Citation Nr: 21010892 Decision Date: 02/26/21 Archive Date: 02/26/21 DOCKET NO. 14-34 211A DATE: February 26, 2021 ORDER 1. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to June 14, 2011, is denied. 2. Entitlement to a disability rating of 70 percent for PTSD, but no higher, from June 14, 2011, to June 5, 2014, is granted subject to the laws and regulations governing the award of monetary benefits. FINDINGS OF FACT 1. The Veteran’s PTSD has not been manifested by occupational and social impairment with deficiencies in most areas, at any point prior to June 14, 2011. 2. Affording the Veteran the benefit of the doubt, from June 14, 2011, to June 5, 2014, PTSD was manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 3. From June 14, 2011, to June 5, 2014, PTSD has not been manifested by total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent for PTSD prior to June 14, 2011, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.125, 4.126(a), 4.130, Diagnostic Code 9411. 2. The criteria for a disability rating of 70 percent for PTSD, from June 14, 2011, to June 5, 2014, but no higher, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.125, 4.126(a), 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1998 to August 2007. In May 2019, the Veteran provided testimony at a video conference hearing before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript is associated with the claims file. Disability ratings are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). The percentage ratings in the Rating Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Diagnostic Codes (DCs) are assigned by the rating officials to individual disabilities. DCs provide rating criteria specific to a particular disability. If two DCs are applicable to the same disability, the DC that allows for the higher disability rating applies. See 38 C.F.R. § 4.7. When a question arises as to which of two ratings apply under a particular DC, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. See id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of a veteran. 38 C.F.R. § 4.3. In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as “staged ratings.” See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007) (holding that staged ratings may be warranted in increased rating claims). PTSD is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, DC 9411. Under the General Rating Formula for Mental Disorders, a 50 percent disability rating is assigned for depression manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks more than once a week, difficulty in understanding complex commands, impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks), impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating requires occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals, which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); or inability to establish and maintain effective relationships. A 100 percent disability rating requires 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; or memory loss for names of close relatives, own occupation, or own name. A Global Assessment of Functioning (GAF) score is a quantifiable assessment of overall functioning used by mental health clinicians that reflects an individual’s “psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness.” See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266 (1996) (both citing the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), p. 32 (1994)). The Veteran’s records include evaluations based on the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV), which includes GAF scores, and the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (5th ed. 2013) (DSM-5), which does not use GAF scores. The Board notes that the use of the GAF scale has been abandoned in the DSM-5 because of, among other reasons, “its conceptual lack of clarity” and “questionable psychometrics in routine practice.” See Diagnostic and Statistical Manual for Mental Disorders, Fifth edition, p. 16 (2013). The United States Court of Appeals for Veterans Claims (Court) has held that the use of GAF scores to assign disability ratings in instances where the DSM-5 applies, is inappropriate. See Golden v. Shulkin, 29 Vet. App. 221 (2018). However, the Court acknowledged that the Secretary did not intend the provisions of this final rule to apply to claims that were pending before the Board (certified for appeal) on or before August 4, 2014. Id. The current Veteran’s claim was certified for appeal to the Board in January 2016, thus, the Board shall not discuss GAF scores below. The Court in Mauerhan v. Principi stated that “when evaluating mental health disorders, the factors listed in the Rating Schedule are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating; analysis should not be limited solely to whether a veteran exhibited the symptoms listed in the Rating Schedule. Rather, the determination should be based on all of a veteran’s symptoms affecting his level of occupation and social impairment.” See Mauerhan, 16 Vet. App. 436, 442-43 (2002). The lists of symptoms under the Rating Schedule are meant to be examples of symptoms that would warrant the disability evaluation but are not meant to be exhaustive. Id. