Citation Nr: 21020936 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 18-12 469 DATE: April 8, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for the service-connected right knee patellofemoral syndrome with osteoarthritis prior to July 22, 2020 and a rating in excess of 20 percent thereafter is denied. Resolving reasonable doubt in the Veteran's favor, a separate rating of 20 percent for right knee meniscal tear is granted. Resolving reasonable doubt in the Veteran’s favor, a separate rating of 10 percent, and no higher for right knee instability is granted. Entitlement to an initial rating in excess of 10 percent for the service-connected left knee patellofemoral syndrome with osteoarthritis is denied. Resolving reasonable doubt in the Veteran’s favor, a separate rating of 20 percent for left knee meniscal tear is granted. Resolving reasonable doubt in the Veteran's favor, a separate rating of 10 percent, and no higher for left knee instability is granted. REMANDED Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Prior to July 22, 2020, the Veteran’s right knee patellofemoral syndrome with osteoarthritis had functional loss due to painful motion of the knee; since July 22, 2020 the knee disability has manifested, at worst, with flexion limited to 30 degrees. 2. During the course of the appeal, the Veteran’s left knee patellofemoral syndrome with osteoarthritis manifested at worst with flexion limited to 50 degrees. 3. The competent and credible evidence shows the Veteran has bilateral knee meniscal tear with joint trace joint effusion. 4. The competent and credible evidence shows the Veteran has slight bilateral knee instability. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 10 percent for the service-connected right knee patellofemoral syndrome with osteoarthritis prior to July 22, 2020 and a rating in excess of 20 percent from July 22, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5003-5260. 2. The criteria for a 20 percent rating for right knee meniscal tear have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5258. 3. The criteria for a 10 percent rating, and no higher for right knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.71a, DC 5257. 4. The criteria for entitlement to an initial rating greater than 10 percent for the service-connected left knee patellofemoral syndrome with osteoarthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5003-5260. 5. The criteria for a 20 percent rating for left knee meniscal tear have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5258. 6. The criteria for a 10 percent rating, and no higher for left knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1958 to February 1962. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2019 the Veteran testified before a Veterans Law Judge (VLJ) at a video conference hearing; a transcript is of record. This claim was remanded in March 2020 for further development. There has been substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes the Veteran’s unsuccessful attempt to opt-into the Appeals Modernization Act (AMA), by submitting a VA Form 20-0995, Decision Review Request: Supplemental Claim on November 13, 2020 for an August 18, 2020 supplemental statement of the case (SSOC). However, as the opt-in request was received more than 60 days after the August 18, 2020 SSOC, it cannot be accepted for review. In January 2021 the Veteran was notified that the VLJ who performed his November 2019 hearing was no longer employed by the Board and afforded a new opportunity for a hearing. The Veteran declined this offer in a January 2021 correspondence. This appeal has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107(a)(2) (2014); 38 C.F.R. § 20.900(c) (2021). Increased Ratings Disability ratings are determined by applying a schedule of reductions in earning capacity from specific injuries or a combination of injuries that is based upon the average impairment of earning capacities. 38 U.S.C. § 1155. Each disability must be viewed in relation to its entire history, with emphasis upon the limitations proportionate to the severity of the disabling condition. 38 C.F.R. § 4.1. Where there is a question as to which of the two disability evaluations is applied, the higher evaluation 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. After careful consideration of the evidence of record, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). When rating the Veteran's service-connected disability, the entire medical history must be reviewed. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board must also fully consider the lay assertions of record. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45 (2016); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). After the evidence has been assembled, it is the Board’s responsibility to evaluate the entire record. 38 U.S.C. § 7104(a) (West 2014). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3. 