Citation Nr: 21072545 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 17-10 151 DATE: December 3, 2021 ORDER Entitlement to a rating in excess of 10 percent prior to September 22, 2020, and in excess of 30 percent thereafter, for degenerative arthritis and patellofemoral syndrome, right knee, with limitation of flexion is denied. Entitlement to a compensable rating for service-connected right knee disability based on limitation of extension is denied. Entitlement to a rating of 10 percent prior to September 22, 2020, and in excess of 30 percent thereafter, for service-connected degenerative arthritis and patellofemoral syndrome, left knee, is denied. Entitlement to a compensable rating for service-connected left knee disability based on limitation of extension prior to September 22, 2020 is denied. Entitlement to a rating of 10 percent from September 22, 2020 for service-connected left knee disability based on limitation of extension is granted. Entitlement to a 10 percent rating for instability of the right knee is granted for the entire period on appeal. Entitlement to a 10 percent rating for instability of the left knee is granted for the entire period on appeal. FINDINGS OF FACT 1. Prior to September 22, 2020, the Veteran's right knee degenerative arthritis and patellofemoral syndrome manifested, at worst, with limitation of flexion to 110 degrees; from September 22, 2020 the Veteran's flexion was limited to, at worst, 5 degrees. 2. Throughout the entire period on appeal, the Veteran right knee disability based on limitation of extension manifested, at worst, with limitation of extension to 5 degrees. 3. Prior to September 22, 2020 the Veteran's left knee degenerative arthritis and patellofemoral syndrome manifested, at worst, with limitation of flexion to 80 degrees; from September 22, 2020 the Veteran's limitation of flexion manifested to, at worst, 3 degrees. 4. Prior to September 22, 2020, the Veteran's left knee disability manifested as limitation of extension, at worst, to 5 degrees; from September 22, 2020 the Veteran's left knee disability manifested as limitation of extension, at worst to 10 degrees. 5. Throughout the period on appeal, the Veteran's right knee disability manifested with mild instability. 6. Throughout the period on appeal, the Veteran's left knee disability manifested with mild instability. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent prior to September 22, 2020, and in excess of 30 percent thereafter, for degenerative arthritis and patellofemoral syndrome, right knee, with limitation of flexion have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5260. 2. The criteria for entitlement to a compensable rating for service-connected right knee disability based on limitation of extension have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5261. 3. The criteria for entitlement to a rating in excess of 10 percent prior to September 22, 2020, and in excess of 30 percent thereafter, for service-connected degenerative arthritis and patellofemoral syndrome left knee have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5260. 4. The criteria for entitlement to a compensable rating for service-connected left knee disability based on limitation of extension prior to September 22, 2020 have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5261. 5. The criteria for entitlement to a rating of 10 percent, but no higher, for service-connected left knee disability based on limitation of extension from September 22, 2020 have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5261. 6. Entitlement to a 10 percent rating for instability of the service-connected right knee disability for the entire appeal period have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5257. 7. Entitlement to a 10 percent rating for instability of the service-connected left knee disability for the entire appeal period have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1975 to August 1995. These matters came before the Board on appeal from a November 2015 rating decision. In January 2019, the Board denied entitlement to an increased rating for the Veteran's right and left knee disabilities. The Veteran appealed to the United States Court of Appeals for Veterans Claims (CAVC). In August 2019, the CAVC granted a July 2019 Joint Motion for Remand (JMR). The Board remanded the appeal in November 2019, July 2020, and June 2021 for further development. Increased Ratings Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. This Rating Schedule is primarily a guide in the rating of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. For the application of this schedule, accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition. Over a period of many years, a veteran's disability claim may require re-ratings in accordance with changes in laws, medical knowledge and his or her physical or mental condition. It is essential, both in the examination and in the evaluation of disability, that each disability be viewed in relation to its history. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). VA's choice of diagnostic code should be upheld so long as it is supported by explanation and evidence. Butts v. Brown, 5 Vet. App. 532, 539 (1993). Evaluation of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses is prohibited. 38 C.F.R. § 4.14. VA regulations generally provide for separate ratings based on separate disabilities, not separate symptoms. See Cullen v. Shinseki, 24 Vet. App. 74, 81-82 (2010). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Id. Such evidence may include facial expression, such as wincing, muscle spasm, and crepitation. See 38 C.F.R. § 4.59. