Citation Nr: 21007540 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 11-06 856 DATE: February 9, 2021 ORDER An initial rating of 50 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted, subject to the laws and regulations governing the payment of monetary benefits. An initial rating in excess of 10 percent for residuals of right femur fracture with limitation of extension of the right hip is denied. As of July 25, 2014, but no earlier, a separate noncompensable rating, but no higher, for right hip limitation of flexion associated with right femur fracture residuals is granted, subject to the laws and regulations governing the payment of monetary benefits. The separate rating for right thigh impairment associated with right femur fracture residuals, evaluated as noncompensably disabling as of April 14, 2018, is proper; the appeal is denied. An initial rating in excess of 10 percent for patellofemoral pain syndrome of the right knee with limitation of motion is denied. An initial compensable rating for residual scars of the bilateral lower extremities is denied. As of July 25, 2014, but no earlier, a separate 10 percent rating, but no higher, for right anterior distal thigh scar is granted, subject to the laws and regulations governing the payment of monetary benefits. FINDINGS OF FACT 1. For the entire appeal period, the Veteran’s PTSD is manifested by psychiatric symptomatology resulting in occupational and social impairment with reduced reliability and productivity, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas or total occupational and social impairment. 2. For the entire appeal period, the Veteran has been assigned the maximum schedular rating for limitation of extension of the right hip residual to his right femur fracture. 3. Prior to July 25, 2014, the Veteran’s right femur fracture residuals did not result in limitation of right hip flexion and, as of such date, resulted in right hip flexion limited to, at most, 105 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. 4. Prior to April 14, 2018, the Veteran’s right femur fracture residuals did not result in impairment of the right thigh and, as of such date, resulted in right hip abduction limited to, at most, 30 degrees, adduction limited to, at most, 25 degrees, external rotation limited to, at most, 40 degrees, and internal rotation limited to, at most, 25 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. 5. For the entire appeal period, the Veteran’s residuals of right femur fracture did not result in ankylosis of the hip, flail joint of the hip, or impairment of the femur. 6. For the entire appeal period, the Veteran’s patellofemoral pain syndrome of the right knee with limitation of motion is manifested by flexion limited to, at most, 130 degrees and full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without ankylosis, recurrent subluxation or lateral instability, dislocation or removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. 7. For the entire appeal period, the Veteran’s residual scars of the bilateral lower extremities are manifested by a single deep scar measuring approximately 6.25 square centimeters and multiple superficial scars that did not cover a total area of 929 square centimeters or greater, which did not result in any disabling effects and, with the exception of right anterior distal thigh scar as of July 25, 2014, are not painful or unstable. 8. As of July 25, 2014, the Veteran’s right anterior distal thigh scar was unstable, but not painful. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 50 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for an initial rating in excess of 10 percent for residuals of right femur fracture with limitation of extension of the right hip have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5251. 3. As of July 25, 2014, but no earlier, the criteria for a separate noncompensable rating, but no higher, for right hip limitation of flexion associated with right femur fracture residuals have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.31, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5252. 4. The separate rating for right thigh impairment associated with right femur fracture residuals, evaluated as noncompensably disabling as of April 14, 2018, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.31, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5253. 5. The criteria for an initial rating in excess of 10 percent for patellofemoral pain syndrome of the right knee with limitation of motion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 6. The criteria for an initial compensable rating for residual scars of the bilateral lower extremities have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Code 7805. 7. As of July 25, 2014, but no earlier, the criteria for a separate 10 percent rating, but no higher, for right anterior distal thigh scar have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Code 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1988 to April 1990 and May 1997 to February 2009. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in March 2009, August 2009, and November 2009 by a Department of Veterans Affairs (VA) Regional Office. In November 2012, the Veteran testified at a Board hearing before one of the undersigned Veterans Law Judges, who has now been appointed as the Board’s Chairman. A transcript of the hearing is associated with the record. The law prohibits the Chairman from participating in a proceeding as an individual member, but she may participate in a proceeding assigned to a panel. The law also provides a veteran the option of additional hearing(s) before the additional two Veterans Law Judges assigned to the panel. Arneson v. Shinseki, 24 Vet. App. 379, 386 (2011). In June 2018 and September 2018, the Board sent letters to the Veteran and his representative to determine whether he desired additional hearings; however, as he did not respond in the requisite time period, the Board finds that he does not wish to testify at additional hearings. In February 2014, the Board