearing impairment from Table VI or VIA. 38 C.F.R. § 4.85, Diagnostic Code 6100. To evaluate the degree of disability from the Veteran's hearing loss; the rating schedule establishes 11 auditory acuity levels, designated from Level I for slightly impaired hearing acuity through Level XI for profound deafness. Schedular disability ratings for hearing impairment are "derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered." Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). In Martinak v. Nicholson, 21 Vet. App. 447 (2007), the United States Court of Appeals for Veterans' Claims (Court) held that, in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. Martinak, 21 Vet. App. at 455. Even if, however, an audiologist's description of the functional effects of a veteran's hearing disability was somehow defective, the veteran bears the burden of demonstrating any prejudice caused by a deficiency in the examination. Id. For purposes of determining the appropriate rating for the period on appeal for the Veteran's service-connected hearing loss, his audiological testing results from various examinations must be evaluated under the appropriate Hearing Impairment Tables provided in 38 C.F.R. § 4.85. Consideration can also be given to patterns of exceptional hearing impairment under 38 C.F.R. § 4.86. On VA examination in August 2009, the Veteran was afforded an air conduction study. Pure tone thresholds, in decibels, were recorded as follows: HERTZ 1000 2000 3000 4000 RIGHT 25 20 35 50 LEFT 20 15 35 60 The frequency average was 32.5 decibels in each ear; Maryland CNC speech discrimination test results were 98 percent in each ear. The Veteran reported difficulty hearing in all situations. On VA examination in October 2010, the Veteran was afforded an air conduction study. Pure tone thresholds, in decibels, were recorded as follows: HERTZ 1000 2000 3000 4000 RIGHT 35 20 40 45 LEFT 35 20 35 50 The frequency average was 35 decibels in the Veteran's right ear and 35 in his left ear. Maryland CNC speech discrimination test results were 96 percent in each ear. The Veteran reported difficulty hearing in all situations. VA treatment records from October 2017 indicate that the Veteran's audio thresholds were obtained at 35dB. There is no other available record of the Veteran's hearing acuity measurements during the appeal period. After thorough review of the evidence of record, the Board finds that the evidence does not support a compensable rating for hearing loss throughout the appeal period. For both the August 2009 and October 2010 VA hearing acuity testing, the Veteran's demonstrated right ear impairment is associated with a Roman numeral I, and the demonstrated left ear impairment is associated with a Roman numeral I under Table VI in accordance with 38 U.S.C. § 4.85. These Roman numeral designations warrant a noncompensable disability rating under Table VII under 38 U.S.C. § 4.86. thus, for the entire appeal period, the Veteran's hearing loss impairment table Roman numeral designations warrant a non-compensable disability rating under Table VII. Additionally, throughout the entire appeal period, an exceptional hearing loss pattern has not been shown in either ear. 38 C.F.R. §§ 4.85, 4.86. Thus, the Board finds that a compensable rating is not warranted. To the extent that the Veteran contended that his hearing loss is more severe than rated, the Board finds that, while competent to report symptoms such as difficulty in hearing the radio or television, he is not competent to report that his hearing acuity is of sufficient severity as to warrant a higher compensable evaluation under VA's tables for rating hearing loss disabilities because such an opinion requires medical expertise (training in evaluating hearing impairment). It has not been established that he had such medical expertise. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran is competent to report difficulty with communication. However, even after considering such contentions as to the effects of the disability on his daily life, the Board finds that the criteria for an evaluation of a compensable rating are not met. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Left Hip Bursitis The Veteran contended that his left hip bursitis warranted a rating in excess of 10 percent. After review of the evidence of record, the Board finds that a rating greater than 10 percent is not warranted. The Veteran's left hip bursitis was rated under 38 C.F.R. § 4.71a, Diagnostic Code 5019. Diagnostic Code 5019 directs that bursitis be rated on limitation of motion of affected parts, as degenerative arthritis. See 38 C.F.R. § 4.71a. Degenerative arthritis is rated based on limitation of motion under the appropriate Diagnostic Code for the specific joint(s) involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Hip disabilities manifested by range of motion impairment are rated under Diagnostic Codes 5250 through 5255. Diagnostic Code 5251 provides that a maximum 10 percent rating may be assigned for disability marked by thigh extension limited to five degrees. Id. Diagnostic Code 5252 provides 10, 20, 30, and 40 percent ratings for limitation of flexion of the thigh, with flexion limited to 45, 30, 20, and 10 degrees, respectively. Id. Diagnostic Code 5253 provides a 10 percent rating for impairment of the thigh with limitation of rotation of, cannot toe-out more than 15 degrees, of the affected leg, or for limitation of adduction, cannot cross legs. A 20 percent rating is warranted for limitation of abduction, motion lost beyond ten degrees. Id. The normal range of hip flexion is from zero to 125 degrees and the normal range of hip abduction is from zero to 45 degrees. Id. at Plate II. Assigning multiple ratings based on the same symptoms or manifestations of a disability constitutes prohibited pyramiding. 