Citation Nr: 21008599 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 15-14 451 DATE: February 17, 2021 ORDER Beginning February 27, 2014, entitlement to an initial disability rating in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD) is denied. Entitlement to an initial disability rating in excess of 20 percent for service-connected left knee meniscal tear with degenerative arthritis (hereafter referred to as a "left knee disability") is denied. Beginning June 21, 2016, entitlement to a separate 20 percent disability rating for moderate instability of the left knee is granted. REMAND Entitlement to total disability based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Beginning February 27, 2014, the Veteran’s service-connected PTSD more closely approximates social and occupational impairment with reduced reliability and productivity. 2. The Veteran’s service-connected left knee disability already manifests dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. 3. Beginning June 21, 2016, the Veteran’s left knee manifests moderate instability. CONCLUSIONS OF LAW 1. Beginning February 27, 2014, the criteria for entitlement to an initial disability rating in excess of 50 percent for service-connected PTSD are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for entitlement to an initial disability rating in excess of 20 percent for service-connected left knee disability are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5258. 3. Beginning June 21, 2016, the criteria for entitlement to a separate compensable rating for moderate left knee instability are met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1967 to April 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. A Board hearing was conducted via video conference with the ROs in Nashville, Tennessee, and Johnson City, Tennessee. A transcript of this hearing is contained within the electronic claims file. See September 7, 2018, Hearing Transcript (Tr.). In a September 2019 decision, the Board dismissed, prior to February 27, 2014, entitlement to an initial disability rating in excess of 10 percent for the Veteran’s PTSD and remanded the remaining issues, all pursuant to the Veteran’s request. For the remanded issues, the Veteran requested that the RO review in the first instance the evidence added to the claims file since the most recent supplemental statement of the case (SSOC). In an August 2020 SSOC, VA reviewed that evidence and continued the denial of these claims. Thus, the Board finds that VA substantially has complied with its remand directives and now may proceed with adjudication of the merits. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). Increased Rating Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3. PTSD For psychiatric disabilities, a 100 percent disability rating contemplates 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. 38 C.F.R. § 4.130. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, 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 an 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); and inability to establish and maintain effective relationships. A 50 percent rating is warranted for 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/or difficulty in establishing and maintaining effective work and social relationships. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant a particular rating, but are not meant to be exhaustive, and the Board need not find all, or even some, of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442–43 (2002). If the evidence shows that a veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a specific rating, the appropriate, equivalent rating will be assigned. Id. at 443. The rating code requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment at a level consistent with the assigned rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116–17 (Fed. Cir. 2013). VA is precluded from differentiating between the symptoms of the Veteran’s service-connected PTSD and those of her other mental disorders in the absence of clinical evidence that clearly shows such a distinction. See Mittleider v. West, 11 Vet. Ap. 181, 182 (1998). Furthermore, because all psychiatric disorders, with the exception of eating disorders, are evaluated under the General Rating Formula for Mental Disorders, a single evaluation will be assigned that encompasses all of the Veteran’s overlapping psychiatric symptoms, however diagnosed. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009). The Veteran originally was awarded service connection for PTSD via a December 2013 rating decision; he was assigned a 10 percent disability rating effective June 10, 2013. The Veteran timely appealed the rating with his December 2013 Notice of Disagreement (NOD). During the pendency of the appeal, in a March 2016 rating decision, the Veteran’s rating was increased to 50 percent effective February 27, 2014. As noted above, the Veteran, at his hearing, requested to withdrawal entitlement to an initial rating in excess of 10 percent prior to that date. Thus, the only issue before he Board with respect to PTSD is entitlement to an initial rating in excess of 50 percent beginning February 27, 2014. A March 2016 VA examination report noted mental examination of the Veteran and review of the claims file and recited the Veteran’s complaints and medical history. The examiner indicated that the Veteran had occupational and social impairment with reduced reliability and productivity. Observed symptoms were depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. With respect to the Veteran’s social history, he gets along well with his current wife of thirty-six years, but does not have a relationship with his son or ex-wife; the Veteran maintains a relationship with his grandson, whom he sees often, via his son’s former wife. The Veteran denied social outlets, except for church, due to suspiciousness and no longer enjoys working on cars. The Veteran does not enjoy being outside for fear of being triggered by events of Vietnam but does enjoy watching television. The Veteran reported sporadic contact with some friends. The Veteran is seventy years old and has not worked since his retirement. In an April 2016 correspondence, the Veteran stated, in pertinent part: I have nightmares and flashbacks at night and can set very startled responses slinging my alarm and hollering. I don’t have any social interactions. I avoid crowds [of] people and any situations that [do not] provide me with a way out or exit or escape. I don’t want or feel like [interacting] with people or anyone. I constantly think about things when I was in Vietnam. [E]xperiences I had [have] become progressive[ly] worse in the last two [years]. In the last [year] or so it may [inhibit] my abilities to perform everyday functions. I can’t remember to do things or complete things I have started. I lose all train of thought. I have sever[e] panic attacks on a weekly [basis]. I relive all my experiences daily. When I was in Vietnam because of this I’m very fatigued and feeling very much like something bad [is] going to happen. Continuous feeling of [uncertainty] and fear. I prefer isolation to social activities and [restrict] my movement to my home and on [occasion] go out with my wife as long as we’re not in crowds and then I get agitated stressed. At his hearing, the Veteran testified that he stopped working due to his psychiatric condition. See Tr. at 10–11. He also testified that his social activities are limited to church and that, within the past year, he has had thoughts of suicide. Id. at 13, 15. VA mental health clinical records span for the period on appeal through August 2020 and show that the Veteran routinely attend biweekly–monthly mental health counseling appointments. A review of those appointments shows that the Veteran habitually reported problems sleeping, frequent nightmares about his time in Vietnam, and anxiety. The records also reveal that the Veteran enjoys a good relationship with his wife, enjoys doing things outside, and continually denied any suicidal or homicidal ideation. Reviewing the relevant evidence, the Board does not find that, beginning February 27, 2014, an initial disability rating in excess of 50 percent for the Veteran’s service-connected PTSD is warranted. First, most, if not all, of the Veteran’s psychiatric symptoms noted on the March 2016 VA examination are symptoms contemplated by a 50 percent or lower rating. True enough, the Veteran testified that he experienced suicidal ideation within the past year. See Tr. 10–11. While the United States Court of Appeals for Veterans Claims (Court) has held that there is no distinction between passive and active thoughts of suicide and that suicidal ideation alone can serve as the basis for a 70 percent rating under the rating criteria, Bankhead v. Shulkin, 29 Vet. App. 10, 19–20 (2017), the Board does not find the Veteran’s testimony credible on this point. A review of the VAMC records shows that the Veteran, at every turn, denied any suicidal ideation. These affirmative denials of suicidal ideation lead the Board to conclude that the Veteran’s testimony is not credible. See Buchanan v. Nicholson, 451 F.3d 1331, 1336–37 (Fed. Cir. 2006) (holding that the Board may weigh the absence of contemporaneous medical evidence against lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence). On this point, the Board stresses that it is not rejecting the Veteran’s testimony merely because it is unaccompanied by contemporaneous medical evidence. To the contrary, the Veteran’s hearing testimony directly contradicts the contemporaneous medical evidence of record where the Veteran affirmatively denied experiencing any such suicidal ideation. Contradiction of evidence is not the same thing as the absence of evidence. It is for that reason that Board does not find credible the Veteran’s statements. With respect to the Veteran’s social functioning, the Board is not persuaded that he experiences at least deficiencies in most areas. The record reveals that he has a great relationship with his wife and grandson, has a few friends with whom he sporadically interacts, attends church, and enjoys some outside activities. While the Veteran largely prefers to be indoors and to avoid crowds, the Board finds that that preference, in and of itself, has not led to a near-complete breakdown in the Veteran’s social interaction/relationships. 