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45. Orthopedic disabilities of the knee joint are evaluated under the criteria of 38 C.F.R. § 4.71a. Under certain circumstances, a knee disability may receive separate ratings based on evidence showing limitation of motion (Diagnostic Codes 5256, 5260, and 5261) or instability (Diagnostic Codes 5257, 5262, and 5263). See VAOPGCPREC 23-97 (July 1, 1997). Additionally, VA General Counsel has held that a veteran who has arthritis resulting in limited or painful motion and instability of a knee may be rated separately under diagnostic codes 5003 and 5257, cautioning that any such separate rating must be based on additional disabling symptomatology. See VAOPGCPREC 9-98 (September 1998). VA's General Counsel has further held that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. See VAOPGCPREC 9-2004 (September 17, 2004). Moreover, an evaluation of a knee disability under diagnostic codes 5257, 5260, or 5261 does not preclude a separate evaluation under diagnostic codes 5258 or 5259. See Lyles v. Shulkin, 29 Vet. App. 107 (2017). Consideration of a higher rating for functional loss, to include during flare ups, due to these factors accordingly is warranted for Diagnostic Codes predicated on limitation of motion. DeLuca v. Brown, 8 Vet. App. 202 (1995). Pain itself does not constitute functional loss, and painful motion does not constitute limited motion for the purposes of rating under Diagnostic Codes pertaining to limitation of motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pain must affect the ability to perform normal working movements with normal excursion, strength, speed, coordination, or endurance in order to constitute functional loss. Id. An adequate orthopedic examination should record the range of motion for pain on active motion and passive motion and in weight-bearing and non-weight-bearing, address the necessary findings to evaluate functional loss during flare-ups, or clearly explain why the required testing cannot be completed or is not necessary. See Correia v. McDonald, 28 Vet. App. 158 (2016). An examination does not need to be conducted during an actual flare-up in order to account for additional functional impairment. Sharp v. Shulkin, 29 Vet. App. 26, 34 (2017). Instead, examiners are asked to estimate the functional impairment experienced during a flare-up, considering all competent evidence of functional loss that is available in the record. Id. Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021). VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. VA must consider the claim for a higher rating pursuant to the former and revised regulations after February 7, 2021. See VAOPGCPREC 3 2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). It is noted, however, that these changes included no pertinent revisions to Diagnostic Codes 5256, 5258, 5259, 5260, and 5261. Prior to February 7, 2021, traumatic arthritis was rated pursuant to the criteria found in Diagnostic Code 5010, which directed that evaluations are to be made pursuant to the criteria for degenerative arthritis found in Diagnostic Code 5003. 38 C.F.R. § 4.71a. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, and a 20 percent rating is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. The 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note (1). Effective February 7, 2021, Diagnostic Code 5010 provides that post-traumatic arthritis is to be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with applicable regulations. Diagnostic Code 5256 provides a 60 percent rating for knee ankylosis that is extremely unfavorable, in flexion at an angle of 45 degrees or more. A 50 percent rating is provided with flexion between 20 degrees and 45 degrees. A 40 percent rating is provided with flexion between 10 degrees and 20 degrees. A 30 percent rating is provided with a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. Prior to the February 2021 regulatory change, recurrent subluxation and lateral instability of the knee warranted a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. "Slight," as relevant to a physical condition, is defined as "small of its kind or in amount." Merriam-Webster's Dictionary (merriam-webster.com/dictionary, accessed February 8, 2021). It is similar to "mild," which is defined as "not severe" or temperate; with "Temperate" being defined as "keeping or held within limits" and "not extreme or excessive." "Moderate" is defined as "tending toward the mean or average amount," "not violent, severe, or intense," and "limited in scope or effect." Id. "Severe" is defined as "very painful or harmful" or "of a great degree." Id. Within the context of the old version of Diagnostic Code 5257, which established a successive, tiered rating structure, "severe" represented the highest or most extreme level of disability. Lay evidence as to lateral instability should be weighed on a case-by-case basis. English v. Wilkie, No. 17-2083, U.S. Vet. App. (Nov. 1, 2018). The terms slight, moderate, and severe are not defined in the rating schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are equitable and just as contemplated by the requirements of the law. 38 C.F.R. § 4.6. Effective February 7, 2021, Diagnostic Code 5257 for knee impairment with recurrent subluxation or lateral instability provides a 30 percent rating with unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation; a 20 percent rating with one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation. (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device(e.g., cane(s), crutch(es), walker) or bracing for ambulation; and 10 percent rating with sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. For knee impairment with patellar instability a 30 percent rating is provided with a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker; a 20 percent rating is provided with a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker; and a 10 percent rating is provided with a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). The changes made to the rating schedule did not alter Diagnostic Code 5258 through 5261. Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking" pain and effusion into the joint. Diagnostic Code 5259 provides a 10 percent rating for removal of semilunar cartilage that is symptomatic. Diagnostic Code 5260 provides a 30 percent rating where knee flexion is limited to 15 degrees; 20 percent where limited to 30 degrees; 10 percent where limited to 45 degrees; and 0 percent where limited to 60 degrees. Diagnostic Code 5261 provides a 50 percent rating where knee extension is limited to 45 degrees; 40 percent where limited to 30 degrees; 30 percent where limited to 20 degrees; 20 percent where limited to 15 degrees; 10 percent where limited to 10 degrees; and 0 percent where limited to 5 degrees. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant. However, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3. The Veteran has undergone several VA examinations throughout the duration of his appeal. In November 2015, the Veteran reported discomfort in both knees at a baseline of 5, with an increase to 8-9 when aggravated. Walking long distances and sitting for extended periods of time were identified as aggravating factors. The Veteran's range of motion (ROM) was at worst right knee flexion to 110 degrees and left knee flexion to 100 degrees; extension was normal bilaterally. The Veteran did not endorse flare-ups at this examination. Pain was noted to cause loss of function and evidence of pain on palpation of the joint or associated soft tissue was noted. There was no evidence of pain with weight bearing on either knee. Muscle strength was normal bilaterally and there was no evidence of muscle atrophy, ankylosis, or instability. The occasional use of a brace was noted. Crepitus was noted bilaterally. A December 2019 addendum opinion addressed reports of popping, cracking, locking, and swelling throughout the appeal period. There is a single notation of popping, cracking, and locking in November 2015. The Veteran reports audible cracking and popping on the left and that his left knee will lock up once or twice a week. Despite these reports, the examiner found no history of subluxation or laxity on testing, and determined that while the knees are painful and occasionally the left knee locks up, the knees are otherwise stable. A December 2020 addendum opinion indicated the Veteran began to experience pain at 50 to 60 degrees flexion and extension in 2015, per the Veteran's estimation. There is no evidence the Veteran' actual motion was limited at these degrees, only that pain began. Contemporaneous medical records note left knee instability, and a sensation of the "knee giving out" with weight-bearing. The left knee manifested positive crepitus throughout full ROM, however no joint effusion or limitation of motion was indicated. A June 2015 note indicated full ROM and no strength deficiencies, but that the Veteran was fitted with a hinged brace for patellar support. In January 2016, the Veteran reported he stopped refereeing basketball games because of the strain on his knees. A September 2018 treatment note indicates instability, clicking, catching, popping, and pain with swelling. The Veteran was afforded another VA examination in December 2019 at which he reported no specific flare-ups, but a constant state of being "highly symptomatic." The Veteran's ROM of his right knee was improved from the previous examination and was recorded to be normal, though pain was noted on movement. The Veteran's left knee ROM was abnormal and was, at worst, flexion limited to 80 degrees and extension limited to 5 degrees. Muscle strength was normal bilaterally and there was no indication of muscle atrophy, ankylosis, or joint instability. The right knee demonstrated pain on flexion, with no quantifiable loss of motion, though functional loss was indicated. There was no pain on weight bearing on the right side. There was pain on weight bearing with the left knee as well as pain on flexion and extension. Crepitus of the left knee was observed. Passive ROM was noted to be the same as active ROM bilaterally. At another VA examination in September 2020, the Veteran reported weekly flare-ups of both knees that lasted three or four days and are moderate to severe. Flare-ups are precipitated by use of the knees and are alleviated by nothing. The Veteran reported pain and swelling after only approximately one hundred steps and that he is barely able to bend either knee. The Veteran's ROM was worst during a flare-up. The right knee's flexion ended at 15 degrees and extension ended at 5 degrees. The Veteran's left knee flexion ended at 10 degrees and extension ended at 10 degrees. Muscle strength was slightly reduced bilaterally, however, no muscle atrophy was noted. No ankylosis was noted. There was no history of recurrent subluxation or lateral instability noted, and stability testing was normal. Pain on weightbearing and passive ROM was noted bilaterally. The Veteran underwent another VA examination in November 2020, where he endorsed essentially the same symptoms and severity. His ROM was essentially the same as the previous examination, except his extension was normal bilaterally and his right knee flexion reduced to 5 degrees, and his left knee flexion reduced to 3 degrees. These measurements were during a flare-up and the examination was noted to be