1. Entitlement to an initial rating in excess of 10 percent for the service-connected right knee patellofemoral syndrome with osteoarthritis prior to July 22, 2020 and a rating in excess of 20 percent thereafter is denied. 2. Resolving reasonable doubt in the Veteran’s favor, a separate rating of 20 percent for right knee meniscal tear is granted. 3. Resolving reasonable doubt in the Veteran’s favor, a separate rating of 10 percent, and no higher for right knee instability is granted. 4. Entitlement to an initial rating in excess of 10 percent for the service-connected left knee patellofemoral syndrome with osteoarthritis is denied. 5. Resolving reasonable doubt in the Veteran’s favor, a separate rating of 20 percent for left knee meniscal tear is granted. 6. Resolving reasonable doubt in the Veteran’s favor, a separate rating of 10 percent, and no higher for left knee instability is granted. Service connection for right and left knee patellofemoral syndrome with osteoarthritis was granted in a January 2017 rating decision. A 10 percent rating was assigned under 38 C.F.R. § 4.71a, DC 5003-5260. The effective date of the grant of service connection is August 3, 2016. The Veteran seeks a 20 percent rating or higher. During the pendency of the appeal, the Veteran was awarded a higher rating of 20 percent for his right knee disability effective July 22, 2020, the date of his VA examination. As this rating does not reflect the full grant of the benefit sought on appeal, the issue remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). The Veteran seeks a higher initial rating for his bilateral knee disability and asserts that the condition is worse than the rating assigned. The Board notes that while portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, this diagnostic code was not changed. 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, DC 5003. DC 5003 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. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, X-ray evidence of arthritis involving two or more major or minor joint groups will warrant a 10 percent rating, and two or more major or minor joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The 10 percent and 20 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, DC 5003 Note 1. In this case, the Veteran's right and left knees are both rated under Diagnostic Code 5003-5260. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the assigned rating; the additional code is shown after the hyphen. Here, the hyphenated diagnostic code indicates that arthritis (DC 5003) is rated under the criteria for limitation of leg flexion (DC 5260). Limitation of motion of the knee is contemplated in 38 C.F.R. § 4.71a, DC 5260 and 5261. Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. DC 5260 provides for a zero percent rating where flexion of the leg is limited to 60 degrees. For a 10 percent rating, flexion must be limited to 45 degrees. A 20 percent rating is warranted where flexion is limited to 30 degrees. A 30 percent rating may be assigned where flexion is limited to 15 degrees. DC 5261 provides for a 10 percent rating requires extension limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating may be assigned where the evidence shows extension limited to 20 degrees. For a 40 percent rating, extension must be limited to 30 degrees. Finally, where extension is limited to 45 degrees a 50 percent rating may be assigned. DC 5257 provides for assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability, a 20 percent rating when there is moderate recurrent subluxation or lateral instability, and a 30 percent evaluation for severe recurrent subluxation or lateral instability. VA's General Counsel has stated that when a knee disorder is rated under 38 C.F.R. § 4.71a , DC 5257 and an appellant also has limitation of knee motion which at least meets the criteria for a noncompensable evaluation under 38 C.F.R. § 4.71a, DC 5260 or 5261, separate evaluations may be assigned for arthritis with limitation of motion and for instability. However, General Counsel stated that if an appellant does not meet the criteria for a noncompensable rating under either DC 5260 or DC 5261, there is no additional disability for which a separate rating for arthritis may be assigned. VAOPGCPREC 23-97 (July 1, 1997), published at 62 Fed. Reg. 63,604 (1997). If a rating is assigned under the provisions for other knee impairment (38 C.F.R. § 4.71a, Code 5257) a separate 10 percent rating may be assigned where some limitation of motion, albeit noncompensable, has been demonstrated. See VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). VA's General Counsel has also stated that separate ratings under DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 (2004). The rating schedule also provides that dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint, warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, DC 5258. DC 5259 provides for the assignment of a maximum 10 percent rating based on symptomatic removal of the semilunar cartilage. 