38 C.F.R. § 4.130, DC 9411. With respect to occupational functioning, the only evidence to suggest that the Veteran’s psychiatric condition has impacted his ability to work is his testimony that he stopped working due to his PTSD. The Board concedes that the Veteran’s PTSD obviously impacts his ability to function occupationally; however, it does not believe that it affects it so severely as to warrant an increase in the Veteran’s rating. Indeed, the Veteran indicated on his application for TDIU that it was his PTSD and cardiac condition that caused him to no longer be employable. Thus, the Board finds that the Veteran’s PTSD has not caused occupational and social functioning above reduced reliability and productivity. Id. The Board is mindful that the Veteran’s representative has argued that the Veteran’s conditions have worsened, requiring an updated VA examination. See July 13, 2017, VA Form 646. Where the record does not adequately reflect the current state of a veteran’s disability, fulfillment of the statutory duty to assist requires a contemporaneous medical examination, particularly if there is no additional evidence that adequately addresses the level of impairment of the disability since the last examination. Allday v. Brown, 7 Vet. App. 517, 526 (1995); Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a). Here, however, the Board, is satisfied that a new examination is not warranted. The last psychiatric examination was performed in March 2016, and, as discussed, the claims file is replete with VAMC records—up until six months ago—disclosing the Veteran’s routine psychiatric appointments. To order a new examination would be to waste resources to tell the Board what it already can discern from these records. Considering the abundant evidence already available to the Board, it does that there is a sufficient basis upon which to evaluate the Veteran’s PTSD. Thus, no updated examination is warranted. See Allday, 7 Vet. App. at 526. The Left Knee A veteran may receive more than one compensable rating for different conditions of the same knee. Thus, the Board will discuss all applicable rating criteria for the knees. See VAOPGCPREC 09-04; VAOPGCPREC 23-97. With normal range of motion, the knee has extension to 0 degrees and flexion to 140 degrees. 38 C.F.R. § 4.71a, Plate II. DC 5256 is assignable for ankylosis of the knee. Extremely unfavorable ankylosis with in flexion at an angle 45 degrees or more carries a 60 percent disability rating. Unfavorable ankylosis with in flexion between 20 degrees and 45 degrees warrants a 50 percent disability rating. A 40 percent disability rating requires unfavorable ankylosis with in flexion between 10 degrees and 20 degrees. A 30 percent disability rating contemplates favorable ankylosis at an angle in full extension or in slight flexion between zero degrees and 10 degrees. Under DC 5257, severe, moderate, or slight recurrent subluxation or lateral instability warrants either a 30, 20, or 10 percent disability rating, respectively. DC 5258 permits a 20 percent disability rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint, and DC 5259 permits a 10 percent rating for symptomatic removal of the semilunar cartilage. DC 5260 is applicable for limitation of flexion of the knee. To qualify for a 30 percent disability rating, flexion must be limited to 15 degrees or less. A 20 percent disability rating requires flexion limited from 16 to 30 degrees. A 10 percent disability rating requires flexion limited to 45 degrees. DC 5261 is applicable for limitation of extension of the knee. To qualify for a 50 percent disability rating, extension of the leg must be limited to 45 degrees or more. A 40 percent disability rating requires extension of the leg be limited from 44 to 30 degrees. A 30 percent disability rating requires extension of the leg be limited from 29 to 20 degrees. A 20 percent disability rating requires extension of the leg be limited from 19 to 15 degrees. A 10 percent disability rating requires extension of the leg be limited from 14 to 10 degrees. Limitation to 5 degrees is rated as noncompensable. DC 5262 is assignable for impairment of the tibia and fibula. For nonunion of either with loose motion requiring a brace, a 40 percent disability rating is warranted. For malunion of the tibia or fibula with either marked, moderate, or slight knee or ankle disability, a 30, 20, or 10 percent disability rating is warranted, respectively. Genu recurvatum, (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated), DC 5263, warrants