Citation Nr: 21008222 Decision Date: 02/12/21 Archive Date: 02/12/21 DOCKET NO. 16-54 109 DATE: February 12, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for left knee arthritis is denied. Entitlement to a separate 20 percent rating for a left knee meniscal disorder is granted. Entitlement to a separate 20 percent rating for a right knee meniscal disorder is granted. Entitlement to a separate noncompensable rating for surgical scar of the left knee is warranted. Entitlement to a separate noncompensable rating for surgical scar of the right knee is warranted. REMANDED Entitlement to an initial rating in excess of 10 percent for right knee arthritis is remanded. FINDINGS OF FACT 1. The Veteran’s left knee arthritis has resulted in subjective complaints of pain and objective evidence of painful motion with functional loss causing limitation of flexion to no less than 110 degrees and limitation of extension to no more than 5 degrees, even in consideration of additional functional loss due to flare-ups of pain, fatigability, pain on movement, and/or weakness, or on repetitive motion. 2. The evidence shows the Veteran has symptomatic left knee meniscal disorder with frequent episodes of joint locking, pain, and effusion. 3. The evidence shows the Veteran has symptomatic right knee meniscal disorder with frequent episodes of joint locking, pain, and effusion. 4. The Veteran’s surgical scar of the left knee has not been shown to be unstable or painful. 5. The Veteran’s surgical scar of the right knee has not been shown to be unstable or painful. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating excess of 10 percent for left knee arthritis have not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, DC 5003, 5260. 2. The criteria for entitlement to a separate rating of 20 percent under Diagnostic Code 5258 for left knee meniscal disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59, 4.71(a), Diagnostic Code (DC) 5258. 3.The criteria for entitlement to a separate rating of 20 percent under Diagnostic Code 5258 for right knee meniscal disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59, 4.71(a), Diagnostic Code (DC) 5258. 4. The criteria for a separate noncompensable rating for a surgical scar of the left knee have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, DC 7805. 5. The criteria for a separate noncompensable rating for a surgical scar of the right knee have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, DC 7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1972 to September 1975. These matters come before the Board on appeal from a March 2016 rating decision issued by a Regional Office (RO) of the United States Department of Veterans Affairs (VA). In August 2019, the Veteran attended a videoconference Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. The issues on appeal were remanded by the Board in a January 2020 decision with instruction to issue a statement of the case under Manlincon v. West, 12 Vet. App. 238 (1999) regarding the petition to reopen the claim for entitlement ot service connection for ischemic heart disease. A statement of the case was issued in March 2020. In his May 2020 substantive appeal, the Veteran requested a hearing before the Board via videoconference. That appeal has been separately docketed, the Board hearing for that appeal will be scheduled at some time in the future, and the appeal will be decided by the Board at a later date in a separate decision, if otherwise warranted. The claim for entitlement to service connection for residuals of a left eye injury was granted on remand, and thus, is no longer before the Board. Pursuant to the January 2020 Board remand instructions the Veteran was afforded VA examination in July 2020. The Board is therefore satisfied that the instructions in its January 2020 remand have been satisfactorily complied with. See Stegall v. West, 11 Vet. App. 268 (1998). In this decision, the Board is granting a separate 20 percent rating for a right knee disability under Diagnostic Code 5258, as discussed below. However, the issue of entitlement to an increased disability rating in excess of 10 percent for service-connected right knee arthritis is REMANDED to the Agency of Original Jurisdiction (AOJ) and is addressed in the REMAND portion of the decision. Increased Rating Disability ratings are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Consideration must be given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Whereas here, the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of the assignment of different ratings for different periods of time, based on the facts found is required. Fenderson v. West, 12 Vet. App. 119 (1999). Because the level of disability may have varied over the course of the claim, the rating may be “staged” higher or lower for segments of time during the period under review in accordance with such variations, to the extent the evidence shows distinct time periods where the service-connected disability have exhibited signs or symptoms that would warrant different ratings under the rating criteria. 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. 38 C.F.R. § 4.40. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Id.; see also 38 C.F.R. § 4.59. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45. 1. Entitlement to an initial rating in excess of 10 percent for left knee arthritis 2. Entitlement to a separate 20 percent rating for a left knee meniscal disorder 3. Entitlement to a separate 20 percent rating for a right knee meniscal disorder The Veteran was initially assigned a 10 percent rating under DCs 5003-5260 for his left knee disability, effective October 21, 2011. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), lateral instability or recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Ratings can also be assigned when the knee disability affects the meniscus, with a 20 percent rating for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint and a 10 percent rating for removal of semilunar cartilage (e.g., meniscectomy) and current residual symptoms. 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259. Ratings can be assigned for impairment of the tibia or fibula, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary 93 (30th ed. 2003). Ratings can be assigned for knee subluxation or instability under Diagnostic Code 5257. 38 C.F.R. § 4.71a. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, including Diagnostic Code 5257, were amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). Prior to February 7, 2021, the Board will consider the old version of the diagnostic codes only; however, for the period beginning February 7, 2021 the Board will consider both the old and amended version (amended code) of the diagnostic code and rate based on whichever is most favorable to the Veteran. Prior to the regulatory change, recurrent subluxation and lateral instability of the knee warranted a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). “Slight,” as relevant to a physical condition, is defined as “small of its kind or in amount.” Merriam-Webster’s Dictionary (merriam-webster.com/dictionary, accessed February 8, 2021). It is similar to “mild,” which is defined as “not severe” or temperate; with “Temperate” being defined as “keeping or held within limits” and “not extreme or excessive.” “Moderate” is defined as “tending toward the mean or average amount,” “not violent, severe, or intense,” and “limited in scope or effect.” Id. “Severe” is defined as “very painful or harmful” or “of a great degree.” Id. The term “severe” is used throughout the rating schedule, including in Diagnostic Code 5257, to indicate a very great degree of the specific listed disability, in order to differentiate between lesser (or sometimes greater) cases of that same disability within the specific diagnostic code. Within the context of Diagnostic Code 5257, which establishes a successive, tiered rating structure, it represents the highest or most extreme level. As of February 7, 2021, Diagnostic Code 5257 contains two sections for rating other impairment of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The first is for recurrent subluxation or instability. The second is for patellar instability. Regarding recurrent subluxation and instability, a compensable rating requires persistent instability. Id.; see also 38 C.F.R. § 4.31. “Persistent” is defined as “continuing or inclined to persist in a course” with “continuing” defined as “constant” and “persist” defined as “to continue to exist.” Merriam-Webster’s Dictionary (merriam-webster.com/dictionary, accessed February 8, 2021). Under these criteria, a 30 percent rating is assigned with unrepaired or failed repair of complete ligament tear which causes persistent instability and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is assigned with either (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation, or (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 10 percent rating is assigned for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device or bracing for ambulation. Lastly, regarding patellar instability, a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker warrants a 30 percent rating, which is the highest allowable rating for patellar instability. A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace, cane, or walker warrants a 20 percent rating. A diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker warrants a 10 percent rating. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. 38 C.F.R. § 4.71a, Diagnostic Code 5257, Note (1). A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Id. Note (2). The February 2016 VA examination report, it was noted that the Veteran had degenerative arthritis and meniscal tears in both knees. At that time the Veteran complained of constant aching pain and difficulty going up and down the steps, sitting with knees bent, squatting, kneeling, and bending. The Veteran’s left knee range of motion was noted to be five degrees extension to 110 degrees flexion. The Veteran performed repetitive use testing with at least three repetitions without additional functional loss or range of motion. There was no history of recurrent subluxation or recurrent effusion and no instability. Examination also revealed pain causing functional loss in flexion and extension as well as pain with weight bearing and on palpation. There was also objective evidence of crepitus. The examination did not indicate malunion of the tibia and fibula. The examiner noted that the function impact would be that activities including climbing ladders, increased standing, driving long distance, kneeling, squatting, and bending would be difficulty for the Veteran. The examiner was unable to say without mere speculation if pain, weakness, fatigability, or incoordination significantly limited functional ability with flareups or with repeated use over a period of time; however, he observed that there was no change in range of motion with repetitive use. Pursuant to the Board remand, the Veteran was afforded another VA examination in July 2020. At that time, the diagnose listed were right knee arthritis with limitation of flexion and extension and meniscal tear status post surgical repair with scars and left knee arthritis with limitation of flexion and meniscal tear status post surgical repair with scars. The Veteran complained of flare-ups where weather makes the pain worse. He also reported that he cannot walk or stand for prolonged periods of time. The Veteran’s left knee range of motion was noted to be from zero degrees extension to 140 degrees flexion. There