Citation Nr: 21013812 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 16-48 644 DATE: March 10, 2021 ORDER Entitlement to service connection for erectile dysfunction (ED) is denied. Entitlement to an initial disability rating in excess of 30 percent for headaches, not otherwise specified (NOS), is denied. FINDINGS OF FACT 1. ED did not manifest in service and not otherwise attributable to service. 2. At worst, the Veteran’s headaches NOS do not manifest as very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for ED have not been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.102, 3.303, 3.304. 2. The criteria for an initial disability rating in excess of 30 percent for headaches NOS have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8100. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from January 1965 to May 1967. The Veteran also served in the United States Naval Reserve from March 1964 until August 1993 with several periods of active duty for training purposes (ACDUTRA) and inactive duty for training (INACDUTRA). These matters come to the Board of Veterans’ Appeals (Board) on appeal from a December 30, 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which denied entitlement to service connection for ED and granted service connection for headaches NOS; a 30 percent rating was assigned from November 2, 2012. In a November 2018 decision, the Board denied the Veteran’s claim of entitlement to service connection for ED, as well as entitlement to a higher initial rating for service-connected headaches NOS. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veteran’s Claims (Court), resulting in a Joint Motion for Partial Remand (JMPR). A January 2020 Order partially vacated that portion of the Board’s decision as to the denial of service connection for erectile dysfunction and as to the denial of an initial disability rating in excess of 30 percent for headaches (NOS), remanding these two issues on appeal for compliance with instructions in the December 2019 JMPR. In a May 2020 Board decision, the claims were remanded for further evidentiary development in order to comply with the JMPR. As will be detailed below, a review of the record reflects substantial compliance with the Board's Remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Supplemental statements of the case (SSOCs) were issued in November 2020 and December 2020. The Veteran’s VA claims file has been returned to the Board for further appellate proceedings. In December 2020, the Veteran attempted to opt-into the AMA, via VA Form 20-0996 (Request for Higher Level Review). In correspondence of the same month, the RO indicated that such an opt-in was not possible as more-than-one year had elapsed since the decision was decided. At this time, the RO indicated that the Veteran must file a VA Form 20-0995 (Review Request: Supplement Claim) to begin the opt-in process. While the evidence of record discloses that a blank VA Form 20-0995 has been associated with the claims file, a completed VA Form 20-0995 has not been submitted. As such, this appeal remains in the Legacy system. Service Connection The Veteran contends that ED was incurred in, aggravated by, or otherwise attributable to, active duty service. More specifically, the Veteran advances that ED is a residual of a circumcision that took place in service. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). If the evidence is competent, the Board must then determine if the evidence is credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). A layperson is generally not capable of opining on matters requiring medical knowledge. Bostain v. West, 11 Vet. App. 124, 127 (1998). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In order to establish service connection on a direct basis, the record must contain competent evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F. 3d 1039, 1043 (Fed. Cir. 1994). Evidence and Analysis A review of the Veteran’s service treatment records discloses that he underwent a circumcision in October 1965, under local anesthesia. In the Veteran’s May 1967 separation report of medical examination, a clinician indicated normal evaluations of the Veteran’s abdomen and viscera and genitourinary system. There is no mention of the October 1965 circumcision in this report. Notably, this report includes the clinician and the Veteran’s signatures. In an October 1979 Reserves report of medical history, the Veteran reported that he had not had and did not have frequent or painful urination; however, he responded affirmatively to venereal disease (VD)—syphilis, gonorrhea, etc. In the associated Reserves report of medical examination, a clinician only indicated an abnormal clinical evaluation of identifying body marks, scars, and/or tattoos. This report provides no guidance as to the Veteran’s 1965 circumcision or any associated residuals. Furthermore, the clinician did not report an abnormal clinical evaluation of the Veteran’s genitourinary system. In an October 1981 Reserves report of medical history, the Veteran reported that he had not had and did not have frequent or painful urination. In this report, the Veteran responded affirmatively to having had or having gonorrhea. In the report’s summary, a clinician confirmed that the Veteran had (without stipulating a time frame) gonorrhea. A review of subsequent