a 10 percent disability rating. When assessing the severity of musculoskeletal disabilities that are, at least partly, rated on the basis of limitation of motion, VA also must consider the extent that a veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when a veteran’s symptoms are most prevalent (“flare-ups”) due to the extent of his or her pain (and painful motion), weakness, premature or excess fatigability, and incoordination, assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204–07 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59. The Veteran originally was awarded service connection for his left knee disability via an October 2016 rating decision; he was assigned a 20 percent rating under DC 5258, effective June 21, 2016. The Veteran timely appealed his rating in a November 2016 NOD. An August 2016 VA examination report noted physical examination of the Veteran and review of the claims file and recited the Veteran’s complaints and medical history. The Veteran reported flare-ups in the left knee, which he described as aggravation of symptoms in climbing stairs, walking up a hill, mowing the yard, etc. Flare-ups caused functional loss described as increased pain and occasional swelling with increased use of knee as referenced above. Left knee flexion was limited to 125 degrees, but extension was normal; however, both ranges of motion caused pain. There was moderate point tenderness over the lateral joint line, pain on weight bearing, and no evidence of crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions, but it resulted in decreased flexion to 120 degrees due to lack of endurance. While the Veteran was not observed after repeated use over time, the examiner determined that, due to pain and lack of endurance, the Veteran’s functional ability would reduce, but the examiner could not equate that reduction in terms of range of motion lost because the Veteran would need to be observed under such conditions. The Veteran was not observed after repeated use over time, the examiner determined that, due to pain and lack of endurance, the Veteran’s functional ability would reduce, but the examiner could not equate that reduction in terms of range of motion lost because the Veteran would need to be observed under such conditions. Left knee extension and flexion muscle strength were noted as 4/5. There was no muscle atrophy, ankylosis, or tibial and/or fibula impairment. The examiner noted that the Veteran’s left knee experienced slight recurrent subluxation, moderate instability, and a history of effusion. Interestingly, however, the examiner noted that, upon joint stability testing, the Veteran’s left knee was normal. The report also notes the Veteran’s meniscal tear, which produces frequent episodes of joint locking, pain, and effusion. No assistive devices were noted. Imaging studies were performed, which documented degenerative arthritis in the left knee. With respect to occupational impact, the examiner stated the Veteran would experience pain and swelling in his left knee if required to walk more than a quarter mile or if required to stand for thirty-five–forty minutes. A July 2017 VA examination report noted physical examination of the Veteran and review of the claims file and recited the Veteran’s complaints and medical history. The Veteran reported flare-ups in the left knee, which he described as occurring with sitting and driving/riding more than ten minutes; prolong standing greater than two–three minutes, walking more than 200 feet, lifting/carrying more than three–four pounds. The Veteran must change positions every five–ten minutes; avoids working overhead and pushing/pulling; and is unable to squat/kneel, climb ladders, or operate foot controls. These flare-ups occur daily and last anywhere from forty-five minutes–twelve hours and are alleviated only by ceasing activity, ice, rest, and medication. Left knee flexion was limited to 85 degrees, but extension was normal; however, both ranges of motion caused pain. There was moderate–severe pain that was intermittently continuous, pain on weight bearing, and crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions, which did not result in decreased range of motion. After repeated use over time, pain, fatigue, weakness, lack of endurance, and incoordination all limited functional ability, but did not result in a decrease in range of motion. The Veteran was not observed during a flare-up, but the examiner indicated that it would not cause a decrease in the Veteran’s range of motion. Left knee extension and flexion muscle strength were noted as 4/5. There was no muscle atrophy, ankylosis, tibial and/or fibula impairment, or recurrent subluxation or instability. The report also notes the Veteran’s meniscal tear, which produces frequent episodes of joint pain and effusion. No assistive devices were noted. No additional imaging studies were performed. VAMC records show the continued care and treatment for the Veteran’s left knee. 1. Entitlement to an initial disability rating in excess of 20 percent for service-connected left knee disability is denied. As noted above, DC 5258 is used for rating meniscal conditions. The Veteran currently receives the highest schedular rating (20 percent) for his service-connected left knee disability, so a higher rating under this DC is denied. See 38 C.F.R. § 4.71a, DC 5258. Even considering the Veteran’s pain he may experience in his left knee, he already is receiving the maximum schedular rating for this condition, which adequately accounts for pain. Thus, no higher rating may be awarded. See DeLuca, 8 Vet. App. 202, 204–07 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5258. 