Citation Nr: 21074910 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 11-29 035 DATE: December 16, 2021 ORDER Entitlement to an evaluation in excess of 10 percent prior to January 28, 2019 for service-connected right lower extremity radiculopathy is denied. Entitlement to an evaluation of 20 percent, but no higher, beginning January 28, 2019, but no earlier, for right lower extremity radiculopathy is granted. Entitlement to an evaluation in excess of 20 percent since September 5, 2014 for service-connected left lower extremity radiculopathy is denied. REMANDED Entitlement to service connection for a right knee disorder as secondary to service-connected disability is remanded. Entitlement to service connection for a left knee disorder as secondary to service-connected disability is remanded. Entitlement to service connection for a bilateral hip disorder as secondary to service-connected disability is remanded. Entitlement to a total disability rating due to individual unemployability (TDIU) prior to October 17, 2011 is remanded. Entitlement to special monthly compensation based on aid and attendance and/or housebound is remanded. Entitlement to automobile or other conveyance and adaptive equipment or adaptive equipment is remanded. FINDINGS OF FACT 1. Prior to January 28, 2019, the Veteran reported radiating pain to his lower extremities; however, the preponderance of the evidence shows the service-connected radiculopathy had not manifested to moderate incomplete paralysis for right lower extremity radiculopathy. 2. Beginning January 28, 2019, the evidence is in equipoise that the Veteran's service-connected radiculopathy in his right lower extremities manifested to moderate incomplete paralysis; but it has not manifested to moderately severe incomplete paralysis of the sciatic nerve thereafter. 3. Since September 5, 2014, the preponderance of the evidence indicates that the Veteran's service-connected radiculopathy in his left lower extremities manifested to moderate incomplete paralysis; but it has not manifested to moderately severe incomplete paralysis of the sciatic nerve thereafter. CONCLUSIONS OF LAW 1. The criteria for entitlement to an evaluation in excess of 10 percent for service-connected right lower extremity radiculopathy prior to January 28, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.3, 4.7, 4.124a, Diagnostic Code (DC) 8520. 2. The criteria for entitlement to an evaluation of 20 percent, but no higher, for right lower extremity radiculopathy beginning January 28, 2019 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.3, 4.7, 4.124a, DC 8520. 3. The criteria for entitlement to an evaluation in excess of 20 percent for service-connected left lower extremity radiculopathy since September 5, 2014 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.3, 4.7, 4.124a, DC 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1986 to August 1986, and from July 1990 to July 1993. These matters come before the Board of Veterans' Appeals (Board) on appeal from multiple rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). By way of history, in the January 2018 Board decision, the Board, in part, remanded entitlement to a rating in excess of 10 percent for right lower extremity radiculopathy and in excess of 20 percent for left lower extremity radiculopathy; and entitlement to service connection for a right knee condition and a left knee condition, a bilateral hips/thigh joint condition; and entitlement to TDIU, SMC based on aid and attendance and entitlement to automobile or other conveyance and adaptive equipment or adaptive equipment only. Following development, an October 2020 Board decision denied service connection for recurrent rash, left shoulder strain, a higher evaluation for the back disability, and a higher rating for bilateral pes planus. The 2020 Board decision also granted separate 10 percent ratings for right lower and left lower extremity radiculopathy from September 23, 2010 to September 4, 2014 and for service connection for a right shoulder disability. As such, those issues are no longer on appeal. Finally, the Board remanded the claims for service connection for the right knee and left knee disabilities, the bilateral hip disorder, and for higher evaluations for the right and left lower extremity radiculopathy since September 5, 2014, entitlement to TDIU prior to October 17, 2011, and entitlement to SMC based on aid and attendance and to automobile or other conveyance and adaptive equipment or adaptive equipment. Subsequent to the 2020 Board remand development, in a June 2021 rating decision, the Veteran's claim for higher evaluation for right lower extremity radiculopathy was granted with a 20 percent rating, effective May 13, 2021. As this does not constitute a full grant, this issue remains on appeal. AB v. Brown, 6 Vet. App. 35, 39 (1993). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to active service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where, as in the present case, entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Evidence obtained during, or leading up to, the appeal period may indicate that the degree of disability increased or decreased during the pendency of the appeal. In such circumstances, VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the rating claim has been pending, and "staged" ratings may be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is a balance of positive and negative evidence regarding any material issue, the benefit of the doubt shall be given to the claimant. See 38 U.S.C. § 5107(b). Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. See 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. Gilbert, 1 Vet. App. at 54. The Board has reviewed all the evidence of record. Although the Board has an obligation to provide adequate reasons and bases supporting its decisions, there is no requirement that the Board discuss every piece of evidence in the record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Board will summarize the relevant evidence, as deemed appropriate, and the Board's analysis will focus on what the evidence shows, or fails to show, as to each claim. By way of history, an August 2015 rating decision granted service connection for left lower extremity radiculopathy with a 20 percent evaluation and a separate 10 percent evaluation for right lower extremity, both effective September 22, 2014. The RO issued a statement of the case (SOC) in January 2017 that continued the 20 percent rating for radiculopathy of the left and 10 percent for the right lower extremities associated with the back disability. Subsequent to the October 2020 Board decision, a June 2021 rating decision granted an increased rating for the right lower extremity radiculopathy to 20 percent effective May 13, 2021. In addition, the 2020 Board decision granted separate 10 percent ratings for right lower and left lower extremity radiculopathy from September 23, 2010 to September 4, 2014 as such, the period on appeal begins September 5, 2014 as it was determined in the October 2020 rating decision that this decision was a full and final determination. Therefore, currently, the Veteran's left lower extremity radiculopathy is rated 10 percent disabling prior to September 5, 2014, and 20 percent thereafter; and the right lower extremity radiculopathy is rated 10 percent prior to May 13, 2021 and 20 percent thereafter. The Veteran's service-connected lower extremity radiculopathy is evaluated under Diseases for Peripheral Neuropathy, under DC 8520 for sciatic nerves. The Board has considered whether the Veteran has objective neurological abnormalities which would warrant separate and/or higher ratings. The Veteran is in receipt of separate ratings for left and right lower extremity symptoms under DC 8520. As the evidence shows that the ratings are separate and distinct throughout the period on appeal, separate discussions are appropriate for each extremity. Under DC 8520, a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent rating is warranted for moderate incomplete paralysis; a 40 percent rating is warranted for moderately severe paralysis; a 60 percent rating is warranted for severe paralysis, with marked muscular atrophy; and a maximum 80 percent rating for complete paralysis (the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost). The terms "mild," "moderate," "moderately severe," and "severe" under applicable diagnostic codes are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6 Upon review of the evidence, the Board finds the evaluation for right lower extremity radiculopathy should be increased to 20 percent as of January 28, 2019, rather than May 13, 2021. However, the preponderance of the evidence is against an evaluation in excess of 10 percent prior to January 28, 2019; and against an evaluation in excess of 20 percent thereafter. Further, the preponderance of the evidence is against finding that an evaluation in excess of 20 percent for left lower extremity radiculopathy. See below. Right Lower Extremity Radiculopathy Prior to January 28, 2019 As noted above, the Veteran's initial 10 percent rating prior to May 13, 2021 was based on VA medical records and examinations, which revealed his condition more nearly approximated that of mild incomplete paralysis. Specifically, he reported complaints of numbness and tingling in legs. Based on this record, he was granted service connection for right lower and left lower extremities radiculopathy. Specifically, in the August 2015 VA examination, the examiner opined the Veteran had incomplete paralysis of the sciatic nerves due to his service-connected back disability, with his right side mild and left side moderate in severity. Further, his VA medical records show that in July 2013, his MRI lumbar spine findings revealed degenerative changes with mild root nerve indentation, and he had slight muscle weakness in the bilateral lower extremities. His ongoing records indicate he takes Gabapentin daily for nerve pain and that his gait was antalgic at times (though it was mostly noted to be normal). His medical records also showed symptoms that prior to January 2019 were only mild in severity for the right lower extremity. For example, in the July 2013 VA ortho consult, it was noted he had negative straight leg raising tests and only slight muscle weakness. In his September 2013 ortho consult examination, his straight leg raising testing was positive for back pain only; it was specially noted reflexes were intact and his straight leg raising was negative for sciatica. The impression was chronic low back pain without significant evidence or neural compression. Additionally, his reports of inability to walk due to pain in his knees in the October 2013 consult is separate from radicular pain. In September 2017, his muscle strength was noted to be normal with range of motion normal with no pain. His gait, as noted, was also noted to be normal throughout the period on appeal. Based on the foregoing, although the Veteran reported experiencing occasional lower extremity pain, he denied numbness to his extremities and his gait was mostly normal, and the overall symptoms as described to and by his VA medical doctors was that his radiculopathy was, at the most, mild in severity. The Board has considered all other potentially applicable Diagnostic Codes but has found that no other Diagnostic Codes would result in more favorable findings. Therefore, the Board finds that for the period on appeal prior to January 2019, the Veteran's disability picture more closely approximated the criteria for a 10 percent