conducted during a flare-up. There was moderate strength reduction in both knees on both extension and flexion. Prior to September 22, 2020, the Veteran's limitation of flexion manifested, at worst, at 110 degrees of the right knee at the November 2015 VA examination, and 80 degrees of the left knee at the December 2019 VA examination. The Veteran has consistently reported painful motion, and is in receipt of a 10 percent rating for painful flexion of each knee. At no point during this period was either of the Veteran's knees shown to manifest limitation of flexion of a compensable degree even when considering limited motion during a flare-up or after repeated use. At the September 2020 VA examination, the Veteran's right and left knee's flexion manifested with limitation consistent with the 30 percent rating, which is the highest rating under the diagnostic code. A higher rating is not warranted without evidence of ankylosis. While the Veteran's flexion has worsened since the September 2020 VA examination, there is no evidence of ankylosis. Throughout the appeal period, the Veteran's right knee manifested with limitation of extension at 5 degrees. This is consistent with a noncompensable rating. The Veteran's limitation of extension of the left knee was at worst 10 degrees at the September 2020 VA examination. There is no evidence the Veteran's limitation of extension manifested to a compensable degree prior to this date as previous VA examinations and treatment records demonstrate normal extension or extension limited to at most 5 degrees. Further, and there is no evidence the Veteran's limitation of extension has manifested as more than 10 degrees limitation since this examination. In fact, the following VA examination indicated the Veteran's extension had improved. However, the Board finds the evidence at least in equipoise that the measurement from September 2020 is an accurate representation of the Veteran's limitation of extension of the left knee as prolonged improvement has not been shown subsequently. Accordingly, the Board finds a separate compensable rating is warranted for the left knee limitation of extension since the September 22, 2020 VA examination. The Board notes that an adequate discussion of functional loss includes consideration of manifest functional loss during flare-ups. Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Flare-ups must be quantifiable and must result in limitation of motion or function beyond that contemplated by the already provided evaluation. In addition, because VA regulations under 38 C.F.R. § 3.344(a) and 38 C.F.R. § 4.1 address the stabilization of ratings, flare-ups must be of such length as to establish that the overall impairment is more severe than currently evaluated, rather than a brief snapshot in time. Here, the Board has used the Veteran's reported and estimated loss of motion during a flare-up in assigning the above ratings, thus contemplating the Veteran's functional loss during a flare-up in the evaluation. The Veteran has been prescribed braces for both his knees since June 2015 for patellar support and has endorsed feeling like his knees will "go out" throughout the period on appeal. Treatment records from June 2015 and September 2018 note instability. Stability testing at VA examinations have not shown lateral instability, however. Based on the Veteran's lay reports and his prescribed brace for patellar support, the Board finds the evidence at least in equipoise that he has experienced slight instability of the bilateral knees throughout the appeal period. The evidence does not support a finding of moderate instability, sufficient to warrant a higher rating, as the Veteran's stability testing has consistently been normal, indicating the severity of his instability is slight. A higher rating is similarly not warranted under the new Diagnostic Criteria as the Veteran has not had a surgical repair to the knee, as required by the higher 20 percent rating. The Board has considered the potential of a higher rating under the other diagnostic codes relevant to the knees. However, the record does not support existence of ankylosis, impairment or malunion of the tibia or fibula, or genu recurvatum to the extent that higher ratings may be assigned. 38 C.F.R. § 4.71a, DC 5256, 5262, 5263. Consideration has also been given for a potential rating under DC 5258 or 5259 based on the Veteran's reports that his knees lock up. However, there is no evidence of a dislocation or removal of the semilunar cartilage. As such, DC 5258 and 5259 are not applicable. Further, the Veteran's reports of locking are contemplated by the separate compensable rating for instability under DC 5257. To compensate the Veteran separately would result in impermissible pyramiding. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. In sum, the Board finds the evidence of record is against finding the Veteran's right and left knee manifested as more than painful flexion prior to September 22, 2020. As such a rating in excess of 10 percent for either knee based on limitation of flexion is not warranted. Similarly, the Veteran's left and right knee did not manifest with limitation of motion warranting a compensable rating prior to September 22, 2020. After the September 22, 2020 VA examination, the evidence is at least in equipoise that the Veteran's left knee limitation of extension manifested to a compensable degree. The lay evidence and medical record support a finding of instability for the entire period on appeal; accordingly, a separate compensable rating for each knee is warranted. M.W. Kreindler Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Rekowski 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.