Citation Nr: 21074998 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 14-41 322A DATE: December 17, 2021 ORDER Entitlement to rating of 60 percent, but no higher, from January 1, 2019, for prostate cancer residuals is granted. REMANDED Entitlement to an initial rating in excess of 10 percent for degenerative disc disease of the lumbar spine prior to November 17, 2009, and in excess of 20 percent thereafter is remanded. Entitlement to a compensable rating for left lower extremity radiculopathy prior to November 17, 2009, and a rating in excess of 20 percent thereafter is remanded. Entitlement to a compensable rating for right lower extremity radiculopathy prior to November 17, 2009, and a rating in excess of 20 percent thereafter is remanded. Entitlement to service connection for myasthenia gravis, to include under 38 U.S.C § 1151, is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities for the appeal period prior to November 17, 2009, is remanded. FINDING OF FACT From January 1, 2019, the evidence is in equipoise as to whether the Veteran's prostate cancer residuals more closely approximated voiding dysfunction requiring the wearing of absorbent materials which must be changed more than four times per day; and there is no associated renal dysfunction. CONCLUSION OF LAW The criteria for entitlement to rating of 60 percent, but no higher, from January 1, 2019, for prostate cancer residuals have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.119, Diagnostic Code 7528. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1967 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Albuquerque, New Mexico. The Veteran testified before the undersigned Veterans Law Judge during an April 2018 hearing. A transcript of the hearing is associated with the Veteran's claim file. This matter was previously before the Board in July 2018 and March 2021. The matter has returned to the Board for appellate review. The Veteran also appealed a decision for entitlement to service connection for an acquired psychiatric disorder. The Veteran was granted service connection for depressive disorder with anxiety and somatic symptom disorder in a subsequent rating decision by the RO in August 2021. Since entitlement to service connection for an acquired psychiatric disorder has been already granted, this issue is not under appeal and therefore, is not before the Board. 1. Entitlement to rating of 60 percent, but no higher, from January 1, 2019, for prostate cancer residuals In March 2021, the Board denied a rating in excess of 40 percent for the appeal period prior to October 6, 2011 and granted a 60 percent rating from October 6, 2011, to November 25, 2014, for the Veteran's prostate cancer residuals. The Board also found that from November 26, 2014, to December 31, 2018, the Veteran was in receipt of the maximum schedular rating for voiding dysfunction associated with his prostate cancer residuals and there was no associated renal dysfunction. The Board remanded the issue to determine if a rating in excess of 40 percent from January 1, 2019, was warranted as the evidence showed that there was a possible recurrence of prostate cancer verus benign prostatic hypertrophy as noted in a September 2019 VA treatment record. As such, the Board found that a remand was warranted for a contemporaneous VA examination to properly assess the severity of the Veteran's prostate condition for this appeal period. Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Parts 4. When rating a service-connected disability, the entire history must be considered. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board must consider entitlement to "staged" ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the appeal. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability for the time period beginning one year before filing the claim until the VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's residuals of prostate cancer are currently rated at 40 percent for the period from January 1, 2019, under Diagnostic Code (DC) 7528, for malignant neoplasms of the genitourinary system. 38 C.F.R. § 4.115. Prostate cancer is evaluated under 38 C.F.R. § 4.115b, DC 7528, which covers malignant neoplasms of the genitourinary system and provides for an initial 100 percent disability rating. The 100 percent disability rating is provided until at least six months following the cessation of surgical, X-ray, antineoplastic chemotherapy, or other therapeutic procedure, at which time the Veteran is to be provided a VA examination. 38 C.F.R. § 4.115b, DC 7528, Note. Based upon that or any subsequent VA examination, the disability rating is open to revision in accordance with the criteria set forth in 38 C.F.R. § 3.105(e). If there is no local reoccurrence or metastasis, the service-connected genitourinary disease is to be rated on residuals as a voiding dysfunction or a renal dysfunction, whichever is predominant. 