Citation Nr: 21008888 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 16-43 943 DATE: February 18, 2021 ORDER Entitlement to an increased evaluation in excess of 70 percent for the Veteran’s posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for gastroesophageal reflux disease (GERD) to include as due to an undiagnosed illness is remanded. Entitlement to service connection for sleep apnea to include as secondary to PTSD is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDING OF FACT The Veteran’s PTSD symptoms have not manifested in severity that results in total occupational and social impairment. CONCLUSION OF LAW The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. § 1155, 5103, 5107, 38 C.F.R. § 3.102, 3.159, 4.7, 4.124(a), 4.130, DC 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in active duty service with the Army from April 1989 to April 1992 to include service in Southwest Asia. This matter is on appeal from an August 2014 rating decision. The Veteran was afforded a February 2019 hearing before the undersigned Judge. A transcript of the hearing has been associated with the claims record. The Board remanded this appeal in July 2019 for additional development. The Board notes that the July 2019 BVA decision increased the Veteran’s PTSD to 70 percent effective October 27, 2009 encompassing the appeal period, and remanded the matter of entitlement to a higher rating. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). Increased Rating A disability rating is determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155 ; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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 claimant. 38 C.F.R. § 4.3. The Board will consider whether separate ratings may be assigned for separate periods of time based on the facts found, a practice known as “staged ratings.” Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442 ; see also Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran’s impairment must be “due to” those symptoms, a veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107 ; 38 C.F.R. § 3.102 ; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Posttraumatic stress disorder (PTSD) The Veteran is currently service connected for PTSD evaluated at 70 percent under Diagnostic Code 9411. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustments during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on the social and occupational impairment, rather than solely on the examiner’s assessment of the level of disability at the time of examination. The rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. A 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Lastly, a 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: 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 closes relatives, own occupation, or own name. See 38 C.F.R. § 4.130, DC 9411. The “such symptoms as” language means “for example,” and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The list of examples provides guidance as to the severity of symptoms contemplated for each rating. Id. However, this fact does not make the provided list of symptoms irrelevant. See Vasquez-Claudio v. Shinseki, 713 F.3d 112, 11617 (Fed. Cir. 2013). The Veteran must still demonstrate either the particular symptoms associated with the rating sought, or other symptoms of similar severity, frequency, and duration. Id. at 117. Review of the medical treatment record shows in November 2009 the Veteran reported that he was doing “pretty good I guess…” The Veteran was observed as appropriately addressed and “unchanged” from previous visits. The Veteran was noted to be with somewhat restricted affect and to be on edge; the Veteran demonstrated fair insight and judgement with no abnormal thought. The Veteran denied suicidal and homicidal ideation. In January 2011 the Veteran was seen for a mental health followup; the Veteran stated that “They told me I couldn’t get my medication refills unless I cam in for an appointment. I have got to have my anxiety medicine!” The Veteran stated that he lives with anxiety, depression, and “all that mess.” The Veteran was observed to be unchanged in appearance since his last visit with an anxious mood with congruent and somewhat labile affect. The Veteran demonstrated fair insight and judgement with no abnormal thought. The Veteran denied suicidal and homicidal ideation. In an April 2011 psychiatric followup note, the Veteran reported that “I’m doing … pretty good I guess.” The Veteran was observed with an unchanged appearance and mood described as “pretty good I guess” with congruent affect. The Veteran demonstrated fair insight and judgement with no abnormal thought. The Veteran denied suicidal and homicidal ideation. In a later April 2011 social work initial evaluation, the Veteran reported “I’ve been having a lot of anxiety issues” and having problems with anxiety and depressed moods for the last 10 years. The Veteran identified several sources of stress to include family, work, the military, VA claims, and the IRS. The Veteran stated that he would get anxiety attacks and nervousness where it felt like his heart was racing; the Veteran noted that his anxiety attacks were “sporadic … comes and goes… maybe one a week and maybe I won’t have one for 3 weeks” and also that these attacks rarely occurred when he was at work. The Veteran denied any other significant current depression or history of suicidal and homicidal ideation. The Veteran stated that he currently works as a correctional officer for the past 17 years as well as a part time security position. The Veteran stated that he owes the IRS 29 thousand dollars for not filing taxes since he left the military in 1992. In a July 2011 social work note followup, the Veteran reported no significant change or particular distress. The Veteran discussed ongoing stressors to include “the bills, the stress of the job” and concern about his health. In a November 2011 psychiatry note the Veteran reported that he was “pretty good, I’m doing alright for the most part.” The Veteran noted that he was feeling more “anxious” but admitted that he was only taking his prescribed medication “every now and then” despite instructions for daily compliance. The Veteran was observed to