remanded the appeal for additional development. While on remand, in a rating decision issued in May 2018, the Agency of Original Jurisdiction (AOJ) granted an increased rating of 50 percent for PTSD, effective July 11, 2014, and separate noncompensable ratings for impairment of the right thigh and limitation of flexion of right hip, effective April 14, 2018. Inasmuch as higher ratings are available for such disabilities, and the Veteran is presumed to seek the maximum available benefit for a disability, his claims for higher ratings remain on appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). In December 2018, the Board again remanded the appeal for additional development and it now returns for further appellate review. In October 2020, the Veteran was sent a letter indicating that he had elected an in-person hearing with a Veterans Law Judge and, in light of COVID 19, was encouraged to opt into a virtual hearing; however, such letter was sent in error as his Board hearing was previously held in November 2012 and he has not subsequently requested a second hearing. Quinn v. Wilkie, 31 Vet. App. 284 (2019). Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history, and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. As relevant to the evaluation of the Veteran’s right hip and right knee disabilities, disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the Court held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). The appeal period for the Veteran’s increased rating claims begins on February 23, 2009, the date service connection was awarded for his PTSD, residuals of right femur fracture, patellofemoral pain syndrome of the right knee with limitation of motion, and residuals scars of the bilateral lower extremities. 1. Entitlement to an initial rating in excess of 30 percent prior to July 11, 2014, and a rating in excess of 50 percent thereafter for PTSD. The Veteran’s PTSD is rated under Diagnostic Code 9411, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders (General Rating Formula). 38 C.F.R. § 4.130. In pertinent part, the General Rating Formula provides a 30 percent rating when there is 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; and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when there is 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. The United States Court of Appeals for the Federal Circuit has held that the evaluation under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering “not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas” - i.e., “the regulation...requires an ultimate factual conclusion as to the Veteran’s level of impairment in most areas.” Vazquez-Claudio, 713 F.3d at 117-118; 38 C.F.R. § 4.130, Diagnostic Code 9411. Further, when evaluating a mental disorder, the Board must consider the “frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission,” and must also “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.” 38 C.F.R. § 4.126(a). Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term “psychosis” to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and replace them with references to the recently updated DSM-5. 79 Fed. Reg. 149, 45094 (August 4, 2014). The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction (AOJ) on or after August 4, 2014. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014, even if such claims are subsequently remanded to the AOJ. 80 Fed. Reg. 53, 14308 (March 19, 2015). In the instant case, the Veteran’s claim was certified to the Board in October 2012 and, as such, the DSM-IV applies to his claim. In this regard, the Board notes that the DSM-5 removed reference to Global Assessment of Functioning (GAF) scores. However, as the DSM-IV governs the Veteran’s claim, such scores are relevant to the evaluation of his PTSD. A GAF score is another component considered to determine the entire disability picture for the Veteran. The GAF scale is a scale reflecting the “psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness” from 0 to 100, with 100 representing superior functioning in a wide range of activities and no psychiatric symptoms. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting DSM-IV). With respect to the Veteran’s psychiatric symptomatology during the pendency of the appeal, the record reflects consistent reports of depressed mood, anxiety, hypervigilance, suspiciousness, nightmares, chronic sleep impairment, feelings of detachment, irritability, obsessive/ritualistic behavior, auditory hallucinations, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work relationships. Notably, the Veteran also testified at the November 2012 Board hearing to previously experiencing panic attacks at least once or twice a week, which he was able to prevent by avoiding certain triggers. Pertinent to occupational impairment, a July 2009 VA examiner found the Veteran’s mood lability and problems with concentration and recent memory, in connection with his physical problems, limited his employment opportunities. In particular, the VA examiner found the Veteran had limited prospects for work because of his need to avoid noises and crowds. At that time, the Veteran was medically retired from the military and not employed. However, a February 2011 VA treatment record noted the Veteran planned to return to school, and an August 2012 VA treatment record shows he had begun school online to study occupational safety and health. According to such record, he had grades of As and Bs in his first semester and planned to complete an associate’s degree, a four-year degree, and a master’s degree in occupational safety. VA treatment records dated in 2013 indicate the Veteran had continued his schooling, and those dated in 2014 show he was currently pursuing his bachelor’s degree. A July 2014 VA examination report also shows the Veteran had been working over 50 hours per week as a contractor in construction safety, which was his first job since his military retirement, and was going to try attending school full-time that month as well. Notably, the Veteran reported performing