38 C.F.R. § 4.115b, DC 7528. Voiding dysfunction is evaluated under 38 C.F.R. § 4.115a, which provides that any voiding dysfunction shall be rated by the particular condition as urine leakage, urinary frequency, or obstructive voiding. Under urine leakage conditions (continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence), a 60 percent disability rating is warranted for the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. A 40 percent disability rating is warranted for the wearing of absorbent materials which must be changed two to four times per day. A 20 percent disability rating is warranted for the wearing of absorbent materials which must be changed less than two times per day. 38 C.F.R. § 4.115a. Under urinary frequency conditions, a 40 percent disability rating is warranted for a daytime voiding interval of less than one hour or awakening to void five or more times per night. A 20 percent disability rating is warranted for a daytime voiding interval between one and two hours or awakening to void three to four times per night. A 10 percent disability rating is warranted for a daytime voiding interval between two and three hours or awakening to void two times per night. Id. Under obstructed voiding conditions, a 30 percent disability rating is warranted for urinary retention requiring intermittent or continuous catheterization. A 10 percent disability rating is warranted for marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: (1) post void residuals greater than 150 cc; (2) uroflowmetry demonstrating markedly diminished peak flow rate (less than 10 cc/sec); (3) recurrent urinary tract infections secondary to obstruction; or (4) stricture disease requiring periodic dilation every two to three months. A non-compensable disability rating is warranted for obstructive symptomatology with or without stricture disease requiring dilation one to two times per year. Id. Renal dysfunction is also evaluated under 38 C.F.R. § 4.115a. A 100 percent disability rating is warranted for regular dialysis or such dysfunction that precludes more than sedentary activity from one of the following: persistent edema and albuminuria; or, a BUN [blood urea nitrogen] level more than 80 mg% [milligrams of urea nitrogen per 100 milliliters of blood]; or a creatine level more than 8mg% [milligrams of serum creatine per 100 milliliters of blood]; or, markedly decreased function of the kidney or other organ systems, especially cardiovascular. An 80 percent disability rating requires persistent edema and albuminuria with a BUN level of 40mg to 80mg; or a creatine level of 4mg to 8mg; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 60 percent disability rating is warranted for constant albuminuria with some edema; or definite decrease in kidney function; or hypertension at least 40 percent disabling under DC 7101. A 30 percent disability 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 DC 7101. A non-compensable disability rating is warranted for albumin and casts with history of acute nephritis; or hypertension non-compensable under DC 7101. Id. Turning to the evidence of record, an April 2019 VA treatment record showed that the Veteran had an active prescription for a belted undergarment extra absorbent, and that he was to use 1 pad as directed four times a day. An August 2019 VA treatment record notes that the Veteran reported wearing 3 to 4 pads per day and they get moderately wet. He also stated he wishes to discuss artificial urinary sphincter (AUS) as he is going through 4 diapers and 3 pads per day. In July 2021, the Veteran was afforded a VA examination in conjunction with the remand instructions from the March 2021 Board decision. The VA examiner indicated the condition was in remission, but he had urinary incontinence. At the examination, the Veteran reported having urinary incontinence and he uses 4 to 5 pads a day. The VA examiner indicated the Veteran has a voiding dysfunction that causes urine leakage which required absorbent material which must be changed 2 to 4 times per day. He also had daytime voiding interval between 2 and 3 hours. There was no obstructed voiding or recurrent symptomatic urinary tract or kidney infections. The examiner also stated the Veteran did not have any other residual conditions and/or complications due to prostate cancer or treatment for prostate cancer. From January 1, 2019, while resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's symptoms manifested the criteria contemplated by the 60 percent rating. As noted above, he stated in August 2019 that he is going through 4 diapers and 3 pads per day. At the July 2021 VA examination, although the VA examiner found that the Veteran required absorbent material which must be changed 2 to 4 times per day, the Veteran reported that he uses 4 to 5 pads a day. The Veteran is competent to report changing his absorbent material more than four times a day and there is no evidence to suggest that his report is not credible. Generally, in assessing the evidence of record, the Board acknowledges the Veteran is competent to provide evidence regarding the lay observable symptoms of his prostate cancer residuals. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007), abrogated on other grounds by Walker v. Shinseki, 708 F.3d 1331 (2013), (holding that while a lay person is not competent to opine as to medical etiology or render medical opinions, they are competent to establish the presence of observable symptomatology). Finally, the Board finds that a rating in excess of 60 percent from January 1, 2019, is not warranted. The Board notes that 60 percent is the maximum schedular rating that can be assigned for voiding dysfunction and there is no evidence of record establishing renal dysfunction at any time during the period at issue. The VA medical records demonstrate no local reoccurrence or metastasis of the Veteran's prostate cancer, and the Veteran has not contended otherwise. Accordingly, the Veteran is not entitled to an 80 percent or 100 percent disability rating at any time during the appeal period from January 1, 2019. In sum, the Veteran's rating for residuals of prostate cancer is increased from 40 percent to 60 percent from January 1, 2019, but a rating in excess of 60 percent is denied. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). 1. Entitlement to an initial rating in excess of 10 percent for degenerative disc disease of the lumbar spine prior to November 17, 2009, and in excess of 20 percent thereafter The Veteran asserts that his lumbar spine disability warrants higher disability ratings than as currently reflected. The March 2021 Board decision found that the prior remand instructions from the July 2018 Board decision were not complied with and that a VA examination that tested for pain in active motion, passive motion, weight-bearing, and non-weight bearing was required. The March 2021 Board decision noted that while the October 2019 VA examiner provided range of motion testing for active motion and noted that passive range of motion was the same, the examiner did not record the range of motion measurements for where pain began despite finding that pain was noted on examination with forward flexion, extension, and left lateral flexion that resulted in functional loss. The October 2019 VA examiner did not provide an explanation for her failure to provide the required range of motion measurements as required in Correia v. McDonald, 28 Vet. App. 158 (2016). The Veteran was afforded a VA examination in July 2021 pursuant to the March 2021 Board remand instructions. The Board specifically requested that the examiner must test the Veteran's range of motion on active and passive range of motion, and on weight-bearing and non-weight bearing. The VA examiner tested the Veteran's range of motion on active range of motion and stated that testing was not necessary for passive range of motion because there was normal active range of motion; however, the examiner did not record the range of motion in weight-bearing and non-weight bearing. The VA examiner did not comply with the requirements as noted in Correia. Furthermore, where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). Additionally, at the July 2021 VA examination, the Veteran noted that he receives chiropractic care for his lower back disability. The RO should attempt to obtain these private treatment records on remand. 2. Entitlement to a compensable rating for left lower extremity radiculopathy prior to November 17, 2009, and a rating in excess of 20 percent thereafter 3. Entitlement to a compensable rating for right lower extremity radiculopathy prior to November 17, 2009, and a rating in excess of 20 percent thereafter The Veteran contends that he is entitled to higher ratings than as currently assigned for his left lower extremity radiculopathy and right lower extremity radiculopathy. The March 2021 Board decision remanded the issues for a retrospective opinion regarding the Veteran's service-connected left and right lower extremity radiculopathy associated with his service-connected lumbar spine disability. The VA examiner was asked to discuss the severity of the Veteran's left and right lower extremity radiculopathy since October 13, 2000, to include whether such manifested as mild, moderate, moderately severe, or severe incomplete paralysis, or complete paralysis of the sciatic nerves. The Veteran was examined by the VA in July 2021. The VA examiner indicated he reviewed the pertinent evidence of record to include 1) the November 2000 SSA DDU evaluation assessing the Veteran was recurrent lumbar pain with sciatic radiation; 2) the July 2007 VA treatment record reflecting worsening right sciatic pain; and 3) the May 2008 private Independent Medical Examination addressing lower extremity symptomatology. While he provided a statement that the Veteran's left and right lower extremity radiculopathy is mild to moderate (incomplete paralysis), there was no rationale provided with his opinion. The Board remand instructions specifically stated that a rationale should be provided for all opinions expressed. In light of the above deficiency with the medical opinion, remand is warranted to ensure compliance with the Board's remand pursuant to Stegall. 4. Entitlement to service connection for myasthenia gravis, to include under 38 U.S.C § 1151 The Veteran maintains that his myasthenia gravis is related to his military service, or in the alternative, secondary to his service-connected conditions, or due to VA procedures. The March 2021 Board decision remanded the issue as it found that the last VA opinion in October 2019, was inadequate. The October 2019 VA nexus opinion for secondary service connection was inadequate because the VA examiner utilized the incorrect standard in finding that the Veteran's disability was not aggravated by his service-connected disability. Furthermore, regarding direct service connection, the Board found that the October 2019 VA examiner did not consider the Veteran's reports of fatigue and illness after his discharge from service were symptoms of his later diagnosed myasthenia gravis. The Veteran was examined for his myasthenia gravis by the VA in July 2021. Regarding direct service connection, the 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. He stated as rationale that the Veteran was seen by a neurologist and diagnosed with myasthenia gravis in 2005 and there is no evidence of symptoms during his military service or within one year of separation from service. In this regard, the Board finds that the VA examiner failed to address the Veteran's contention that it is not uncommon for individuals with myasthenia gravis to experience a delay in diagnosis. He also did not discuss and consider the Veteran's service treatment records that showed he had a sore throat, the 2001 reports and medical records