38 C.F.R. § 4.14. However, assigning separate ratings based on different manifestations, such as actual limitation of extension, flexion, adduction, and rotation of the hip under Diagnostic Codes 5251, 5252 and 5253 does not amount to pyramiding under 38 C.F.R. § 4.14. Indeed, separate ratings under different Diagnostic Codes may be assigned where "none of the symptomatology for any of [the] conditions is duplicative of or overlapping with the symptomatology of the other . . . conditions." Esteban v. Brown, 6 Vet. App. 259 (1994). When assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must, in addition to applying schedular criteria, also consider evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-207 (1995). On VA examination in August 2009, the Veteran's left hip range of motion was measured as 100 degrees of flexion, 15 degrees of extension, and 25 degrees of abduction, without objective evidence of pain upon motion. Significantly, the rotation of the left hip could only be approximated to be decreased by about 10 degrees because amputation. On VA examination in October 2016, the Veteran's left hip was found to have full range of motion without any exhibited pain, with no additional contributing factors of the disability. The examiner did find 4/5 muscle strength in the left hip as a result of the Veteran's left hip injury. VA treatment records from 2016 and 2017 indicated a worsening of the Veteran's left hip condition when he requested a wheelchair due in part to left hip pain. He had weakness in the left hip and left lower extremity and trouble with walking. He was diagnosed with degenerative joint disease and osteopenia in both hips. A February 2017 VA assessment indicated left hip flexion to 95 degrees, abduction to 25 degrees, internal rotation to 30 degrees and external rotation to 25 degrees. In this case, the Board finds that a separate or higher rating is not warranted under Diagnostic Code 5251, as there is no probative evidence that the Veteran's left thigh extension, even considering functional impairment factors such as painful motion, has ever been limited to five degrees. Rather, the Veteran has consistently been shown to have extension of his left hip of at least 15 degrees. Additionally, the Veteran's left hip flexion has not been shown to be limited to 45 degrees, as is required for a separate or higher rating under Diagnostic Code 5252. The Board also considered whether a higher rating under Diagnostic Code 5253 for limitation of abduction should be warranted. While the August 2009 examiner speculated that the Veteran's left hip rotation was limited by 10 degrees, it was also noted that limitation of abduction was to 25 degrees. The February 2017 assessment found the same limitation. Based on this, the Board finds that the Veteran's limitation of abduction was, at worst, 25 degrees, and does not warrant a rating greater than 10 percent under Diagnostic Code 5253 throughout the appeal period. Finally, there is no evidence to indicate the Veteran has ever experienced ankylosis of the left hip, flail joint, or impairment of her femur on the left side. As such, Diagnostic Code 5250 (for ankylosis), Diagnostic Code 5254 (for hip flail joint), and Diagnostic Code 5255 (for impairment of the femur) do not provide a basis for higher ratings in this case. See 38 C.F.R. § 4.71(a). Residuals of Left Knee Injury The Veteran contended that his left knee condition warranted a rating in excess of the 20 percent rating currently assigned for left knee instability pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5299-5257. As noted above, when evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). With any form of arthritis, painful motion is an important factor of disability; the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. Regulations pertaining to rating the knee were amended effective February 7, 2021, but that those regulation changes do not apply to this appeal due to the death of the Veteran in January 2019. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the claimant will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. In this case, the Veteran died prior to February 7, 2021. Therefore, as the entire claim period is prior to February 7, 2021, the Board may only consider the appellant's claim under the former criteria and the revised criteria are not for application in this instance. Under the criteria for Diagnostic Code 5257 prior to February 7, 2021, "recurrent subluxation or lateral instability" with three levels, severe (30 percent), moderate (20 percent), and slight (10 percent). The rating on appeal reflects the AOJ's finding that the Veteran's left knee was manifested by moderate recurrent subluxation or lateral instability. The Board notes that the Veteran had undergone a left leg amputation below the left knee, which was not service-related. On VA examination in August 2009, the Veteran's left knee flexion was measured to 120 degrees with extension to 0 degrees. The examiner did not observe any objective evidence of pain on examination. While there was medial femoral condyle tenderness, the left knee soft tissues were unremarkable on X-ray. In a June 2013 VA treatment note, the Veteran reported having fallen due to locking in his left knee 4 weeks prior the appointment, but had been using a cane to walk without incident since then. In April 2014, he reported that he stopped walking for fear that his knees would buckle. His left knee muscle were graded 3+/5, and no effusion was found from radiology. VA records from June 2016 indicate full range of motion of the left knee. VA treatment records from February 2017 show severe tightness in the Veteran's left knee, however, range of motion was not measured at the time. In order to grant a rating in excess of 20 percent under Diagnostic Code 5257, the Board must find that the Veteran's left knee instability was "severe." In this case, the buckling of the Veteran's left knee, leading him to use a wheelchair constitutes severe instability. The instability and buckling are more than intermittent, and the Veteran began using a wheelchair in April 2014 due to knee buckling. As such, the Board finds that the Veteran's left knee instability warrants a rating of 30 percent, beginning April 26, 2014. A rating of 30 percent disabling is the maximum rating available under Diagnostic Code 5257. However, the Board has considered whether a separate rating for other manifestations of a knee disability is appropriate. Under Diagnostic Code 5260, leg flexion limited to 60, 45, 30, or 15 degrees warrants ratings of 0, 10, 20, or 30 percent disabling, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5261, leg extension limited to 5, 10, 15, 20, 30, and 45 degrees warrants 0, 10, 20, 30, 40, and 50 percent disability ratings, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5258. 