Citation Nr: 21010909 Decision Date: 02/26/21 Archive Date: 02/26/21 DOCKET NO. 13-19 579 DATE: February 26, 2021 ORDER Entitlement to an initial increased rating greater than 20 percent for left knee arthritis with internal derangement and meniscal tear prior to July 15, 2013 and from November 1, 2013 to July 31, 2018 is denied. Entitlement to an initial increased rating of 20 percent, but no higher, for left knee instability prior to September 27, 2017 is granted. Entitlement to an increased rating greater than 20 percent for left knee instability from September 27, 2017 to August 1, 2018 is denied. Entitlement to an increased rating greater than 60 percent for total left knee replacement from October 1, 2019 is denied. Entitlement to an initial compensable rating for surgical scars associated with left knee internal derangement is denied. Entitlement to an initial increased rating greater than 10 percent for a surgical scar associated with total left knee replacement is denied. FINDINGS OF FACT 1. Prior to July 15, 2013 and from November 1, 2013 to July 31, 2018, the Veteran’s dislocated semilunar cartilage of the left knee was manifested by frequent episodes of locking, pain, and effusion into the joint; it was not manifested by ankylosis, limitation of flexion to 15 degrees or less, or extension limited to 20 degrees or more. 2. Prior to August 1, 2018, the Veteran’s left knee condition was manifested by moderate instability. 3. From October 1, 2019, the Veteran has been in receipt of the maximum 60 percent schedular rating for the residuals of a left total knee arthroplasty. 4. Throughout the appeal period, the Veteran reported two surgical scars from left knee internal derangement that were not painful or unstable. 5. From August 1, 2018, the date of the Veteran’s total left knee replacement, the Veteran’s total left knee replacement scar was painful but not unstable. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating greater than 20 percent for a left knee condition prior to July 15, 2013 and from November 1, 2013 to July 31, 2018 have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2018); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.10, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5258 (2020). 2. The criteria for an initial disability rating of 20 percent, but no higher, for left knee instability prior to September 27, 2017 have been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257 (2020). 3. The criteria for a disability rating greater than 20 percent for left knee instability from September 27, 2017 to August 1, 2018 have not been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257 (2020). 4. From October 1, 2019, the criteria for a disability rating greater than 60 percent for a total left knee replacement have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2018); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.10, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055 (2020). 5. The criteria for a compensable initial disability rating for two left knee scars have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2018); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.56, 4.7, 4.118 Diagnostic Code 7805 (2020). 6. The criteria for an initial disability rating greater than 10 percent for one left knee scar have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2018); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.56, 4.7, 4.118 Diagnostic Code 7804 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1980 to June 1984. He originally appealed a December 2011 rating decision by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) denying entitlement to initial ratings greater than 10 percent for left knee internal derangement; 10 percent for left knee instability, and a compensable rating for a left knee scar. Originally, the Veteran requested a Board of Veterans’ Appeals (Board) hearing on his July 2013 VA Form 9; however, he withdrew this hearing request in April 2014. See April 2014 Veteran correspondence. See 38 C.F.R. § 20.704(e). In August 2017, the Board remanded the appeal for further development. Subsequent to this development, the AOJ increased the Veteran’s left knee instability rating to 20 percent, effective September 27, 2017. See September 2018 rating decision. In January 2019, the Board again remanded the claim. Thereafter, the AOJ recharacterized the Veteran’s left knee internal derangement to include a left knee meniscal tear with an initial rating of 20 percent. Additionally, the Veteran underwent two left knee surgeries during the appeal period. The first, a left knee arthroscopy resulted in a temporary total disability rating, or 100 percent, based on surgical treatment necessitating convalescence under 38 C.F.R. § 4.30 from July 15, 2013 to October 31, 2013. See April 2014 rating decision. The second surgery included a total left knee replacement, that resulted in a second temporary total disability rating from August 1, 2018 to September 30, 2019. See September 2018 rating decision. As the Veteran was granted a total disability rating following his two left knee surgeries from July 15, 2013 to October 31, 2013 and again from August 1, 2018 to September 30, 2019, this is considered a full grant of the benefit sought and these periods are no longer on appeal. AB v. Brown, 6 Vet. App. 35 (1993). The Veteran was also assigned a separate rating for a painful scar that resulted from this second left knee surgery and the Veteran’s left knee condition was recharacterized under Diagnostic Code (DC) 5055 and the previous diagnostic codes were discontinued, effective the date of his surgery. See September 2020 rating decision. From October 1, 2019, the Veteran’s left knee was rated at 60 percent disabling under 38 C.F.R. § 4.71a DC 5055. Id. Disability ratings are determined by applying a schedule of ratings based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. When considering the propriety of the evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection is required. See Fenderson v. West, 12 Vet. App. 199, 125-26 (1999). 