showing swallowing problems, the Veteran's March 2010 contentions that when he was sick in service, including when he had a sore throat that may have been early symptoms of myasthenia gravis and that he felt fatigued ever since his discharge from service, and the Veteran's friend statement that the Veteran often missed class in the early 1970s and reported that he was sick. The VA examiner also 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 conditions. As rationale, he stated that there is no documentation of evaluation/treatment during the Veteran's service years for symptoms of myasthenia gravis including diplopia, ptosis, easy fatigability, and muscle weakness that was found upon review of his claim file/records. He also found that there is no definitive evidence in the medical literature that shows that exposure to herbicides causes myasthenia gravis. Here, the VA examiner did not include a comprehensive rationale for the opinion rendered and did not include what medical literature he relied on when determining that there is no definitive evidence in the medical literature that shows that exposure to herbicides causes myasthenia gravis. Also, the examiner did not properly address secondary service connection and aggravation. The examiner was asked to consider whether the Veteran's myasthenia gravis was caused by or aggravated by his service-connected disabilities, to include diabetes mellitus, but the examiner only addressed the service-connected diabetes mellitus by stating 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 connection disability, to include diabetes mellitus. He stated that the Veteran was not diagnosed with myasthenia gravis until 2004, that diabetes mellitus usually develops with aggressive treatment of myasthenia gravis and the Veteran received steroid therapy and that he was diagnosed with diabetes mellitus in 2007 and therefore, it is less likely the diabetes mellitus caused the myasthenia gravis because it is more likely than not the opposite occurred. Additionally, regarding whether the Veteran has an additional disability as a result of his prostate cancer surgery and related anesthesia treatment provided by VA, to include the Veteran's allegation that he had sleep problems from the surgery that aggravated his myasthenia gravis, the VA examiner merely wrote "N/A. No additional disability" without any further explanation or rationale. As such, the medical opinion has an inadequate rationale and therefore, has no probative value. The Board finds that a remand is warranted to determine the nature of the Veteran's claim for service connection for myasthenia gravis because the July 2021 medical opinions do not fully address the questions posed in the March 2021 remand directives and does not consider all the relevant and lay and medical evidence of record. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 5. Entitlement to a TDIU due to service-connected disabilities for the appeal period prior to November 17, 2009 The issue of entitlement to a TDIU for the appeal period prior to November 17, 2009, is inextricably intertwined with the appeal for the issues being remanded, and thus the Board will defer consideration of the appeal with regard to entitlement to a TDIU. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). The matters are REMANDED for the following action: 1. Obtain VA treatment records from May 2021 to present. All reasonable attempts should be made to obtain any identified records. 2. The Veteran should also be afforded the opportunity to submit any outstanding private treatment records from the private chiropractic clinic or in the alternative, provide a release so that VA can attempt to obtain those records. All efforts to obtain the records should be documented in the claims file. 3. After completion of the above, obtain an addendum opinion from the provider who conducted the July 2021 examination for the Veteran's low back and lower radiculopathy disabilities (or if no longer available, an appropriate replacement). The decision for an in-person examination of the Veteran is left to the discretion of the examiner. The Veteran's record, to include a copy of this remand, should be made available to and reviewed by the examiner, and an opinion as follows is requested: (a) Provide range of motion measurements for the Veteran's low back disability in both weight-bearing and non-weightbearing positions. If this cannot be provided, the examiner should explain why. The examiner should record the range of motion of the in terms of degrees. If there is evidence of pain on motion, the examiner should indicate the degree of range of motion at which such pain begins, as well as whether such pain on movement results in any loss of range of motion. (b) The examiner indicated at the July 2021 examination that the Veteran's left and right lower extremity radiculopathy is mild to moderate (incomplete paralysis) but did not provide any rationale to this opinion. Please provide a detailed explanation and rationale for your opinion. In providing this opinion, the VA examiner should consider all pertinent evidence of record, including the (1) the November 2000 SSA DDU evaluation assessing the Veteran with recurrent lumbar pain with sciatic radiation; (2) the July 2009 VA treatment record reflecting worsening right sciatic pain; and (3) the May 2008 private Independent Medical Examination addressing lower extremity symptomatology. If providing any opinions are not feasible, the examiner must provide a detailed explanation and rationale for why such could not be accomplished. Specifically, if the examiner cannot provide an opinion without resorting to mere speculation, he or she must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. In considering any lay statements of record, the examiner should note that the Veteran is competent to attest to matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiners should provide a fully reasoned explanation. 