2. Beginning June 21, 2016, entitlement to a separate 20 percent rating for moderate instability of the left knee is granted. While the Veteran may not be entitled to a higher rating under DC 5258, the record reveals that his entitled to a separate rating for other symptoms of his left knee. See VAOPGCPREC 09-04; VAOPGCPREC 23-97. The United States Court of Appeals for Veterans Claims (Court) has held that a veteran be assigned ratings under either DC 5257 or 5261 (or both) and 5258 or 5259. Lyles v. Shulkin, 29 Vet. App. 107, 114, 116 (2017) (“Significantly, § 4.71a does not expressly prohibit separate evaluation under DC 5257 or 5261 and a meniscal DC.”). The August 2016 VA examination noted that the Veteran experiences slight subluxation and moderate instability. While the July 2017 VA examination report is contradictory, but upon testing indicates a diagnosis of lateral instability. Based on this evidence, the Board finds that, beginning June 21, 2016, entitlement to a separate 20 percent rating for moderate instability of the left knee is warranted. See 38 C.F.R. § 4.71a, DC 5257. A rating in excess of 20 percent, however, is not warranted. The VA examinations are the only pieces of evidence that discuss the Veteran’s instability. Without any sort of evidence—lay or medical—that discusses the frequency or severity of the Veteran’s instability, the Board can rely on only these examinations. Thus, only a 20 percent rating is warranted for moderate instability. The Board wishes to discuss one further point about the rule against pyramiding. This rule states that the evaluation of the same disability under various diagnoses is to be avoided. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation. 38 C.F.R. § 4.14. When determining whether separate ratings are applicable, the critical element is that none of the symptomatology for any condition is duplicative of or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261 (1994). The rationale for the prohibition on pyramiding is that “the rating schedule may not be employed as a vehicle for compensating a claimant twice (or more) for the same symptomatology” because “such a result would overcompensate the claimant for the actual impairment” in earning capacity suffered. Lyles, 29 Vet. App. at 113 (quoting Brady v. Brown, 4 Vet. App. 203, 206 (1993)). Although the Veteran has documented arthritis and painful, limited motion, a separate award for such cannot be granted. As noted above, a 20 percent rating under DC 5258 requires “frequent episodes of ‘locking,’ pain, and effusion into the joint.” The symptoms are conjunctive because of the word “and,” meaning that all three symptoms must be present for the Veteran to qualify for this rating. Thus, the Veteran currently is compensated for the pain he experiences in his knee. Unless the Veteran objectively meets the criteria for a separate rating based on limitation of motion, he cannot be awarded one, as to do so would violate the rule against pyramiding. Thus, the Board is satisfied that the Veteran’s pain, even due to arthritis, adequately has been considered in his current ratings. See DeLuca, 8 Vet. App. at 204–07; 38 C.F.R. §§ 4.40, 4.45, 4.59. REASONS FOR REMAND In light of the award herein for the separate 20 percent rating, and to preserve the Veteran’s right to “one review on appeal,” the Board finds it proper to remand the issue of entitlement to TDIU so that the RO may take into consideration his additional disability, so as to give him every benefit of the doubt in obtaining a TDIU rating. See 38 U.S.C. § 7104(a); 38 C.F.R. § 20.904(a). 1. Obtain any ongoing VA treatment records. Should they exist, associate them with the claims file. 2. Conduct any other development deemed necessary and then readjudicate the Veteran’s claims. The Veteran has the right to submit additional evidence and argument on the matter that the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369, 372 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded for additional development or other appropriate action by the Board or United States Court of Appeals for Veterans Claims must be handled in an expeditious manner. 38 U.S.C. §§ 5109B, 7112. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Trevor T. Bernard, 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.