Citation Nr: 21077032 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 17-49 686 DATE: December 28, 2021 ORDER Entitlement to a rating in excess of 30 percent for bipolar disorder is denied. FINDING OF FACT The evidence is not in approximate balance that the Veteran's service-connected bipolar disorder manifested in occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. CONCLUSION OF LAW The criteria for entitlement to a rating in excess of 30 percent for bipolar disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9432. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1984 to December 1987. He served honorably in the U.S. Army, including service in Germany. The Board thanks the Veteran for his service to our country. The Board acknowledges that the Veteran submitted a Rapid Appeals Modernization Program (RAMP) Opt-in Election form that was received by VA in February 2019. However, the appeal had already been activated at the Board and is therefore no longer eligible for RAMP. Accordingly, the Board will undertake appellate review of the case. Entitlement to a rating in excess of 30 percent for bipolar disorder is denied. The Veteran contends generally that a rating in excess of 30 percent is warranted for service-connected bipolar disorder. The Board finds that a higher rating is not warranted. Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more nearly approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran's entire history is reviewed when making disability ratings. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is the propriety of the initial disability rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Bipolar disorder is rated by applying the criteria in 38 C.F.R. § 4.130, DC 9432. The VA Schedule rating formula for mental disorders reads in pertinent part as follows: 100 percent rating (the maximum scheduler rating) - Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 70 percent - Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. 50 percent - Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 30 percent - Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). When determining the appropriate disability rating to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436, 441 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442. Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms; a veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). The Board has reviewed all of the evidence in the Veteran's record. Although the Board is required to provide reasons and bases supporting its decision, there is no need to discuss each item of evidence in the record. The Board will summarize the pertinent evidence as deemed appropriate, and the Board's analysis will focus specifically on what the evidence of record shows, or does not show, with respect to the claim. See Gonzalez v. West, 218 F.3d 1278, 1380-81 (Fed. Cir. 2000). The claimant bears the responsibility to present and support a claim for benefits. 38 U.S.C. § 5107(a); Fagan v. Shinseki, 573 F.3d 1282, 1286 (Fed. Cir. 2009). However, when there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The benefit of the doubt doctrine, however, is not applicable based on "pure speculation or remote possibility." Fagan, 573 F.3d at 1287. Rather, the evidence must rise to a state of approximate balance for the veteran to prevail. See Skoczen v. Shinseki, 564 F.3d 1319, 1324 (Fed. Cir. 2009). Indeed, the Federal Circuit rejected the idea that a veteran must be awarded benefits unless VA produces affirmative evidence refuting the claim. See Skoczen, 564 F.3d at 1329. Instead, the Federal Circuit concluded that if zero evidence is produced in support of a material issue, 1) it may be that no evidence exists to support the particular issue, in which case VA can rule against the claim; or 2) VA may have failed its duty to assist. Id. In a May 2012 mental health consultation note, the Veteran reported being easily angered and having outbursts. He reported being unemployed since June 2010 when he was injured on the job. In a June 2012 initial evaluation note, he reported becoming easily distracted, easily agitated, avoiding family and friends, having sleep difficulties, and having difficulty concentrating. In a November 2012 VA examination report, the Veteran reported getting hit as a child if he did something wrong and being physically abused by his peers when his family moved to another state. He reported that he earned a bachelor's degree in management in 2008. He reported having difficulty maintaining a job due to his foot, back, and knee pain. He reported that he had last been employed in 2010 as a security guard. The examiner noted a May 2011 psychology consultation note which stated that he was receiving workman's compensation from an injury sustained while working as a security guard and was a full-time student, working towards a doctorate in psychology. The examiner noted that the Veteran did not disclose his continuing education during the evaluation. The examiner noted diagnoses of bipolar disorder, NOS, and personality disorder, NOS, remarking that they were rendered by the Veteran's current