4. Obtain an addendum opinion from the provider who issued the July 2021 medical opinion for myasthenia gravis (or if no longer available, an appropriate replacement). The decision for an in-person examination of the Veteran is left to the discretion of the examiner. The Veteran's record, to include a copy of this remand, should be made available to and reviewed by the examiner, and an opinion as follows is requested: (a) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's myasthenia gravis (1) had an onset in service; (2) manifested to a compensable degree within one year of separation from service; or (3) is otherwise related to service, to include the Veteran's conceded herbicide agent exposure? The examiner should ADDRESS the Veteran's contention that it is not uncommon for individuals with myasthenia gravis to experience a delay in diagnosis. In this regard, the Veteran provided articles on myasthenia gravis, to include citations to a Myasthenia Gravis Fact Sheet (from National Institute of Neurological Disorders and Strokes) that because weakness is a common symptom of many other disorders, the diagnosis of myasthenia gravis is often missed in people who experience mild weakness or in those individuals whose weakness is restricted to only a few muscles. See March 2010 statements. In providing the above opinion, the VA examiner should also consider and address as appropriate: (1) the Veteran's service treatment records including records showing he had a sore throat; (2) the 2001 reports and medical records showing swallowing problems; (3) the Veteran's March 2010 contentions that when he was sick in service, including when he had a sore throat that may have been an early symptom of myasthenia gravis and that he felt fatigued ever since his discharge from service; and (4) the Veteran's friend's statement that the Veteran often missed class in the early 1970s and reported that he was sick. (b) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's myasthenia gravis is (1) caused by or (2) aggravated by a service-connected disability, to include diabetes mellitus, depressive disorder with anxiety and somatic symptom disorder, residuals of prostate cancer, degenerative disc disease of the lumbar spine, radiculopathy of the lower extremities, erectile dysfunction, and/or right inguinal hernia? If aggravation is found, the examiner should quantify the degree of aggravation, if possible, and state whether there was an increase in disability regardless of permanence, but medically ascertainable. The examiner is reminded that permanent aggravation need not be shown. Rather, aggravation refers to any incremental increase in disability resulting from service-connected conditions regardless of its permanence. See Ward v. Wilkie, 31 Vet. App. 233, 241-42 (2019). The examiner should ADDRESS the Veteran's contention that he experienced sleep problems from his prostate cancer surgery and those sleep problems worsened his myasthenia gravis. In providing the above opinion, the examiner should consider and address as appropriate: (1) the May 2009 private Independent Medical Examination that the Veteran was diagnosed with myasthenia gravis and had significant problems with his lower extremity fatigue and weakness associated with this problem but that it was extremely difficult to make an assessment on how much of his symptomatology was related to his low back and sciatic disability versus his myasthenia gravis; (2) the April 2018 letter from the Veteran's private physician that it can be difficult to distinguish myasthenia gravis issues with diabetes, that both prescriptions can cause gastrointestinal disorders, and that he has seen more than one diabetic with myasthenia gravis and Agent Orange exposure but he does not know if a true connection has been confirmed by medical literature or the military; and (3) a September 2019 VA treatment record reflecting a concern that incontinence issues are related to myasthenia gravis. (c) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran has an additional disability as a result of his prostate cancer surgery and related anesthesia treatment provided by VA, to include the Veteran's allegation that he had sleep problems from the surgery that aggravated his myasthenia gravis? (d) If an additional disability is shown, was such additional disability the result of, or caused by, a lack of proper care or negligent treatment on the part of VA caregivers? Alternatively, did any action or inaction by VA caregivers cause additional disability or constitute carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault? If so, did VA fail to exercise the degree of care that would be expected of a reasonable health care provider? (e) If the additional disability is shown, was the additional disability due to an event not reasonably foreseeable? A complete rationale should be given for each opinion expressed with a fully reasonable explanation. In this regard, a discussion of facts and medical principles involved would be of considerable assistance to the Board, to include citations to any medical literature, if appropriate. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Kim, 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.