okay at his job, but he indicated that he did not have much contact with co-workers. Nevertheless, he stated that he had experienced no difficulty when he was forced to do so. As a result, the VA examiner found the Veteran’s PTSD symptoms did not seem to be interfering with his employment, which might be due, at least in part, to the way his job was structured. VA treatment records dated in March 2016 indicate the Veteran had completed school and was successfully working, without medication, as a construction site safety inspector, and, importantly, enjoyed his job. With respect to social impairment, on VA examination in July 2009, the Veteran reported that he had a good relationship with his step-children and a fair relationship with his wife, and also stayed close with several childhood friends. Nevertheless, the record shows the Veteran could no longer sleep in the same bed as his wife because of his assaultive behavior towards her during combat-related dreams. In addition, the VA examiner noted that the Veteran isolated himself socially and had few, if any, recreational activities that involved others. Although VA treatment records dated in July 2010 indicate the Veteran considered himself more outgoing and better able to interact with others, an August 2010 VA treatment record shows that he was divorcing his wife. Similarly, although an August 2011 VA treatment record shows the Veteran was better able to interact with people, an October 2012 VA treatment record indicates he did not go out of his house and avoided crowds. In April 2013, the Veteran again reported isolating socially, and a February 2014 VA treatment record shows he was anxious in crowds and felt detached from his family and friends. On VA examination in July 2014, the Veteran reported going out with his friends to restaurants but avoiding crowded bars and clubs. Although he did not trust many people, he was able to get along with his co-workers and enjoyed activities with his children and grandchildren. The VA examiner found it notable that all of the Veteran’s relationships, to include his family and friends, were well established prior to his deployment, with the exception of his children’s spouses and grandchildren. VA treatment records dated in October 2018 indicate the Veteran continued to feel numb and detached from others, activities, and his surroundings. Pursuant to the December 2018 Remand, the AOJ scheduled the Veteran for a VA examination so as to assess the nature and severity of his PTSD in January 2019. However, according to an internal VA document, the Veteran canceled his examination. A letter dated that same month notified the Veteran of such cancellation and requested clarification as to whether he wished to reschedule the examination. Thereafter, while there is no indication that the Veteran responded to such letter, VA attempted to reschedule the requested examination in March 2019 and May 2019; however, such were also cancelled, a fact that he was notified of in the May 2019 supplemental statement of the case. However, the Veteran has not provided good cause for his failure to attend the scheduled examinations or requested that such be rescheduled. Moreover, the evidence does not suggest, and the Veteran does not contend, that he did not receive notice of the VA examinations. Baldwin v. West, 13 Vet. App. 1, 6 (1999). In fact, despite acknowledging the cancellations of the requested examination in an August 2019 Appellant’s Brief, the Veteran’s representative did not provide good cause for the Veteran’s failure to attend the examination nor did he request that such examination be rescheduled. Thus, the Board will adjudicate the claim based on the evidence of record and any additional evidence expected to be obtained as a result of the aforementioned VA examination cannot be considered herein. 38 C.F.R. § 3.655; Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, based on a review of the foregoing evidence, the Board finds that, for the entire appeal period, the Veteran’s PTSD is manifested by psychiatric symptomatology resulting in, at most, occupational and social impairment with reduced reliability and productivity. Thus, an initial 50 percent rating, but no higher, for such disability is warranted. In this regard, the Board finds that, prior to July 11, 2014, during which period a 30 percent rating was initially assigned, the evidence shows the Veteran experienced disturbances of motivation and mood in connection with his schooling and difficulty in establishing effective work and social relationships, which is indicative of a 50 percent, rather than 30 percent, rating. Additionally, the July 2009 VA examiner found the Veteran experienced daily PTSD symptoms best described as “moderate to severe” in nature, and his mood lability and problems with concentration and recent memory limited his employment opportunities. Moreover, the July 2009 VA examiner characterized the Veteran’s occupational and social impairment as resulting in reduced reliability and productivity, which is consistent with a rating of 50 percent under the General Rating Formula. As for a rating in excess of 50 percent, the evidence of record, to include the Veteran’s lay statements, does not demonstrate symptoms of suicidal ideation, impaired speech, near-continuous panic or depression, impaired impulse control, spatial disorientation, or neglect of personal appearance and hygiene. The Board notes the Veteran’s reports of obsessional rituals, which he described as having to double-check the locks on his doors. In this respect, such behavior does not appear to, nor has it been reported to, interfere with routine activities as described in the criteria for a 70 percent rating under the General Rating Formula. Similarly, although the record reflects reports of fair impulse control and episodes of violence, such are only described as occurring during combat-related nightmares. Nevertheless, the Board has considered such with respect to their impact on the Veteran’s romantic relationships, particularly with his ex-wife. In addition, the