treatment provider. The examiner stated that it is not possible to differentiate which symptoms are attributable to which diagnosis, noting that personality disorders can also cause instability, impulsivity, and aggressiveness. The examiner did not identify any symptoms of the service-connected disability or render conclusions as to the Veteran's occupational and social impairment. The examiner noted his report of experiencing depressed mood "quite often" that causes him to not go out often and to lie on the couch; anxiety when he goes to the grocery store; sleep difficulties; mood swings including anger, irritability, and aggressiveness; and "hearing voices." The examiner stated that the Veteran was administered the Miller Forensic Assessment of Symptoms Test (M-FAST). The examiner explained that the M FAST is an interview that provides information regarding the probability that an individual is feigning psychiatric illness and stated that his score was highly indicative of feigning. The examiner explained that the Positive Predictive Power (PPP) is the likelihood that an individual with positive test results is correctly classified, and stated that his score on the M-FAST indicated a PPP of 100 percent. The examiner further explained that individuals with scores equal to or greater than his score are correctly classified as malingering 100 percent of the time. The examiner stated that when there is significant exaggeration or feigning of symptoms, it is impossible to determine without mere speculation what symptoms a person is truly experiencing and what symptoms are feigned or exaggerated. Even with symptoms the individual may truly have, the examiner continued, it is impossible to determine without mere speculation what, if any, functional impairment there is as a result of those symptoms. In a January 2014 primary care note, the Veteran reported having stress with his boss at school, creating more anxiety. In an April 2014 psychiatry note, he reported trusting "K" and relying on K for emotional support. He reported doing ok at one point and starting a teaching job one year before but having difficulties with his boss, and that he was fired the week before. He reported dealing with depression, guilt, hearing the voices of his Army supervisors like auditory hallucinations and as loud thoughts which distracted him, and having poor sleep. The provider noted a pattern of medication noncompliance. The provider noted a prior history of psychotic symptoms, consistent auditory hallucinations of superiors' voices with no visual hallucinations or paranoid delusional thought in his history; and suicidal ideation one month prior when using alcohol in a binge fashion. Later that month, he arrived at his appointment with his friend K, who reported that trazadone had not been helping his sleep and that one night he had slept 3 to 4 hours. K also reported continued depressed moods, dissociative periods, and distrust and anxiety. The provider noted that the Veteran was dissociative 3 to 4 times during the interview that day. Later that day, K called to report that the Veteran had gotten angry while they were driving, jumped out of the car, and stormed off. K expressed concern as, in the past, the Veteran had stood on a bridge and thought about jumping and had thought of shooting himself with a gun. K later reported receiving a message from him that he was ok. The next day, the Veteran reported that he had a fight with K and had walked home and never had any thoughts of hurting himself. In an August 2014 mental health case manager note, the provider noted that the Veteran was mildly irritable and defensive but asked appropriate questions and responded to the information presented. The provider noted that he was very direct but appropriate and non-aggressive and that he would benefit from coping skills, specifically those aimed at increasing distress tolerance and emotional regulation skills. In an August 2014 psychiatric note, the Veteran reported that he had gotten a full time job and that the work was hard on his knees. In an October 2015 VA examination report, the Veteran denied any type of physical, emotional, or sexual abuse prior to service. The examiner noted the inconsistency with the November 2012 examination report. He reported his highest education was his bachelor's degree in management; the examiner noted that this was inconsistent with the May 2011 note indicating that he was studying toward a PhD in psychology. He indicated that he had no friends and the examiner noted that he later contradicted himself when referring to his best friend K. He reported a history of two suicide attempts in service and once in January 1988 when he was hospitalized; he also reported playing Russian roulette in 1988. He reported that 4 weeks prior a man asked him for money in a parking lot and called him an expletive and spit on his truck, resulting in violence with no police intervention. He reported that he was currently working as a bridge tender and reported previous jobs at a car wash, as a dishwasher, and babysitting. The examiner noted that he did not report his prior work as a security