Citation Nr: 21072727 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 12-11 524A DATE: December 6, 2021 ORDER Prior to December 14, 2010, entitlement to a 70 percent rating, but no higher, for posttraumatic stress disorder (PTSD) with major depression is granted. From December 14, 2010 to March 18, 2018, entitlement to a 100 percent rating for posttraumatic stress disorder (PTSD) with major depression is granted. REMANDED Entitlement to service connection for Peyronie's disease is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in favor of the Veteran, prior to December 14, 2010, the functional impairment resulting from his PTSD with major depression has more nearly approximated occupational and social impairment with deficiencies in most areas; but it has not resulted in total occupational and social impairment. 2. Resolving reasonable doubt in favor of the Veteran, from December 14, 2010 to March 18, 2018, the functional impairment resulting from his PTSD with major depression has more nearly approximated total occupational and social impairment. CONCLUSIONS OF LAW 1. Prior to December 14, 2010, the criteria for a 70 percent rating, but no higher, for PTSD with major depression have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. From December 14, 2010 to March 18, 2018, the criteria for a 100 percent rating for PTSD with major depression have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1969 to April 1971. This matter is before the Board of Veterans' Appeals (Board) on appeal of November 2010, November 2011, August 2013, July 2019, and December 2019 rating decisions of a Regional Office (RO) of the Department of Veterans Affairs (VA). In October 2017, the Veteran and his wife testified at a hearing before the undersigned. In June 2017, February 2018 and June 2020 the Board remanded the claims addressed below for additional development. During the pendency of this appeal, a December 2019 rating decision allowed a 100 percent disability rating for PTSD with major depression from March 19, 2018. As no higher rating is available under the rating schedule, the issue of entitlement to an increased rating for PTSD with major depression from March 19, 2018 is moot. The Board will address whether any increased rating is warranted prior to this date. Additionally, an August 2021 rating decision granted entitlement to service connection for ischemic heart disease. This represents a complete grant as to the benefit sought and the issue of entitlement to service connection for ischemic heart disease is no longer before the Board. Entitlement to an initial increased rating for posttraumatic stress disorder (PTSD) with major depression, currently rated as 30 percent prior to March 19, 2018 The Veteran seeks an increased initial rating for his service-connected psychiatric disability. This condition is diagnosed as PTSD with major depression. Currently a 30 percent rating is applied prior to March 19, 2018. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disabilities must be viewed in relation to their entire history. 38 C.F.R. § 4.1. VA is required to interpret reports of examination in 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. 38 C.F.R. § 4.2. VA is also required to evaluate functional impairment on the basis of lack of usefulness and the effects of the disabilities upon the claimant's ordinary activity. 38 C.F.R. § 4.10. If there is a question as to which of two ratings apply, VA will assign the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. Where service connection has been granted and the assignment of an initial evaluation is disputed, separate evaluations may be assigned for different periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). VA will resolve reasonable doubt in favor of the claimant when there is an approximate balance of positive and negative evidence regarding any material issue. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. Under the General Rating Formula for Mental Disorders, a 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of ability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent rating is assigned when there is reduced reliability and productivity in occupational and social situations due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotypical speech; panic attacks that occur more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is justified when 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 inability to establish and maintain effective relationship. Id. A 100 percent disability rating is reserved for total occupational and social impairment, 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 maintenance of minimal personal hygiene); disorientation to time or place; and 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 a 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); Mauerhan v. Principi, 16 Vet. App. 436 (2002). Because 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, 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; see also Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). 