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational and social impairment equivalent to that which would be caused by those listed in the rating criteria the appropriate equivalent rating will be assigned. Id. at 442. The Veteran contends that his PTSD should be rated higher than the assigned disability rating of 50 percent prior to June 6, 2014, under 38 C.F.R. § 4.130, DC 9411. Specifically, the Veteran testified that prior to 2014, his PTSD had affected his employment and his family life. He stated that he tried to work numerous times with no success to provide for his family and it hampered things with his marriage. The Veteran reported that he left his family in 2012 for eight months because he could not cope and did not go to events because he did not want to be around the crowds and interact with his kids. Affording the Veteran the benefit of the doubt, the Board finds that an increased 70 percent rating for PTSD, but no higher, is warranted from June 14, 2011, to June 5, 2014. The preponderance of the evidence is against a finding that the Veteran has met the criteria for a 70 percent rating prior to June 14, 2011. Specifically, the Veteran’s PTSD has not been manifested by symptomatology more nearly approximating occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. January 2011 VA medical records reflects the Veteran’s complaints of worsening forgetfulness, difficulty concentrating, increasing irritability, and poor sleep. The Veteran had a 3.0 grade point average (G.P.A.) in his college coursework, however, had begun to struggle increasingly and had two C’s in the last two statistics courses. The Veteran had begun a work-study internship and was concerned about performance. He also had problems with disorientation, often getting lost and forgetting where he was going and walking in a building. He described feeling “nervy and shaking with anxiety” at times which caused him to drop things. The Veteran also reported decreased short term memory, poor attention, easily distracted, hard time relaxing, occasional nightmares and flashbacks, anxiety, “jumpy” with crowds and people, family withdrawal, and anger/frustration. The medical professional noted that the Veteran’s MOCA cognitive screening would indicate “mild cognitive impairment” and described him as a high functioning individual who had difficulty adjusting to life routines which returning from Iraq. In an April 2011 VA medical record, the Veteran reported that he had continued trouble engaging with his wife and kids and felt that it was causing problems with his marriage. He related that he still enjoyed listening to music but found that it was a real effort to do things with people. He stated that his representative convinced him to put in for an increase for his service-connected PTSD, he was still doing well in college, but dreaded being around people in class. The Veteran denied suicidal and homicidal ideation. As of May 2011, the Veteran was in school full time, worked full time, and was also a full-time dad and husband, which was noted to be too much for him in VA medical records. He indicated that he “freaks out over little things like losing his keys, kids making noise,” and that he had felt very depressed, anxious and had trouble sleeping. He also reported mood swings, irritability and was “forcing self to go to the gym. The Veteran was advised to work only part-time and requested medication adjustments. He denied suicidal and homicidal ideations and auditory or visual hallucinations. He had passive suicidal thought once in the preceding week but “just thought about it once” and “told [himself] that I couldn’t do that.” The Veteran’s PTSD symptomology prior to June 14, 2011, was fully contemplated by a 50 percent disability rating as manifested by occupational and social impairment with reduced reliability and productivity. The Veteran was shown to have difficulty in establishing and maintaining effective work and social relationships, however, he was still doing well in school with a 3.0 G.P.A. and managing his full-time duties as a dad and husband and worked full time. In June 2011, the Veteran indicated that he was “not good” and that he needed to combat it on his own. He stated that he had a job described an event where he got anxious because his supervisor took him into a room and stated that she, “didn’t hire a veteran who was nervous.” The Veteran reported that he waited until everyone else left and reminded his supervisor that he had PTSD and it was not a good thing what she did and that her supervisor indicated that she did not remember that he had PTSD. It was noted that the Veteran denied past suicide attempts but explained that he had a hard time battling those feelings of killing himself and had to press on. The Veteran also reported that he was going to drive a car into another car and that his sister was worried. He then stated that he had to try and was not a quitter and did not want to see his wife like this and worry, that he did not want to “jeopardize.” The VA psychiatrist discussed with the Veteran that he did not recommend that that he be under so much stress, over-extending himself with work, school, and at home. The Veteran was admitted to the hospital afterwards on June 14, 2011. Hospital records indicate that the Veteran was on a Baker Act after thinking of driving his car into the path of another vehicle. It was noted that the Veteran stated that every little thing bothered him and that everything needed to be in order, or he just did not cope. The medical professional noted that what precipitated the Baker Act was that the Veteran felt singled out inappropriately by his supervisor due to his disability. The Veteran denied that he was actively suicidal or had any thoughts to hurt anybody else. The Baker Act was lifted and arrangements had been made for admission to a PTSD treatment program at Tampa VA that the Veteran “very much wanted to go