38 C.F.R. § 4.71a, DC 5259. The Board finds that the preponderance of the evidence is against an initial rating in excess of 10 percent prior to July 22, 2020 and a rating in excess of 20 percent thereafter for the right knee disability. Likewise, the preponderance of the evidence is against an initial rating in excess of 10 percent for the left knee disability. The Board acknowledges the Veteran's lay reports of symptoms and that there is functional loss due to pain. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements he has pain and weakness, would not result in limitation of motion more nearly approximating flexion limited to 30 degrees for the right knee prior to July 22, 2020 or the left knee during the appeal period. Turning to the evidence of record, a private treatment note reports the right knee as having full extension and flexion limited at 110 degrees. X-rays showed osteoarthritis of the right knee. There were no complaints or reports regarding the left knee. A VA examination in November 2016 noted range of motion of the right and left knee from zero to 130 degrees. The Veteran reported that his bilateral knee condition worsened. He shared that he was walking, and the knees “gave out.” On examination, pain on flexion was noted as causing additional functional loss; however, range of motion was not reported. After observed repetitive use, there was no additional loss of range of motion for either knee. Although it was reported that for both knees, pain, fatigue, and lack of endurance significantly limited functional ability with repeated use over time, there was no additional loss of range of motion. The examination was not conducted during a flare-up; however, the examiner noted that pain fatigue, and lack of endurance caused functional loss. The range of motion for both knees during a flare-up was zero to 120 degrees. There was crepitus and pain on weight-bearing for both knees. There was no instability, ankylosis or meniscus condition found on examination for either knee. The Veteran reported using a cane for his knees and a knee wrap. A March 2017 VA radiology report indicated that both the right and left knee had mild/moderate degenerative changes without evidence of fracture or dislocation. No significant joint effusion or soft tissue swelling was seen. There was vascular calcification. A November 2017 VA MRI of the right knee showed a diffuse complex tear of the macerated medial meniscus with horizontal/radial components; mild popliteal tendinosis; nonspecific patchy subchondral bone marrow edema of the medial tibiofemoral compartment which may reflect degenerative stress reaction; severe medial tibiofemoral compartment chondrosis; trace joint effusion with lipoma arborescens and medium popliteal cyst. Regarding the left knee, the MRI showed a complex tear of the body of the medial meniscus; horizontal tear of the body of the lateral meniscus with parameniscal cysts; nonspecific patchy subchondral bone marrow edema of the medial tibiofemoral compartment which may reflect degenerative stress reaction; severe medial tibiofemoral compartment chondrosis; and probable trace joint effusion. The Veteran underwent a VA examination in January 2018. He again shared that his right knee gave out while walking and he fell. He reported loss function, pain, and weakness, and that his right knee was “giving way.” The examiner noted range of motion of the right knee was zero to 120 degrees and for the left knee, zero to 140 degrees. On examination, pain on flexion was noted bilaterally but did not result in additional functional loss. After observed repetitive use, there was no additional loss of range of motion for either knee. No symptoms were reported as significantly limiting the Veteran’s functional ability with repeated use over time. Flare-ups were not examined. Crepitus and pain on weight-bearing was reported only for the right knee. There was no instability, ankylosis or meniscus condition reported in the examination report for either knee. The Veteran continued use of his cane and was now using a knee brace for his right knee. A September 2019 VA radiology report found in the right knee that there was mild to moderate medial compartment narrowing with the subarticular sclerosis, slightly worse than previous study. Alignment at the knee joint was intact. There was spurring of the tibial spine, mild narrowing of the patellofemoral joint, and vascular calcifications. It was also noted that trace suprapatellar joint effusion was likely. Regarding the left knee, there was no acute fracture in the left knee and again noted the mild medial compartment narrowing with trace spurring of the tibial spine. Alignment at the knee joint was intact and there was no abnormal soft tissue or significant joint effusion identified. Vascular calcifications were also noted again. In October 2019, the Veteran was seen by a private physician for a motorized wheelchair evaluation. It was noted that the Veteran had bilateral upper extremity and lower extremity weakness and impaired static dynamic standing balance. He