Citation Nr: 21072569 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 16-36 568 DATE: December 3, 2021 ORDER Entitlement to a rating in excess of 50 percent prior to April 22, 2019, and in excess of 70 percent thereafter, for major depressive disorder with insomnia is denied. REMANDED Entitlement to service connection for right ankle disability, to include as secondary to service-connected bilateral plantar fasciitis or right shin splints, is remanded. FINDINGS OF FACT 1. Prior to April 22, 2019, the severity, frequency, and duration of the Veteran's symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 2. From April 22, 2019, the severity, frequency, and duration of the Veteran's symptoms did not more closely approximate total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 50 percent for psychiatric disability have not been met prior to April 22, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9434. 2. The criteria for entitlement to an initial rating in excess of 70 percent for psychiatric disability have not been met from April 22, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, DC 9434. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1993 to April 2013. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2013 rating decision. In October 2019, the Board remanded for additional development. In a June 2021 rating decision, the Veteran's rating for psychiatric disability was increased to 50 percent disabling from May 1, 2013, and 70 percent disabling from April 22, 2019. As the increases do not represent a full grant of the benefit sought, the claim remains before the Board. See AB v. Brown, 6 Vet. App. 35 (1993). The issue of entitlement to a TDIU has not been raised by the Veteran or by the record as part of the Veteran's psychiatric increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding that a request for a TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation). Although the Veteran filed a claim for TDIU, he asserted he was unable to work due solely to his migraine disability. The Veteran has not maintained that he is unable to work due to his psychiatric disability, but rather has worked for much of the claim period, has obtained degrees during the claim period, and reported that he was still working on his doctoral degree at the February 2021 psychiatric examination. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). 1. Entitlement to a rating in excess of 50 percent prior to April 22, 2019, and in excess of 70 percent thereafter, for major depressive disorder with insomnia is denied. The Veteran contends that he is entitled to a higher initial rating in excess of 50 percent prior to April 22, 2019, and in excess of 70 percent from April 22, 2019 for his service-connected psychiatric disability. The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher prior to April 22, 2019, and for 100 percent from April 22, 2019. Under the General Formula for Mental Disorders (General Formula), a noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. Additionally, the General Formula indicates that the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The Veteran is currently service connected for psychiatric disability, rated 50 percent from May 1, 2013 (the month following separation from service) and 70 percent from April 22, 2019. The Board concludes that prior to April 22, 2019, the Veteran's symptoms did not cause the level of impairment required for a disability rating of 70 percent or higher. Prior to April 22, 2019, the Veteran's symptoms and their corresponding level of impairment most closely approximate the level of impairment associated with a 50 percent rating. From April 22, 2019, the Board concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 100 percent. From April 22, 2019, the Veteran's symptoms and their corresponding level of impairment most closely approximate the level of impairment associated with a 70 percent rating. The Veteran filed a claim for service connection for psychiatric disability in November 2012, before leaving service. Historically, the Veteran has experienced sleep problems and anger issues and depression. The Veteran was hospitalized and prescribed medication during service in 2009 for suicidal ideation and thoughts of harming others without intention to act. During service in 2009, the Veteran reported that he had never acted on his anger against another person. The Veteran's service treatment records in 2009 note that the Veteran has no past or current active thoughts of harming himself or others. The Veteran's in-service treatment records in September 2012 show normal mood and affect and that the Veteran was not thinking about suicide and did not have homicidal thoughts. In a November 2012 report of medical history at separation, the Veteran reported a history of depression, sleep issues, and memory problems. In December 2012, the Veteran underwent VA contract examination. The examiner noted that the Veteran has always been in contact with both of his parents and that he was divorced in 1996 but remarried his spouse in August of 2012. The Veteran reported unhappiness and anger during service around 2007 to 2009 and that he was hospitalized for a