was no pain noted on exam and no localized tenderness or pain on palpation. Passive range of motion was reportedly the same as active range of motion findings. The Veteran performed repetitive use testing with at least three repetitions without additional functional loss or range of motion. The examiner noted that pain, fatigue, and weakness caused functional loss with repetitive motion and flare-ups, limiting flexion to 130 degrees. There was no history of recurrent subluxation and no instability. There was also objective evidence of crepitus. The examination did not indicate malunion of the tibia and fibula. The examiner also observed the Veteran had frequent episodes or joint locking, pain, and effusion. The examiner also noted that the function impact would be that activities including climbing ladders, increased standing, driving long distance, kneeling, squatting, and bending would be difficulty for the Veteran. The Veteran’s left knee disability is rated under 38 C.F.R. § 4.71a, DC 5003. Under DC 5003, a 10 percent evaluation is appropriate because the left knee is noncompensable under the appropriate diagnostic codes; therefore 38 C.F.R. § 4.59 allows consideration of functional loss for the joint due to painful motion to be rated to at the minimum compensable evaluation of 10 percent. Under DC 5260, the Veteran’s knee disability would be noncompensable because extension is not typically limited, and the Veteran’s flexion is generally limited to no less than 110 degrees. Under DC 5260, evaluations of 10 percent are only warranted for flexion limited to 31-45 degrees, thus as flexion limitation has not been 45 degrees or less, a 10 percent evaluation under DC 5260 has not been warranted for the appeal period. Similarly, the Veteran’s limitation of motion of the left knee does not equate limitation of extension of the leg to 10 degrees or more and as a result a higher rating under Diagnostic Code 5261 is also not warranted. Treatment records do not show greater limitation of motion than the examination findings. Notably, the 2020 VA examiner estimated range of motion during flare-up and after repetitive use over time would be at worst 130 degrees of flexion and 0 degrees of extension. Although the 2016 VA examiner did not provide an estimate, range of motion was unchanged after three repetitive use testing. Given the above, even when considering the knee pain’s impact on physical activities, a higher or separate rating is not warranted based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5260, 5261. A separate rating under DC 5258 is also warranted in this case. As noted in the February 2016 VA examination report, the Veteran experienced a meniscus tear, and has also experienced locking, pain, and effusion in his left knee as reported in the 2020 VA examination report. Under DC 5258, a 20 percent rating is warranted for dislocation of semilunar cartilage, which encompasses a meniscus tear, with frequent episodes of joint locking, pain, and effusion. 38 C.F.R. § 4.71a, DC 5258. As 20 percent is the highest schedular rating for dislocation of semilunar cartilage under DC 5258, there is no basis to award a higher evaluation. The Board has also considered the other diagnostic codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban, 6 Vet. App. at 261-62; Lyles, 29 Vet. App. 107. In this case the evidence does not reflect and the Veteran does not allege that he has tibia or fibula impairment, genu recurvatum, or ankylosis involving the left knee. As such, those diagnostic codes are not for application. Regarding the version of Diagnostic Code 5257 in effect prior to February 7, 2021, a higher or separate rating is not warranted as the evidence is against a finding of the presence of slight lateral instability or recurrent subluxation. Regarding the version of Diagnostic Code 5257 in effect since February 7, 2021, a rating for recurrent subluxation or instability is not warranted because the evidence is against a finding of persistent instability. Notably, diagnostic testing for stability at the 2016 and 2020 examinations did not reveal any instability, which is strong evidence against a finding of persistent instability. Put another way, when multiple medical tests for instability fail to detect instability, constant instability is not present. A compensable rating is not warranted for patellar instability either. The evidence does not show surgical repair involving the patellofemoral complex (quadriceps tendon, the patella, and the patellar tendon), and, as discussed above, the evidence is against a finding of recurrent instability. The competent and probative evidence shows the Veteran has left knee arthritis with painful motion and symptomatic left knee meniscal disorder with frequent episodes of joint locking, pain, and effusion; and the evidence is against a finding of left knee flexion limited to less than 110 degrees or extension limited to more than 5 degrees. Thus, a rating in excess of 10 percent under DC 5003-5260 is not warranted; however, a separate rating of 20 percent is warranted under DC 5258. The Veteran’s right knee arthritis is also rated under DC 5003-5260. As noted above, the Veteran’s right knee arthritis claim is being remanded in this decision for additional development; therefore, the Board will not complete a full analysis on all of the potentially applicable DCs. However, as mentioned above, the record clearly shows entitlement to a separate initial rating under DC 5258 for a right knee disability. Under Diagnostic Code 5258, dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint warrants a 20 percent rating. 