consultant. The Board observes that he did not report his prior job as a schoolteacher. The examiner noted diagnoses of bipolar disorder and personality disorder. The examiner attributed symptoms of irritability, racing thoughts, and chronic sleep difficulties to the Veteran's bipolar disorder and impulsivity, irritability and aggressiveness as indicated by repeated physical fights or assaults, and argumentativeness to his personality disorder. The examiner noted symptoms of chronic sleep impairment and disturbances of motivation and mood. The examiner concluded that the Veteran's service connected disability manifested in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self care and conversation. The examiner remarked that there were multiple inconsistencies noted between his reported (subjective) symptoms and objective evidence. The examiner noted that he exhibited a strong personality disorder and that some symptoms overlap with bipolar disorder. In an October 2015 addendum opinion, a separate clinician stated that the impact of the personality disorder and bipolar disorder could not be fully differentiated and that both can cause significant interpersonal problems and poor judgment. The clinician remarked that the available evidence showed that the Veteran was not a reliable historian, which makes occupational history and functioning difficult to discern. In another addendum opinion, the clinician stated that the available evidence indicates that the Veteran's psychiatric issues detract from his judgment but that there was no evidence that he was incompetent. In a January 2016 psychiatry note, the Veteran reported that he could not deal with people whom he feels are controlling. He reported having held many jobs and losing them due to inability to deal with supervisors, but did not clarify when he lost said jobs. In a July 2016 psychiatry note, he reported that all he had been doing was working and sleeping. He reported that one time he cursed at a guy at work but was not fired. In an October 2016 disability benefits questionnaire, the Veteran reported having no friends except his dog, and that he did not sustain social relationships and did not desire them. He reported working as a bridge tender and that he preferred to work alone. He relayed having been fired or suspended from a job more than 10 times, having verbal and physical altercations with past coworkers, and that he was able to maintain this job because of the solitude; the Board observes that it is unclear when he was fired from said jobs or was involved in said altercations. He reported that he had a bachelor's degree. He reported that he had attempted suicide 4 times, most recently in 2000; the Board observes that he previously reported two suicide attempts in service and one in January 1988. He reported recurrent suicidal thoughts without a plan. He reported recurrent auditory hallucinations. He relayed riding his motorcycle at an excessive velocity without a helmet. He reported having multiple fights with strangers, coworkers, and his Army roommate, and that during those fights he had to be physically removed or he would have been homicidal; the Board observes that he previously indicated getting in an altercation with a stranger in a parking lot with no police intervention. He reported that during mood fluctuations, he had bashed his head against trees; the evaluator, a private psychologist, noted scars visible on his knuckles and forehead. The evaluator rendered a diagnosis of bipolar disorder, severe with psychotic features, with rapid cycling. The evaluator noted no other diagnoses. The evaluator noted symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, impaired judgment, disturbances of motivation and mood, difficulty and inability in establishing and maintaining effective work and social relationships, difficulty adapting ot stressful circumstances, suicidal ideation, impaired impulse control, and persistent delusions or hallucinations. The evaluator noted other symptoms including reduced activity, fatigue, poor self esteem and grandiosity, helplessness, alcohol abuse, guilt, anxiety, social withdrawal, memory and cognitive impairment, no interest in sex, hopelessness, and a history of lost employment opportunities. The evaluator concluded that the Veteran's bipolar disorder manifested in occupational social impairment with deficiencies in most areas. The evaluator indicated that no records were reviewed. In a December 2016 independent VA rating evaluation by a certified VA compensation and pension examiner, G.U., G.U. presented contentions and argument based on the October 2016 disability benefits questionnaire but did not present a medical evaluation of the Veteran's disability. G.U. stated that a Beck's Depression Inventory, which is not of record, indicated extreme depression. G.U. concluded that, given the October 2016 disability benefits questionnaire, the evidence was at least in equipoise that a 70 percent rating is warranted. In a January 2017 psychiatry report, the Veteran reported that his friend K had moved out of state for a new job. He relayed working alone on bridgework and having contact