rating under 38 C.F.R. § 4.124a, DC 8520, because there was no objective medical evidence showing symptoms comparable to a moderate condition. As such, the overall functional impairment resulting from the Veteran's service-connected right lower extremity radiculopathy was at most, mild in severity, and a rating in excess of 10 percent prior to January 28, 2019 is denied. Beginning January 28, 2019 As noted above, in a June 2021 rating decision, the Veteran's evaluation for right lower extremity radiculopathy was increased to 20 percent, effective May 13, 2021. However, the evidence is in equipoise as to whether the Veteran's condition more nearly approximated the criteria for a 20 percent evaluation during the January 28, 2019 VA medical consultation. As such, in giving the benefit of the doubt to the Veteran, January 28, 2019 is the date it was factually ascertainable that the Veteran's condition had worsened. For example, in the January 2019 consultation, it was noted that the Veteran had chronic lumbar radiculopathy with his right worse than left and his paresthesias worse with standing, and the radicular pain radiates to his feet. Later that month, there was a prosthetic request due to, in part, his right leg, and it was noted it was due, in part, to his documented musculoskeletal or neurological condition. In February 2019, he reported two falls after his leg gave out, and the examiner noted the lumbar radiculopathy caused chronic pain that is worse on weight bearing and his right ankle had muscle weakness; he reported the severity of the pain was at worst 10/10 with least amount of pain rated 7/10. The May 2021 VA examination report noted that the Veteran stated that he has numbness, tingling and pains to bilateral legs and described it as sharp and aching pains with numbness and tingling to bilateral legs. It was noted he had decreased strength in his ankles; hypoactive reflexes in the bilateral knees and ankles; and moderate constant pain and numbness in the left and right lower extremities. The examiner noted that sciatic nerves in both the left and right extremities had incomplete paralysis that was moderate in severity. The examiner also opined that there had been a worsening of the symptoms. The Board notes that subsequent to the 2018 Board remand, an examination was requested in October 2019. However, the Board deems this examination inadequate for purposes of rating the lower extremity radiculopathy. Specifically, the 2019 examination report indicates that the Veteran does not have a diagnosis for lower extremity radiculopathy, which is clearly erroneous. Further, his muscle strength testing revealed normal strength, which contradicts the findings in the November 2019 VA medical records which found the right lower extremity had muscle weakness. The Board therefore affords little, if any, probative weight to the 2019 VA examination as it pertains to radicular symptoms. As such, the October 2019 VA examination holds negligible value as to the severity of the Veteran's right lower extremity sciatica disability. That leaves the August 2015 and May 2021 VA examinations and the VA medical records as the remaining probative evidence of the severity of the Veteran's disability. As noted above, the August 2015 VA examination supports the rating criteria for a 10 percent rating for the Veteran's right lower extremity radiculopathy, and the May 2021 examination supports the rating criteria for 20 percent for the disability. However, in giving the benefit of the doubt to the Veteran, and as he has reported worsening symptoms to his right lower extremity pain and numbness which is supported by the January 2019 VA medical examination in his VA medical records the Board finds that the evidence is at least in equipoise that his disability had increased in severity; which would have been noted but for the inadequate 2019 examination. Additionally, when considering a claim for an increased disability rating, the Board must not consider the ameliorative effects of medication unless those effects are explicitly contemplated by the relevant rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 61 (2012). Here, DC 8520 does not mention the effects of medication, and, as noted above, the Veteran has taken daily Gabapentin for his nerve pain. Therefore, even for a wholly sensory involvement, incomplete paralysis of the sciatic nerve can indeed be considered moderate, as even the rating criteria does not require constant symptoms. The Board also notes that VA medical records corroborate with the 2021 examiner's finding for "moderate" severity as discussed above. Finally, as the Board has assigned a higher rating herein based on the January 2019 medical records and lay evidence describing the symptoms of radiculopathy, the Board finds that the Veteran is not prejudiced by the inadequacies of the 2019 VA examination. In light of the above, the Board finds that the evidence is at least in equipoise as to whether the Veteran's right leg sciatica condition increased during the appeal period. As such, the benefit of the doubt should be afforded to the Veteran, in accordance with 38 C.F.R. § 4.3. Thus, in affording the Veteran the benefit of the doubt, the Board finds that it became factually ascertainable that an increase of the right lower extremity radiculopathy had occurred beginning January 28, 2019, but no earlier, and a higher 20 percent rating, but no higher, is warranted. Left Lower Extremity Radiculopathy As for the left lower extremity radiculopathy, that condition is rated 10 percent disabling prior to September 5, 2014, and 20 percent thereafter. The Veteran's medical records or examinations do not describe results or findings consistent with ratings in excess of 20 percent for the left lower extremity. In August 2015, the Veteran