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. Importantly, the evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998); 38 C.F.R. § 3.102. Left Knee Knee disabilities are generally rated under DCs 5256 through 5263 of 38 C.F.R. § 4.71a. DC 5256 addresses ankylosis of the knee. DC 5257 addresses recurrent subluxation or lateral instability. DC 5258 addresses dislocated semilunar cartilage in the knee manifested by frequent episodes of “locking,” pain, and effusion into the joint. DC 5259 addresses symptomatic residuals related to removal of semilunar cartilage. DC 5260 addresses limitation of motion on flexion while DC 5261 addresses limitation of motion on extension. DC 5262 addresses impairment of the tibia and fibula from malunion or nonunion. DC 5263 addresses genu recurvatum. The Board must consider the Veteran’s service-connected left knee condition under each DC and apply the appropriate ratings without having any of the symptomatology by duplicative or overlapping. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Veteran cannot receive compensation under two different codes for the same manifestations of symptoms as this would constitute impermissible pyramiding under 38 C.F.R. § 4.14. The regulations pertaining to rating musculoskeletal disabilities were revised, effective February 7, 2021. Claims, such as this, pending prior to the effective date will be considered under both old and new rating criteria from that date, and whatever criteria is more favorable to the Veteran will be applied from the effective date of the change. For rating the knee, changes were made to DCs 5257 and 5262. Additionally, changes were made to DC 5055 for total knee replacement. Thus, both the old and new rating criteria for these DCs will be analyzed by the Board for the Veteran’s ratings from February 7, 2021. A. Meniscal tear with limitation of motion The Veteran’s left knee condition prior to July 15, 2013 and from November 1, 2013 to July 31, 2018 was rated at 20 percent disabling under DC 5258, which provides a flat 20 percent rating for limitation of motion reflected by the symptoms or findings of pain, locking, and effusion into the joint with a dislocated semilunar cartilage. See 38 C.F.R. § 4.71a. The record reflects the Veteran had a meniscal tear and suffered from pain, locking, and effusion of the left knee prior to his total left knee replacement. See, e.g., December 2012 PeeDee Orthopaedic records (“meniscal tear”); December 2012 Cheraw records (“his knee locks up…pain”); January 2013 VA examination (frequent locking, pain, effusion due to meniscal tear”). 20 percent is the maximum rating under this diagnostic code; as such, the Veteran is not entitled to a higher rating. After review of the evidence, the Board finds the Veteran is also not entitled to a higher rating under either DC 5260 or 5261 for limitation of motion. Under DC 5260, a 10 percent disability rating is assigned where flexion of the leg is limited to 45 degrees. See 38 C.F.R. § 4.71a. A 20 percent disability rating is in order where leg flexion is limited to 30 degrees. Id. A maximum schedular 30 percent disability rating is assigned where leg flexion is limited to 15 degrees. Id. Similarly, DC 5261 provides ratings for limitation of extension with the following ratings assigned: 10 percent for limitation of extension to 10 degrees, 20 percent for limitation of extension to 15 degrees, 30 percent for limitation of extension to 20 degrees, 40 percent for limitation of extension to 30 degrees, and 50 percent for limitation of extension to 45 degrees. Id. For reference, normal range of motion (ROM) for the knee is defined under the regulations as consisting of extension to zero degrees and flexion to 140 degrees. See 38 C.F.R. § 4.71, Plate II. In December 2011, a VA examiner recorded the Veteran’s flexion as limited to 45 degrees. This is the most severe limitation of motion of record. See, e.g., December 2012 PeeDee Orthopaedic records (range of motion: 5- 80 degrees); January 2013 Cheraw records (ROM: zero- 110 degrees); March 2013 Cheraw records (ROM: 5- 80 degrees); September 2017 VA examination report (ROM: zero- 100 degrees); July 2018 VA treatment records (ROM: 2- 114 degrees). For entitlement to a rating greater than 20 percent under either DC 5260 or DC 5261, the Veteran would need to exhibit flexion limited to 15 degrees or less, or extension limited to 20 degrees or more. However, the record does not reflect the Veteran’s left knee exhibited this severity of decreased motion, even during reported flare-ups and repeated use over time. The Veteran is also not entitled to a separate rating under DC 5260 or DC 5261. The predicate element in assigning several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban, 6 Vet. App. at 261-62. Assigning separate ratings under DCs 5260 or 5261 based on limitation of motion due to pain would violate the rules prohibiting pyramiding as it would compensate the Veteran twice for the same symptomatology. 