with few people. In an April 2017 psychiatry note, he reported difficulty staying focused at work and that he was keeping his job as he did a good job and managed his routine work. He reported having no emotional feelings toward people in a long time except for his dog. In a November 2017 psychiatry note he reported that his brother had a bypass surgery and he had not spoken to him in years and did not bother to get back to him. He reported feeling like his family had not been close to him as they were not caring and all had their own lives and he had his own. In a March 2018 psychiatry note, the Veteran reported having recurring panic attacks, one of which occurred while operating a bridge and jeopardizing safety as he could not follow his procedure manual. He reported losing blocks of time and inattentiveness. He reported working the night shift and sleeping for 7 hours. He reported that his job was insecure due to errors. In a May 2018 VA examination report, the Veteran reported that he had divorced in 1999 and that his ex-spouse had taken his daughter away. He reported that he had a son from a relationship prior to his marriage, whom he met once. He reported that he had one close friend. He reported that he was a bridge tender and that he had gotten a final warning about one month before as he almost caused damage to the bridge and the vessel. He reported that he did not know if it was panic attacks or anxiety attacks, which he experienced at work and at home. He estimated being involved in 4 or 5 physical altercations since the October 2015 examination. The Veteran reported feeling anxious every day and feeling depressed every day. He reported enjoying spending time with his dog. He reported sleeping an average of about 3 hours for "months, several months"; the examiner noted that he reported in March 2018 sleeping an average of 7 hours. He reported difficulties in concentration and low self-esteem. When questioned about manic symptoms he reported impulsively spending money. The examiner did not render a diagnosis or note symptoms. The examiner noted that the Veteran was well groomed with appropriate hygiene and that there were no behavioral signs of psychosis or mania. The examiner stated that he recalled 3 of 3 items immediately and 1 of 3 items after a delay of a few minutes, noting that it was questionable whether he put forth good effort on that task. The examiner noted no evidence of remote memory impairment. The examiner noted no evidence of psychosis. The examiner stated that the Veteran completed a self-administered forced choice questionnaire that provides an overall estimate of the likelihood that an individual is feigning or exaggerating symptoms of psychiatric or cognitive dysfunction and that his score was above the cutoff score identified by the test's authors for the identification of likely feigning. Acknowledging that subsequent research indicated that the cutoff score should be raised, the examiner stated that the Veteran's score was also above the revised cutoff score. The examiner noted that he endorsed several symptoms that are highly atypical of individuals who have genuine psychiatric or cognitive disorders and concluded that the results were suggestive of feigning symptoms. The examiner additionally stated that following the evaluation, the Veteran completed a self-administered test in the waiting room and that his responses produced a significant elevation on a scale measuring overreporting of symptoms, indicating that the test results were invalid and uninterpretable. The examiner stated that it could not be determined whether the Veteran currently met the DSM-5 criteria for bipolar disorder or another mental disorder because he was not cooperative with the examination, as results of both tests were indicative of feigning symptoms. The examiner stated that this was not tantamount to saying that the criteria for bipolar disorder were not met, but that because he was uncooperative, possible legitimate symptoms could not be differentiated from feigned symptoms. The examiner stated that this was why no symptoms were noted in the examination. During the period on appeal, the Veteran's providers consistently recorded unremarkable mental status evaluations except for nervous, dysphoric, and irritable mood with congruent affect and auditory hallucinations or flashbacks. His records indicate a history of medication noncompliance. During the period on appeal, the evidence indicates that the Veteran's reports and presentations of pertinent symptomatic impairment were repeatedly found by various mental health professionals to be intentionally inaccurate, including demonstration of the inaccuracy of his responses through professional analysis of his responses in objective testing (with determinations that of high probabilities of feigning or exaggeration). In light of the noted inconsistencies in the November 2012, October 2015 and May 2018 VA examination reports and the October 2016 disability benefits questionnaire; notations by the November 2012 and May 2018 examiners that possible legitimate symptoms could not be differentiated from feigned symptoms; the notation