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 the 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; Mauerhan, 16 Vet. App. at 442. In September 2009, the Veteran filed a claim seeking service connection for PTSD. VA treatment records include a January 2010 PTSD screening which documents the Veteran's reports of trouble sleeping, flashbacks, irritability, and anger. During the screening, the Veteran was fully alert, oriented, well groomed, and neatly dressed. His affect was flat, and his mood was sad. In February 2010, the Veteran initiated VA psychiatric treatment. His VA psychiatrist confirmed he was retired and lived with his wife and son. He reported sleeping three hours each night and feeling tired and exhausted. His energy level and ability to concentrate were decreased. He was irritable and frustrated. He had frequent flashbacks and almost nightly nightmares. He felt guilty, helpless, fearful and on edge. He did not report any suicidal or homicidal ideation. In March 2010, his irritability and poor sleep continued. He was unable to enjoy things. He was neatly groomed, appropriately dressed, oriented and cooperative. In June 2010, the Veteran reported feeling depressed and irritable. He spent time reading his bible and being with his wife and children. He was neatly groomed, logical, and oriented. He did not report suicidal ideation. In September 2010, a VA PTSD examination was provided to evaluate the claim. The examiner diagnosed PTSD and major depression. The examiner noted PTSD symptoms of re-experiencing a traumatic event, avoidance, diminished interest in activities, difficulty falling and staying asleep, irritability, hypervigilance, exaggerated startle response. The Veteran reported almost nightly nightmares. His social involvement had declined, and his irritability resulted in some interpersonal strain. The examiner also noted depressive symptoms of hopelessness, guilt, sadness, dissatisfaction, apathy, declining appetite, and difficulty making decisions. He observed the Veteran was clean, appropriately dressed, and oriented. His mood was irritable and his attitude towards the examiner was hostile. Veteran had been married over thirty years. He had four grown children and four grandchildren. He reported good family relationships despite his irritability. He was social with his family members, but rarely contacted friends. Most days he walked around the house and listened to the radio. The examiner described the Veterans' PTSD symptoms as transient or mild with decreased his work efficiency and reduced ability to perform occupational tasks only during periods of significant stress. A December 14, 2010 VA psychiatric progress note documents the Veteran's report of feeling depressed, anxious, and panicked. He was not sleeping well, and he heard voices "when he was not sleeping well." He did not feel like doing anything and he forgot to do things his wife requested. He was neatly groomed and cooperative; his thinking was logical and coherent; and he denied suicidal ideation. March 2011 VA treatment notes indicate the Veteran continued to be depressed and frustrated. He did not feel like doing things or taking care of himself. He was not sleeping well and had recurring dreams of water. The examiner noted he was neatly groomed and cooperative. In August 2011, the Veteran's sleep difficulties, nightmares, and flashbacks continued. He was anxious and unable to relax. He reported a good relationship with his wife. He was neatly groomed, cooperative, and logical. He did not report suicidal ideation or hallucinations. Notes from September 2011 document continuing symptoms with the additional notation of crying spells. In February 2012, the Veteran reported sleeping only two hours each night. He spent most of his time in bed or on the couch. He described feeling afraid, frustrated, upset, and miserable. He reported seeing images of people who had died. He continued to appear neatly groomed. He was cooperative. The examiner indicated no hallucinations and no suicidal ideation. Records associated with the Veteran's claim for Social Security Administration (SSA) disability benefits are associated with the claims file. They include an August 2011 statement from the Veteran's wife which describes the Veteran as staying in bed most of the time. They also include a May 2012 mental health evaluation. The SSA examiner noted the Veteran got along with his wife and children but did not have any close friends. He slept poorly and was up and down all night. He spent his days lying around and pacing the floor. He was clean and casually groomed for the appointment. She described him as initially "argumentative," but more cooperative later in the evaluation. He spoke in a normal tone but frequently refused to answer questions. She noted the Veteran had been "hearing a lot of chatting voices in the background" and he had vague paranoid feelings. He denied suicidal or homicidal intentions. The SSA examiner diagnosed major depressive disorder, recurrent with severe psychotic features and rule out PTSD, delayed response with psychotic features. She also diagnosed a personality disorder. In August 2012, the Veteran's wife submitted a statement. She observed the Veteran was unable to sleep, unable to concentrate, very irritable, and angry. He had panic attacks and crying episodes. His memory was poor. She noted his reports of auditory and visual hallucinations including recurrent images of Vietnam. She assisted him with daily activities including