be unchanged in appearance with a somewhat frustrated and argumentative mood and affect. The Veteran demonstrated limited to fair insight and judgement with no abnormal thought content. The Veteran denied suicidal and homicidal ideation. In a December 2011 social work note, the Veteran reported “I guess I’m doing alright” and continued to work full time at the correctional facility. The Veteran stated that the prescribed medication and exercised helped; and although the Veteran reported some depressed moods and “a lot of stress”, the examiner found the Veteran’s mood was stable. In a July 2013 psychiatric note, the examiner noted that they had last seen the Veteran in November 2011. The Veteran noted that it had “been a while” but reported his symptoms of anxiety had worsened and identified symptoms of anxiety, worry and stress resulting in anxiety attacks with physical symptoms such as hyperventilating. The Veteran was observed to be appropriately groomed with an anxious mood and appropriate affect. The Veteran denied suicidal or homicidal ideation. In a September 2013 social work note followup, the Veteran reported that he no longer worked at the part time security position but recently was promoted at his job at the correctional facility. The Veteran noted that he continued to work “5 days on/5 days off” from 6 AM to 6 PM with about 4 to 5 hours of sleep. The Veteran denied any particular distress other than disappointment with VA claim on appeal and noted he and his wife were exploring retirement options. In an October 2013 statement from the Veteran’s wife, she stated that their marriage has suffered with the Veteran’s severe panic attacks “feeling like he’s dying” and sleepless nights where he wakes up in a cold sweat. The Veteran’s wife noted that the Veteran also “sleeps all the time and [is] constantly tired …even after plenty hours of sleep.” The Veteran was afforded a February 2014 VA examination. The Veteran reported a good relationship with his parents and is somewhat close to his other siblings. The Veteran stated that he has been married since 1998 with a good relationship and doing pretty well. The Veteran stated that his mother has noted that he sometimes loses his focus and concentration. The Veteran reported having some friends, but they rarely got together as he typically declines their invitations. The Veteran stated that for the past 20 years he has worked at the correctional facility; the Veteran stated that he gets along well with people and does not miss work. The Veteran noted that for the past 5 years he has noticed trouble doing his reports because of difficulty with concentration and focus and others have noticed that “sometimes [the Veteran’s] sentences in reports do not flow or make sense.” The Veteran reported symptoms of markedly decreased interest in leisure activities; detachment and withdrawal from his wife and others; hypervigilance and exaggerated startle; problems with concentration; difficulty making decisions; sleep impairment and low energy; and increased irritability. The examiner noted the Veteran was currently “preoccupied with the experiences he has been having dealing with compensation claims with the VA.” The Veteran expressed frustration with the claims process with his mood observed to be dysphoric and frustrated; the Veteran attributed his down mood to his frustration with VA. The Veteran’s affect was noted to be full range with the ability to laugh at points. The Veteran was observed to be alert and oriented but was noted to have missed an appointment because he incorrectly remembered the month or days it was scheduled. The Veteran’s thought processes were organized with no hallucinations or delusions. The Veteran’s remote and short-term memory were found to be slightly impaired. The Veteran demonstrated grossly intact concentration with reports that he would often become distracted by his thoughts about the war and his struggles with VA. The Veteran reported sleep trouble, noting that he works the night shift at work “five days on and five days off”; the Veteran’s difficulty maintaining his sleep schedule cause him to be “tired all the time” and result in difficulty with concentration and focus. The Veteran reported having panic attacks every three days characterized by difficulty breathing, tightness in his chest and feeling hot and jittery which leaves him drained afterwards. The examiner found the Veteran with symptoms of depressed mood; anxiety; panic attacks occurring weekly or less often; near continuous panic or depression; chronic sleep impairment; mild memory loss; and difficulty establishing and maintaining relationships. The examiner found the Veteran’s symptoms resulted in occupational and social impairment with occasional decreased in work efficiency and intermittent periods of inability to perform occupational tasks but able to generally functional satisfactorily with normal routine behavior, self-care and conversation. In a September 2014 psychiatry note, the Veteran reported that “I’m hanging in there.” The Veteran stated that he continues to have stress from his job working the night shift at the correctional facility and from his wife. The Veteran was observed to be appropriately groomed with a self-contemplative mood and appropriate affect. The Veteran demonstrated no abnormal thought process and denied suicidal and homicidal ideation. In a March 2015 psychiatry note, the Veteran reported that “I didn’t make this [appointment]… [the provider] thought I needed it I don’t really know why.” The Veteran initially did not report any new complaints, but when prompted, stated that he continued to have anxiety. The Veteran reported having “weird dreams of death” but noted that he recently attended a funeral. The Veteran was observed to be appropriately groomed with cooperative mood and appropriate affect. No abnormal though process was found, and the Veteran denied suicidal and homicidal ideation. In a March 2016 psychiatry note, the Veteran reported “Yeah, I got problems” and indicated that his anxiety medication was not working. The Veteran endorsed worsening anxiety, panic attacks, PTSD and nightmares. In a separate March 2016 social work note, the Veteran reported that “there really ain’t nothing you can do for me” and