was afforded a VA examination. He reported having daily severe low back pain with morning stiffness and muscle spasms. The examination findings noted that he had normal muscle strength, no atrophy, decreased reflexes (1+), normal sensation; positive straight leg raise on left side only. Radiculopathy examination showed signs and symptoms with complaints of severe pain, paresthesias, numbness. The examiner indicated that the Veteran had moderate left lower extremity sciatic nerve radiculopathy. As noted above, the 2019 VA examination report has been deemed inadequate for rating purposes for the increased ratings claims for radiculopathy. The May 2021 VA examination report noted that the Veteran stated that he has numbness, tingling and pains to bilateral legs and described it as sharp and aching pains with numbness and tingling to bilateral legs. It was noted he had decreased strength in his ankles; hypoactive reflexes in the bilateral knees and ankles; and moderate constant pain and numbness in the left and right lower extremities. The examiner noted that sciatic nerves in both the left and right extremities had incomplete paralysis that was moderate in severity. The examiner also opined that there had been a worsening of the symptoms (which, as noted above, was applied in favor of the Veteran to increase his disability rating for the right lower extremity). Applying the regulations to the facts in the case, the evidence of record shows that the Veteran's left lower extremity is moderate at most in severity and a 20 percent rating was assigned to reflect his symptom complaints. The evidence of record does not show that the Veteran has moderately severe left lower extremity radiculopathy. Therefore, the criteria for a schedular rating in excess of 20 percent for the Veteran's left lower extremity radiculopathy have not been met. The Board has considered all other potentially applicable Diagnostic Codes but has found that no other Diagnostic Codes would result in more favorable findings. Accordingly, the criteria for a schedular ratings in excess of 20 percent for the Veteran's left lower extremity radiculopathy have been not been met, and his claim is denied. REASONS FOR REMAND As for the claims for service connection for a right knee disability, left knee disability, bilateral hip disability, and entitlement to TDIU prior to October 17, 2011 and to SMC for aid and attendance and financing for automobile or equipment, although the Board sincerely regrets the additional delay, a remand is necessary to afford the Veteran due process of law and to ensure that there is a complete record upon which to decide the Veteran's appeal, so that he is afforded every possible consideration. See 38 U.S.C. § 5103a; 38 C.F.R. § 3.159. 1. Service connection for a right knee disorder, left knee disorder, and bilateral hip disorder as secondary to service-connected disabilities. First, as for the claims of service connection for the right knee and left knee disorders, and the bilateral hip disorder, to include as secondary to service-connected disabilities, the Board notes that the medical examinations and opinions obtained failed to comply with the remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, the Board finds that additional addendum opinions are necessary because the VA opinions of record do not comply with the October 2020 Board remand directives. Stegall, 11 Vet. App. at 268. The Board instructed the RO to obtain adequate medical opinions regarding the etiology of the Veteran's bilateral knee and hip disabilities. As noted in the 2020 Board remand, the prior medical opinion of record from 2019 was inadequate as it did not address Veteran's specific contention about abnormal gait due to his pes planus and lumbar spine disabilities and did not address secondary aggravation due to his service-connected disabilities. Unfortunately, the resulting May 2021 opinion and June 2021 addendum opinion both failed to include a sufficiently detailed rationale on the etiology of the Veteran's conditions. Instead, the VA examiners both simply stated there is no literature to support causation or aggravation. However, the Board finds that the May and June 2021 addendum opinions remain insufficient upon which to decide the claim and is tainted by the same flaws which rendered the 2019 VA examination report inadequate. First, the Board notes that while the prior Remand noted that the 2019 opinion did not address the Veteran's specific contention about abnormal gait due to his pes planus and lumbar spine disabilities and did not address secondary aggravation due to his service-connected disabilities, neither the May 2021 nor the June 2021 examiners considered this contention in their opinions. Further, the May 2021 opinions on the left knee, right knee, and bilateral hips is conclusory and inadequate; the examiner simply stated there is no medical literature that supports a back disability, right lower extremity radiculopathy or bilateral pes planus would cause any of the above conditions. The examiner's aggravation opinion repeated the causation opinion and did not consider aggravation at all. Further, the examiner only considered right lower extremity radiculopathy, but the Veteran is also service connected for his left lower extremity radiculopathy as well. In an addendum opinion in June 2021, the examiner again stated there is no literature to support that those conditions are caused or are complications of right knee but the right knee is not currently service connected, but rather is one of the etiology opinions that was requested. Regardless, this simply repeats what the May 2021 examiner stated with no supporting rationale or discussion of the Veteran's particular medical history. As such, the Board finds that the VA examiners failed to expressly opine, with a clear rationale, whether the right knee disability, left knee disability, and bilateral hip disabilities were caused or aggravated by the service-connected back disability, bilateral pes planus, and/or bilateral lower extremity radiculopathy, to include the abnormal gait caused by these conditions. 