Citation Nr: 21015436 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 17-46 431 DATE: March 17, 2021 ORDER Entitlement to a disability rating greater than 10 percent prior to November 28, 2016, for lumbar spine degenerative disc disease with intervertebral disc syndrome (IVDS), herniated disc of L5-S1, and arthritis (hereinafter, service-connected low back disabilities) is denied. Entitlement to a 20 percent disability rating, but no higher, for the Veteran’s service-connected low back disabilities from November 28, 2016, to September 15, 2020, is granted, subject to the applicable regulations concerning the payment of monetary benefits. Entitlement to a disability rating greater than 40 percent from September 16, 2020, for the Veteran’s service-connected low back disabilities is denied. Entitlement to a 20 percent disability rating, but no higher, for right sacroiliac joint dysfunction with painful episodes of dislocation is from June 22, 2015, to the present, is granted, subject to the applicable regulations concerning the payment of monetary benefits. Entitlement to a disability rating in excess of 20 percent for right lower extremity radiculopathy from September 28, 2017, is denied. Entitlement to a disability rating in excess of 40 percent from September 28, 2017, until September 16, 2020, and of 20 percent, thereafter, for left lower extremity radiculopathy is denied. REMANDED Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected generalized anxiety disorder, is remanded. FINDINGS OF FACT 1. From June 22, 2015 until November 28, 2016, the Veteran’s From November 28, 2016 until September 16, 2020, the Veteran’s lumbar spine degenerative disease with IVDS, herniated disc of L5-S1, and arthritis was manifested by forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85degrees. From November 28, 2016 until September 16, 2020, the Veteran’s lumbar spine degenerative disease with IVDS, herniated disc of L5-S1, and arthritis was manifested by forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees. From September 16, 2020, the lumbar spine degenerative disease with IVDS, herniated disc of L5-S1, and arthritis was manifested by forward flexion of the thoracolumbar spine of 30 degrees or less. 2. From June 22, 2015, the Veteran’s right sacroiliac joint dysfunction with painful episodes of dislocation is manifest by localized tenderness resulting in abnormal gait or abnormal spinal contour. 3. From September 18, 2017, the Veteran’s right lower extremity radiculopathy manifest as moderate, incomplete paralysis of the sciatic nerve. 4. From September 28, 2017 until September 16, 2020, the Veteran’s left lower extremity radiculopathy manifest as moderately severe paralysis of the sciatic nerve. From September 16, 2020, the Veteran’s left lower extremity radiculopathy manifest as moderate paralysis of the sciatic nerve. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for lumbar spine degenerative disease with IVDS herniated disc of L5-S1, and arthritis were not met prior to November 28, 2016. The criteria for a rating in excess of 20 percent for lumbar spine degenerative disease with IVDS herniated disc of L5-S1, and arthritis have not been met from November 28, 2016 until September 16, 2020. The criteria for a rating in excess of 40 percent for lumbar spine degenerative disease with IVDS herniated disc of L5-S1, and arthritis have not been met from September 16, 2020. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5010 and 5243. 2. The criteria for Entitlement to a disability rating in excess of 20 percent from June 22, 2015 for right sacroiliac joint dysfunction with painful episodes of dislocation have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5236. 3. The criteria for a disability rating in excess of 20 percent for right lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 4. The criteria for Entitlement to a disability rating in excess of 40 percent from September 28, 2017 until September 16, 2020 and of 20 percent thereafter for left lower extremity radiculopathy have not been met. The criteria for a disability rating in excess of 40 percent from September 28, 2017 until September 16, 2020 and for 20 percent thereafter for left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1986 until August 2006. In a June 2019 decision, the Board denied the issues of entitlement to a compensable rating for service-connected right sacroiliac joint dysfunction with painful episodes of dislocation and entitlement to an evaluation in excess of 10 percent disabling for service-connected lumbar spine degenerative disc disease, and remanded the issue of entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected generalized anxiety disorder. The Veteran subsequently appealed to the United States Court of Appeals for Veterans Claims (Court). In April 2020, the Court granted an Order vacating the part of the June 2019 Board decision that denied an increased rating for degenerative disc disease and a compensable rating for right sacroiliac joint dysfunction and remanding the matter for further adjudication pursuant to a Joint Motion for Partial remand (JMPR). In July 2020, the Board remanded the issues of degenerative disc disease and a compensable rating for right sacroiliac joint dysfunction to the agency of original jurisdiction (AOJ) for additional development including a new medical examination. Both the remanded degenerative disc disease and sacroiliac joint dysfunction have now been returned to the Board. The Board finds there has been substantial compliance with its prior remand directives and will proceed to adjudication of these issues. Stegall v. West, 11 Vet. App. 268, 271 (1998). The issue of obstructive sleep apnea has also been returned to the Board. Unfortunately, there has not been substantial compliance with the Board’s prior remand directives regarding this issue, and another remand is now required. Id. Increased Rating 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. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The effective date for an award of increased compensation will be the date of receipt of claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (o)(1). Entitlement to a disability rating greater than 10 percent prior to November 28, 2016, greater than 20 percent from November 28, 2016 until September 16, 2020 and in excess of 40 percent thereafter for lumbar spine degenerative disease with IVDS, herniated disc of L5-S1, and arthritis In a June 22, 2015 Supplemental Claim, the Veteran requested increased evaluation of her service-connected lower back condition. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Raters must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare-ups. 38 C.F.R. § 4.14. The guidance provided by the Court in DeLuca must be followed in adjudicating claims where a rating under the diagnostic codes governing limitation of motion should be considered. However, the Board notes that the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45. In February 2021, the Code of Federal Regulations containing Diagnostic Codes 5003 and 5010 regarding the rating of arthritis disabilities were amended. The Board has considered both the February 2021 amended version of Diagnostic Codes 5003 and 5010 as well as the version that existed prior to the February 2021 amendments. Finding that using the amended version of the Code of Federal Regulations does not prejudice the Veteran, the Board has applied the amended version. Arthritis shown by X-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint so affected. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 (degenerative arthritis) and 5010 (traumatic arthritis). Diagnostic Code 5010 (traumatic arthritis) direct that the evaluation of arthritis be conducted under Diagnostic Code 5003, which states that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5010. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations is assigned a 20 percent rating. Arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups without incapacitating exacerbations are assigned a 10 percent rating. At the time the Veteran filed her supplemental claim, she was assigned a 10 percent disability rating for lumbar spine degenerative disc disease pursuant to Diagnostic Code 5237, which pertains to lumbosacral strain. 38 C.F.R. § 4.71a, DC 5237. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is appropriate when forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; or the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; or there is muscle spasm, guarding; or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more in height. 38 C.F.R. § 4.71a. A 20 percent rating is appropriate when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, muscles spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 40 percent evaluation is appropriate when forward flexion of the thoracolumbar spine is 30 degrees or less or there is favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent evaluation is appropriate when there is unfavorable ankylosis of the entire thoracolumbar spine. Id. A 100 percent evaluation is appropriate when there is unfavorable ankylosis of the entire spine. Id. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 2. Turning to the evidence of record, the Veteran was provided with a VA medical examination to evaluate his back condition in October 2015. The examination showed forward flexion of 0-80 degrees, extension of 0-20 degrees, right lateral flexion of 0-25 degrees, left lateral flexion of 0-30 degrees, right lateral rotation of 0-45 degrees, and left lateral rotation of 0-45 degrees. There was no pain on weight-bearing, no localized tenderness or pain on palpation, no additional loss of function or range of motion after repetitive use over time, no flares reported, no guarding or muscle spasms, no ankylosis, and no IVDS. The Veteran submitted private medical treatment records in August 2017. A November 2016 physical therapy note from Mathis Physical Therapy and Hand Center notes that the Veteran’s “forward bending” lumbar range of motion as 50 degrees, “backward bending” as 5 degrees, “right side bending” as 15 degrees, and “left side bending” as 15 degrees. A January 2017 note from the same provider shows that the Veteran’s “forward bending” lumbar range of motion as 55 degrees, “backward bending” as 10 degrees, “right side bending” as 15 degrees, and “left side bending” as 20 degrees. The Veteran was provided with another VA medical examination in October 2017. However, that examination has been deemed inadequate by the Court and is, therefore, non-probative. The Veteran was provided with a third VA examination in September 2020. That examination showed initial range of motion as follows: forward flexion of 0-15 