continued difficulty coping with stress, poor concentration, avoidance behaviors, and “dreams about dying.” The Veteran did not endorse any significant depression, suicidal or homicidal ideation. The Veteran noted that he retired last year from a 20-year career as a correctional officer. The Veteran was observed to be appropriately groomed with a cooperative mood and appropriate affect congruent to mood. The Veteran did not demonstrate abnormal thought process and denied suicidal or homicidal ideation. In a May 2016 psychiatry note, the Veteran presented with complaints of PTSD and panic attacks occurring most days. The Veteran described his panic attacks as accompanied by symptoms of shortness of breath, chest tightness, “sense of impending doom”, diaphoretic, flushing, and dizziness that lasts 15 to 30 minutes and also resulted in several emergency room visits. The Veteran also noted having nightmares, avoidance symptoms, poor concentration, irritability and insomnia. The Veteran reported a “so-so” marriage with few friends. The Veteran noted that he retired when the prison he worked at closed in 2015. The Veteran was observed to be alert and oriented, and relaxed with a broad range of affect. The Veteran demonstrated linear and logical thought process with fair judgement. The Veteran denied suicidal and homicidal ideation. In a separate May 2016 psychology consultation, the Veteran reported “I didn’t want to be here. I could be home sleeping. [The provider] told me to come; after a long debate with him I agreed to come, but there’s no reason for me to be here.” The treating provider noted the Veteran presented with severe anxiety attacks occurring once daily on average; generalized anxiety; and PTSD symptomology. The Veteran reported possible exacerbation following his retirement in 2015 after working 20 years as a correctional facility officer. The Veteran also reported long-standing anger, bitterness and resentment regarding denials, delays and frustration with his VA claims. The provider noted the Veteran reported negative alterations in mood to include chronic dysphoria, anger, anhedonia, an inability to experience positive feelings; issues with cognition where the Veteran felt “perpetually unsafe and [blamed] the VA system for perpetuating his distress”; and symptoms of hyperarousal marked by irritability, hypervigilance, excessive startle, decreased concentration and sleep disturbance. The Veteran reported a close relationship with his mother and a more distant relationship with his father. The Veteran stated that he is married for 18 years with a history of marital strain secondary to his unstable mood, irritability, PTSD symptoms, and social withdrawal. The Veteran noted that he had a history of bankruptcy in 2014 secondary to debt related to unpaid income tax. The Veteran reported frequent panic attacks that occur daily and were severe enough to result in emergency room visits “due to the Veteran’s fear that he was dying.” The Veteran was observed to be appropriately groomed with a mood that was “irritable, anxious, and angry.” The Veteran’s affect was noted to be appropriate, angry, anxious and anhedonic. The Veteran’s thought content was preoccupied but otherwise demonstrated normal and linear thought flow. The Veteran demonstrated fair insight and good judgement and denied suicidal and homicidal ideation. In a June 2016 psychotherapy note, the Veteran reported a significant improvement in mood and anxiety symptoms in response to prescribed medication and stated that he has been able to avert full blown panic attacks. The Veteran stated that he continues to have some bad days with increased irritability, depressed mood, intolerance of social interaction, and withdrawal; the Veteran noted having distressing dreams “in which he is dying.” In general, the Veteran reported improved mood and outlook with increased hope in his VA claims, improved self-care and enjoyment in his life. The Veteran’s mood and affect were observed to be euthymic to mildly dysphoric, much brighter, less anxious and irritable, and negative for suicidal and homicidal ideation. In an August 2016 psychotherapy note, the Veteran reported having more good days than bad days but noted he had a panic attack this past weekend and went to the emergency room; the treating provider noted the Veteran later stated that the emergency room visit was over fears “that he was having an allergic reaction to salmon.” The Veteran’s mood and affect were observed to be euthymic to anxious with increased range and negative for suicidal and homicidal ideation. In a September 2016 psychotherapy note, the Veteran reported worsening dysphoria to include anxiety, irritability, depressed mood, sleep disturbance, and increased social withdrawal and isolation. in the past 2 weeks. The Veteran was unable to identify a precipitating event but noted that he was “feeling intolerant of his wife’s behavior which he described as worried, volatile and controlling.” In an October 2016 psychotherapy note, the Veteran continued to complain of significant dysphoria to include anxiety, irritability, depressed mood, sleep disturbance, social withdrawal, and isolation. The Veteran stated that he continues to feel overwhelmed and preoccupied with anxiety regarding his and his wife’s medical problems. The treating provider noted the Veteran remained “consumed” with anger regarding denied compensation claims. The Veteran’s mood and affect were observed to be anxious and agitated, but brighter at times with increased energy and range. The provider did not find evidence of suicidal and homicidal ideation. In a November 2016 psychotherapy note, the Veteran reported ongoing generalized anxiety and increased frequency of panic attacks; the Veteran stated having 4 such panic attacks in the past week. The Veteran associated his symptoms with preoccupation with medical problems and “fears that he is dying.” The Veteran’s mood and affect were observed to be anxious but brightening at times. The provider did not find evidence of suicidal and homicidal ideation. In a December 2016 psychotherapy note, the Veteran continued to report generalized anxiety associated with medical problems and “fears that he is dying”; however, the Veteran reported a decrease in the frequency of panic attacks since the last session to only once a week. The Veteran reported that in general he has been feeling more depressed, discouraged and fatigued in the context of worsening marital discord; the Veteran stated that he uses avoidance-based coping and stays in bed to avoid his stressors. In a separate December 2016 psychiatry note, the Veteran reported “I’ve had 5 ER visits and 2 emergency Dr. visits because of my panic. I need something. The treating provider noted the Veteran continued to struggle with severe anxiety and PTSD symptoms to include regular nightmares and insomnia, avoidance, irritability, and frequent panic symptoms. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran demonstrated logical thought process and fair judgement with no evidence of delusional, obsessive patterns or paranoia. The Veteran denied suicidal and homicidal ideation, and the provider deemed the Veteran as safe and at low risk. In a January 2017 psychotherapy note, the Veteran reported that his holiday season was free of panic attacks and had decreased generalized anxiety related to prescribed medication. The Veteran continued to voice his preoccupation with medical problems and “fears that he is dying”; the Veteran did report a decrease in marital discord. The Veteran’s mood and affect were found to be euthymic to mildly anxious, brighter and with increased range. The treating provider did not find evidence of suicidal and homicidal ideation. In a separate January 2017 psychiatry note, the Veteran stated, “It’s not working.” The Veteran stated that he continued to struggle with severe anxiety symptoms and PTSD symptoms to include avoidance, irritability, frequent panic symptoms and nightmares. The Veteran’s wife stated that “[the Veteran] isn’t doing anything.” The treating provider noted the Veteran “lies in bed all day and suffers lots of anxiety and somatic symptoms”; the Veteran indicated that he was not taking his prescribed medication and was “overwhelmed with anxiety that he does nothing but worry.” The Veteran was observed to ba appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In a February 2017 psychotherapy note, the Veteran presented with much improved mood and outlook with decreased generalized anxiety and freedom of panic attacks in the past week. The treating provider noted these improvements as secondary to the Veteran’s prescribed medication. The provider noted the Veteran as taking charge of treatment to include exercise, meditation and applying for jobs and volunteer work to increased daily structure. The Veteran’s mood and affect were euthymic to mildly anxious, bright with broad range. The provider did not find evidence of suicidal or homicidal ideation. In a February 2017 private mental examination, the Veteran reported symptoms of daily panic attacks; generalized anxiety; intrusive memories, nightmares and flashbacks; negative alterations in mood and motivation; irritability exaggerated startle and hypervigilance; and sleep disturbance. The private examiner found the Veteran’s symptoms would interfere or rendered the Veteran unable to maintain a persistent pace to engage in employment and moderately impaired the Veteran’s activities of daily living and social function. The examiner further noted the Veteran would miss work twice a month due to his symptoms. In a March 2017 psychotherapy note, the Veteran reported recurrence of more severe generalized anxiety to include severe worry, rumination and hypochondriasis, and depressed mood in the past month. The Veteran stated that he has managed his symptoms with medication and “averted severe panic attacks or ER visits.” The Veteran stated that he has decreased engagement in health self-care with physical exercise and noted escalating discord with his spouse whom he complains as “unsympathetic to and dismissive of his symptoms and psychological suffering.” The Veteran’s mood and affect were anxious and depressed and more constricted; there was no evidence of suicidal and homicidal ideation. In a separate March 2017 psychiatry note, the Veteran stated, “I’m not doing as well.” The Veteran complained of poor energy and avoidance symptoms and has stopped going to the gym and looking for work. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In an April 2017 psychotherapy note, the Veteran reported “good days and bad days” overall; the Veteran stated the bad days were marked by generalized anxiety with severe worry, rumination and hypochondriasis, and depressed mood. The Veteran’s mood and affect were found to be moderately anxious, depressed and fatigue with some increase in range. There was no evidence of suicidal and homicidal ideation. In a June 2017 psychiatry note, the Veteran stated, “I’m doing alright” and described constant anxiety that worsened in certain situations such as crossing bridges and groups of people. The Veteran noted that walking daily was helpful and was currently applying for part-time jobs. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In a separate June 2017 psychiatry note, the Veteran stated, “I got a job” and indicated that he has obtained a part-time job. The Veteran’s wife believed the Veteran is doing better but the Veteran stated that he continues to struggle with his lifetime history of anxiety, nightmares, and panic symptoms. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In an August 2017 psychotherapy note the Veteran reported “good days and bad days” overall but with more good days than bad since returning to working part-time. The Veteran’s bad days were described as marked by generalized anxiety with severe worry, rumination, hypochondriasis and depressed mood. The Veteran’s mood and affect were euthymic to mildly anxious, brighter with increased range, and no evidence of suicidal and homicidal ideation. In a separate August 2017 psychiatry note, the Veteran stated, “I’m working and working out.” The Veteran stated that he continues his part-time job and works out at the gym regularly. The Veteran and his wife both agree that he continues to do better but still struggles with lifetime anxiety and nightmares with fewere panic symptoms. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In an October 2017 psychiatry note, the Veteran stated, “I’ve had a hard month.” The Veteran reported continuing to work at his part-time job but has stopped working out at the gym regularly. The Veteran stated that a friend of his died and his parents have not been doing well. The Veteran noted struggling with anxiety but with no emergency room visits for panic symptoms. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In a November 2017 psychotherapy note, the Veteran reported having a difficult couple of months where his cousin died, and two brothers had acute medical problems. The Veteran continued to complain of generalized anxiety, panic attacks and depressed mood that was managed by prescribed medication. The Veteran noted that he enjoyed working part-time which keeps him focused and feeling productive; however, the Veteran stated that he was required to reduce his work hours due to recently being approved for “SSD.” The Veteran’s mood and affect were mildly anxious and dysphoric but with adequate range. There was no evidence for suicidal and homicidal ideation. In a December 2017 psychiatric note, the Veteran stated, “I’ve got a lot of stress.” The Veteran reported decreasing his part-time work and noted that his mother’s health continues to decline. The Veteran stated he continued to struggle with anxiety but responded well to prescribed medication. The Veteran’s wife noted that the Veteran was “snappier” and more reactive, although the Veteran has had no emergency room visits for panic symptoms. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In a March 2018 psychotherapy note, the Veteran reported much improved mood and outlook with decreased generalized anxiety, decreased panic attacks, and less preoccupation and worry regarding his medical issues. The Veteran continued to enjoy working part-time and spending time with his grandchildren; however, the Veteran reported some ongoing marital discord. The Veteran’s mood and affect was euthymic and bright with broad range but negative for suicidal and homicidal ideation. In a separate March 2018 psychiatry note, the Veteran reported a number of worries to include his parents not doing well medically, and his wife “fell out” over the weekend and has sent his anxiety “through the roof.” The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In a May 2018 psychotherapy note, the Veteran reported “good days and bad days” in general with a recent increase in PTSD symptoms and episodes of worsening generalized anxiety, panic attacks, and preoccupation relating to medical issues. The Veteran reported the frequency of panic has increased to two to three times a week but not too severe and managed by medication. The Veteran continued to work part-time which he describes keeps him focused and feeling productive. In a July 2018 psychotherapy note, the Veteran reported increased stress associated with caregiving for his parents which resulted in diminished self-care and increased discord with his spouse. The Veteran stated that he has had an exacerbation of generalized anxiety and panic which has included a visit to the emergency room for a panic attack. The Veteran reports having a panic attack on average once a week. The Veteran’s mood and affect were fatigue and anxious with constricted affect and no evidence of suicidal or homicidal ideation. In a separate July 2018 psychiatric note the Veteran stated, “I’m having a hard time.” The Veteran reported significant stress relating to worsening sleep, ongoing medical issues, and increased pain and demands from his mother which impact him and his marriage. The Veteran stated that his anxiety has worsened with nightly nightmares and panic symptoms. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In an August 2018 psychotherapy note, the Veteran reported an exacerbation of anxiety, panic and nightmares in the past 4 weeks, leading to increased avoidance-based coping. The Veteran stated he has increased stressed associated with caregiving for his ailing parents; as such, the treating provider noted “in this context, [the Veteran] is more prone to become anxious and hypochondrial, ruminating about his medical concerns and feeling increasingly overwhelmed.” The Veteran’s mood and affect were anxious but somewhat brighter and increased range; there was no evidence of suicidal and homicidal ideation. In a separate August 2018 psychiatry note, the Veteran stated, “I’m doing much better.” The Veteran reported to have significant stress, nightmares and panic, but feeling “much better” as a result of increasing medication. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In a November 2018 psychiatric note, the Veteran stated, “I’m making it.” The Veteran reported that he has stopped working but has now begun to volunteer as an assistant basketball coach for a middle school. The Veteran stated that he still has significant anxiety and worry. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In a December 2018 psychiatric note, the Veteran reported that overall, he is doing much better but continues to worry. The Veteran stated that he still is volunteering as an assistant basketball coach. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In a January 2019 psychotherapy note, the Veteran reported a relatively positive mood and outlook during the past 5 weeks. The Veteran noted that his volunteer assistant basketball coaching position has been a “highly rewarding distraction” but did report one full-blown panic attack “precipitated by shortness of breath associated with bronchitis” resulting in an emergency room visit prior to Christmas. The Veteran otherwise reported relatively successful management of generalized anxiety and worry regarding to his health. The Veteran’s mood and affect were euthymic to mildly anxious, brighter with increased range and negative for suicidal and homicidal ideation. At the Veteran’s February 2019 hearing, the Veteran testified to having monthly visits with a psychiatrist, psychologist, and a social worker in treating his PTSD. In a March 2019 psychotherapy note, the Veteran noted that he had recently attended an appeal hearing for his VA claims which the entire process has been “intensely frustrating for im.” The Veteran stated managing stress associated with caregiving for his ailing parents and able to continue as the head basketball coach for a middle school team. The Veteran’s mood and affect were mildly anxious and worried, but hopeful and optimistic with adequate range; there was no evidence of suicidal or homicidal ideation. In an April 2019 psychiatric note, the Veteran stated, “I’m making it.” The Veteran noted that his energy has returned some since finishing cancer treatment but continues to take care of his ailing parents and wife’s father which weights on him. The Veteran noted that volunteering as an assistant basketball coach has finished but he has considered becoming a “know-nothing coach” for baseball. The Veteran also indicated that he was looking forward to an upcoming cruise. Overall, the Veteran stated that he was stable but with some depressive symptoms and refractory anxiety and continued worry. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In a May 2019 psychiatric visit, the Veteran stated, “I’m not doing well.” The Veteran noted that he became sick during his cruise and was now with low energy and dysphoria. The Veteran stated that he has been fighting with VA over benefits and “getting nothing but frustration” and continuing to take care of his sick parents. The Veteran noted that his spouse was not supportive and critical of him. The Veteran reported symptoms of self-criticism, low motivation, dysphoric and poor sleep, low energy, irritability, and anxiety. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In a June 2019 psychotherapy note, the Veteran reported persistent anxiety, worry, irritability, and worsening depressive symptoms. The Veteran described preoccupation with medical problems, and expressed frustration and anger associated with “being in limbo” regarding his claim. The Veteran’s mood and affect was moderately anxious, dysphoric and irritable with adequate range with no evidence of suicidal and homicidal ideation. In a separate June 2019 psychiatric note, the Veteran stated, “I’m doing better.” The Veteran denied significant change in his circumstances but stated that his mood is improved, he is less intense and more upbeat. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In an August 2019 psychiatric note, the Veteran stated, “I’m not doing well” and appeared tired and unhappy. The Veteran stated he had a hearing to adjudicate his VA claim and describing coming away from it as angry, hopeless and depressed. The Veteran described feeling violated and concerns that the system is corrupt, “is my enemy” and was “working to prevent him from getting his just due.” The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was sad appearing with poor energy and limited affective range. The Veteran’s thought process was rapid and focused on the “injustice of [the Veteran’s] interactions with the VA system.” The provider found no evidence of delusional material, but some slight obsessive pattern mixed with slight paranoia but no evidence of psychosis. The Veteran demonstrated fair judgement and intact impulse control. The Veteran denied suicidal and homicidal ideation. In a September 2019 psychiatric note, the Veteran stated, “I’m doing good.” The Veteran noted that junior varsity basketball was set to begin and was excited. The Veteran noted that his VA rating had increased and was feeling less anxious and was well overall. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In a separate September 2019 psychotherapy note, the Veteran reported a much-improved mood overall in the past 3 months but with episodic spikes in anxiety and irritability. The Veteran stated that he was eager to resume coaching middle school basketball in the next month and continued to enjoy his time with his grandchildren. The Veteran stated that he had no severe panic attacks during this period but did discuss having frustrating interactions with his spouse that can precipitate worsening anxiety and aggravation. The Veteran’s mood and affect was euthymic to mildly anxious and brighter with increased range; there was no evidence of suicidal or homicidal ideation. In a December 2019 psychiatric note, the Veteran stated, “I’m doing good.” The Veteran noted that junior varsity basketball seasons was in progress and he was actively engaged; the Veteran stated that this helps but, in some ways, “stresses me out.” The Veteran was noted to become dysphoric about his marriage where they lacked common ground; finances; and his parents health. The Veteran stated that he was feeling more anxious and overall a little unsettled. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. In a separate December 2019 psychotherapy note, the Veteran stated that his coaching of middle school basketball provides enjoyment, meaning and structure to his life. The Veteran reported chronic and episodic spikes in anxiety and irritability, typically in the context of chronic marital discord. The Veteran reported only one episode of a full-blown panic attack and was en-route to the emergency room when his medication took effect and he instead returned home. The Veteran also reported chronic stress associated with the care of his mother who is in “constant pain” and relies heavily upon the Veteran for support. The Veteran’s mood and affect were euthymic to mildly anxious and brighter with increased range and negative for suicidal and homicidal ideation. In a February 2020 psychotherapy note, the Veteran reported an exacerbation of anxiety, dysphoria and nightmares in the past 2 months; the Veteran stated it has been more stressful because of his mother’s recent hospitalization, the Veteran becoming sick with the flu, and losing three friends in the past month. The Veteran noted difficulty structuring his time since basketball season ended. The Veteran’s mood and affect were more anxious and dysphoric with adequate range and no evidence for suicidal and homicidal ideation. In a separate February 2020 psychiatric note the Veteran stated, “It’s been a rough month.” The Veteran noted his mother’s hospitalization, three former members of his unit die in the past couple weeks, nightmares, and the performance of his basketball team not doing as well as hoped. The Veteran stated that he was “stressed out”, feeling more anxious and overall a little unsettled. The Veteran was observed to be appropriately dressed, alert and