few days in 2009. The Veteran reported suicidal ideation in 2009 during an episode of depression but reported that his symptoms of depression improved after a work transfer. The examiner noted that the Veteran has not had an episode of major depression since that time but has had symptoms consistent with dysthymic disorder. The examiner noted symptoms of depressed mood, suspiciousness, chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events), flattened affect, low energy, fatigue, low self-esteem, poor concentration, and disturbances of motivation and mood. The Veteran reported that his feelings of hopelessness had been alleviated by his planned retirement from service. The examiner noted that the Veteran did not appear to pose any threat of danger of injury to himself or others. The examiner opined that the Veteran's psychiatric disability had been formally diagnosed, but symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. The Veteran's treatment records from May 2013 to December 2017 show trouble sleeping but negative depression screenings, normal mood and affect, and no delusions, suicidal ideation, or mania. See, e.g., May 2013, June 2013, January 2014, July 2014, October 2014, April 2015, May 2015, June 2015, December 2015, January 2016, February 2016, March 2016, May 2016, August 2016, October 2016, March 2017, May 2017, December 2017 Treatment Records. In February 2017, the Veteran answered no to the questions "Have you wished you were dead or wished you could go to sleep and not wake up?"; "Have you actually had any thoughts of killing yourself?"; and "Have you ever done anything, started to do anything, or prepared to do anything to end your life?" The Veteran was noted to be fully oriented and cooperative. In February 2018, the Veteran was noted to have normal mood and affect. The Veteran reported that once over the prior two weeks: he had little interest or pleasure in doing things, felt down, depressed, or hopeless, had trouble falling asleep, felt tired or had little energy, had a poor appetite or overate, felt bad about himself, had trouble concentrating on things, such as reading the newspaper or watching television, and moved slowly or was fidgety. He reported no thoughts that he would be better off dead or of hurting himself in some way. He reported that his depression symptoms made it somewhat difficult to do work, take care of things at home, or get along with other people. In treatment records from April 2018 to September 2018, the Veteran reported no depression or anxiety and no thoughts of harming himself or others and was noted to have normal mood and affect. See, e.g., April 2018, August 2018, September 2018 Treatment Records. The Veteran underwent VA contract examination on April 22, 2019. During the examination, the Veteran reported no friends, distance from his siblings, obsessive compulsiveness about cleanliness, investigating his home when returning, and panic that turns to anger quickly (noting this once resulted in him pulling a knife on a customer). He denied suicidal ideation and prior attempts. The Veteran reported no serious romantic relationships. The Veteran lives with his mother since 2017 and takes care of her since she has dementia. The Veteran reported that he began working in auto maintenance in 2013, cooked pizzas and food samples at Sam's Club in 2014, went back to auto maintenance work, then drove for Lyft. He reported working for World Financial Group in an unpaid position. He received a bachelor's degree in 2014 and master's degree in 2015 and was currently in a doctoral program. The examiner noted that chronic pain can affect the Veteran's mood and sleep. The examiner noted symptoms of depressed mood, anxiety, suspiciousness, distressing dreams, panic attacks more than once a week, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, flattened affect, disturbances of motivation and mood, inability to establish and maintain effective relationships, and obsessional rituals which interfere with routine activities. The Veteran was fully oriented with no evidence of a thought disorder, was dressed casually, had a flat/blunted affect and despondent mood, and spoke in a monotone and quiet voice. The examiner opined that the Veteran's disability results in occupational and social impairment with reduced reliability and productivity. During the April 2019 examination, the Veteran reported that he was hospitalized with depression in 2009 and that he had a second major depressive episode in 2017 but was not treated. The examiner opined that the Veteran's psychiatric disability worsened since separation after having the 2017 episode but noted that medical records available for review in the Veteran's claims file ended in 2015. In a treatment record also dated April 22, 2019, the Veteran reported several days of worrying too much about different things, little interest or pleasure in doing things, thoughts that he would be better off dead or of hurting himself in some way, feeling nervous, anxious, or on edge, moving or speaking so slowly that other people could have noticed or being so fidgety or restless, feeling down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, poor appetite or