Citation Nr: 21074531 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 16-02 008 DATE: December 15, 2021 ORDER Entitlement to a compensable rating for diabetic nephropathy with hypertension prior to February 13, 2021 is denied. Entitlement to a rating higher than 60 percent for diabetic nephropathy with hypertension since February 13, 2021 is denied. Entitlement to a rating higher than 20 percent for peripheral neuropathy of the right upper extremity prior to January 07, 2021 is denied. Entitlement to a rating of 40 percent for peripheral neuropathy of the right upper extremity since January 07, 2021 is granted. Entitlement to a rating higher than 20 percent for peripheral neuropathy of the left upper extremity prior to January 07, 2021 is denied. Entitlement to a rating of 30 percent for peripheral neuropathy of the left upper extremity since January 07, 2021 is granted. Entitlement to a rating higher than 10 percent for peripheral neuropathy of the right lower extremity prior to January 07, 2021 is denied. Entitlement to a rating of 40 percent for peripheral neuropathy of the right lower extremity since January 07, 2021 is granted. Entitlement to a rating higher than 10 percent for peripheral neuropathy of the left lower extremity prior to January 07, 2021 is denied. Entitlement to a rating of 40 percent for peripheral neuropathy of the left lower extremity since January 07, 2021 is granted. Entitlement to an effective date of March 20, 2008 for the grant of service connection for residuals of a stroke is granted. REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to a rating higher than 10 percent for residuals of a stroke is remanded. Entitlement to an effective date earlier than August 31, 2010 for a grant of a total disability rating based on individual unemployability (TDIU) is remanded. Entitlement to special monthly compensation based on the need for regular aid and attendance is remanded. FINDINGS OF FACT 1. Prior to February 13, 2021, diabetic nephropathy with hypertension was not manifested by albumin constant or recurring with hyaline and granular casts or red blood cells; or transient or slight edema or hypertension at least 10 percent disabling under Diagnostic Code 7101. 2. Since February 13, 2021, diabetic nephropathy with hypertension is not manifested by persistent edema and albuminuria with BUN 40 to 80 mg percent; or, creatinine 4 to 8 mg percent; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. 3. Prior to January 07, 2021, peripheral neuropathy of the right upper extremity was manifested by mild impairment. 4. Since January 07, 2021, peripheral neuropathy of the right upper extremity is manifested by moderate impairment. 5. Prior to January 07, 2021, peripheral neuropathy of the left upper extremity was manifested by mild impairment. 6. Since January 07, 2021, peripheral neuropathy of the left upper extremity is manifested by moderate impairment. 7. Prior to January 07, 2021, peripheral neuropathy of the right lower extremity was manifested by no more than mild impairment. 8. Since January 07, 2021, peripheral neuropathy of the right lower extremity is manifested by moderately severe impairment. 9. Prior to January 07, 2021, peripheral neuropathy of the left lower extremity was manifested by no more than mild impairment. 10. Since January 07, 2021, peripheral neuropathy of the left lower extremity is manifested by moderately severe impairment. 11. By rating decision in November 2015, the RO granted entitlement to service connection for residuals of stroke, and assigned an effective date of April 26, 2012, the date of receipt of the claim. 12. In resolving reasonable doubt, the Board finds that an informal claim for service connection for a stroke was received March 20, 2008. CONCLUSIONS OF LAW 1. The criteria for entitlement to a compensable rating for diabetic nephropathy with hypertension prior to February 13, 2021 have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.119, Diagnostic Codes 7913-7541. 2. The criteria for entitlement to a rating higher than 60 percent for diabetic nephropathy with hypertension since February 13, 2021 have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.119, Diagnostic Codes 7913-7541. 3. The criteria for a rating higher than 20 percent for peripheral neuropathy of the right upper extremity prior to January 07, 2021 have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.124a, DC 8512. 4. The criteria for a rating of 40 percent for peripheral neuropathy of the right upper extremity since January 07, 2021 have been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.124a, DC 8512. 5. The criteria for a rating higher than 20 percent for peripheral neuropathy of the left upper extremity prior to January 07, 2021 have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.124a, DC 8512. 6. The criteria for a rating of 30 percent for peripheral neuropathy of the left upper extremity since January 07, 2021 have been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.124a, DC 8512. 7. The criteria for a rating higher than 10 percent for peripheral neuropathy of the left lower extremity prior to January 07, 2021 have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.124a, DC 8521. 8. The criteria for a rating of 40 percent for peripheral neuropathy of the left lower extremity since January 07, 2021 have been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.124a, DC 8620. 9. The criteria for a rating higher than 10 percent for peripheral neuropathy of the right lower extremity prior to January 07, 2021 have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.124a, DC 8520. 10. The criteria for a rating of 40 percent for peripheral neuropathy of the right lower extremity since January 07, 2021 have been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.124a, DC 8620. 