38 C.F.R. § 4.14. In the case of DC 5258, limitation of motion is reflected by the symptoms or findings of pain, locking, and effusion into the joint. In the case of DCs 5260 and 5261, such limitation of motion is encompassed by the limitation of flexion and extension, including limitation of motion due to pain. Both diagnostic codes overlap, as “locking” is a form of limitation of motion that is usually accompanied by pain. Therefore, these three diagnostic codes rate on knee pain and limitation of motion due to pain. Were the Board to grant separate ratings under both DC 5258, 5260, and 5261, the Veteran would receive compensation under three different codes for the same manifestations of pain and limitation of motion, which would constitute impermissible pyramiding. 38 C.F.R. § 4.14. For these reasons, the Veteran is not entitled to separate disability ratings under DCs 5260 and 5261 for the painful limitation of motion associated with his left knee disability. B. Instability As noted above, the rating criteria under DC 5257 changed on February 7, 2021. However, for this Veteran, his separate rating under DC 5257 ended on August 1, 2018, when he underwent total left knee replacement surgery. As this is before the implementation date of the new rating criteria, only the old rating criteria applies to the Veteran’s instability rating. DC 5257 provides ratings for demonstrated knee joint instability with the following ratings assigned: 10 percent for slight, 20 percent for moderate, and 30 percent for severe, recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. The words “slight,” “moderate,” and “severe” as used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all the evidence, to the end that its decisions are “equitable and just.” See 38 C.F.R. § 4.6. “Nothing in [Code] 5257 provides that objective medical evidence is required or is to be favored over lay evidence.” See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). After review of the medical and lay evidence of record, the Board finds the Veteran’s left knee exhibited moderate instability during the entire appeal period prior to August 1, 2018. The Veteran reported left knee instability during the entire appeal period. See, e.g., December 2012 PeeDee Orthopedic records (“giving way”); December 2013 Cheraw records (“still having some instability” “wearing a brace”); December 2018 VA examination (Veteran “states he has fallen numerous times”). For example, in August 2018, the Veteran noted he fell frequently due to his left knee “giving out” while ambulating in unfamiliar terrain, including people’s yards during his job as a mailman. See August 2018 VA treatment records. However, prior to this report, the Veteran reported his left knee “slips out and [he] almost falls.” See March 2016 VA treatment records. Thus, while the record suggests the Veteran does have a history of numerous falls during the long appeal period, the record reflects his left knee more frequently gave out but did not result in falls. The record also reflects the Veteran wore a brace for support starting around June 2013. See, e.g., October 2012 VA treatment records (Veteran has instability… “wonders about a brace”); June 2013 VA treatment records (Veteran requests a knee brace); June 2013 and December 2013 Cheraw records. In November 2014, the Veteran noted his knee brace was to “give him stability” after his arthroscopic surgery. See November 2014 VA treatment records. However, the Veteran reported his initial “sleeve” knee brace did not completely prevent instability and he requested a sturdier brace from his physician. See March 2016 VA treatment records. Thus, the Board finds the Veteran’s symptoms of giving away and use of a knee brace more closely reflects moderate instability throughout the entire appeal period, not severe instability. This moderate level of instability is also corroborated by the medical evidence. In December 2011, a VA examiner tested the Veteran’s stability and found his left knee exhibited “1+” anterior and posterior instability out of a 3-point scale; which reflects mild anterior and posterior instability. The examiner also found no patellar subluxation. See December 2011 VA examination report. In March 2013, a private physician noted the Veteran had “mild instability” despite a negative instability test. See March 2013 Cheraw records. A November 2013 VA examiner tested the Veteran’s left knee and concluded he had no instability. In September 2017, a VA examiner found the Veteran exhibited “moderate lateral instability” with a finding of increased instability measured to “2+” anterior and medial instability and “1+” posterior and lateral instability on the 3-point scale. The September 2017 VA examiner also found no recurrent subluxation. Thus, the Board finds the medical evidence reflecting mild to moderate instability, when paired with the Veteran’s lay statements