degrees, extension of 0-10 degrees, right lateral flexion of 0-10 degrees, left lateral flexion of 0-10 degrees, right lateral rotation 0-10 degrees, and left lateral rotation of 0-10 degrees. After repetitive use and during flare-ups, the forward flexion was reduced to 0-10 degrees, right lateral flexion was reduced to 0-5 degrees, left lateral flexion was reduced to 0-5 degrees, and left lateral rotation was reduced to 0-5 degrees. The examiner also reported that the Veteran experienced guarding and muscle spasm that resulted in abnormal gait or spine contour. IVDS was also noted, but associated episodes of incapacitation were not recorded. The Board concludes that the evidence of record does not support a disability rating in excess of 10 percent prior to November 28, 2016. Based upon the Veteran-submitted private treatment records, the Board concludes that, as of November 28, 2016, the Veteran’s disability manifested as forward flexion of 50 degrees, and that assignment of a 20 percent rating, but no higher, from that date is warranted. Finally, the VA examination conducted in September 2020 shows that the Veteran’s disability manifested as forward flexion limited to 10 degrees. A disability rating of 40 percent is appropriate from the date of the third VA examination. Rating the Veteran’s disability using the formula for rating intervertebral disc syndrome is not appropriate as there is no indication the Veteran has experienced incapacitating episodes. The ratings that would otherwise be appropriate for arthritis are not considered here as they cannot be combined with ratings based upon limitation of motion. DC Code 5003, Note 2. Entitlement to a disability rating in excess of 20 percent from June 22, 2015 for right sacroiliac joint dysfunction with painful episodes of dislocation The Veteran’s right sacroiliac joint dysfunction has been rated under Diagnostic Code 5236. The criteria for rating a disability under Diagnostic Code 5235 are rated under the General Rating Formula for Diseases and Injuries of the Spine, which are delineated in the preceding section. The Veteran submitted private treatment records with her Supplemental Claim in June 2015. A July 2014 private treatment note states “There was tenderness to digital palpation and muscle tension on the right sacroiliac joint. There was muscle hypertonicity present on the right sacroiliac joint.” It was also noted that the Veteran walked with a right limp. The Veteran was provided with a VA hip examination in October 2015. That exam diagnosed right sacroiliac joint dysfunction but noted no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. During a VA back examination also conducted in October 2015, the examiner reported “no evidence of localized tenderness, pain on palpation, muscle spasms, or guarding. Although no pain was observed on examination, stiffness was noted…hip flexion was described as normal.” In November 2016, the Veteran stated on a notice of disagreement that her ilium moves out of place causing great pain, muscle spasms, immobility, and loss of time from work. In August 2017, the Veteran reported on a VA Form 9 that she experiences pain, muscle spasms, tenderness to pressure, unlevel pelvis, limited range of motion, and an abnormal gait. An October 2017 VA examination described right sacroiliac joint with palpable slipping while standing, joint instability, and loss of lumbar lordosis. An October 2020 VA examination showed objective evidence of localized tenderness or pain on palpation of the joint of associated soft tissue of the thoracolumbar spine. Additionally, guarding and muscle spasms that result in abnormal gait and spinal contour were also noted. The Board concludes that the evidence of record demonstrates that the Veteran’s sacroiliac joint dysfunction has most closely approximated 20 percent disabling for the entire appeal period due to localized tenderness resulting in abnormal gait. Because the evidence of record demonstrates that entitlement arose within one year prior to the Veteran’s filing of a supplemental claim seeking increased evaluation, the date of the Veteran’s supplemental claim is the appropriate effective date for the increased rating. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (o)(1). Entitlement to a disability rating in excess of 20 percent for right lower extremity radiculopathy from September 28, 2017 Entitlement to a disability rating in excess of 40 percent from September 28, 2017 until September 16, 2020 and of 20 percent thereafter for left lower extremity radiculopathy When considering an increase rating claim for a back disability, the Board must consider all manifestations of that disability including both musculoskeletal and neurological. Because the Veteran’s lower extremity radiculopathy is related to the Veteran’s lumbar spine degenerative disease with IVDS, herniated disc of L5-S1, and arthritis, the severity of her lower extremity radiculopathy will be considered. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term incomplete paralysis indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. Diagnostic Code 8520 provides the rating criteria for paralysis of the sciatic nerve, and therefore neuritis and neuralgia of that nerve. Complete paralysis of the sciatic nerve, which is rated as 80 percent disabling, contemplates foot dangling and dropping, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. Disability ratings of 10 percent, 20 percent and 40 percent are assignable for incomplete paralysis which is mild, moderate or moderately severe in degree, respectively. A 60 percent rating is warranted for severe incomplete paralysis with marked muscle atrophy. 