to,” thus, could be voluntary. Following hospitalization, VA medical records indicate that the Veteran was a transfer with complaints of worsening depressive, anxiety and PTSD symptoms. The Veteran reported that commotion drove him crazy and that his representative “fought with [him] to put in a claim.” The Veteran stated that he could not “cope anymore,” had to “push on,” and that he felt like “a machine.” Following an event which his supervisor stated she would not hire someone who was “anxious and depressed,” the Veteran felt that she was directing that comment towards him and felt that this event put him over the edge. He had thought about suicide, specifically running into a car, but denied current suicidal ideation. At discharge, the Veteran reported that he “felt like [he] was in jail” and he felt his “mood [was] more stable” when his medication was adjusted and appeared calmer, less anxious, and denied suicidal or homicidal ideation. Of record is a June 21, 2011 letter from the VA staff psychiatrist which asked that the Veteran be excused from work until further notice due to his current diagnosis. VA medical records indicate that the Veteran requested the letter/written excuse from work and stated, “my supervisor says I have to call in every day and its really stressing me out.” The Veteran reported that “I felt like a guinea pig, I felt like I was the patient and the doctor… too many med[ication]s.” He firmly denied suicidal and homicidal ideations. It was noted that the Veteran continued to have poor insight into his illness and was urged to minimize his stress. The Veteran was not to return to school just yet and not to go back to work for the need to be much more stable. It was noted that he may very well not ever be able to return to work and the Veteran was less resistant to this fact. In a subsequent June 2011 VA medical record, the psychiatrist noted that the Veteran was clearly still unable to work and would benefit from 100 percent service-connection and employability, which was specifically noted as something that the Veteran and his wife were pursuing. July 2011 VA medical records indicate that the Veteran was transported to the hospital, was not suicidal but had abruptly stopped taking his medications after his mental health clinic appointment. The Veteran had severe manic episodes for several days, was not sleeping, and losing weight. The Veteran was inpatient at the hospital after he did not sleep for 5 days from July 27 to August 1. The Veteran was hypervigilant and paranoid with flashbacks and nightmares but denied any suicidal or homicidal ideation and auditory and visual hallucinations. August 2011 VA medical records after discharge confirm that the Veteran presented for a mixed episode of mania and depression and the reason for admission was not suicidality and the Veteran had denied having suicidal thoughts at the time. As of August 2nd, the Veteran was noted as low risk but not stable from a psychiatric standpoint and a safety plan was given. The Veteran indicated that he was “doing ok” and “feeling a little better.” The Veteran called VA on August 5, 2011 and reported that he was “feeling better” and ready to go back to work” and was informed that the work request is a “clearance.” The Veteran stated that he was “ok to return to work,” denied suicidal and homicidal ideation, and stated that his medication was working. On August 10, 2011, the Veteran presented to VA with a chief complaint of, “I want to go back to work.” The Veteran was noted to be cordial and friendly, appropriate in answering questions, and denied any mania, periods of hypomania or depression, delusions or hallucinations which he was voluntarily admitted to the hospital for. The Veteran stated that he needed to go back to work due to financial reasons and denied suicidal and homicidal ideation. He was taking his medications appropriately and did state that he cannot deny that he had a problem, he acknowledged that he had control over the disease process by taking his medications as ordered and needed to learn to use coping skills as positive motivation. An August 17, 2011, VA medical record indicates that the Veteran was back to work and was handling work “ok.” He again denied suicidal and homicidal ideations. September 2011 VA medical records show that the Veteran had issues with mental health symptomatology that had led him to leave from work and initiation of a regimen of medications for his worsening symptoms. In November 2011, the Veteran was seen on an emergency basis for a psychopharmacological assessment and the medical provider requested that he be excused from work from November 18 to the 22nd. The Veteran stated that he stopped taking Lithium because he was missing too much work from the nausea and vomiting from it. He admitted to feeling better but was getting moody again. In subsequent November 2011 records, the Veteran stated that he was doing better when it comes to the “man icky feelings” but was a little depressed and would like to work through it. He denied suicidal and homicidal ideations, auditory visual hallucinations and paranoia. In December 2011, the Veteran reported that his mood was not good but was trying to cope. He complained of racing thoughts, mood swing, and poor focus/concentration. In the February 2012 VA PTSD examination report, the examiner noted diagnoses of mental disorders including bipolar disorder not otherwise specified (NOS) and PTSD. The examiner noted that bipolar disorder appeared to be the primary mental health condition at this time and labile moods impacted interpersonal, social, and