11. The criteria for entitlement to an effective date of March 20, 2008 for the grant of service connection for residuals of a stroke have been met. 38 U.S.C. §§ 5107, 5110; 38C.F.R. §§3.114, 3.155, 3.156, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1972 to September 1979. The Board notes that when this appeal was last before the Board in October 2019 the issue of entitlement to service connection for posttraumatic stress disorder (PTSD) with depression was remanded for further development. In an August 2020 rating decision, service connection for major depressive disorder was granted. As the benefits sought on appeal have been granted, the Board no longer has jurisdiction over this issue. The Board also notes that in an August 2021 statement, the Veteran's representative expressed that the Veteran is in need of aid and attendance. This reasonably raises the issue of entitlement to SMC based on aid and attendance and/or housebound status which must be deemed part of the rating claim on appeal. Thus, the Board finds that the issue of SMC is a component of the increased rating claims on appeal. See Buie v. Shinseki, 24 Vet. App. 242, 251 (2011); see also Bradley v. Peake, 22 Vet. App. 280, 293 (2008). As noted, this issue is addressed in the remand section below. Increased Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In Fenderson v. West, 12 Vet. App. 119 (1999), the United States Court of Appeals for Veterans Claims (Court) held that evidence to be considered in the appeal concerning an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the 'staging' of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126-127; see also Hart v. Mansfield, 21 Vet. Entitlement to a compensable rating for diabetic nephropathy with hypertension prior to February 13, 2021 and a rating higher than 60 percent thereafter. The Veteran appeals the denial of a compensable rating for diabetic nephropathy with hypertension prior to February 13, 2021 and a rating higher than 60 thereafter. The Veteran's diabetic nephropathy with hypertension is rated under 7913-7541. Hyphenated Diagnostic Codes are used when a rating under one code requires use of an additional Diagnostic Code to identify the basis for the rating. 38 C.F.R. § 4.27. Nephropathy as due to diabetes mellitus, type II, is rated under 38 C.F.R. § 4.115b, Diagnostic Code 7541. Under Diagnostic Code 7541, renal involvement in diabetes mellitus is rated as renal dysfunction. Under 38 C.F.R. § 4.115a, renal dysfunction is rated as noncompensable for albumin and casts with history of acute nephritis; or, hypertension noncompensable under Diagnostic Code 7101. A 30 percent rating is warranted for albumin constant or recurring with hyaline and granular casts or red blood cells; or transient or slight edema or hypertension at least 10 percent disabling under Diagnostic Code 7101. Constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code 7101 (diastolic pressure predominantly 120 or more) warrants a 60 percent evaluation. An 80 percent rating is warranted for persistent edema and albuminuria with BUN 40 to 80 mg percent; or, creatinine 4 to 8 mg percent; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. Hypertension is rated pursuant to 38 C.F.R. § 4.104, Diagnostic Code (DC) 7101, for hypertensive vascular disease (hypertension and isolated systolic hypertension). Under DC 7101, a 10 percent rating is warranted for diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; it is the minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. Hypertension with diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more, is rated 20 percent disabling. Hypertension with diastolic pressure predominantly 120 or more is rated 40 percent disabling. Hypertension with diastolic pressure predominantly 130 or more is rated 60 percent disabling. Note (3) to Diagnostic code 7101 provides that hypertension is to be rated separately from hypertensive heart disease and other types of heart disorders. 38 C.F.R. § 4.104. The Board notes that the Veteran is currently in receipt of a separate 20 percent rating for diabetes mellitus type II pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 7913. The symptoms related to that disability cannot be considered in evaluating the level of disability due to diabetic nephropathy with hypertension. See 38 C.F.R. § 4.14 (pyramiding, or rating the same manifestation under different diagnoses, is to be avoided). Here, the evidence shows that prior to February 13, 2021, the Veteran's disability was not manifested by albumin constant or recurring with hyaline and granular casts or red blood cells; or transient or slight edema or hypertension at least 10 percent disabling under Diagnostic Code 7101. Rather, during the April 2012 VA examination, the Veteran's blood pressure readings were noted as: 124/53 and 146/80 on March 30, 2012; 145/81 on March 9, 2012 and 146/68 on November 1, 2011. The Veteran had renal dysfunction with persistent proteinuria (albuminuria). There was no showing of edema. He did not require regular dialysis. The Veteran did not have hypertension and/or heart disease due to renal dysfunction or caused by any kidney condition. He did not have a history of or current kidney, ureteral or bladder calculi (urolithiasis). Likewise, he did not have a history of recurrent symptomatic urinary tract or kidney infections. He had not had a kidney transplant or removal. He did not have a benign or malignant neoplasm or metastases related to a kidney condition. It is also noted that urinalysis did not disclose hyaline casts and/or granular casts. With regard to hypertension, the Board notes that blood pressure was recorded as 166/108 and 148/71 in November 2015, 139/71, 165/85 and 132/75 in December 2015, 152/74 in January 2016, 155/81 in February 2016, 120/63 in March 2016, 142/71 in June 2016, 135/76 and 142/70 in July 2016, 194/93 and 198/94 in August 2016, 135/70 in September 2016, 125/53 in October 2016, 177/79 in November 2016, 135/67 in December 2016, 137/68 and 174/78 in January 2017, 163/81 in May 2017, 174/81 and 147/76 in February 2018, 162/84 in March 2018, 156/75 in June 2018, 163/75 and 134/67 in August 2018, 170/76 in September 2018, 153/70 and 167/73 in March 2019, 143/78 and 135/74 in June 2019, 138/65 in July 2019. Although there were times when diastolic pressure was over 100 and systolic pressure was over 160, during this period of time diastolic pressure was predominantly less than 100 and systolic pressure was predominantly less than 160. Based on the above, the Board finds against a compensable rating for diabetic nephropathy with hypertension prior to February 13, 2021. The probative lay and medical evidence of record does not establish constant or recurring albumin with hyaline and granular casts or red blood cells during this period of time. There is no finding of edema on examination. The Veteran also does not warrant a rating of 10 percent for hypertension under DC 7101 during this period, as a history of diastolic pressure predominantly 100 or more is not shown during this period. Additionally, the Veteran does not have systolic pressure predominantly 160 or more, or a history of diastolic pressure predominately 100 or more, requiring continuous medication for control. Prior to February 13, 2021, a 30 percent rating for renal dysfunction is not warranted, nor is a 10 percent rating for hypertension warranted. Thus, a compensable rating for diabetic nephropathy with hypertension prior to February 13, 2021 must be denied. The Board also finds against a rating higher than 60 percent for diabetic nephropathy with hypertension after February 13, 2021. In this regard, during the February 2021 VA examination, the Veteran was diagnosed with diabetic