Board is cognizant of the Veteran’s reports of delusions and auditory hallucinations; however, the record does not indicate that such symptomatology is of a nature, frequency, duration, or severity such that it has had a significant impact on his occupational and social functioning. In this respect, the Board has paid particular attention to the overall occupational impairment resulting from the Veteran’s PTSD. Here, the evidence demonstrates fairly consistent efforts to isolate, which include adjustments to work in solitude and avoid contact with co-workers. However, the record also shows the Veteran successfully completed schooling and is able to maintain full-time employment. Similarly, the Board acknowledges the overall social impairment resulting from the Veteran’s PTSD as demonstrated in the record. In this respect, the evidence shows the Veteran was able to maintain good relationships with his children, grandchildren, and childhood friends. However, the Board attributes probative value to the VA examiner’s notation that such relationships were primarily forged prior to the Veteran’s separation from service and, as such, his ability to establish new relationships is unclear. Moreover, even considering the totality of the Veteran’s psychiatric symptomatology and the resulting functional impairment of his PTSD, the July 2009 VA examiner found that, such resulted in, at most, occupational and social impairment with reduced reliability, which is consistent with the current 50 percent rating assigned under the General Rating Formula, and the July 2014 VA examiner determined that such resulted in, at most, 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, which only meets the criteria for a 30 percent rating under the General Rating Formula. In this regard, the Board affords great probative weight to the VA examiners’ assessments as they are medical professionals with expertise in psychiatric disorders, i.e., a psychiatrist and Ph.D.-level psychologist, respectively, considered the Veteran’s medical history and reported symptoms, and performed mental status examinations. Finally, the Board finds that the GAF scores assigned during the appeal period likewise support, at most, a 50 percent rating. In this regard, although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Carpenter, supra. An assigned GAF score, like an examiner’s assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). 38 C.F.R. § 4.126(a). Accordingly, an examiner’s classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered, but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; 38 C.F.R. § 4.126, VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). In the instant case, at the July 2009 VA examination, a GAF score of 60, which is indicative of moderate symptoms or moderate difficulty in social, occupational, or school functioning, was assigned. Further, while the Veteran’s VA treatment records reflect the assignment of GAF scores ranging from 45, which is reflective of serious symptoms or any serious impairment in social, occupational, or school functioning, to 70, which is indicative of some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, his contemporaneous mental status examinations and resulting occupational and social impairment, as discussed in detail above, are consistent with, at most, a 50 percent rating. Based on the foregoing, and with consideration of the benefit-of-the doubt rule, the Board finds the evidence reflects a severity of symptomatology resulting in, at most, occupational and social impairment with reduced reliability throughout the pendency of the appeal. Thus, the award of an initial 50 percent rating, but no higher, is warranted as such contemplates the Veteran’s overall disability picture due to his PTSD throughout the pendency of the appeal. 2. Entitlement to an initial rating in excess of 10 percent for residuals of right femur fracture with limitation of extension of the right hip. 3. Propriety of the separate rating for right hip limitation of flexion associated with right femur fracture residuals, evaluated as noncompensably disabling as of April 14, 2018. 4. Propriety of the separate rating for right thigh impairment associated with right femur fracture residuals, evaluated as noncompensably disabling as of April 14, 2018. Since February 23, 2009, the date of service connection, the Veteran’s residuals of right femur fracture with limitation of extension of the right hip is evaluated as 10 percent disabling pursuant to Diagnostic Code 5251 based on painful limitation of motion. 38 C.F.R. §§ 4.59, 4.71a. As of April 14, 2018, the Veteran is also in receipt of separate noncompensable ratings for right hip limitation of flexion and right thigh impairment associated with his right femur fracture residuals pursuant to Diagnostic Codes 5252 and 5253, respectively. 38 C.F.R. §§ 4.31, 4.71a. Normal range of hip motion is 125 degrees of flexion, 140 degrees of extension, and 45 degrees of abduction. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5251 provides that limitation of extension of the thigh to 5 degrees warrants a 10 percent rating. Diagnostic Code 5252 provides that limitation of flexion of the thigh to 45 degrees warrants a 10 percent rating. Flexion limited to 30 degrees warrants a 20 percent rating. Flexion limited to 20 degrees warrants a 30 percent rating and flexion limited to 10 degrees warrants a 40 percent rating. Diagnostic Code 5253 provides that impairment of the thigh resulting in limitation of rotation of the affected leg such that the veteran cannot toe-out more than 15 degrees warrants a 10 percent rating. Impairment of the thigh resulting in limitation of adduction and an inability to cross legs warrants a 10 percent rating. Impairment of the thigh resulting in limitation of abduction and motion lost beyond 10 degrees warrants a 20 percent rating. 