occupational functioning but it was not possible to differentiate which symptoms were attributable to each diagnosis. He explained that both conditions were active and have interactions that can result in symptom aggravation. At the time, the Veteran was currently working on his Associates of Arts degree with a 3.0 G.P.A. and had been hired as a human resources assistant on a temporary job placement at VA until May 2012 when he would be evaluated. The report also notes that the Veteran was hospitalized at a private hospital for 6 days until August 2011 for sleep deprivation, racing thoughts, and irritability and at Tampa VAMC in June 2011 for suicidal ideations. It was also noted that the Veteran had an initial mental health evaluation in September 2011 and had two medication rechecks since the initial evaluation. The Veteran was hospitalized in October 2011 for bipolar manic episodes. During the examination, the Veteran reported that his treatment was going “pretty well” and that his mood could cycle every two weeks. He has had impulse behavior, increased physiological arousal when manic and reported that his medications can make him feel “drugged”, sluggish, and think slower. The Veteran had not appeared to the Vet Center since he was hired by VA. The examiner found that the Veteran’s psychiatric symptoms at the time included depressed mood, anxiety, chronic sleep impairment, impaired judgment, and disturbances of motivation and mood. The Veteran also reported only two hours of sleep per night with no maps during the day and that medications did not help sleep quantity. The Veteran stated that he did not want to lose his job but employment did not compliment mental health needs. When asked which of the following best summarized the Veteran’s level of occupational and social impairment with regard to all of the Veteran’s psychiatric disorders, the examiner checked “occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication,” which is the criteria for a 10 percent rating. The Veteran was found capable of managing his own financial affairs. In September 2012 VA medical records, the Veteran reported that he had been having a difficult time at work and reported a panic attack. He reported flashbacks experienced in school and when a co-worker was crying because she did not get a job she hoped for, which triggered his anxiety and prevented him from sleeping. The Veteran requested a break from work just to see if he would feel any better. He stated that he really wanted to work to take care of his family but could not work when he was like this. On September 26, the medical provider wrote a letter indicating that the Veteran was seen for a routine psychopharmacological assessment and presented worsened bipolar and PTSD symptoms which prevented him from functioning appropriately on his job and requested that the Veteran be excused from work until October 1. In October 2012, the Veteran reported that he was in marriage counseling and that PTSD had become severe, was affecting his marriage and caused him to terminate his employment at the VAMC. A November 2012 VA medical record reflects the Veteran’s report that he had to resign from his job and had a current stressor of a new baby in the family and financial issues. The Veteran reported instability, irritability, poor focus / concentration, and insomnia in March 2013. The Veteran stated that he stayed home to take care of the baby and two children while his wife worked. The Veteran indicated that he worked again from August 2013 to June 2014 at VA in records. In November 2013 VA medical records, the Veteran reported that he was working and going to school and really wanted to work to help other veterans. He stated that it was both rewarding and triggering working with fellow veterans. The Veteran had frequent mood swings, trouble sleeping, frequent panic attack, and was frequently anxious. He described difficulty with stressful interactions that evoke panic or anger in response. The Veteran was separated from his wife and children and “don’t want to associate with anybody, isolated, don’t want to associate with friends or family.” The Veteran reported that he had thoughts about suicide, “sometimes I think I would be better off dead… so no one will have to worry about me,” and a Baker Act was initiated. The Veteran was having difficulty coping with school and work. He denied homicidal ideation. December 2013 VA medical records show that the Veteran experienced panic at work when too many things were going on. The Veteran was finishing up his bachelor’s degree at the time and started a five-week course. He was five courses away from completing an online degree. In March 2014, the Veteran reported chronic anxiety that was worse while working but he did not like just sitting at home. In addition to work, the Veteran also went to the gym and did some yard work. In April 2014 VA medical records, the Veteran indicated that he felt numb to a lot of things and was cycling feeling happy then sad and depressed, snappy. The Veteran was on edge, irritated with little things and tried to cope by staying active at work and engaged. The Veteran indicated that he was very pressured and on edge in May 2014, however stated that he “cannot fail.” He stated that he cannot quit his job, school or being with his family at home. In June 2014, the Veteran reported increased stressors at work and that he felt like a “machine” but that he “must just push through.” The Veteran reported that stress with work and home life were too much to manage at this point. The weight of the evidence