nephropathy with an onset of 2012. It was noted that the Veteran's disability had progressed/worsened since its onset. The Veteran had renal dysfunction with persistent proteinuria (albuminuria). The Veteran did not have hypertension and/or heart disease due to renal dysfunction or caused by any kidney condition. There were no frequent attacks of colic with infection and the Veteran did not have a history of or current kidney, ureteral or bladder calculi (urolithiasis). Likewise, he did not have a history of recurrent symptomatic urinary tract or kidney infections. Laboratory testing disclosed normal BUN findings of 15 but abnormal creatinine results of 1.42 (0.76 to 1.27). There were also abnormal EGFR and proteinuria results. A rating higher than the current 60 percent requires a showing of persistent edema and albuminuria with BUN 40 to 80 mg percent; or, creatinine 4 to 8 mg percent; or generalized poor health characterized by lethargy, weakness, anorexia, weight loss. See 38 C.F.R. § 4.115a; Diagnostic Code 7541. These symptoms are not shown here, and the record does not reflect symptoms of similar severity. Rather, creatinine is shown to be less than 4 mg percent and BUN is shown to be less than 40 mg. The Board also notes that the VA examiner did not find symptoms of edema, lethargy, weakness, anorexia and/or weight loss due to renal dysfunction on examination. Therefore, as of February 13, 2021, a rating higher than 60 percent for diabetic nephropathy with hypertension is not warranted. Accordingly, the claim is denied. Entitlement to a rating higher than 20 percent for peripheral neuropathy of the right upper extremity prior to January 07, 2021 and a rating higher than 30 percent thereafter. Entitlement to a rating higher than 20 percent for peripheral neuropathy of the left upper extremity. The Veteran appeals the denial of a rating higher than 20 percent for peripheral neuropathy of the right upper extremity prior to January 07, 2021 and a rating higher than 30 percent thereafter. He also appeals the denial of a rating higher than 20 percent for peripheral neuropathy of the left upper extremity. Prior to January 07, 2021, peripheral neuropathy of the right upper extremity was rated under DC 8512. Peripheral neuropathy of the left upper extremity is also rated under DC 8512. DC 8512 pertains to the lower radicular group, which includes the radial, median, and ulnar nerves. Pursuant to applicable law and regulation, a 20 percent evaluation is warranted where there is evidence of mild incomplete paralysis of the major lower radicular group, which is to say, the intrinsic muscles of the hand and some or all of the flexors of the wrist and fingers. A 40 percent evaluation is warranted where there is evidence of moderate incomplete paralysis, with a 50 percent evaluation indicated for severe incomplete paralysis of the major lower radicular group. A 70 percent evaluation is warranted for complete paralysis of the major lower radicular group, in which all intrinsic muscles of the hand, and some or all of flexors of the wrist and fingers are paralyzed (substantial loss of use of hand). A 20 percent evaluation is warranted where there is evidence of mild incomplete paralysis of the minor lower radicular group, with a 30 percent evaluation indicated for moderate incomplete paralysis of that same group. A 40 percent evaluation is indicated where there is evidence of severe incomplete paralysis of the minor lower radicular group. Finally, a 60 percent evaluation is indicated for complete paralysis of the minor lower radicular group, in which all intrinsic muscles of the hand, and some or all of flexors of the wrist and fingers are paralyzed (substantial loss of use of hand). 38 C.F.R. § 4.124a, DC 8512. Since January 07, 2021, peripheral neuropathy of the right upper extremity is rated under DC 8614 for the musculospiral (radial) nerve. Under the criteria for DC 8614, mild incomplete paralysis is rated as 20 percent for both the major and minor extremity. Moderate incomplete paralysis is rated as 30 percent for the major extremity and 20 percent for the minor extremity. Severe incomplete paralysis is rated as 50 percent for the major extremity and 40 percent for the minor extremity. Complete paralysis is rated as 70 percent for the major extremity and 60 percent for the minor extremity, and is identified as drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity. 38 C.F.R. § 4.124a. Under 38 C.F.R. § 4.124a, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, at most, the moderate degree. The ratings for peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. Descriptive words, such as "mild," "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." 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. The evidence of record establishes that the Veteran is right-hand dominant. As such, his right upper extremity is the major extremity, and his left upper extremity is the minor extremity. In March 2008, the Veteran complained of numbness in all extremities. Examination revealed reflexes were 2+ throughout, strength was 4/5 throughout and sensation showed "decreased in a G-S to all extremities to LT/PP." An impression was given of abnormal study, evidence of bilateral motor polyneuropathy and evidence of bilateral median nerve compression syndrome at the wrist. During the April 2012 VA examination, it was noted that the Veteran had been diagnosed with neuropathy of the bilateral upper and lower extremities. Examination disclosed mild constant pain of the upper extremities and moderate constant pain of the lower extremities. Intermittent pain, paresthesias and/or dysesthesias and numbness were described as moderate for the upper and lower extremities. Muscle strength and reflexes were normal for the upper and lower extremities. Light touch was normal with the exception of decreased findings for hands/fingers and feet/toes. Position sense, vibration sensation and cold sensation were normal for the lower and upper extremities. The Veteran did not have muscle atrophy. During the January 2021 VA examination, it was noted that the Veteran started having bilateral upper and lower extremity tingling and numbness and he had an EMG study done to the lower extremity in 2014 that showed sensory motor poly neuropathy affecting the lower extremities. Since that time, the Veteran has had constant pain, numbness, burning sensation and tingling to bilateral hands and legs, burning sensation to the fingertips and difficulty walking. He expressed that walking felt like he was walking on rocks and that he can only walk ten steps after which he has to sit down. He used a walker with a seat. Constant pain, paresthesias and/or dysesthesias, and numbness of the upper extremities and lower extremities were