overeating, feeling bad about himself, trouble concentrating on things, such as reading the newspaper or watching television, not being able to stop or control worrying, trouble relaxing, being so restless that it is hard to sit still, becoming easily annoyed or irritable, and feeling afraid as if something awful might happen. The Veteran reported that these problems have made it very difficult to work, take care of things at home, or get along with other people. In June 2019, the Veteran reported that he has not wished he were dead or that he could go to sleep and not wake up, has not had any actual thoughts of killing himself, has not been thinking about how he might do this, has not had these thoughts and had some intention of acting on them, and has not started to work out or worked out the details of how to kill himself. The Veteran reported that he has done something, started to do something, or prepared to do something to end his life but not within the last three months. The Veteran was noted to have normal mood and affect. The Veteran reported several days of feeling down, depressed, or hopeless, little interest or pleasure in doing things, feeling bad about himself, trouble concentrating on thing, and thoughts he would be better off dead or of hurting himself in some way. He reported trouble falling or staying asleep more than half the days and feeling tired or having little energy nearly every day. In August 2019 treatment, the Veteran reported no depression. In October 2019 treatment, the Veteran reported that he had wished he was dead or that he could go to sleep and not wake up in the past month. He reported that he had done something, started to do something, or prepared to do something to end his life at some point but that he had not had any actual thoughts of killing himself in the past three months. The Veteran was screened for suicide risk and it was noted that he was not at elevated suicide risk. The Veteran reported not feeling down, depressed, or hopeless in the past month but having little interest or pleasure in doing things several days in the past month. The Veteran was noted to have normal mood and affect. In treatment from November 2019 to October 2020, the Veteran denied depression, hallucinations, memory loss, or suicidal ideation, and had normal affect and mood. The Veteran underwent further VA contract examination in February 2021. The examiner noted the Veteran's recurrent severe major depressive disorder with insomnia disorder. The Veteran reported taking care of his mother who lives with him and helping his father who lives close to him. The Veteran reported stress from caretaking, trying to finish his doctorate degree, and in the past also working full-time. He reported that he is trying to complete his doctorate degree, that he has completed all but his dissertation, and that he last worked for Lyft in October 2018. The examiner noted symptoms of depressed mood, anxiety, panic attacks that occur weekly or less often, irritability, isolation, problems with concentration and attention, fear, trust issues, anger, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events), flattened affect, difficulty in understanding complex commands, disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work-like setting, suicidal ideation, obsessional rituals which interfere with routine activities, neglect of personal appearance and hygiene. The examiner noted the Veteran's affect was flat with anxious, sad, tearful mood. The Veteran reported difficulty controlling his temper. The Veteran denied suicidal ideation at the time of examination but reported passive suicidal ideation with no intent or plan. The examiner noted the Veteran was fully oriented with good knowledge and fair insight and judgment. The examiner opined that the Veteran's disability results in occupational and social impairment with reduced reliability and productivity. In a May 2021 statement, the Veteran reported that his condition had worsened over time and recent examination should reflect that worsening. A June 2021 treatment record notes that the Veteran was clean and well-dressed, cooperative, and logical, with normal rate and volume of speech, goal-directed thought process, and full range of affect. The Veteran denied suicidal and homicidal ideations. The Veteran reported not at all when asked whether he has little interest or pleasure in doing things or feels down, depressed, or hopeless. The Board notes that this increased rating matter is ready for adjudication. Although records were added to the file after the June 2021 supplemental statement of the case (SSOC), any records relevant to the Veteran's psychiatric increased rating claim are duplicative of those already in the file at the time of the June 2021 SSOC. The Board also finds that there has been substantial compliance with the Board's former remand. See Stegall v. West, 11 Vet. App. 268 (1998). Although 2017 hospitalization records were noted in the October 2019 remand, further review of the claims file shows that the Veteran reported a 2017 depressive episode but reported that he did not seek treatment at that time. As directed in the October 2019 remand, another psychiatric