of record, more nearly approximate the criteria for moderate instability under DC 5257. As such, the Board grants an initial increased rating of 20 percent, but no higher, prior to September 27, 2017, and denies a rating greater than 20 percent from September 27, 2017 to August 1, 2018. C. Total Knee Replacement As stated above, on August 1, 2018, the Veteran underwent a total left knee replacement. For this, he was in receipt of a total rating from August 1, 2018 to September 30, 2019; this period is not under review by the Board as it is complete grant of benefits. From October 1, 2019, the Veteran’s left knee was rated as 60 percent disabling under 38 C.F.R. § 4.71a, DC 5055. See September 2020 rating decision codesheet. DC 5055 provides ratings for knee replacements. The rating criteria under DC 5055 changed on February 7, 2021. The Board must consider the Veteran’s current rating of 60 percent under the new and old rating criteria. Under the old DC 5055, for one year following implantation of a knee prosthesis for a service-connected knee disability, a 100 percent rating is assigned. Thereafter, a 60 percent rating is assigned when there are chronic residuals consisting of severe painful motion or weakness in the affected extremity; or, a minimum 30 percent rating is assigned. 38 C.F.R. § 4.71a , DC 5055. DC 5055 specifies that a minimum 30 percent rating is assigned, and when there are intermediate degrees of residual weakness, pain, or limitation of motion, the disability is to be rated by analogy under 38 C.F.R. § 4.71a , DCs 5256 (knee ankylosis), 5261 (limitation of extension), or 5262 (impairment of the tibia and fibula). However, no such rating by analogy is applied when there is evidence of chronic residuals consisting of severe painful motion or weakness in the affected extremity. A 60 percent rating is the maximum rating available under DC 5055, and DCs 5256, 5261, and 5262 do not provide for any higher ratings. The maximum ratings available under these codes are 60 percent, 50 percent, and 40 percent, respectively. Under the new rating criteria, DC 5055 provides a 100 percent rating for the four months following implantation of a knee prosthesis for a service-connected knee disability. Thereafter, the rating criteria remains the same with the exception that a separate evaluation for resurfacing after the conclusion of the 100 percent evaluation period may be warranted. Here, there is no evidence the Veteran’s left knee has undergone resurfacing since October 1, 2019. Thus, as it pertains to this specific Veteran, the old and new rating criteria are the same. The Veteran’s service-connected total left knee replacement has been assigned the maximum schedular rating available since October 1, 2019. The Board therefore finds there is no basis upon which to award a higher schedular evaluation. As such, entitlement to a rating greater than 60 percent is not warranted on a schedular basis. See Sabonis v. Brown, 6 Vet. App. 426 (1994). Additionally, the “amputation rule” provides that the combined rating for disabilities of an extremity cannot exceed the rating for amputation at the elective level. 38 C.F.R. § 4.68. A 60 percent rating is assigned if there was an amputation of the thigh, above the knee, at the middle or lower third. 38 C.F.R. § 4.71a, DC 5162. Amputation of a leg with defective stump and thigh amputation recommended or amputation not improvable by prosthesis controlled by natural knee action may also be assigned a 60 percent evaluation. 38 C.F.R. § 4.71a, DCs 5163 and 5164. Thus, considering the “amputation rule” pursuant to 38 C.F.R. § 4.68 and 38 C.F.R. § 4.71a , DCs 5161, 5162, 5163, and 5164, a 60 percent evaluation would be the maximum assignable schedular rating for the Veteran’s left knee disability; thus, separate disability ratings under additional diagnostic codes applicable to the knee, including 5257, 5260, and 5261, are not available. D. Other Diagnostic Codes The medical and lay evidence of record does not suggest the Veteran exhibited left knee ankylosis at any point in the appeal period; hence, a separate rating under DC 5256 is not warranted. Additionally, the evidentiary record does not suggest impairment of tibia and fibula or genu recurvatum. As such, separate disability ratings under DCs 5262 and 5263 are also not warranted during the appeal period. Finally, the Veteran is not entitled to a separate rating under DC 5259 for residual symptoms after removal of the semilunar cartilage as the Veteran’s left knee symptoms, such as pain, locking, and limitation of movement following his surgeries are already contemplated in DC 5258 and DC 5055. Assigning an additional, separate rating would violate the rules prohibiting pyramiding as it would compensate the Veteran twice for the same symptomatology of painful motion. 