described as moderate. There was no intermittent pain of the lower and/or upper extremities. Muscle strength testing revealed 3/5 and 4/5 findings for the both the lower and upper extremities. Reflexes disclosed decreased findings for the upper and lower extremities. Light touch disclosed decreased findings in all areas with the exception of the shoulder area and inner/outer forearm. Position sense was decreased in all areas, and vibration and cold sensation were decreased in all areas except the right lower extremity which showed absent findings. The Veteran had muscle atrophy of the bilateral calf muscle. Examination disclosed moderate incomplete paralysis of the right radial nerve and mild incomplete paralysis of the left radial nerve. There was also moderate incomplete paralysis of the right median nerve and mild incomplete paralysis of the left median nerve, and mild incomplete paralysis of the left and right ulnar nerve. The Veteran was noted to have difficulty writing because of the right upper neuropathy, dropping things because of the neuropathy, and dizziness from taking gabapentin. He was also noted to have an unsteady gait and was off balance due to neuropathy. It was noted that he could not walk more than 10 steps due to peripheral neuropathy of lower extremity. Initially, the Board finds against the claim for a rating higher than 20 percent for peripheral neuropathy of the left and right upper extremity prior to January 07, 2021 as no more than mild impairment is shown during this period of time. As noted, descriptive words, such as "mild," "moderate" and "severe," are not defined in the Rating Schedule. The Board notes, however, that moderate has been defined as tending toward the mean or average amount of dimension. https://www.merriam-webster.com/dictionary/moderate. The Board further notes that severe has been defined as "of a great degree." See https://merriam-webster.com/dictionary/severe. During this period of time, muscle strength and reflexes were essentially normal for the left and right upper extremities. Position sense, vibration sensation and cold sensation were normal. With the exception of decreased findings for the hands/fingers, light touch was also normal, and the Veteran did not have muscle atrophy. When the relative impairment of sensory, muscle and reflex abnormalities discussed above are considered, prior to January 7, 2021, the Board finds that the Veteran's peripheral neuropathy of the left and right upper extremity was manifested by no more than mild, incomplete paralysis thereby warranting no more than a 20 percent rating under DC 8512. The Board, however, finds that since January 07, 2021, peripheral neuropathy of the left and right upper extremity is shown to be manifested by moderate impairment thereby warranting a rating of 30 percent for the left (minor extremity) and a rating of 40 percent for the right (major extremity) under DC 8512. As of January 07, 2021, the Veteran has had constant pain, numbness, burning sensation and tingling to the bilateral hands and burning sensation to the fingertips. His pain, paresthesias and/or dysesthesias, and numbness of the upper extremities has been described as moderate during this time. Furthermore, muscle strength testing revealed 3/5 and 4/5 findings for the upper extremities. Reflexes were decreased and light touch disclosed decreased findings in all areas with the exception of the shoulder area and inner/outer forearm. Position sense was decreased in all areas, and vibration and cold sensation were also decreased in all areas. The Veteran was noted to have difficulty writing because of the right upper neuropathy and dropping things because of the neuropathy. When the relative impairment of sensory, muscle and reflex abnormalities are considered as whole, the Board finds that the Veteran's peripheral neuropathy of the left and right upper extremity is shown to be manifested by moderate incomplete paralysis during time. The Board cannot conclude, however, that the impairment is of a great degree, i.e., severe, to warrant the next higher rating. Accordingly, a rating of 30 percent for peripheral neuropathy of the left upper extremity and a rating of 40 percent for peripheral neuropathy of the right upper extremity is granted as of January 7, 2021. In so finding, the Board is mindful that, as of January 07, 2021, the RO changed that the Veteran's Diagnostic Code from DC 8512 to DC 8614. While the record is unclear as to why a rating change was made, the Board finds that DC 8512 remains the most appropriate rating code for the Veteran's peripheral neuropathy of the right upper extremity. DC 8512 pertains to the lower radicular group, which includes the radial, median, and ulnar nerves. As the January 2021 VA examination report found involvement of the radial, median, and ulnar nerves, i.e., the lower radicular group, the Board finds that DC 8512 is the most appropriate rating code and that a 40 percent rating is warranted for the right upper extremity under this code as moderate disability of the major joint is shown by the record. The Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the appellant or his representative, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board has found no section that provides a basis upon which to assign higher disability ratings than the ratings above. Entitlement to a rating higher than 10 percent for peripheral neuropathy of the left and right lower extremity prior to January 07, 2021 and a rating higher than 20 percent thereafter. The Veteran appeals the denial of a rating higher than 10 percent for peripheral neuropathy of the left and right lower extremity prior to January 07, 2021 and a rating higher than 20 percent thereafter. Prior to January 7, 2021, the Veteran's peripheral neuropathy of the left lower extremity was rated as 10 percent disabling under Diagnostic Code 8521. DC 8521 rates neurologic manifestations of the external popliteal nerve (common peroneal nerve). A 20 percent rating requires evidence of moderate incomplete paralysis of the common peroneal nerve. A 30 percent rating requires evidence of severe incomplete paralysis of this nerve. Finally, the maximum 40 percent rating requires evidence of complete paralysis, where there is a foot drop and slight drop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes. See 38 C.F.R. § 4.124a, DC 8521. Prior to January 7, 2021, the Veteran's peripheral neuropathy of the right lower extremity was rated as 10 percent disabling under Diagnostic Code 8520. Under Diagnostic Code 8520, incomplete paralysis of the sciatic nerve warrants a 10 percent evaluation when mild, a 20 percent evaluation when moderate, a 40 percent evaluation when moderately severe, and a 60 percent evaluation when severe, with marked muscular