38 C.F.R. § 4.71a. In addition to the foregoing Diagnostic Codes, Diagnostic Code 5250 provides ratings for ankylosis of the hip, Diagnostic Code 5254 provides an 80 percent rating for flail joint of the hip, and Diagnostic Code 5255 provides ratings for impairment of the femur. In regard to the Veteran’s reported right hip/thigh symptoms, at the March 2009 VA examination, he indicated that he experienced intermittent soreness of his right thigh with weather changes and demonstrated no extremity symptoms on physical examination at that time. At an October 2009 VA examination, the Veteran reported pain, stiffness, weakness, decreased speed of joint motion, and functional limitations with standing and walking. At the November 2012 Board hearing, the Veteran testified that he experienced pain that caused him to limp at times, but he denied a large loss in range of motion. At a July 2014 VA examination, the Veteran reported pain, weakness, and difficulty stretching, and, at a December 2016 VA examination, he indicated that had “persistent sensation” in the hip region since his in-service injury. Finally, on VA examination in April 2018, the Veteran reported pain and trouble with squatting, kneeling, and climbing. However, even taking into consideration such reports of right hip/thigh symptomatology, the Board finds that, as will be discussed below, such does not result in functional loss that more nearly approximates higher or separate ratings under any relevant Diagnostic Code. See DeLuca, supra; Mitchell, supra. Specifically, the Veteran has been in receipt of the maximum schedular rating for residuals of right femur fracture with limitation of extension of the right hip under Diagnostic Code 5251 for the entire appeal period. Consequently, a higher rating is not available under such Diagnostic Code. Furthermore, as noted previously, while the Veteran has been assigned a separate noncompensable rating for right hip limitation of flexion pursuant to Diagnostic Code 5252 as of April 14, 2018, the Board finds that, as he exhibited noncompensable limitation of flexion as of July 25, 2014, such rating is warranted as of such date, but no earlier. In this regard, the Veteran had normal active range of motion of the right hip in July 2009 and had full flexion of the right hip to 125 degrees, with no additional limitation following three repetitions and no report of flare-ups, on VA examination in October 2009. However, upon VA examination in July 2014, the Veteran’s right hip flexion was limited to 105 degrees. Thus, as he exhibited noncompensable right hip limitation of flexion as of July 25, 2014, such separate rating is warranted as of such date. 38 C.F.R. § 4.31. However, at no point since July 25, 2014, has the Veteran’s right hip disability resulted in limitation of flexion to 45 degrees or less such that a compensable rating is warranted. Specifically, as noted previously, while the Veteran had right hip flexion limited to 105 degrees upon VA examination in July 2014, there was no additional loss after repetitive motion testing. Additionally, while he reported flare-ups, such were reported to only result in increased pain, rather than additional limitation of motion. Furthermore, while tested following repeated use over time, he had normal range of right hip motion with flexion to 125 degrees, with no additional limitation following three repetitions and no report of flare-ups in December 2016. Finally, upon VA examination in April 2018, the Veteran had full flexion to 125 degrees with an additional 10 degrees lost following repetitive-use testing. Furthermore, while the examination was not conducted following repeated use over time or during a flare-up, the examiner noted that such was medically consistent with the Veteran’s statements describing functional loss based on such factors. In this regard, the Board notes that the Veteran described flare-ups manifested by increased pain that made it more difficult to walk and run, but he did not describe additional loss of range of motion during such flare-ups. Thus, at no point since July 25, 2014, is a compensable rating warranted under Diagnostic Code 5252. Further, the Board finds the evidence of record does not demonstrate impairment of the thigh so as to warrant a separate rating under Diagnostic Code 5253 prior to April 14, 2018. Specifically, the Veteran had normal active range of motion of the right hip in July 2009, and he could cross his legs and toe-out more than 15 degrees, and abduction was normal to 45 degrees, with no additional limitation following three repetitions and no report of flare-ups, on examination in October 2009. Similarly, the July 2014 VA examination report shows the Veteran could toe-out more than 15 degrees, cross his legs, and abduction was not lost beyond 10 degrees, without additional loss after repetitive motion testing. Additionally, while he reported flare-ups, such were reported to only result in increased pain, rather than additional limitation of motion. Further, while he was tested following repeated use over time, the Veteran had normal range of right hip motion with abduction to 45 degrees, adduction to 25 degrees, external rotation to 60 degrees, and internal rotation to 40 degrees, with no additional limitation following three repetitions and no report of flare-ups, in December 2016. Thus, as the Veteran had normal abduction, adduction, and rotation on examination prior to April 14, 2018, a separate rating prior to such date is not warranted under Diagnostic Code 5253. Likewise, the evidence of record does not reflect impairment of the thigh that meets the criteria for a higher rating under Diagnostic Code 5253 as of April 14, 2018. Specifically, the April 2018 VA examination report reflects that, upon range of motion testing, the Veteran had abduction limited to 30 degrees, adduction limited to 25 degrees, external rotation limited to 40 degrees, and internal rotation limited to 25 degrees, adduction was not limited such that he could not cross his legs. Furthermore, there was no additional loss in range of motion after three repetitions and, while the examination was not conducted following repeated use over time or during a flare-up, the examiner noted that such was medically consistent with the Veteran’s statements describing functional loss based on such factors. In this regard, the Board notes that the Veteran described flare-ups manifested by increased pain that made it more difficult to walk and run, but he did not describe additional loss of range of motion during such flare-ups. As a result, the Board finds a higher rating is not warranted under Diagnostic Code 5253 as of April 14, 2018. The Board has also considered whether higher and/or separate ratings are warranted under any other applicable Diagnostic Code. However, as the medical evidence does not reflect ankylosis of the hip, flail joint of the hip, or impairment of the femur, higher and/or separate ratings are not warranted under Diagnostic Codes 5250, 5254, or 5255. 