oriented. The Veteran was mildly anxious with an easy smile and broad affective range. The Veteran’s thought progress was found to be logical and coherent with no evidence of delusion, obsession, paranoia, suicidal or homicidal ideation. The Veteran demonstrated fair judgement and intact impulse control. The Veteran was afforded a June 2020 VA examination. The Veteran reported being married for 23 years and indicated he gets along with his parents and siblings. The Veteran indicated that he had associates and maintains contact with friends from the military. The Veteran stated that he worked for the Department of Corrections for 22 years until his retirement in 2014; worked a short-term projection supervising female inmates from 2016 to 2017; and currently is an assistant basketball coach for a middle school from November to January. The Veteran denied any psychiatric hospitalizations or history of suicide attempts but noted that he has been to the emergency room for panic attacks. The examiner found the Veteran with symptoms of depressed mood; anxiety; panic attacks that occur weekly or less; chronic sleep impairment; and disturbances of motivation and mood. The Veteran was observed to be cooperative throughout the examination, with affect and mood appropriate to the situation. The Veteran was oriented, and his thought processes were found to be logical with intact memory. The Veteran denied suicidal and homicidal ideation. The Board finds that after review of the evidence of record above, the Board does not find that the Veteran’s symptoms of his service-connected PTSD are enough to warrant a 100 percent rating. As noted above, a 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: 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 closes relatives, own occupation, or own name. The Board finds the preponderance of evidence does not show Veteran does not manifest or nearly manifest the behavioral elements of 100 percent disability. There is no documented instance of grossly inappropriate behavior. There is no evidence of intermittent ability to perform activities of daily living to include maintaining minimal personal hygiene. There is no consistent documentation during this period to show the Veteran being an imminent danger to himself or others, let alone persistence of such danger. Review of the record does show a reported history of multiple divorces and a June 2009 hospitalization where the Veteran’s wife reported the Veteran’s statements wanting to run her over with her car. However, the Veteran has denied that statement as well as consistently deny being violent to his wife, and there is no clinical evidence or documented finding to show the Veteran is of persistent danger to others. There is no clinical evidence of actual disorientation to time and place. The evidence does not show persistent delusions or hallucinations. Although the Veteran at the August 2014 examination was found with mild memory impairment, the examiner did not find the reported symptoms of memory loss to rise to the level of forgetting the names of close relatives, occupation or of his own name and later examinations found the Veteran’s memory to be intact. The Board has considered the Veteran’s statements regarding the severity of the Veteran’s PTSD. However, as lay persons, they do not have the training or expertise to render a competent opinion which is more probative than the evidence of record as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the lay opinions are outweighed by the evidence of record. See id. ; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court’s conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert’s opinion more probative on the issue of medical causation). As such, based on the totality of the disability picture, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s PTSD symptoms is manifested by an evaluation in excess of 70 percent. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). REASONS FOR REMAND The Board finds that remand is warranted for additional development. Gastroesophageal reflux disease (GERD) The Veteran asserts entitlement to service connection for GERD to include as due to an undiagnosed illness. Review of the Veteran’s service treatment records (STRs) shows multiple reports for gastrointestinal complaints and symptoms. At the February 2019 hearing, the Veteran testified that regarding his GERD he recalls that he took an experimental “PB” or “anthrax” pill to protect against chemical agents and weapons during his service in Southwest Asia and felt this was a contributing factor. The Board remanded this issue in July 2019 for a VA examination on the nature and etiology of the Veteran’s claimed GERD. The Board instructed the examiner to consider in-service gastrointestinal symptomology and Southwest Asia service to include environmental exposure. The Veteran was afforded a June 2020 VA examination. The examiner opined that it was less likely than not that the Veteran’s GERD was related to service. The examiner found the Veteran’s diagnosis for GERD was years after his separation from service; no medical evidence to show the Veteran’s GERD occurred within a year of separation from service; and medical literature did not support environmental exposure as a cause of GERD. However, the opinion does not specifically address the Veteran’s reports of gastrointestinal symptoms or complaints in his STRs or his testimony of taking the experimental “PB” or “anthrax” pill on whether they were a factor in his development of GERD. The Board also notes that the examiner listed several risk factors in causing GERD but did not discuss how these specifically applied to or affect the Veteran’s case. The Veteran in January 2021 also stated that his GERD was also a result of having to consume his meals during basic training in under 5 minutes; asserting that eating too quickly contributed to his GERD. This statement was made after the examination but should be considered as probative for the examiner to address. In addition, the Veteran has asserted his GERD to include as due to an undiagnosed illness. The June 2020 VA examiner has not provided an opinion on whether the Veteran’s claimed GERD is due to an undiagnosed illness or medically unexplained chronic