38 C.F.R. § 4.71a. At the July 2020 examination, the examiner noted the Veteran’s joint locking, pain, and effusion. Thus, the Board finds that a separate rating is warranted under DC 5258, which contemplates dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion. See Lyles v. Shulkin, 29 Vet. App. 107 (2017). In light of the July 2020 VA examination findings of such, a separate 20 percent rating for a right knee disability under Diagnostic Code 5258 is granted. The Board will consider higher ratings under other applicable codes once the remand development directed below is completed and the claim is readjudicated. 4. Entitlement to a separate noncompensable rating for surgical scar of the left knee 5. Entitlement to a separate noncompensable rating for surgical scar of the right knee With regard to the Veteran’s knee scars, the Board finds that the Veteran is entitled to separate noncompensable ratings for surgical scars of his left and right knees. In this regard, scars are rated under 38 C.F.R. § 4.118, DCs 7800 through 7805. Disfigurement of the head, face, or neck is rated pursuant to DC 7800. In this case, the Veteran’s scar is on her right knee and a rating under this DC is not applicable. DC 7801 pertains to burn scars or scars due to other causes, not of the head, face, or neck that are deep and nonlinear. 38 C.F.R. § 4.118. Under this DC, a 10 percent rating is to be 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). Area or areas of at least 12 square inches (77 sq. cm) but less than 72 square inches (465 sq. cm) is assigned a 20 percent rating. Area or areas of at least 72 square inches (465 sq. cm) but less than 144 square inches (929 sq. cm) is assigned a 30 percent rating. Area or areas of 144 square inches (929 sq. cm) or greater is assigned a 40 percent rating. The Board notes that the evidence of record does not indicate that the Veteran’s surgical scars are deep and nonlinear, or that involves a total area of at least 6 square inches (39 sq. cm). See 2016 and 2020 VA examination reports DC 7802 pertains to burn scars or scars due to other causes not of the head, face, or neck that are superficial and nonlinear. 38 C.F.R. § 4.118. Under this DC, a 10 percent rating is assigned when the scar(s) cover an area or areas of 144 square inches (929 sq. cm) or greater. No other rating is provided by this DC. Note (1) states that a superficial scar is one not associated with underlying soft tissue damage. In this case, it does not appear that the scars have the requisite measurement for a compensable rating under this DC. DC 7804 provides that one or two scars that are unstable or painful warrant a 10 percent evaluation. 38 C.F.R. § 4.118. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. at Note (1). 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. Id. at Note (2). Scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an evaluation under DC 7804, when applicable. Id. at Note (3). Here, it does not appear that the Veteran’s scars are unstable or painful. DC 7805 provides that other scars (including linear scars) and other effects of scars evaluated under DCs 7800, 7801, 7802, and 7804 require the evaluation of any disabling effect(s) not considered in a rating provided under DCs 7800-7804 under an appropriate diagnostic code. 38 C.F.R. § 4.118. Here, the 2016 and 2020 VA examiners noted that the Veteran has three minor scars, with measurement of 1 centimeter by 1 centimeter. Therefore, the Board finds the Veteran is entitled to noncompensable ratings for surgical scars of the left and right knees under DC 7805. REASONS FOR REMAND Entitlement to an initial rating in excess of 10 percent for right knee arthritis is remanded. Remand is warranted as the evidence indicates that the Veteran’s service-connected right knee disability may have worsened since the most recent VA examination. Specifically, the Veteran’s medical records show that, since the last exam, the Veteran has complained of pain on palpation although there was none at the July 2020 VA examination. It was also noted that the physician requested x-ray and follow up with orthopedic. See August 2020 VA treatment records. Therefore, as the evidence reflects that his right knee disability may have worsened, the Board finds that a remand is necessary in order to obtain a new VA examination to ascertain the current severity of his service-connected right knee disability. As the Veteran’s claim is being remanded, the Board requests that the AOJ ensure all available medical records have been obtained and associated with the claims file. The VA’s duty to assist includes obtaining records of relevant VA medical treatment. 38 U.S.C. § 5103A (c)(2); 38 C.F.R. § 3.159 (c)(2), (c)(3). See also Bell v. Derwinski, 2 Vet. App. 611 (1992) (The VA is charged with constructive, if not actual, knowledge of evidence generated by the VA). The matters are REMANDED for the following actions: 1. Obtain and associate with the electronic claims file any outstanding VA treatment records from December 2020 to current to include any right knee x-ray report. Pursuant to 38 C.F.R. § 3.159 (e), any efforts to secure these records MUST be documented in the electronic claims file, and the Veteran must be informed if any of these records are unable to be secured. 2. After any additional records are associated with the claims file, the AOJ should schedule the Veteran for a VA medical examination with an appropriate qualified physician to assess the current severity of his service-connected right knee disability. All necessary diagnostic testing and evaluation should be performed, and all findings set forth in detail. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results, the examiner is asked to describe the nature and severity of any current symptomatology and functional impairment related to the Veteran’s service-connected right knee arthritis. Cynthia M. Bruce Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Williams, 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.