Reserves annual reports through 1981 reflects periodic reports of venereal disease (gonorrhea) and sugar or albumin in urine. However, these reports do not show either clinical notations or subjective endorsements of either other genitourinary abnormalities or residuals of the October 1965 circumcision. In a May 1999 urology consultation, a private clinician noted that the Veteran sought care for an enlarged prostate. Private treatment records from D., a private medical facility, disclose that the Veteran sought urological treatment from 2004 to 2010. Clinicians monitored the condition of the Veteran’s urological status. He underwent a prostatectomy, which also included removal of the bilateral seminal vesicles and bilateral vasa deferentia, in 2010. Additionally, the Veteran underwent a radical resection of the urethra. He endorsed symptoms of ED after these procedures. VA treatment records from 2009 reflect that urethritis was an ongoing problem. A clinician prescribed an antibiotic and noted that the urethritis could have an infectious cause or an inflammatory cause. Private treatment records from G.U., a private medical facility, reveal that the Veteran sought treatment for malignant neoplasm of the prostate; dysuria; stress incontinence; and impotence of organic origin in 2011. A clinician recommended a course of physical therapy. The Veteran also underwent procedures for benign prostatic hyperplasia and hematuria, to ameliorate the hyperplasia and bladder outlet obstruction. Private treatment records from C. Hospital dated in 2012 show that the Veteran did not have problems with incontinence. In September 2013, VA received private treatment records from several private providers, to include those discussed above. Additionally, Dr. K. indicated a risk for ED in January 2012. He also reported that the Veteran’s genitourinary system was negative for flank pain, hematuria, and sexual dysfunction in July 2013. In December 2013, the Veteran was afforded a VA examination. A VA clinician reviewed the claims file; considered the Veteran’s subjective accounts; and conducted an appropriate evaluation (hereinafter “VA exam protocols”). This clinician provided no current diagnosis for a male reproductive systems disability. The clinician noted that the Veteran conveyed that he had had a circumcision in 1965 and his symptoms began in 1975. Here, the clinician indicated that the Veteran experienced urine leakage; however, he did not meet the diagnostic for a voiding dysfunction; urinary tract infection; ED; or male reproductive organ infections. Upon an examination of the Veteran’s penis and testes, the clinician reported that varicocele was not present and there was no tenderness or mass located at the bilateral testicles. Based upon consideration of the totality of evidence, to include findings from the instant examination, the December 2013 VA clinician indicated that a male genitourinary disability (“residuals of circumcision”) was less likely than not incurred in or caused by the Veteran’s claimed in-service incurrence. As a rationale for this negative nexus opinion, the clinician underscored that there was no evidence of a current genitourinary disability. Moreover, there was no medical evidence of record or medical history that shows that the Veteran had such. In a May 2015 letter, Dr. F., a private physician, wrote that he was continuing the Veteran’s urological course of treatment. Dr. F. indicated that the Veteran suffered from attacks of dysuria, which has been present for several years; treatment consisted of courses of antibiotics. Noting the Veteran’s history of prostate cancer, Dr. F. reported current side effects of ED and stress incontinence. As to the Veteran’s epididymides, Dr. F. reported the presence of a tender cyst on the tail (globus minor) of the left. However, the right epididymites was normal—without tenderness or masses. In a September 2016 lay statement, the Veteran wrote that he was circumcised in 1965 (during active duty service) to “correct” burning sensations in his penis. After this procedure, the Veteran conveyed that he made several sick calls because the surgery was done poorly. The Veteran indicated that he has sought extensive urological treatment in several locales. Over the years, the Veteran reported that urologists indicated that they could correct the circumcision by surgically removing skin from his penis head. However, the Veteran refused surgery because he did not want to endure the pain. Nevertheless, the Veteran advanced that he should be granted compensation for this alleged circumcision negligence that “will plague” him for the duration of his life. Moreover, the Veteran wrote that he had ED due to prostate surgery that was performed in November 2010. In a December 2017 brief, the Veteran’s representative recapitulated the Veteran’s contentions, noting the evidence is at least in equipoise. In a July 2018 letter, Dr. F. wrote that the Veteran endorsed that his dysuria began in 1965. A circumcision brought no relief. In this letter, Dr. F. again indicated that ED was a side effect of the Veteran’s prostate treatment, to include the prostatectomy and external beam radiation (which last occurred in December 2015). The Veteran failed to appear for a VA penile deformity examination in May 2019. A review of the Veteran’s VA treatment