demonstrates that from June 14, 2011, to June 5, 2014, the criteria for an increased disability rating in excess of 70 percent for PTSD have not been met. Specifically, the Veteran’s PTSD has not been manifested by symptomatology more nearly approximating total occupational and social impairment. The Veteran’s PTSD has shown to manifest with difficulty in adapting to stressful circumstances (including work or a work-like setting) and inability to establish and maintain effective relationships, which is contemplated in the criteria of a 70 percent rating. The Veteran had relationships with his family members, which, although were strained during periods of which he tackled employment and education at the same time, affirmatively shows that he does not have total social impairment. The Veteran also felt that it was rewarding to work with fellow veterans. The Veteran was working full time with two stints at VA while going to school full time, which affirmatively shows that he does not have total occupational impairment. Board has considered the frequency, severity, and duration of all of the Veteran’s psychiatric symptoms with respect to their effect on other areas of overall occupational and social functioning. 38 C.F.R. § 4.126(a). The Board has considered the Veteran’s risk of self-harm, the persistent danger of which VA generally considers indicative of a 100 percent disability evaluation. See Bankhead v. Shulkin, 29 Vet. App. 10 (2017); 38 C.F.R. § 4.130. The preponderance of the evidence, such as the VA examination report and clinical records, is against a finding of risk of self-harm. The Veteran denied auditory-visual hallucinations and suicidal/homicidal ideation and plan in June 2011, July 2011, August 2011September 2012, March 2013, November 2013, December 2013, March 2014, April 2014, and June 2014. In an August 2011 statement, the Veteran’s representative also requested a temporary 100 percent evaluation due to claimed PTSD convalescence leave from June 20, 2011, to August 10, 2011. It was also noted that the Veteran was withdrawing his claim for individual unemployability because he had returned to work. The Board has considered whether a temporary 100 percent rating for the Veteran’s PTSD is warranted and finds that the evidence does not support the award. A temporary total, i.e., 100 percent, evaluation may be assigned under 38 C.F.R. § 4.28 when a veteran is medically discharged from service due to an unstable disability deemed to be severe and substantially gainful employment is not feasible or advisable. 38 C.F.R. § 4.28. Under 38 C.F.R. § 4.29, a temporary total rating is assigned when it is shown that a service-connected disability has required hospital treatment in a VA or VA-approved hospital for a period in excess of 21 days. This is true regardless of whether the hospital admission was for a service-connected disability, as long as hospital treatment for a service-connected disability is instituted and continued for a period of 21 days. 38 C.F.R. § 4.29 (b). Under 38 C.F.R. § 4.30, a temporary total evaluation is established when a disability, subject to VA compensation required surgery necessitating at least one month of convalescence, surgery with severe postoperative residuals, or treatment with immobilization by case of one major joint or more. 38 C.F.R. § 4.30. As indicated in more detail above, the Veteran was admitted to a private hospital on June 14, 2011 and had been released by June 21, 2011. In a June 21, 2011 letter, a VA staff psychiatrist asked that the Veteran be excused from work until further notice due to his current diagnosis. The Veteran was once again admitted to the hospital from July 27 to August 1. On August 10, 2011, the Veteran presented to VA with a chief complaint of, “I want to go back to work.” Thus, the hospital admissions have been no more than 7 days in June 2011 and 6 days in July 2011, which are less than the 21 days required. The correspondence from the Veteran and the private and VA treatment records do not establish that the Veteran was hospitalized in excess of 21 days or that he underwent any surgery or other treatment requiring at least one month of convalescence for his PTSD. Further, the evidence does not show that he was medically discharged from service due to an unstable disability deemed to be severe and substantially gainful employment is not feasible or advisable. Therefore, the Board finds that the Veteran does not meet the criteria for a temporary total evaluation for his PTSD with depression under 38 C.F.R. §§ 4.28, 4.29, or 4.30. In reaching this determination, the Board acknowledges that the Veteran had an absence of work. However, he was assigned a 70 percent evaluation for his PTSD during these times, which specifically contemplates occupational impairment. 38 C.F.R. § 4.118, DC 9411. In sum, affording the Veteran the benefit of the doubt, from June 14, 2011, to June 5, 2014, the Veteran’s PTSD manifests in occupational and social impairment with deficiencies in most areas, which warrants an increased 70 percent disability rating. However, the preponderance of the evidence is against a finding that a disability rating in excess of 70 percent for PTSD is warranted at any point during the appeal period and in excess of 50 percent prior to June 14, 2011. As the preponderance of the evidence is against the claim for a higher rating to this extent, the benefit of the doubt doctrine is not for application, and the Veteran’s claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Cheng, 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.