from the October 2015 clinician that functioning was difficult to discern as the Veteran was not a reliable historian; and objective testing in November 2012 and May 2018 showing high likelihoods of feigning of symptoms, the Board must accordingly conclude that the Veteran's descriptions of his mental health symptomatology during this period are not credible evidence in this case. See Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (noting that the credibility of a witness may be impeached by a showing of interest, bias, inconsistent statements, and consistency with other evidence), aff'd, 78 F.3d 604 (Fed. Cir. 1996), superseded in irrelevant part by statute, VCAA, Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000). The Board notes that the Veteran's testimony in this regard is self-serving (if accepted, it would support his appeal for increased disability benefits). See Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration the appellant's statements, it may consider whether self-interest may be a factor in making such statements). The Board also finds that further development beyond the multiple VA examination reports and supplemental opinions already obtained during the course of the appeal is not warranted as there is no indication that any such further development would not be futile given the consistent issues with the lack of reliability in the Veteran's reports throughout the appeal. As functional impairment cannot be accurately assessed based on the Veteran's non-credible reports, there is no need for the Board to discuss the symptoms reported by the Veteran during the period on appeal. This includes the suicidal ideation reported by the Veteran and reported by K in 2014 as K's reports were based on the Veteran's reports. To summarize in substantial part symptoms otherwise noted during the period on appeal, in the April 2014 note, K reported that the Veteran had impaired sleep, continued depressed moods, dissociative periods, and distrust and anxiety; the provider also noted dissociated periods during the interview. Later that day, K reported that the Veteran had stormed off after getting angry. In an August 2014 note, a mental health case manager noted that the Veteran was mildly irritable and defensive but non-aggressive and that he would benefit from coping skills. In the October 2015 VA examination report, the examiner noted symptoms of chronic sleep impairment and disturbances of motivation and mood and concluded that his service-connected disability manifested in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The October 2015 clinician noted that his psychiatric disorders detract from his judgment but neither the October 2015 examiner nor the clinician noted impaired judgment. In the May 2018 VA examination report, the examiner noted short-term memory impairment but stated that it was questionable whether he put forth good effort on the task. During the period on appeal, providers noted nervous, dysphoric, and irritable mood as well as hallucinations and/or flashbacks; the Board finds notations of hallucinations and/or flashbacks to be of little probative value as they are based on the Veteran's non-credible reports. While the October 2016 evaluator noted multiple symptoms and concluded that the Veteran's disability disorder manifested in occupational social impairment with deficiencies in most areas, the Board assigns this little to no probative value as it is based on the Veteran's non-credible report. The Board finds that the most probative, credible evidence of record does not reach approximate balance such that a rating in excess of 30 percent for bipolar disorder is warranted. While the Veteran was noted to have stormed off once in April 2014 after becoming angry, the Board finds that this was not of such frequency or severity to constitute impaired impulse control such as unprovoked irritability with periods of violence; nor is it of such frequency to constitute impaired judgement. K reported, and the provider noted on the same day, dissociation; however, the Veteran was consistently noted to be fully oriented, and this single notation is not of such frequency or duration to constitute spatial disorientation, disorientation to time or place, or persistent delusions or hallucinations. Short term memory impairment was noted once in May 2018; assuming that the Veteran put forth good effort on the task, this single notation is not of such frequency or duration to constitute short-term memory impairment as contemplated by the regulations. While the October 2015 examiner noted disturbances of motivation and mood, the examiner concluded that his service-connected disability manifested in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. Hence, after reviewing all the evidence of record, the Board finds that the evidence does not reach equipoise that a rating in excess of 30 percent for bipolar disorder is warranted. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The claim is, therefore, denied. See Skoczen, 564 F.3d at 1324; 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Vashaw, 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.