38 C.F.R. § 4.59 grants a minimum compensable rating under applicable diagnostic code for range of motion that is painful. Normal range of knee motion is 140 degrees of flexion and 0 degrees of extension. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5258 provides for a single 20 percent evaluation on the basis of dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Diagnostic Code 5259 provides for a 10 percent evaluation on the basis of symptomatic removal of the semilunar cartilage. 38C.F.R. §4.71a, Diagnostic Code 5259. This is the only available evaluation under Diagnostic Code 5259. Diagnostic Codes 5256, 5262, and 5263 also address ratings for knee disabilities. However, in this case, the evidence does not demonstrate ankylosis of the knee (Diagnostic Code 5256), impairment of the tibia and fibula (Diagnostic Code 5262), or genu recurvatum (Diagnostic Code 5263); thus, the Diagnostic Codes pertaining to such impairments are not applicable. Moreover, as discussed in the evidence section above, there is no evidence of limitation of motion sufficient to warrant a separate compensable rating, and no evidence of effusion or symptomatic removal of the semilunar cartilage. Accordingly, a separate compensable rating is not warranted. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. §3.303(d). Service connection may also be established with certain chronic diseases based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38C.F.R. §§3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 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; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran contended that he had a respiratory condition related to his active service, to include a chronic lung disease secondary to asbestos exposure. However, a thorough review of medical evidence of record did not reveal any diagnosed respiratory disease or chronic lung illness diagnosed during the appeal period. The Board thus finds there is insufficient evidence to show the Veteran had a respiratory condition related to his active military service, to include the claimed asbestos exposure. The Appellant has not argued otherwise or provided any medical evidence to the contrary. Given the foregoing, the Board finds that the medical evidence outweighs the Appellant's contentions. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In reaching this conclusion, the Board has considered the Veteran's contentions, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue of a respiratory disease or syndrome in this case, it falls outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Although the Veteran is competent to report his current symptoms, this is not the type of condition that is amenable to mere lay diagnosis or probative comment regarding its etiology, as the evidence shows that specific findings are needed to properly assess and diagnose a respiratory or lung condition and determine its etiology. Jandreau; Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). In sum, the evidentiary requirement of demonstrating a current disability has not been satisfied. There is simply no evidence that a respiratory condition was diagnosed at any time during the appeal period. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Without a diagnosis, the claim for service connection fails. Brammer v. Derwinski, 3 Vet. App. 223 (1992). There is no doubt of material fact to be resolved in the Appellant's favor, and the claim for service connection for a respiratory disability must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to service connection for a right knee condition is remanded. Entitlement to service connection for a cervical spine (neck) condition is remanded. Entitlement to service connection for a low back condition is remanded. Entitlement to service connection for a coccyx condition is remanded. The Appellant contends that the Veteran's right knee condition, neck condition, and low back, and coccyx conditions were related to his military service. To that end, during the appeal period, service connection for the Veteran's right hip disability was granted as secondary to the service-connected left knee condition. There has been no examination or opinion obtained concerning a potential relationship between the claimed right knee, low back, coccyx, or neck, and a service-connected disability. In light of the grant of service connection for the right hip condition, and the July 2016 treatment note which related the Veteran's lower extremity conditions, pain, and weakness as interrelated to each other and to the Veteran's use of a wheelchair, the Board finds that it is necessary to obtain appropriate medical opinions concerning the etiology of the Veteran's additional claims for his right knee, low back, coccyx, and neck, to include as secondary to service-connected left knee and bilateral hip conditions. The matters are REMANDED for the following actions: 1. Obtain any outstanding available medical records concerning the Veteran's multiple joint and muscle conditions. Any attempt to obtain such records should be documented in the claims file. 2. Provide the entire claims file, to include this remand, to appropriate VA examiners to review the records and determine the diagnoses and etiologies of the Veteran's right knee condition, low back and coccyx conditions, and neck or cervical condition. The examiner(s) is(are) must provide a medical opinion, supported by adequate rationale, as to whether each of the claimed conditions is at least as likely as not (50 percent probability or greater) caused or aggravated by, or is otherwise related to the Veteran's active duty service, or as secondary to a service-connected disability, to include his left knee and/or hip conditions. A detailed rationale for the opinions must be provided. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. J. Kirby Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. E. Lee 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.