records through 2020, among others, disclose active problems of hypertrophy of prostate without urinary obstruction and prostate cancer treated with radiation therapy and a robotic prostatectomy. October 2019 private treatment records from U.G.A. disclose that the Veteran has a medical history of disorder of male genital organs; cyst of epididymis; urge incontinence; urgency of urination; ED due to diseases classified elsewhere; and other related issues. The Veteran received treatment for bladder neck obstruction and the Veteran’s urethra was found to be without strictures or masses. Moreover, the bilateral urethral orifices were normal. Dr. F.’s 2020 treatment records show that the Veteran endorsed a painful burning sensation when he urinates. Dr. F. noted that the Veteran suffered from arteriosclerosis; hypertension; and diverticula of the colon. And, a renal sonogram disclosed the presence of bilateral kidney cysts and minimal post-void bladder residual. Dr. F. did note that the Veteran does have problems with erections and urinary incontinence. While Dr. F. noted the October 1965 circumcision, Dr. F. offered no guidance as to whether this procedure related to either problems with erections or urinary incontinence. In an April 2020 brief, the Veteran’s representative reiterated a possible nexus between the Veteran’s contention of ED and residuals due to the in-service circumcision to include (among others), dysuria, leakage and incontinence. Pursuant to the May 2020 Board Remand, the Veteran was afforded a VA male reproductive organ conditions examination in December 2020. The clinician performed VA exam protocols. The clinician provided an extensive discussion of the Veteran’s many subjective accounts. The Veteran reported that he experienced problems with his erection but only in 2008 was he unable to get a full erection. He indicated that his urologist prescribed Cialis and Viagra in 2008, but he did not take the medication due to possible side effects. The Veteran reported that he sought care in 1965 for burning and pain upon urination and a circumcision was recommended. The Veteran claimed that, a few days after the in-service circumcision, he sought treatment for pain and the same burning and pain upon urination that existed prior to the circumcision. The Veteran reported that he was subsequently told that he needed another circumcision; however, the Veteran decided not to proceed with it. Since that time, the Veteran conveyed that he has suffered from dysuria. Now, he sees a urologist on a regular basis for pain. The Veteran elaborated that, before his prostate cancer diagnosis, he was seen for an enlarged prostate and experienced increased urinary frequency and incontinence. The Veteran stated that, since the prostatectomy, these symptoms fluctuate. The Veteran now wears incontinence underwear and cannot achieve an erection. He reported that, at night, he gets up 4 times to urinate. As to dysuria, the Veteran endorses constant pain in his penile area of 4/10 in severity with burning upon urination. However, the Veteran does not take medication for these symptoms. As to other issues, the December 2020 VA clinician indicated that the Veteran has not had an orchiectomy or renal dysfunction. The clinician indicated that the etiology of the Veteran’s voiding dysfunction was prostate cancer. The clinician indicated that the etiology of the Veteran’s ED was prostate cancer. Upon physical examination, the Veteran’s penis appeared abnormal, notably there was a partial circumcision. The testes were normal; the epididymis was normal. As to functional impact, the Veteran conveyed that he needed frequent access to bathrooms. Upon a thorough contemplation of the totality of evidence, to include the Veteran’s subjective endorsements of penile deformity, dysuria, leakage and incontinence as residuals of a circumcision that took place during active duty service in 1965, the December 2020 VA clinician opined that ED was less likely than not incurred in or caused by the 1965 circumcision and/or residuals of penile deformity, dysuria, leakage and incontinence. The clinician explained that: 1) The Veteran’s medical records are silent for any objective evidence of ED that may have resulted from the circumcision and residuals. The Veteran’s medical record of October 1965, as noted above, mentions that the Veteran has had a history of venereal disease that was treated with antibiotics. The Veteran underwent circumcision on October 26, 1965 but the record contains no subjective evidence following the circumcision suggestive of ED. Moreover, there is no medical literature that would support that circumcision can cause ED. 2) The Veteran had undergone circumcision in October 1965. The Veteran had preexistent venereal disease prior to active service. Treatment records also show that the Veteran had a transurethral resection of the prostate (TURP) in 2003. An examination of December 2013 did not reveal any remarkable findings. Penis, testes, and epididymis were normal. The Veteran underwent a prostatectomy in 2010. While the Veteran had penile complaints in STRs, there is no objective evidence of any penile deformity. As such, the Veteran’s penile deformity is less likely a not incurred in or otherwise attributable to active duty service; AND 3) The Veteran’s medical record discloses that