atrophy. Complete paralysis of the sciatic nerve, the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost, is rated 80 percent disabling. Since January 7, 2021, the Veteran's peripheral neuropathy of the left and right lower extremity is rated as 20 percent disabling under Diagnostic Code 8620. Diagnostic Code 8620 is rated under the criteria for neuralgia of sciatic nerve. Diagnostic Code 8620 provides that mild incomplete paralysis of the sciatic nerve is rated as 10 percent and that moderate incomplete paralysis is rated as 20 percent. Moderately severe incomplete paralysis is rated as 40 percent, and severe incomplete paralysis with marked muscular atrophy is rated 60 percent. Complete paralysis is rated as 80 percent, and is manifested by the foot dangling and dropping, no active movement possible of the muscles below the knee, and flexion of the knee weakened and (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8620. In March 2008, the Veteran complained of numbness in all extremities. Examination revealed reflexes were 2+ throughout, strength was 4/5 throughout and sensation showed "decreased in a G-S to all extremities to LT/PP." An impression was given of abnormal study, evidence of bilateral motor polyneuropathy and evidence of bilateral median nerve compression syndrome at the wrist. During the April 2012 VA examination, it was noted that the Veteran had been diagnosed with neuropathy of the bilateral upper and lower extremities. Examination disclosed mild constant pain of the upper extremities and moderate constant pain of the lower extremities. Intermittent pain, paresthesias and/or dysesthesias and numbness were described as moderate for the upper and lower extremities. Muscle strength and reflexes were normal for the upper and lower extremities. Light touch was normal with the exception of decreased findings for hands/fingers and feet/toes. Position sense, vibration sensation and cold sensation were normal for the lower and upper extremities. The Veteran did not have muscle atrophy. The September 2019 VA examination disclosed normal sensory and reflex findings for the lower extremities. Muscle strength testing disclosed there was active movement against some resistance for the lower extremities. There was no muscle atrophy. During the January 2021 VA examination, it was noted that the Veteran started having bilateral upper and lower extremity tingling and numbness and he had an EMG study done to the lower extremity in 2014 that showed sensory motor poly neuropathy affecting the lower extremities. Since that time, the Veteran has had constant pain, numbness, burning sensation and tingling to bilateral hands and legs, burning sensation to the fingertips and difficulty walking. He expressed that walking felt like he was walking on rocks and that he can only walk ten steps after which he has to sit down. He used a walker with a seat. Constant pain, paresthesias and/or dysesthesias, and numbness of the upper extremities and lower extremities were described as moderate. There was no intermittent pain of the lower and/or upper extremities. Muscle strength testing revealed 3/5 and 4/5 findings for the both the lower and upper extremities. Reflexes disclosed decreased findings for the upper and lower extremities. Light touch disclosed decreased findings in all areas with the exception of the shoulder area and inner/outer forearm. Position sense was decreased in all areas, and vibration and cold sensation were decreased in all areas except the right lower extremity which showed absent findings. The Veteran had muscle atrophy of the bilateral calf muscle. Examination disclosed moderate incomplete paralysis of the left and right sciatic nerve, and mild incomplete paralysis of the left and right femoral nerve. The Veteran was noted to have dizziness from taking gabapentin. He was also noted to have an unsteady gait and was off balance due to neuropathy. It was noted that he could not walk more than 10 steps due to peripheral neuropathy of lower extremity. Prior to January 07, 2021, muscle strength and reflexes were essentially normal for the left and right lower extremities. Position sense, vibration sensation and cold sensation were normal. With the exception of decreased findings for the feet and toes, light touch was also normal. Muscle strength testing disclosed there was active movement against some resistance for the lower extremities, but the Veteran did not have muscle atrophy. When the relative impairment of sensory, muscle and reflex abnormalities discussed above are considered as a whole, prior to January 7, 2021, the Board finds that the Veteran's peripheral neuropathy of the left and right lower extremity was manifested by no more than mild, incomplete paralysis thereby warranting no more than a 10 percent rating under DCs 8520 and 8521. The Board, however, finds in favor of a rating of 40 percent for peripheral neuropathy of the left and right lower extremity under DC 8620, since January 07, 2021, as a moderately severe disability is shown by the record. To that end, during this time, the evidence shows decreased reflexes, decreased sensory findings and muscle strength findings 3/5 and 4/5. There is also a showing of muscle atrophy of the bilateral calf muscle. The Board is mindful of the Veteran's report of difficulty walking. Examination also disclosed the Veteran has an unsteady gait and was off balance due to his neuropathy. It was noted that he cannot walk more than 10 steps due to peripheral neuropathy of lower extremity. When the relative impairment of sensory, muscle and reflex abnormalities are considered as whole, the Board concludes that the impairment more so approximates moderately severe impairment. Therefore, the Board finds that the Veteran's peripheral neuropathy of the left and right upper extremity is manifested by moderately severe incomplete paralysis thereby warranting a 40 percent rating under DC 8620. In so finding, the Board notes that when the relative impairment of sensory, muscle and reflex abnormalities are considered as whole, the Board cannot conclude that the impairment is severe, i.e., of a great degree. The Board acknowledges the Veteran's assertions to include his reports of pain, tingling and numbness. The Veteran is competent to report his symptoms and has presented credible testimony. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board has also considered the lay statements of record which discuss the Veteran's functional limitations. The Board finds, however, that neither the lay nor medical evidence demonstrates that the criteria for a higher evaluation have been met for peripheral neuropathy of the left and right lower extremity prior to January 07, 2021. The most probative evidence is that prepared by neutral skilled professionals, and such evidence demonstrates that no more than a 10 percent evaluation is warranted for peripheral neuropathy of the left and right lower extremity prior to January 07, 2021 and that a 40 percent rating, but no higher, is warranted thereafter. Effective Dates Entitlement to an effective date prior to April 26, 2012 for the grant of service connection for residuals of a stroke. The Veteran appeals the denial of an effective date earlier than April 26, 2012 for the grant of service connection for residuals of a stroke. In a November 2015 rating decision, the Veteran was granted service connection for residuals of a stroke. The Veteran was assigned an effective date April 26, 2012, the date of his formal claim for compensation. Service connection for residuals of a stroke was established as related to the service-connected diabetes mellitus which has been service connected as of March 20, 2008. The Veteran essentially argues that since his stroke disability is conceded as a medical complication of his diabetes mellitus, it shares an underlying date of claim. Section 5110(a) of title 38, U.S. Code, governs the assignment of an effective date for an award of benefits: The effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(a). The implementing regulation similarly states that except as otherwise provided, the effective date of an evaluation and award of pension, compensation or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. See 38 C.F.R. § 3.400. VA amended its adjudication regulations on March 24, 2015 to require that all claims governed by VA's adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. The amendments implement the concept of an intent to file a claim for benefits, which operates similarly to the informal claim process, but requires that the submission establishing a claimant's effective date of benefits must be received in one of three specified formats. The amendments also eliminate the constructive receipt of VA reports of hospitalization or examination and other medical records as informal claims to reopen under 38 C.F.R. § 3.157. See 38 C.F.R. § 3.1. The amended regulations, however, apply only to claims filed on or after March 24, 2015. Thus, prior to March 24, 2015, the standardized forms were not required. Although a claimant need not identify the benefit sought "with specificity," see Servello v. Derwinski, 3 Vet. App. 196, 199-200 (1992), some intent on the part of the Veteran to seek benefits must be demonstrated. See Brannon v. West, 12 Vet. App. 32, 34-35 (1998). See also Talbert v. Brown, 7 Vet. App. 352, 356-7 (1995) (noting that while VA must interpret a claimant's submissions broadly, VA is not required to conjure up issues not raised by claimant). The United States Court of Appeals for the Federal Circuit has emphasized VA has a duty to fully and sympathetically develop a Veteran's claim to its optimum. Hodge v. West, 155 F.3d 1356, 1362 (Fed. Cir. 1998). This duty requires VA to "determine all potential claims raised by the evidence, applying all relevant laws and regulations," Roberson v. West, 251 F.3d 1378, 1384 (Fed. Cir. 2001), and extends to giving a sympathetic reading to all pro se pleadings of record. Szemraj v. Principi, 357 F.3d 1370, 1373 (Fed. Cir. 2004). The mere presence of medical evidence does not establish intent on the part of the Veteran to seek service connection for a disability. Brannon v. West, 12 Vet. App. 32, 35 (1998). The effective date of service connection is not based on the date of the earliest medical evidence demonstrating a causal connection, but rather, on the date the application was filed with VA. Lalonde v. West, 12 Vet. App. 377, 382 (1999). For the time period prior to March 24, 2015, any communication or action indicating an intent to apply for one or more benefits under laws administered by the VA from a claimant may be considered an informal claim. Such an informal claim had to identify the benefits sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form was to be forwarded to the claimant for execution. If the application form was received within one year from the date it was sent to the claimant, it would have been considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155(a). To determine when a claim was received, the Board must review all communications in the claims file that may be construed as an application or claim. See Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992). Here, the evidence shows that on March 20, 2008, the Veteran submitted a claim for service connection for diabetes mellitus and service connection for several secondary complications resulting therefrom including a heart condition. In May 2008, the Veteran submitted an authorization and consent form to allow VA to obtain records related to his heart condition from Tampa General hospital. In a September 2008 statement, the Veteran submitted a letter that he sent to Tampa General hospital requesting his records for his 2002 stroke. Later that month, records from Tampa General Hospital were received which showed a history of a stroke and heart disease. In a January 2012 rating decision, the Veteran was granted service connection for diabetes mellitus, effective February 16, 2011. In a statement received on April 26, 2012, the Veteran stated that he had two heart attacks and one stroke. The RO construed this statement as a claim for service connection for a stroke. The Veteran was granted an effective date of March 20, 2008 for the grant of service connection for diabetes mellitus in January 2017. In a November 2015 rating decision, the Veteran was granted service connection for residuals of a stroke. The Veteran was assigned an effective date of April 26, 2012, the date the RO determined was the date of claim. The Veteran's representative argues that the Veteran's residuals of stroke was service-connected as a complication of his underlying diabetes mellitus, and thus the Veteran's residuals of a stroke must be awarded the same underlying date of claim for diabetes mellitus, i.e., March 20, 2008. As it relates to the Veteran's claims, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has repeatedly rejected the argument that a disability service-connected as secondary to an underlying service-connected disability be entitled to the effective date of the underlying disability. See Manzanares v. Shulkin, 863 F.3d 1374 (Fed. Cir. 2017); Ellington v. Peake, 541 F.3d at 1364. See also Ross v. Peake, 21 Vet. App. 528 (2008). The Federal Circuit has also found that there is nothing in the history of 38 C.F.R. § 3.310(a) to suggest that a claim for secondary service connection should be treated as part of a claim for primary service connection. Manzanares v. Shulkin, 863 F.3d at 1374. Additionally, the Federal Circuit has determined that nothing in 38 C.F.R. § 3.155(d)(2) regarding "ancillary benefits" supports the Veteran's position taken here. Id. The governing regulations dictate that the effective date will be the date of receipt of the claim, or the date entitlement arose, whichever is the later, and the Board is bound by that authority. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. After resolving any reasonable doubt in favor of the Veteran, however, the Board finds in favor of the claim for an effective date of March 20, 2008 for the grant of service connection for residuals of a stroke. In this regard, the RO has found that the Veteran's April 26, 2012 statement was a claim for service connection for a stroke. The Board has, however, reviewed the Veteran's claims file to determine if any communication prior to April 26, 2012 may be interpreted as a request for benefits. While the Veteran did not expressly state that he intended to file a claim for service connection for stroke prior to April 26, 2012, the Board notes that on March 20, 2008 he filed a claim for a "heart condition" and in May 2008 he submitted a request for authorization and consent form to allow VA to obtain records for his "heart condition" from Tampa General hospital. In September 2008, he sent a letter to Tampa General hospital and expressed that he had a stroke in 2002 and that VA needed his records as time was running out. The Board is mindful that the Veteran did not expressly state that he was filing a claim for service connection for stroke in his March 20, 2008 claim for compensation. In resolving reasonable doubt, however, the Board finds that Veteran's March 2008 claim for compensation requesting service connection for a heart condition and the September 2008 request for his records related to his heart condition and stroke may be construed as an informal claim for a stroke. In so finding, the Board notes that the Veteran seems to have linked his heart disease and stroke together during that time as he was treated at Tampa General for his heart conditions and his stroke. In the April 26, 2012 statement, the Veteran expressed that he had "two heart attacks and one stroke." While the RO found this statement constituted a claim for service connection for a stroke, the Board finds that the March 2008 and September 2008 statements can also constitute an informal claim for service connection for a stroke. Accordingly, an effective date of March 20, 2008, for the grant of service connection for residuals of a stroke is warranted. See 38 C.F.R. § 3.400(b)(2). An effective date prior to March 20, 2008, is not warranted as the Board has reviewed the record but has not found any formal or informal written communication that could be construed as a claim for service connection for a residuals of a stroke prior to March 20, 2008. See 38 C.F.R. § 3.155(a). Furthermore, the Board notes that service connection for diabetes mellitus, which is a basis for the grant of service connection for residuals of a stroke, was not in effect until March 20, 2008. The claim is granted. REASONS FOR REMAND Entitlement to service connection for sleep apnea. Entitlement to service connection for a low back disability. The Veteran appeals the denial of service connection for sleep apnea and a low back disability. This case was remanded by the Board in October 2018 for further development to include obtaining an opinion as to the relation, if any, between the Veteran's service and his sleep apnea and lumbar spine disability. The Veteran was afforded a VA examination in September 2019. During the VA examination, the Veteran was diagnosed with lumbosacral strain and spinal stenosis. The Veteran was unable to remember the exact date of onset, but he expressed that it was around 2001. He stated that his back condition started while he was in south east Asia in service and that throughout the years the condition worsened. The VA examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that from 1972-1979 there is no evidence on record about complaints for any thoracolumbar spine conditions for the Veteran while in service. While the examiner rendered a reasoning for the opinion, the Board finds that the rationale is inadequate to address the claim. To that end, the VA examiner essentially reasoned that there are no complaints for the spine in service. The examiner, however, did not address and/or reconcile the Veteran's lay statements that his lumbar spine condition started in service and that it continued to worsen over time. An addendum opinion is needed so that the lay statements can be taken into consideration. With regard to service connection for sleep apnea, the VA examiner opined that the claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. The examiner reasoned that the "sleep apnea diagnosis was not caused by complaints during service as there is no evidence on medical record to support this notion. Claim files lacks evidence for diagnosis nor treatment rendered until 2006." The VA examiner further found that "there is no evidence of evidence that sleep apnea has been aggravated beyond its natural progression by the service-connected condition." The Board again finds that the opinion provided is inadequate to properly address the claim for service connection for sleep apnea. In this regard, while the VA examiner found that sleep apnea was not caused by a service-connected disability, the rationale provided does not correlate with the opinion. Rather, the reasoning provided essentially supports the opinion for direct service connection. The examiner, however, did not provide a reasoning to support the opinion against secondary service connection. Furthermore, while the examiner found that the Veteran's sleep apnea was not caused or aggravated by "the service-connected condition," the examiner does not actually pinpoint a particular service-connected condition. As the Veteran is service-connected for several disabilities, the examiner's failure to specifically identify a service-connected disability renders the opinion inadequate. Once VA undertakes the effort to provide a medical opinion, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). Accordingly, a remand is warranted to obtain another opinion on these matters as detailed above. Entitlement to a rating higher than 10 percent for residuals of a stroke. The Veteran appeals the denial of a rating higher than 10 percent for residuals of stroke. Pursuant to 38 U.S.C. § 5103A(d)(2) and 38 C.F.R. § 3.159(c)(4)(i), VA will obtain an examination or an opinion if it is necessary to decide the claim. After review of the record, the Board finds that a VA examination is necessary for the purpose of ascertaining the current severity and manifestations of the Veteran's service-connected residuals of a stroke. To ensure that the record reflects the current severity of the Veteran's residuals of a stroke, a contemporaneous examination is warranted. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination) and Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered "contemporaneous"). Furthermore, as the Board has granted entitlement to an earlier effective date, the RO must assign an initial rating in the first instance. Accordingly, the claim is remanded. Entitlement to an effective date earlier than August 31, 2010 for a grant of a total disability rating based on individual unemployability (TDIU). Entitlement to special monthly compensation based on the need for regular aid and attendance. The Veteran has raised the issue of entitlement to SMC based on the need for regular aid and attendance by another person due to his service-connected disabilities. The Veteran, however, has not been afforded a VA examination to address the impact that his service-connected disabilities have on his daily functioning. As such, prior to adjudicating entitlement to SMC based on the need for aid and attendance, the Board finds that remand is necessary for an examination. Regarding the claim for an effective date earlier than August 31, 2010 for the grant of TDIU, the Board finds that the issue is inextricably intertwined with the remanded claims and must also be remanded. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 2 Vet. App. 180, 183 (1991). The matters are REMANDED for the following actions: 1. Associate with the claims folder any outstanding VA treatment records. 2. Schedule the Veteran for an aid and attendance examination to assess the Veteran's functional impairment due to his service-connected psychiatric and physical disabilities. The examiner should review the entire claims file and the report of examination should include discussion of the Veteran's documented history and assertions. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. It is requested that the guides for conducting aid and attendance examinations be used, and that all clinical findings as to the service-connected disabilities be set forth in detail. The examiner is to consider the following: the inability of Veteran to dress or undress himself, or to keep himself ordinarily clean and presentable; the inability of the Veteran to feed himself through loss of coordination of upper extremities or through extreme weakness; the inability to attend to the wants of nature; and the incapacity, physical or mental, which requires care or assistance on a regular basis to protect the Veteran from hazards or dangers incident to his daily environment. In so finding, the examiner must specifically document when the need for regular aid and attendance started. A complete rationale is required for all opinions rendered. 3. Obtain an addendum opinion addressing the etiology of the Veteran's lumbar spine disability. Access to the electronic claim files must be made available to the examiner for review. As to each and every lumbar spine disorder diagnosed in the record, the examiner must opine whether it is at least as likely as not, i.e., is there a 50/50 chance that the Veteran's disability had its onset in service or is otherwise related to service. In doing so, the examiner is requested to discuss whether there is any medical reason to accept or reject the Veteran's belief that his lumbar spine problems that started in service demonstrated the onset of a chronic lumbar spine disorder since service. A complete rationale for any opinion should be provided. The examiner must not rely solely on the absence of a diagnosis or symptom in service as the basis for a negative opinion. It is also noted that the mere passage of time without treatment is not a sufficient basis for finding that no relationship between a current disability and service exists. Any opinion should be reconciled with the service treatment and personnel records, any post-service diagnoses, lay statements, and testimony of the Veteran. If the lay evidence is rejected, an explanation must be provided. If an opinion cannot be made without resort to speculation, please state so and include an explanation for that conclusion. If it is determined that an opinion cannot be entered without additional examination, such an examination must be scheduled in accordance with applicable procedures. 4. Obtain an addendum opinion addressing the etiology of the Veteran's sleep apnea. Access to the electronic claim file must be made available to the examiner for review. The examiner must opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's sleep apnea had its onset in service or was caused by service. The examiner must also opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's sleep apnea was caused or aggravated (a medically discernible increase in symptoms even if temporary) by the service-connected major depressive disorder and/or diabetes mellitus. A complete rationale for any opinion should be provided. The examiner must not rely solely on the absence of a diagnosis or symptom in service as the basis for a negative opinion. It is also noted that the mere passage of time without treatment is not a sufficient basis for finding that no relationship between a current disability and service exists. Any opinion should be reconciled with the service treatment and personnel records, any post-service diagnoses, lay statements, and testimony of the Veteran. If the lay evidence is rejected, an explanation must be provided. If an opinion cannot be made without resort to speculation, please state so and include an explanation for that conclusion. If it is determined that an opinion cannot be entered without additional examination, such an examination must be scheduled in accordance with applicable procedures. 5. Schedule the Veteran for a VA examination to assess the current severity of his service-connected residuals of a stroke. Access to the electronic record must be made available to the examiner. All testing deemed necessary should be conducted and the results reported. In accordance with the latest worksheets for rating residuals of a stroke the examiner is to provide a detailed review of the Veteran's pertinent medical history, current complaints and the nature and extent of his disability. A rationale for any opinion expressed should be provided. 6. Upon completion of the above requested development and any additional development deemed appropriate, the AOJ should readjudicate the remanded issues. (Continued on next page) If any benefit sought on appeal remains denied, the Veteran and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. Stephanie M. Owen Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T.S. Willie 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.