bathing, dressing, and taking medications. In August 2012, VA treatment notes reflect the Veteran continued receiving psychiatric care with a different psychiatrist. Progress notes confirm continuing anxiety, agitation, frustration, irritation, impaired family relationships, and "hearing voices and seeing dead people when he has nightmares." The examiner observed the Veteran was neatly dressed, but his behavior was very guarded. He was oriented, anxious, and moody. His insight was limited. In September 2012, a second VA PTSD examination was provided. The VA examiner diagnosed PTSD (with ongoing symptoms consistent with reexperience, avoidance, and increased arousal) and major depressive disorder (with symptoms of despondence and social isolation, above and beyond that expected with a diagnosis of PTSD). He also diagnosed "Feigned Cognitive Impairment or Factitious Disorder." He stated the Veteran's cognitive abilities, as presented during the September 2012 VA examination and during the May 2012 examination were inconsistent with his cognitive abilities as observed by his treating clinicians. He described the Veteran's presentation as an "intentional misrepresentation" of his true cognitive abilities. Nevertheless, the examiner stated it was not possible to differentiate the symptoms related to the multiple conditions diagnosed. The examiner confirmed symptoms of depressed mood, anxiety, panic attacks, near continuous panic or depression, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, and intermittent inability to perform activities of daily living. He stated the psychiatric diagnoses would result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. An October 2012 VA Mental Health Comprehensive Plan for Care notes increasing symptoms of nightmares, flashbacks, anxiety, agitation, impaired family relations, hearing voices and seeing dead people when he has nightmares. In March 2013, the Veteran reported increased PTSD symptoms and night sweats. Psychiatric progress notes from October 2013 reflect the Veteran's report of "enormous difficulties in relating to others." His nightmares and flashbacks continued to be increased. He reported voices and visions of dead people related to his war experience. He appeared well groomed. His clinician observed he was anxious and moody and experienced perceptual disturbances of seeing dead people after nightmares. His thoughts were linear, and their content was intact. His insight and judgment were limited. Psychiatric notes from January 2014, March 2014, and May 2014, show these symptoms and behavioral observations continued. In June 2014, the Veteran reported slamming doors and avoiding all outside activities. His psychiatrist observed he was well groomed, but initially avoided eye contact. He was anxious, irritable, and preoccupied with his symptoms. His insight was limited. Treatment notes from August 2014, September 2014, and November 2014 reflect continuing symptoms. February 2015 psychiatric progress notes show the Veteran was depressed, irritable and guarded. In April 2015, the Veteran continued feeling "the same." In August 2015, the Veteran's son submitted a statement describing the Veteran as argumentative with his family and isolated. The Veteran's wife submitted an August 2015 statement noting the Veteran was stressed, frustrated, argumentative, and depressed. VA treatment records from September 2015 confirm continuing symptoms with additional reports of the Veteran cussing and throwing things in his home. His grooming and hygiene were fair. His psychiatrist noted intermittent eye contact, no delusions or preoccupations, and linear thoughts. The Veteran's insight and judgment were fair. In December 2015, he reported continuing symptoms with some improvement with his ability to sleep. He had infrequent good days. His memory had declined over the previous months. His grooming, insight, and judgement were fair. In February 2016, the Veteran reported his wife had undergone a surgery. He described wanting to assist her and feeling helpless. His psychiatrist observed he was less irritable and more engaged. His eye contact was fair, and his mood was "okay." In April 2016, the Veteran had returned from his brother's funeral. He was irritable and reluctant to discuss his symptoms or goals of treatment. In June 2016, he reported continuing nightmares, anxiety, hypervigilance, irritability. His grooming, eye contact, judgment and insight were fair. In September 2016, the Veteran returned for additional treatment with a different VA psychiatrist. He described continuing symptoms and reported avoiding crowds and isolating at home. He spent time with his wife and, on occasion, with his children. The psychiatrist observed the Veteran was uncooperative, his grooming was fair, and his judgment and insight were limited. In November 2016, the Veteran's symptoms continued. He stated he still found joy in his wife and family. He was pleasant, cooperative, calm, and polite. His hygiene, judgment, and insight were fair. In February 2017, the Veteran reported being in a bad mood all the time. He had feelings of shame, guilt, and sadness. In March 2017, the Veteran's son submitted a statement which described the Veteran as being socially withdrawn. He observed his father talking to people who