his physical examination of December 2013 showed a normal penis, testes, and epididymis. The Veteran’s latest laboratory test revealed PSA <1.0 ng/ml. The Veteran had a pre-existing venereal disease and a treatment record of 2005 also revealed that the Veteran had unprotected sex. The Veteran reported that he would always have problems after this sexual encounter. Although several medical studies mention that penile deformity may cause problems with obtaining or maintaining an erection, the Veteran’s treatment records are silent for any subjective or objective evidence of penile deformity as well as ED. The Board observes that the clinician also offered etiological opinions as if prostate cancer were service connected. Such is not the case. The Board recognizes that one of its remand directives touches upon the issue of proximate causation and aggravation beyond natural progression. However, even within this context, the probative weight of this clinician’s negative nexus opinion as to direct service connection (and the extensive rationales presented) are in no way diminished. As the extraneous remand directive and opinion as to service connection on a secondary basis do not prejudice the interests of the Veteran, the Board finds this error to be harmless. The Veteran contends that ED was caused by an in-service circumcision. The Board recognizes the Veteran’s belief in this theory of etiology and causation. Nevertheless, as a lay person, this Veteran lacks the highly specialized medical training to render complex medical opinions as to etiology or causation. See Jandreau and Bostain, both supra. Upon careful scrutiny of the record, the Board observes that neither the Veteran nor his representative have presented any competent medical or scientific evidence to support this theory. Here, the Board informs the Veteran and reminds his representative that a claimant still ultimately bears some burden of production. 38 U.S.C. § 5107(a); Cromer v. Nicholson, 455 F. 3d 1346 (Fed. Cir. 2006). As such, these lay contentions as to etiology warrant highly diminished probative weight. Critically, the weight of competent evidence fails to establish an in-service incurrence. While the Veteran’s STRs do document the October 1965 circumcision, STRs do not disclose ED. Here, the Board takes note of the Veteran’s May 1967 separation report of medical examination, a clinician indicated normal clinical evaluations of the Veteran’s abdomen and viscera and genitourinary system. Both the clinician and the Veteran signed this report. Moreover, the plethora of Reserve STRs fail to disclose complaints of, treatment for, or diagnoses of ED. Without an in-service incurrence or predicate, a nexus cannot be drawn; without a nexus, service connection cannot be established. See Shedden, supra. Therefore, the weight of competent and credible evidence is against the Veteran’s service connection claim; there are no doubts to be resolved. See 38 U.S.C. § 5107(b); Gilbert, supra. Initial Disability Rating: Headaches NOS The Veteran contends that the 30 percent disability rating assigned to his service-connected headaches NOS does not contemplate the severity of his symptoms. Ratings for service-connected disabilities are determined by comparing the Veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran’s headache disorder has been evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8100. This Diagnostic Code provides that The Veteran’s headache disorder has been evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8100. This Diagnostic Code provides that very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability are rated 50 percent disabling. When characteristic prostrating attacks occur an average of once a month over the last several months, a 30 percent rating is warranted. Id. Evidence and Analysis In December 2013, the Veteran was afforded a VA headaches examination. A VA clinician performed VA exam protocols. The clinician provided a diagnosis of headaches NOS. The Veteran indicated that he did not take medication for headaches. The Veteran endorsed constant head pain on both sides of the head. Endorsed non-headache symptoms included sensory changes. Duration of typical head pain lasted for more than two days—on both sides of the head. The Veteran reported that prostrating attacks of migraine headache pain occurred more frequently than once a month. The Veteran also endorsed that that prostrating attacks of non-migraine headache pain occurred more frequently than once a month. As to functional impact, the Veteran’s headaches NOS impacted the Veteran’s ability to work because the Veteran indicated that he has to rest periodically, especially during severe headaches. In July 2014, January 2015, May 2015, April 2016. February 2017, December 2017, June 2018, and November 2018 VA primary care systems reviews, the Veteran did not indicate that he experiences headaches. However, the Veteran’s VA problems lists indicate that headaches NOS was an ongoing problem as of July 2014. Private treatment records from Dr. S., dated in 2014, include notations that the Veteran’s dizziness and headache are associated with right-ear tinnitus. This physician noted that there has been no associated disequilibrium; history of head trauma; history of seizures; nausea; vertigo; visual disturbances; or vomiting. In