38 C.F.R. § 4.71a. 5. Entitlement to an initial rating in excess of 10 percent for patellofemoral pain syndrome of the right knee with limitation of motion. Since February 23, 2009, the date of service connection, the Veteran’s patellofemoral pain syndrome of the right knee with limitation of motion is evaluated as 10 percent disabling pursuant to Diagnostic Code 5260 based on painful limitation of motion. 38 C.F.R. §§ 4.59, 4.71a. Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5260 provides for a zero percent rating where flexion of the leg is only limited to 60 degrees. For a 10 percent rating, flexion must be limited to 45 degrees. For a 20 percent rating is warranted where flexion is limited to 30 degrees. A 30 percent rating may be assigned where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for a zero percent rating where extension of the leg is limited to five degrees. A 10 percent rating requires extension limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating may be assigned where the evidence shows extension limited to 20 degrees. For a 40 percent rating, extension must be limited to 30 degrees. Finally, where extension is limited to 45 degrees a 50 percent rating may be assigned. VA’s General Counsel has also stated that separate ratings under Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 (2004). In regard to the Veteran’s reported right knee symptoms, he reported activity-related anterior pain, which was worse with prolonged sitting and climbing stairs at a March 2009 VA examination. At his November 2012 Board hearing, the Veteran testified to constant pain and giving way of the right knee. At a July 2014 VA examination, he indicated that he had constant aching in the right knee, to include increased pain with standing for more than 20 minutes, and occasional episodes of locking, but such had not occurred in the last several years. At an April 2017 VA examination, the Veteran again indicated that he experienced right knee pain. Finally, at an April 2018 VA examination, he reported right knee pain and trouble with squatting, kneeling, and climbing. However, even taking into consideration such reports of right knee symptomatology, the Board finds that, as will be discussed below, such does not result in functional loss that more nearly approximates higher or separate ratings under any relevant Diagnostic Code. See DeLuca, supra; Mitchell, supra Specifically, on examination in March 2009, right knee flexion was limited to 135 degrees and extension was normal to zero degrees, without pain or additional limitation following repetition or during flare-ups, and a September 2010 VA treatment record indicates the Veteran did not experience crepitation or pain with range of motion. Although he had crepitus with range of motion according to a November 2012 VA treatment record, the Veteran had full range of right knee motion. Likewise, a July 2014 VA examination report shows the Veteran had no limitation of flexion or extension of the right knee, to include following repetitive motion testing. In March 2017, a VA examiner reviewed the July 2014 VA examination report and indicated that there was insufficient medical evidence upon which to base an opinion with respect to any additional loss of range of motion in degrees following repeated use over time or during flare-ups without resorting to mere speculation. Nonetheless, the Board notes that, while the Veteran reported flare-ups at the July 2014 VA examination, such were reported to only result in increased pain with standing, rather than additional limitation of motion. On VA examination in April 2017, the Veteran had full flexion and extension of the right knee, with pain that did not result in functional loss, and there was no additional loss of range of motion after repetitive-use testing or following repeated use over time, and he denied flare-ups of the knee. An April 2018 VA examination report reflects right knee flexion limited to 130 degrees and normal extension, without additional loss of range of motion after three repetitions. Furthermore, while the examination was not conducted following repeated use over time or during a flare-up, the examiner noted that such was medically consistent with the Veteran’s statements describing functional loss based on such factors. In this regard, the Board notes that the Veteran described flare-ups manifested by increased pain, but he did not describe additional loss of range of motion during such flare-ups. Based on the foregoing, the Board finds that, as the Veteran’s right knee flexion was limited to, at most, 130 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, a rating in excess of 10 percent is not warranted under Diagnostic Code 5260. Furthermore, as his right knee extension remained full despite such factors, a higher or separate rating is likewise not warranted under Diagnostic Code 5261. Additionally, as the Veteran testified that he experienced giving way of his right knee at his November 2012 hearing, the Board has considered whether a higher or separate rating is warranted under Diagnostic Code 5257. VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63,604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). In this regard, such Diagnostic Code provides for assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability, a 20 percent rating when there is moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. Further, Diagnostic Code 5257 does not require objective medical evidence of lateral instability for a rating to be assigned. English v. Wilkie, 30 Vet. App. 347 (2018). In this regard, while the Veteran is competent to describe feelings of giving way, he is not competent as a lay person to diagnose lateral instability or recurrent subluxation as such requires the administration and interpretation of specialized testing of the ligaments and patella, respectively. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Rather, the March 2009, July 2014, April 2017, and April 2018 VA examiners, who have the training to administer and interpret ligament and patellar testing, found that there was no laxity or subluxation in the right knee. Thus, the Board affords greater probative weight to the VA examiners who found no instability or subluxation in the right knee than the Veteran’s generalized statements regarding the presence of such impairment. See, e.g., Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Therefore, a higher or separate rating under Diagnostic Code 5257 is not warranted. Similarly, as the evidence of record does not demonstrate ankylosis, dislocated or removal of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum at any time during the pendency of the appeal, Diagnostic Codes 5256, 5258, 5259, 5262, and 5263 are not for application. 6. Entitlement to an initial compensable rating for residual scars of the bilateral lower extremities. Since February 23, 2009, the date of service connection, the Veteran’s residual scars of the bilateral lower extremities are rated as noncompensably disabling pursuant to Diagnostic Code 7805. 38 C.F.R. § 4.118. Additionally, in a September 2017 rating decision, the AOJ awarded a separate noncompensable rating for superficial and nonlinear scars of the right lower extremity pursuant to Diagnostic Code 7802, effective February 23, 2009. Id. As the Veteran did not submit a timely notice of disagreement with the propriety of such award, it is not currently before the Board. Scars are rated under 38 C.F.R. § 4.118, Diagnostic Codes 7800 through 7805. Diagnostic Code 7800 pertains to burn scars of the head, face, or neck; scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. However, as the scars at issue affect the Veteran’s bilateral lower extremities, Diagnostic Code 7800 is inapplicable and will not be further considered. Diagnostic Code 7801 pertains to burn scars or scars due to other causes, not of the head, face, or neck, that are, prior to August 13, 2018, deep and nonlinear and, after such date, associated with underlying soft tissue damage. Under this Diagnostic Code, a 10 percent rating is assigned when the scar(s) cover an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.), and a 20 percent rating is warranted when the scar(s) cover an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.). A 30 percent rating is assigned when the scar(s) cover an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.), and a 40 percent rating is warranted when the scar(s) cover an area or areas of 144 square inches (929 sq. cm.) or greater. Diagnostic Code 7802 pertains to burn scars or scars due to other causes not of the head, face, or neck that are, prior to August 13, 2018, superficial and nonlinear and, after such date, not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Under this Diagnostic Code, a single 10 percent rating is assigned when the scar(s) cover an area or areas of 144 square inches (929 sq. cm) or greater. Diagnostic Code 7804 provides that one or two scars that are unstable or painful warrant a 10 percent evaluation. Three or four scars that are unstable or painful warrant a 20 percent rating, while five or more scars that are unstable or painful warrant a 30 percent evaluation. Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) states that if one or more scars are both unstable and painful, the rater is to add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under Diagnostic Code 7804, when applicable. Note (3). Diagnostic Code 7805 provides that other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804 that require the evaluation of any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-7804 should be rated under an appropriate diagnostic code. During the pendency of the appeal, VA amended the criteria for rating the skin, to include scars. See Schedule for Rating Disabilities: Skin, 83 Fed. Reg. 32,592 (July 13, 2018). As pertinent to the instant appeal, such amendment changed Diagnostic Code 7801 by removing the term “deep and nonlinear” and replacing it with “associated with underlying soft tissue damage,” and amending the accompanying notes to read: Note (1): For the purposes of Diagnostic Codes 7801 and 7802, the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. The midaxillary line divides the anterior trunk from the posterior trunk. Note (2): A separate evaluation may be assigned for each affected zone of the body under this diagnostic code if there are multiple scars, or a single scar, affecting multiple zones of the body. Combine the separate evaluations under § 4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this diagnostic code. The amendment further changed Diagnostic Code 7802 by removing the term “superficial and nonlinear” and replacing it with “not associated with underlying soft tissue damage,” and adding the two Notes above. The ratings schedule referable to scars was otherwise unchanged. With regard to the effective date of the new criteria, VA indicated in the Supplementary Information to the Final Rule that its “intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied.” The Veteran’s claim in this case was pending prior to the August 13, 2018, effective date of the new criteria and, therefore, the Board will consider both the old and new criteria. In order to afford the Veteran all possible avenues of entitlement to a higher rating, the Board has considered all