38 C.F.R. § 4.124a , DC 8520. Diagnostic Code 8620 refers to neuritis of the sciatic nerve, and DC 8720 refers to neuralgia of the sciatic nerve. The Veteran’s right lower extremity radiculopathy has been assigned a 20 percent evaluation pursuant to Diagnostic Code 8520 since September 28, 2017. An October 2015 VA examination concluded that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. The October 2017 VA examination recorded signs and symptoms due to radiculopathy in the lower extremities including moderate constant pain bilaterally, moderate intermittent pain in the left and severe intermittent pain in the right, moderate paresthesias and/or dysesthesias in the right and severe in the left, and moderate numbness in the right and severe in the left. The examiner characterized the Veteran’s radiculopathy of the lower extremities as moderate in the right and severe in the left. A September 2020 VA examination showed moderate constant and intermittent pain, moderate paresthesias and/or dysesthesias, and numbness bilaterally in the lower extremities involving the sciatic nerve. The examiner characterized the radiculopathy as moderate bilaterally. Based upon the evidence of record, the Board concludes that the Veteran’s right lower extremity radiculopathy has manifested as moderate incomplete paralysis of the sciatic nerve since the date of the September 2017 VA examination. The Board also concludes that the Veteran’s left lower extremity radiculopathy was first factually ascertainable and manifested as moderately severe incomplete paralysis of the sciatic nerve as of the date of the September 2017 VA examination. However, the September 2020 VA examination showed improvement in the condition such that it manifested as moderate incomplete paralysis of the sciatic nerve. Because the rating had been in place for less than five years at the time of the reduction to 20 percent, the provisions of 38 C.F.R. § 3.344 (a) and (b) do not apply because the disability has not become stabilized and a reexamination disclosing improvement in the disabilities warrants a reduction in rating. 38 C.F.R. § 3.344 (c). REASONS FOR REMAND Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected generalized anxiety disorder, is remanded. The Veteran contends that her diagnosed obstructive sleep apnea is etiologically related to her active military service, to include as secondary to service-connected generalized anxiety disorder. In June 2019, the Board remanded the Veteran’s claim for service connection for sleep apnea to the AOJ for further development including an examination, if appropriate, and a medical nexus opinion. In July 2020, the AOJ obtained a medical nexus opinion from a VA opinion provider. Unfortunately, the obtained medical nexus opinion is inadequate. First, the opinion provider failed to indicate the method used to obtain medical information used to complete the document. Next, the examiner appears to have not considered the various pieces of medical literature submitted by the Veteran on August 26, 2017. A medical opinion that does not consider all relevant evidence of record is inadequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Finally, the opinion provider failed to address the aggravation prong of secondary service connection in their opinion. A medical opinion that applies the incorrect legal standard is inadequate. See El-Amin v. Shinseki, 26 Vet. App. 136, 140–41 (2013). On remand, an adequate medical nexus opinion must be obtained. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician addressing the etiology of the Veteran’s obstructive sleep apnea. The clinician should be provided with a copy of all pertinent documents, including a copy of this remand. If, after a review of all pertinent documentation, the clinician determines they cannot offer an opinion without examination of the Veteran, such an examination should be scheduled. The opinion provider is requested to address the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s obstructive sleep apnea is related to her active military service? (b.) It is at least as likely as not (50 percent or greater probability) that the Veteran’s obstructive sleep apnea is (i) proximately due to or (ii) aggravated by (defined as any increase in disability) the Veteran’s service-connected generalized anxiety disorder? In answering the foregoing, the opinion provider should consider, and address as appropriate, the following: i. Private treatment records and medical literature submitted by the Veteran in August 2017. ii. Private sleep study completed in August 2013. iii. The Veteran’s in-service complaints of sinus symptoms. iv. The Veteran’s reports of sleep trouble, to include as due to her service-connected anxiety disorder. The opinion provider is notified that the Veteran is competent to report any and all symptoms she has experienced. If the opinion provider determines that a requested opinion cannot be provided without resort to speculation, they should say why. SCOTT W. DALE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.D. Collins, 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.