2. TDIU prior to October 17, 2011. The record reflects that the Veteran has requested a Board hearing for his appeal regarding the assigned rating of 30 percent for service connection for depressive disorder disability, effective from October 27, 2008. As a decision on the claim for increased rating for depressive disorder disability could significantly impact a decision on the issue of TDIU prior to October 17, 2011, the issues are inextricably intertwined. As such, the TDIU claim is deferred pending resolution of the other appeal for increased rating for depressive disorder disability. 3. SMC based on aid and attendance and automobile or other conveyance and adaptive equipment or adaptive equipment. Finally, because a decision on the issues of service connection for the right knee, left knee, and bilateral hip disabilities could significantly impact a decision on the issues of SMC based on aid and attendance/housebound status and entitlement to automobile or other conveyance and adaptive equipment or adaptive equipment, these claims are inextricably intertwined. A remand of these claims is required. The matters are REMANDED for the following action: 1. Forward the electronic claims file and a copy of this REMAND to the 2021 VA examiner, or another examiner if that examiner is not available, to obtain an addendum opinion regarding the Veteran's right and left knee disability and bilateral hip disability. The examiner must note his or her review of the complete claims file and should review this remand for a discussion as to why the prior opinion was inadequate. Examinations of the Veteran is not required, unless the VA examiner determines in-person examinations are necessary to provide the below-requested opinions. Following a complete review of the electronic claims file, the examiner must provide an opinion as to: 2. Whether it at least as likely as not that his current left knee disability was caused by his service-connected BILATERAL lower extremity radiculopathy, back disability, and/or bilateral pes planus? Please address the argument that the current left knee condition was caused by abnormal gait due to his service-connected bilateral lower extremity radiculopathy, pes planus, and/or lower back disabilities. 3. Whether it at least as likely as not that his current left knee disability was aggravated by his service-connected BILATERAL lower extremity radiculopathy, back disability, and/or bilateral pes planus? Please address the argument that the left knee condition was aggravated by abnormal gait due to his service-connected bilateral lower extremity radiculopathy, pes planus, and/or lower back disabilities. 4. Whether it at least as likely as not that his current right knee disability was caused by his service-connected BILATERAL lower extremity radiculopathy, back disability, and/or bilateral pes planus? Please address the argument that the current right knee condition was caused by abnormal gait due to his service-connected bilateral lower extremity radiculopathy, pes planus, and/or lower back disabilities. 5. Whether it at least as likely as not that his current right knee disability was aggravated by his service-connected BILATERAL lower extremity radiculopathy, back disability, and/or bilateral pes planus? Please address the argument that the right knee condition was aggravated by abnormal gait due to his service-connected bilateral lower extremity radiculopathy, pes planus, and/or lower back disabilities. 6. Whether it at least as likely as not that his current bilateral hip disability was caused by his service-connected BILATERAL lower extremity radiculopathy, back disability, and/or bilateral pes planus? Please address the argument that the current bilateral hip condition was caused by abnormal gait due to his service-connected bilateral lower extremity radiculopathy, pes planus, and lower back disabilities. 7. Whether it at least as likely as not that his current bilateral hip disability was aggravated by his service-connected BILATERAL lower extremity radiculopathy, back disability, and/or bilateral pes planus? Please address the argument that the bilateral hip condition was aggravated by abnormal gait due to his service-connected bilateral lower extremity radiculopathy, pes planus, and lower back disabilities. The examiner should specifically cite to any evidence that supports these opinions. A complete explanation should be provided for all opinions on causation AND aggravation. The examiner is advised that aggravation of a condition for legal purposes is defined as any incremental increase in disability, meaning any additional impairment of earning capacity above the degree of disability existing before the increase, in a nonservice-connected disability resulting from a service-connected disability, regardless of its permanence. Rationale must be provided for opinions proffered. If the examiner determines a requested opinion is not possible without resort to mere speculation, then the examiner must explain why. 8. After ensuring that the above development, and any other necessary development, has been completed to the extent possible, readjudicate the remanded claims. Ensure that the claim for TDIU prior to October 17, 2011 is adjudicated subsequent to the separate appeal of earlier effective date and higher rating for service-connected depression. B. G. LeMoine Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G.Hoy, Associate Counsel 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.