were not present. He was agitated, angry, and unpredictable. His temper was explosive, and he threw objects. His memory was poor, and he needed reminders to complete routine tasks. He spent time lying in bed and had anxiety attacks characterized by sweating, shaking, and difficulty breathing. In April 2017, the Veteran's brother submitted a statement noting the Veteran was unable to hold conversations, was isolated, and depended on his wife for completing daily activities. In an April 2017 statement, the Veteran's wife reported the Veteran had increased difficulty with everyday situations. He was forgetful and frustrated. His nightmares continued. He became explosively angry. The Veteran paced, was withdrawn from his family, did not communicate, was incoherent in conversations, and described hearing voices from the dead through the television. VA treatment records from May 2017 and August 2017 document continuing anxiety and depression, panic attacks, auditory hallucinations, nightmares, flashbacks, avoiding crowds. At the October 2017 hearing, the Veteran's representative reported the Veteran's PTSD had worsened since the most recent VA examination was provided in September 2012. His wife testified that he was easily agitated, frustrated, and angered. She described trying to "tiptoe around him" to prevent angry outbursts. The Veteran submitted a March 19, 2018 private evaluation by Dr. M. S. Dr. M. S. observed prominent auditory hallucinations which began five years earlier. He also noted increasing isolation, paranoid ideation, psychomotor agitation, limited sleep, and profound short term memory deficit. The Veteran was not oriented to the year or month and was completely dependent on his wife. Dr. M. S. observed neuropsychological deficits were consistent with dementia. He diagnosed PTSD and major neurocognitive disorder with psychotic symptoms, panic and severe depression. An additional VA PTSD examination was provided in June 2018. The examiner diagnosed PTSD with depressive disorder. She did not diagnose a personality disorder, a neurocognitive disorder, or dementia. She attributed symptoms of anxiety, nightmares, flashbacks, avoidance, and acute auditory hallucinations to his PTSD. She attributed depressed mood to the diagnosed depressive disorder. The examiner confirmed additional symptoms of suspiciousness, chronic sleep impairment, difficulty establishing and maintaining effective work and social relationships, and persistent delusions or hallucinations. She described occupational and social impairment with reduced reliability and productivity. The Board notes the May 2012 SSA evaluation indicated a diagnosis of personality disorder and the March 2018 private evaluation indicated a diagnosis of a neurocognitive disorder consistent with dementia. However, VA examinations of September 2010, September 2012, and June 2018 did not identify a personality or neurocognitive disorder at any time over the appeal period. Each VA examiner attributed the Veteran's psychiatric symptoms to PTSD and a depressive disorder. While the September 2012 VA examiner described the Veteran's presentation as a "misrepresentation" of his cognitive ability, he did not attribute any psychiatric symptoms to a non-service-connected disability. Thus, resolving reasonable doubt in favor of the Veteran, a diagnosis of personality disorder or a neurocognitive disorder is not confirmed and all psychiatric symptoms over the appeal period are due to service-connected PTSD and depressive disorder. Resolving reasonable doubt in favor of the Veteran, evidence shows prior to December 14, 2010, his psychiatric symptoms of frequent nightmares, poor sleep, irritability, decreased energy, reduced concentration, flashbacks, sadness, and anxiety limited his ability to function in occupational or social settings. He did not socialize with anyone outside of his family. Symptoms of irritability, anxiety, and avoidance prevented him from successfully interacting with others or adapting in stressful settings. Prior to December 14, 2010, a 70 percent rating is warranted for PTSD with major depression. Over this period the Veteran was at all times neatly groomed and oriented. He participated in his psychiatric treatment and he maintained good relationships with his wife and children. A total disability rating is not warranted prior to December 14, 2010. 38 C.F.R. § 4.130. On December 14, 2010, the Veteran initially reported hearing voices. Thereafter, multiple VA treatment records and the May 2012 SSA mental health evaluation reflect continuing and frequent reports of hearing voices and seeing dead people. In August 2012, the Veteran's wife stated she assisted the Veteran with bathing, dressing, and taking medications. Over this time period, the Veteran lacked interest in doing things, including taking care of himself. He relied on his wife for reminders and assistance in performing daily activities. His angry outbursts included physically slamming doors and banging on tables. He became unable to converse with his family members. Resolving reasonable doubt in favor of the Veteran, from December 14, 2010, his psychiatric disability worsened, and his symptoms manifested in total occupational and social impairment. An increased rating of 100 percent disability is warranted from December 14, 2010 to March 18, 2018. Id. REASONS FOR REMAND VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). 