38 C.F.R. § 4.14. Additionally, a 60 percent rating under DC 5055 is the maximum assignable schedular rating for the Veteran’s left knee disability and DC 5055 does not allow a separate rating under DC 5259. Hence, a separate rating under DC 5259 is not applicable. Accordingly, all potentially applicable diagnostic codes have now been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). In summation, the Board denies an initial rating greater than 20 percent for left knee internal derangement with meniscal tear prior to July 15, 2013 and from November 1, 2013 to July 31, 2018. Additionally, the Board grants entitlement to an initial increased rating of 20 percent, but no higher, for left knee instability prior to September 27, 2017 and denies a rating greater than 20 percent for instability from September 27, 2017 to August 1, 2018. Finally, the Board denies a rating greater than 60 percent from October 1, 2019 for total left knee replacement. Left Knee Scars Originally, the Veteran appealed his initial noncompensable rating for residual surgical scars rated under DC 7805. As noted above, the Veteran underwent a total left knee replacement on August 1, 2018 and received a new surgical scar, which the AOJ subsequently service connected and assigned a 10 percent initial disability rating under DC 7804. The rating criteria for scars were revised during the claim period, effective August 13, 2018. See 83 Fed. Reg. 32, 592 (July 13, 2018). As noted above, claims pending prior to the effective date will be considered under both the old and new rating criteria. Although the Veteran’s claim was filed prior to August 13, 2018, the rating criteria applicable to his claim under DCs 7804 and 7805 were not changed. Here, in pertinent part, DC 7804 provides that one or two scars that are unstable or painful warrant a 10 percent evaluation; whereas, three or four scars that are unstable or painful warrant a 20 percent evaluation. See 38 C.F.R. § 4.118. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. Note (2) provides that if one or more scars are both unstable and painful, 10 percent is added to the evaluation based on the total number of unstable or painful scars. Id. Note (3) provides that scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code when applicable. Id. DC 7805 pertains to other scars, and other effects of scars evaluated under DCs 7800, 7801, 7802, and 7804. Under DC 7805, any disabling effects not considered in a rating provided under DCs 7800-04 are to be evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.118. Here, the Veteran and medical records reflect the Veteran initially had two left knee surgical scars, approximately 2cm long by .3cm wide, that were neither painful nor unstable. See, e.g., January 2013 VA examination report. For example, a December 2011 VA examiner noted no pain or unstable scar upon examination of the Veteran. The Veteran’s extensive medical records also note no evidence of pain or instability of these scars and the Veteran, himself, has also not reported his initial left knee scars were painful or unstable. As such, the Veteran is not entitled to an initial compensable rating for his first service-connected left knee scars from internal derangement. However, during the appeal period, the Veteran received a new, larger scar from his total left knee replacement on August 1, 2018. See December 2018 VA examination report. This new scar was measured as 19cm long by 1cm wide in December 2018 and, alternatively, as 18cm long by 1.5cm wide in November 2019. Id; see also November 2019 VA examination report. The December 2018 VA examiner noted the Veteran scar caused “excruciating pain” with “throbbing, ringing pain that travels across and through the entire knee.” Id. In November 2019, the VA examiner noted the Veteran’s scar was “extremely long” and the Veteran reported “moderate pain to touch.” Id. However, neither VA examiner found the Veteran’s scar unstable and the Veteran did not contend otherwise. Id. A rating greater than 10 percent under DC 7804 requires that a scar be both unstable and painful, or that the Veteran has “three or four scars that are unstable or painful.” See 38 C.F.R. § 4.118, DC 7804. As such, the Veteran is not entitled to an initial rating greater than 10 percent as he has only one painful scar. However, the Board must still address whether the Veteran’s two service-connected left knee scars could receive a higher rating under all other potentially applicable diagnostic codes. See Schafrath, 1 Vet. App. at 593. The Board notes the Veteran’s scars are linear and not on his head, face, or neck; therefore, DCs 7800, 7801, and 7802 are not applicable. Also, the Board finds the evidence of record does not reflect any additional disabling effects or limitations of function of the scars that are not already contemplated in the current rating or in the Veteran’s service-connected total left knee replacement rating under DC 5055. See 38 C.F.R. § 4.118, DC 7805. The December 2018 VA examiner reported that the Veteran’s painful scar resulted in his “limitation to sit or stand for prolonged periods” and he had difficulty with limitation of motion and stairs, but these disabling affects are already fully contemplated by the pain mentioned in DC 7804 and his total left knee replacement rating under DC 5055. (Continued on the next page)   Thus, the Board has considered all potentially applicable diagnostic codes. See Schafrath, 1 Vet. App. at 593. In this case, the Board finds an initial compensable rating for the Veteran’s left knee internal derangement scars, as well as an initial rating greater than 10 percent for a total left knee replacement scar is not warranted and the Board denies the claim. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Bona, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.