May 2017, the Veteran was afforded a VA headaches examination. A VA clinician performed VA exam protocols. The clinician noted that the Veteran indicated he always has a headache that intensifies at times and involves his left eye and numbness around the face. Treatment included medication, namely ibuprofen. The Veteran endorsed symptoms of constant head pain; pain localized to one side of the head; pain on both sides of the head; and steady pain. Additionally, the Veteran endorsed nausea; sensory changes; blurry vision; and neck pain. The Veteran characterized the pain as steady that intensifies at times—bilaterally. There was no indication of characteristic prostrating attacks of migraine or non-migraine pain. The clinician reported that headaches NOS did not functionally impact the Veteran’s ability to work. In January 2015, May 2015, April 2016. February 2017, December 2017, June 2018, and November 2018 VA primary care systems reviews, the Veteran did not indicate that he experiences headaches. In April 2020, the Veteran was afforded a VA headaches examination. A VA clinician performed VA exam protocols. This clinician provided a diagnosis of headaches unspecified. In the medical history section of the report, the clinician opined that the Veteran’s saw a neurologist for dizziness; numbness around the left side of his face; and intermittent blurry vision. This clinician added that the Veteran’s headaches are complicated by a diagnosis of multiple sclerosis. (The Veteran subjectively endorsed that the attribution was advanced by his neurologist but not by Dr. S., as noted above.) The clinician noted that headaches are complicated by tinnitus. The Veteran reported that his headaches had progressed and occur daily. The headaches are of varying intensity and sometimes are associated with dizziness and blurry vision. The Veteran indicated that he took medication on an “as needed” basis. As to multiple sclerosis, the clinician opined that an April 2008 medical note reported that magnetic resonance imaging (MRI) of the Veteran’s brain rendered results suggestive of a demyelinating disease. The Veteran endorsed pain localized to one side of the head; changes in vision; and sensory changes. Typical headache pain lasted for less than one day—on the left side of the head. The Veteran also stated that he experienced characteristic prostrating attacks of headache more than once per month. However, the clinician opined that the Veteran did not have very prostrating and prolonged attacks of migraine/non-migraine pain productive of severe economic inadaptability. As to other findings, the clinician indicated that the Veteran has relapse-remitting multiple sclerosis. As to functional impact on the Veteran’s ability to work, the clinician noted that the Veteran would have difficulty operating machinery or driving during an acute headache episode. In additional remarks, the clinician wrote that it is highly plausible that the Veteran’s headaches are a related symptom of relapse-remitting multiple sclerosis. While there is some evidence to show such, the clinician indicated that he was unable to render such an etiology as he is not the Veteran’s primary care neurologist. Nevertheless, the clinician opined that there have been no significant changes since the Veteran’s last VA headaches examination, as noted above. As noted above, to receive an increased disability for headaches NOS, there would need to be a showing of very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability. Such is not shown in the evidence of record. At worst, the Veteran’s service-connected headaches manifest in characteristic prostrating attacks of headache pain more than once a month that last no more than a day. Upon scrutiny of the evidence, no clinical or subjective evidence even suggests that these attacks are productive of economic inadaptability. The Veteran contends that headaches NOS are more severe than that contemplated by a 30 percent disability rating. Nevertheless, as a lay person, this Veteran lacks the highly specialized medical and neurological training and expertise to render a complex opinion as to the severity of a headaches disorder. See Jandreau, Bostain, both supra. As such, the Veteran’s lay contentions do not constitute competent clinical evidence. The Board assigns significant probative to the three VA examination reports discussed above. In each examination instance, a clinical professional reviewed the claims file; considered the Veteran’s subjective accounts; and conducted an appropriate evaluation. Moreover, these professionals assessed the Veteran’s disability through all applicable prongs of the applicable Diagnostic Code. Therefore, the competent, credible and expert objective medical evidence of record discloses that the Veteran’s headaches NOS, most nearly approximates a disability rating of 30 percent. Thus, the 30 percent rating currently assigned contemplates the severity of the Veteran’s symptoms and the Board finds that a rating in excess of 30 percent is not warranted. The preponderance of evidence is against the Veteran’s higher initial rating claim and there is no doubt to be resolved. See 38 U.S.C. § 5107(b); Gilbert, supra. Katherine Kiemle Buckley Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. J. Komins, 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.