examination was obtained and records from the Veteran (including any records relating to a 2017 depressive episode) were requested. Records identified by the Veteran were obtained and VA has met its duty to assist with this claim. Viewing the medical and lay evidence as a whole, the Board finds the Veteran's psychiatric disability most closely approximates occupational and social impairment with reduced reliability and productivity prior to April 22, 2019. The severity, frequency, and duration of the Veteran's symptoms during this time period are most consistent with the 50 percent rating. The December 2012 examiner noted symptoms of depressed mood, suspiciousness, chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events), flattened affect, and disturbances of motivation and mood, symptoms associated with 30 and 50 percent ratings. The December 2012 examiner also noted low energy, fatigue, low self-esteem, and poor concentration, which most closely resemble symptoms contemplated by the 50 percent rating, such as disturbances of motivation and mood, impairment of short and long-term memory (such as retention of only highly learned material and forgetting to complete tasks), and difficulty understanding complex commands. Treatment records prior to April 22, 2019 show some indications of depression, trouble sleeping, and memory problems, but generally noted the Veteran had normal mood and affect and was fully oriented and cooperative. Depressed mood, sleep impairment, and impairment of short and long-term memory are symptoms contemplated by 30 and 50 percent ratings. In February 2018, when the Veteran reported some depression symptoms, he reported that these symptoms made it "somewhat difficult" to do work, take care of things at home, or get along with other people. He reported that he experienced such symptoms once in the prior two weeks. Treatment records before and after February 2018 generally show negative depression screenings. The records show the Veteran denied any suicidal or homicidal thoughts throughout the claims period (beginning May 2013) prior to April 22, 2019. The December 2012 examiner noted that while the Veteran reported suicidal ideation in 2009 during service, he reported that his symptoms of depression improved after a work transfer and that his feelings of hopelessness had been alleviated by his planned retirement from service. Although the Veteran reported a 2017 depressive episode during the April 2019 VA examination, the Veteran did not report that he experienced symptoms such as suicidal ideation in 2017 and the 2017 treatment records do not show such symptoms but rather show negative depression screenings and normal mood and affect. During the December 2012 examination, the Veteran reported that he was married and in contact with both of his parents. The records also show the Veteran was in school and working during the claim period prior to April 2019. Viewing the Veteran's psychiatric disability as a whole, a rating in excess of 50 percent is not warranted prior to April 22, 2019. The evidence does not show a factually ascertainable increase in the Veteran's psychiatric disability warranting the 70 percent rating until April 22, 2019. Viewing the medical and lay evidence as a whole, the Board finds the Veteran's psychiatric disability most closely approximates occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood from April 22, 2019. The severity, frequency, and duration of the Veteran's symptoms during this time period are most consistent with the 70 percent rating. The April 2019 and February 2021 examiners noted depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, flattened affect, disturbances of motivation and mood, inability to establish and maintain effective relationships, obsessional rituals which interfere with routine activities, mild memory loss (such as forgetting names, directions, or recent events), flattened affect, difficulty in understanding complex commands, disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work-like setting, suicidal ideation, and neglect of personal appearance and hygiene, symptoms contemplated by the 70 percent rating criteria. The examiners also noted the Veteran's distressing dreams, irritability, isolation, problems with concentration and attention, fear, trust issues, anger, difficulty controlling his temper, and panic that turns to anger quickly (noting this once resulted in him pulling a knife on a customer), which appear similar in severity to symptoms contemplated by the 70 percent rating criteria, such as the symptom of impaired impulse control (such as unprovoked irritability with periods of violence) noted in the 70 percent rating criteria. The Board finds the severity, frequency, and duration of the Veteran's unlisted symptoms more closely approximate the symptoms contemplated by a 70 percent rating. The record does not show symptoms associated with a 100 percent rating such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. The April 2019 and February 2021 examiners noted the Veteran was fully oriented with fair insight and judgment and no evidence of a thought disorder. A June 2021 treatment record also notes that the Veteran was clean