multi symptom illness (MUCMI). As such, the Board finds the June 2020 VA opinion to be inadequate and remand warranted for addendum opinion. Sleep apnea The Veteran asserts that his sleep apnea due to his service-connected PTSD. The Board remanded this issue in July 2019 for a VA examination. The June 2020 VA examiner found it was less likely than not that the Veteran’s sleep apnea was caused or aggravated by the Veteran’s PSTD or related to his active duty service. The examiner noted that the most common causes of obstructive sleep apnea was excess weight and obesity along with other anatomical features that may be hereditary in contributing to causing sleep apnea. However, while the examiner lists risk factors in the cause of sleep apnea, the examiner does not discuss how these risk factors specifically apply to the Veteran and his sleep apnea. In addition, the Veteran in October 2020 submitted an article discussing sleep apnea and PTSD that was not yet considered by the June 2020 examiner. As such, the Board finds the opinion inadequate and remand warranted for addendum opinion. As the outcome of the claim could have a significant impact on the Veteran’s claim of entitlement to a TDIU, the issue of entitlement to a TDIU is inextricably intertwined with the remanded claims for service-connection and is also remanded. Harris v. Derwinski, 1 Vet. App. 180 (1991) The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated and outstanding treatment records. 2. After all outstanding records have been associated with the claims file, return the claims file to the VA examiner who provided the June 2020 medical opinion for an addendum opinion include a Gulf War examination opinion, to determine the nature and etiology of the Veteran’s claimed GERD and sleep apnea. If the June 2020 VA examiner is not available, the requested opinion with rationale should be rendered by another appropriate medical professional. The examiner must review the entire claims file, to include a copy of this remand, in conjunction with the examination. Based on this review of the record, and examination if provided, the examiner should provide opinions that respond to the following: (a.) Please state whether the symptoms relating to the Veteran’s claimed GERD is/are attributable to a known clinical diagnosis. If the Veteran does not currently have, but previously had any such condition, when did that condition resolve? (b.) With respect to EACH diagnosis determined or identified, determine whether it is at least as likely as not (50 percent probability or greater) that the diagnosed disease, disability or symptoms were: 1) an undiagnosed illness; or 2) medically unexplained chronic multisystem illness (MUCMI); or 3) diagnosable chronic multi-symptom illness with a partially explained etiology; or 4) is a disease with a clear and specific etiology and diagnosis). (c.) The examiner is informed that a MUCMI means a diagnosed illness without conclusive pathophysiology or etiology, characterized by certain overlapping symptoms and signs, and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. MUCMIs of partially understood etiology and pathophysiology will not be considered “medically unexplained.” See 38 C.F.R. § 3.317. (d.) With respect to EACH diagnosis, IF the diagnosis is NOT considered a MUCMI, determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran’s fibromyalgia and/or chronic fatigue syndrome began during or is etiologically related to the Veteran’s active duty service. (e.) The examiner must consider and discuss the Veteran’s lay statements regarding his duties during active service as well as his statements regarding the onset and continuity of symptoms. (f.) The examiner is also asked to address the Veteran’s STR reports and symptoms relating to gastrointestinal complaints and treatments; statements and testimony relating to taking “PB” pills or “anthrax” pills and eating meals quickly during basic training; and the October 2013 Gulf War examination and VA examination for GERD, as well as statements on service in the Persian Gulf region to include exposure to burning pits, burning oil, and depleted uranium.. The VA examiner should also opine as to the following: (g.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s obstructive sleep apnea is due to his service-connected PTSD. (h.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s obstructive sleep apnea is aggravated by his service-connected PTSD. “Aggravation” is defined as any worsening beyond the natural progression of the disability. The examiner should define a baseline if possible and explain if no baseline is found. (i.) In addressing any of the above, the VA examiner should discuss the Veteran’s assertions and the submitted October 2020 medical article. 3. If the VA examiner is unable to provide an opinion without resort to speculation, he or she should explain whether the inability is due to the limits of the examiner’s medical knowledge, medical knowledge in general or there is evidence that, if obtained, would permit the opinion to be provided. A clearly stated rationale for any opinion offered should be provided. (a.) The provided opinions should include a discussion of any pertinent studies or medical literature, as well as pertinent evidence, statements and testimony on file. The examiner is also advised that the Veteran is competent to report in-service events and treatment, and his symptoms and history, and such reports and assertions must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports, the examiner must provide a reason for doing so. (b.) The examiner should provide a complete rationale for any opinions provided, and if the examiner is unable to provide any opinion request, then the examiner should state so and why. (c.) If the VA examiner is unable to provide an opinion without resort to speculation, he or she should explain whether the inability is due to the limits of the examiner’s medical knowledge, medical knowledge in general or there is evidence that, if obtained, would permit the opinion to be provided. A clearly stated rationale for any opinion offered should be provided. 4. After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Yang, Attorney-Advisor 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.