1. Entitlement to service connection for Peyronie's disease is remanded. In April 2011, the Veteran filed a claim seeking entitlement to service connection for Peyronie's disease. In October 2011, a VA male reproductive system examination was provided to evaluate the claim. The examiner confirmed a diagnosis of Peyronie's disease. At the time of this examination, the service treatment records associated with the claims file documented March 1971 treatment for acute epididymitis. The examiner considered this in-service event and opined the current Peyronie's disease was less likely than not causally related to a "one time acute epididymitis treated during service." In November 2019, additional service treatment records were added to the claims file. These records include a July 1970 notation of acute urethritis. The October 2011 examiner did not consider the July 1970 urethritis. His opinion is not based on the Veteran's complete medical history and it is inadequate to evaluate to the claim. Id. 2. Entitlement to service connection for a left knee disability is remanded. The Veteran seeks service connection for a left knee disability. A June 2018 VA knee conditions examination diagnosed a left knee meniscal tear and degenerative joint disease. In a February 2013 statement, the Veteran reported he injured his left knee during active service when his knee struck a steel door. He also reported continued left knee pain, difficulty walking, and the use of knee braces following this injury. In an October 2013 statement associated with his notice of disagreement (NOD), the Veteran stated he did not initially realize the severity of his left knee injury. In a November 2019 statement, the Veteran explained that after his in-service left knee injury he was provided with an ice pack to relieve swelling. The pain continued, but he did not seek additional treatment because he thought he might be discharged for frequent visits to "sick bay." Instead, he self-treated his pain with over-the-counter medications and ice packs. After separating from service, he continued this self-treatment for continuing left knee pain. In June 2020, the Board found a June 2018 VA etiology opinion was inadequate to evaluate the claim because the examiner did not consider, or provide a reason for dismissing, the Veteran's competent report of an in-service left knee injury. An addendum opinion was obtained in July 2020.. The July 2020 examiner accepted the Veteran's assertion that he injured his knee during active service. He opined the current left knee condition was less likely than not causally related to active service because no left knee condition was indicated at separation and mild degenerative joint disease was not diagnosed until December 2014. The examiner observed the medical records from 2009 did not document a chronic knee condition. The examiner did not discuss or provide any reason for dismissing the Veteran's competent reports of continuing left knee pain and self-treatment after separating from active service. Accordingly, this opinion is not based on consideration of the Veteran's complete medical history. It is inadequate to evaluate the claim. Id. 3. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. Where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The issue of entitlement to a TDIU is inextricably intertwined with the claim remanded claim of entitlement to service connection for a left knee disability. Id The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's Peyronie's disease is at least as likely as not related to in-service conditions of ureteritis (July 1970) and/or epididymitis (March 1971). The clinician's opinion must be supported by a complete rationale. If the clinician determines that an additional examination is necessary to provide the requested opinions, schedule an examination 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's left knee disability is at least as likely as not related to an in-service left knee injury incurred when the Veteran's left knee struck a steel door. The clinician must review the entire claims file, including the Veteran's statements of February 2013, October 2013, and November 2019. The clinician is asked to provide a response to the following: Is the left knee disability at least as likely as not related to service, including an injury incurred when the left knee struck a steel door? Is it at least as likely as not that the left knee arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? The examiner must specifically address the Veteran's reports of continuing symptoms and self care. The clinician is advised that the Veteran is competent to report his observable symptoms and medical treatment sought (including self-treatment.) If the clinician dismisses any competent report from the Veteran, a complete rationale for doing so must be provided. All opinions provided must be supported by a complete rationale. If the clinician determines that an additional examination is necessary to provide the requested opinions, schedule an examination. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jeanne Celtnieks 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.