and well-dressed, with normal rate and volume of speech and goal-directed thought process. The Veteran denied hallucinations throughout the claims period. The Board notes that the Veteran expressed suicidal ideation, which is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran's suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. During the April 2019 examination, the Veteran denied suicidal ideation and prior attempts. During the February 2021 examination, the Veteran denied suicidal ideation at the time of examination but reported passive suicidal ideation with no intent or plan. Treatment records from April 2019 to June 2021 show that the Veteran denied suicidal ideation at times and at other times reported suicidal ideation but indicated that he had not done something, started to do something, or prepared to do something to end his life within the last three months. He was screened for suicide risk and not at elevated suicide risk. The record does not show total social and occupational impairment. During the April 2019 and February 2021 examinations, the Veteran reported taking care of his mother who lives with him and helping his father who lives close to him as well as working on his doctoral degree. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran's symptoms resulted in the level of impairment required for a 70 percent rating prior to April 22, 2019, and a 100 percent rating from April 22, 2019. The criteria for higher ratings have not been met and the claim for increased rating must be denied. REASONS FOR REMAND 1. Entitlement to service connection for right ankle disability, to include as secondary to service-connected bilateral plantar fasciitis or right shin splints, is remanded. In the October 2019 remand, the Board directed that VA medical opinions be obtained regarding whether the Veteran has a current right ankle disability related to service or caused by or aggravated by his service-connected bilateral plantar fasciitis or right shin splints. A March 2021 VA examiner opined that the Veteran's right ankle disability is less likely than not incurred in or caused by service. The examiner explained that while the Veteran was seen for right ankle sprain in 2000 and 2001 his x-rays at that time were normal and his condition was managed with no further right ankle notes or treatment during service even though he stayed active until 2013. The VA examiner noted that a right ankle condition was not noted near discharge or after until the Veteran's current complaints. The VA examiner further explained that the Veteran currently complains of pain at the top of his right ankle while his in-service condition was around the lateral malleolus, a different condition. The VA examiner reported that the Veteran's current right ankle sprain is a separate condition from service. The March 2021 VA examiner also opined that the Veteran's right ankle disability is less likely than not due to or aggravated by his service-connected disabilities. However, the VA examiner did not provide an adequate rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The VA examiner explained that while the Veteran complained of right ankle problems during service in 2000 and 2001, x-rays were normal and he did not complain of right ankle problems for the remainder of service. The VA examiner also explained that the Veteran's current right ankle disability is separate from his in-service ankle problems. As to the Veteran's service-connected bilateral plantar fasciitis and right shin splints, the VA examiner merely indicated that the Veteran's right ankle disability was separate from his right foot and right shin disabilities. The VA examiner did not provide an explanation for the opinion that the Veteran's current right ankle disability was not caused or aggravated by the Veteran's current service-connected disabilities, regardless of whether the Veteran's in-service ankle problem resolved. Accordingly, remand is warranted to obtain additional VA medical opinion regarding whether the Veteran's current right ankle disability is secondary to his service-connected disabilities. See Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following action: 1. Ask the appropriate examiner to review the Veteran's file. The necessity of an in-person examination is left to the discretion of the examiner. The examiner should identify any right ankle disability present at any time during the claim period even if resolved, to include the right ankle sprain diagnosed at the March 2021 VA examination. For each such disability, the examiner should opine regarding whether it is at least as likely as not that the Veteran's service-connected bilateral plantar fasciitis or right shin splints caused or aggravated the right ankle disability. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected condition. The examiner should consider all medical and lay evidence of record. The examiner is asked to explain the reasons behind any opinions expressed. 2. After the above development, and any other development deemed necessary, readjudicate the Veteran's claim. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Purcell, Amy 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.