applicable Diagnostic Codes, to include both the old and new criteria, as well as his specific reports of his symptoms and the medical evidence. With respect to Diagnostic Code 7801, the evidence, to include VA examinations conducted in March 2009, July 2014, December 2016, April 2017, May 2017, and April 2018, is negative for any indication that the Veteran’s bilateral lower extremity scars are deep and nonlinear, or associated with underlying soft tissue damage, with the exception of a scar of the left posterior calf that was deep and nonlinear, and measured 2.5 centimeters by 2.5 centimeters, resulting in a total area of 6.25 square centimeters, as noted at the July 2014 VA examination. In this regard, the Board observes that such description is consistent with the Veteran’s testimony at his November 2012 Board hearing that such scar adheres to the underlying muscle. However, as such does not cover an area of at least 6 square inches (39 sq. cm.), a compensable rating under Diagnostic Code 7801 is not warranted. Likewise, the Board finds a compensable rating under Diagnostic Code 7802 is not warranted as the evidence of record does not show the Veteran’s service-connected residual scars of the bilateral lower extremities cover an area or areas of 144 square inches (929 square centimeters) or greater. In this regard, the Board again notes that the AOJ previously awarded a separate noncompensable rating for superficial and nonlinear scars of the right lower extremity pursuant to such Diagnostic Code. However, the Board finds that a compensable rating under Diagnostic Code 7802 is not warranted. In this regard, the Board observes that the medical evidence is somewhat inconsistent with respect to the number, shape, size, and location of the Veteran’s bilateral lower extremity scars. In March 2009, the total area covered by the four recorded scars equaled 40 square centimeters, whereas, according to a July 2014 VA examination report, the Veteran had a total of seven scars on the lower extremities that covered approximately 30 square centimeters. A May 2017 VA examination report shows four scars on the lower extremities that covered a total area of approximately 18 square centimeters. However, even in consideration of the largest area reported, the criteria for a compensable rating under Diagnostic Code 7802 have not been met. As pertinent to Diagnostic Code 7804, the evidence, to include VA examinations conducted in March 2009, July 2014, December 2016, April 2017, May 2017, and April 2018, fails to show that any of the Veteran’s bilateral lower extremity scars are unstable or painful, with the exception of a right anterior distal thigh scar, which was described as unstable, but not painful, at the July 2014 VA examination. Specifically, it was observed that the scar opened every three to six months, then would scab over and heal in one to two months. Although such scar was not shown to be unstable at subsequent examinations, the Board resolves all doubt in the Veteran’s favor and finds that a 10 percent rating for such scar is warranted under Diagnostic Code 7804 as of July 25, 2014, the date of the VA examination. Additionally, while the Veteran reported tenderness of his left ankle scar with movement at the November 2012 Board hearing, he did not report that such scar, or any other scars of the bilateral lower extremities, was painful. Furthermore, examination of all of his bilateral lower extremity scars failed to reveal that such were painful or unstable. Consequently, further compensable ratings for the Veteran’s service-connected residual scars of the bilateral lower extremities are not warranted pursuant to Diagnostic Code 7804. Finally, the evidence does not show, nor does the Veteran contend, that his scars of the bilateral extremities result in any disabling effects. Rather, VA examinations reflect that such scars do not result in limitation of function or affect his ability to work. Consequently, a higher or separate rating is not warranted under any other potentially applicable Diagnostic Code pursuant to Diagnostic Code 7805. Other Considerations In reaching its conclusions in the instant case, the Board acknowledges the Veteran’s belief that his PTSD, right hip/thigh, right knee, and scar disabilities are more severe than as reflected by the current assigned disability ratings. In this regard, the Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to describe his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert, supra. Ultimately, the Board finds the medical evidence in which professionals with specialized expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disabilities in light of the rating criteria to be more persuasive than his own reports regarding the severity of his disabilities. The Board has also considered whether additional staged ratings under Fenderson, supra, are appropriate for the Veteran’s service-connected disabilities; however, the Board finds that his symptomatology has been stable throughout each period on appeal. Thus, assigning additional staged ratings for such disabilities is not warranted. Furthermore, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the increased rating claims adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). In reaching such determinations, the Board has considered the applicability of the benefit of the doubt doctrine, which has resulted in partial awards of increased ratings for the Veteran’s PTSD, right hip limitation of flexion, and right anterior distal thigh. However, insofar as the Board has denied higher or separate ratings for the disabilities on appeal, the preponderance of the evidence is against such aspects of the Veteran’s claims. Thus, the benefit of the doubt doctrine is not applicable in such regard and his initial rating claims must otherwise be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals JOHN Z. JONES Veterans Law Judge Board of Veterans’ Appeals CHERYL L. MASON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. M. Celli, 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.