had an increased risk for falls, increased pain, and an abnormal gait pattern. The physician noted that due to the Veteran’s bilateral upper extremity weakness, decreased functional endurance/activity tolerance and pain, he was unable to propel manual wheelchair or use rolling walker safely. The assessment found that the Veteran was at moderate fall risk as he reported approximately four falls every other day. During the BERG balance test, any test item that decreased BOS resulted in loss of balance, which required minimal to moderate assistance to recover. In the March 2020 Board remand, it was noted that the January 2018 VA examiner did not identify the point at which motion-limiting began in the Veteran’s knees, though it was reported that there was objective evidence of pain on passive range of motion testing for both knees, and pain with weight bearing in the right knee. Thus, a new VA examination was requested. Pursuant to the Board remand, the Veteran was afforded a new VA examination in July 2020. The report indicated that the Veteran’s knee treatment involved steroid shots and taking Excedrin. It also noted that the Veteran’s 2019 x-rays revealed complete loss of the medial joint space in both knees with severe osteoarthritis. The Veteran reported flare-ups with walking and going up and down stairs. Range of motion of the right knee showed extension and flexion both limited to 30 degrees. The range of motion for the left knee showed extension and flexion both limited to 50 degrees. Pain on weight-bearing was noted bilaterally. On examination, there was pain on flexion bilaterally, but it did not result in additional functional loss. After observed repetitive use, there was no additional loss of range of motion for either knee. No symptoms were reported as significantly limiting the Veteran’s functional ability with repeated use over time. However, while range of motion for the right knee remained the same, the Veteran’s left knee extension and flexion were both limited to 40 degrees. Though the examination was not conducted during a flare-up, the examiner was able to estimate that the right knee range of motion was the same, extension and flexion of 30 degrees. While extension and flexion of the left knee was again 40 degrees. There was no objective evidence of crepitus; instability, ankylosis or meniscus condition found in either knee. However, the Veteran was in use of both a cane and motorized wheelchair for his bilateral knee disability. Based on the July 2020 VA examination findings, specifically, the Veteran’s flexion of 30 degrees in his right knee, his disability rating was increased to 20 percent effective July 22, 2020, the date of his examination. Prior to the July 2020 VA examination, a higher initial rating was not warranted for either of the Veteran’s knees. As seen above, on examination, both his right and left knee flexion have consistently been within 100 degrees, which is noncompensable and he has had normal extension with both knees, which is also noncompensable. Nevertheless, as the Veteran demonstrated painful motion in both knees, he was properly assigned a 10 percent rating for each knee. Indeed, the Veteran’s x-rays have shown multiple conditions affecting his bilateral knee disability; however, the evidence did not substantiate occasional incapacitating exacerbations as required for a higher evaluation per DC 5003. Additionally, treatment records did not show flexion limited between 16 and 30 degrees per DC 5260. Thus, a higher rating was not warranted. After the increased rating for the Veteran’s right knee was awarded, he submitted additional evidence for RO consideration, contending “my injuries are more severe” and his right knee “is literally bone to bone, and the left is not improving.” As a result, he was offered a new VA examination in December 2020. There, the Veteran reported constant, dull, throbbing pain, rated 9 out of 10 for his right knee and intermittent throbbing to sharp pain in his left knee, rated 6 out of 10. The Veteran continued to report that his right knee “gives way” causing him to fall at least six times. Range of motion of the right knee showed extension limited to 5 degrees and flexion limited to 110 degrees. The range of motion for the left knee showed extension limited to 5 degrees and flexion limited to 120 degrees. Pain was noted on both flexion and extension as causing functional loss. Pain was also noted on weight-bearing bilaterally. After observed repetitive use, there was no additional loss of range of motion for either knee. No symptoms were reported as significantly limiting the Veteran’s functional ability with repeated use over time. It was noted that bilaterally, pain, fatigue, weakness, lack of endurance, and incoordination significantly limited functional ability with repeated use over time. For the right knee, extension remained the same at 5 degrees, but the flexion was limited to 110 degrees. For the left knee, extension was also 5 degrees, but flexion was limited to 115 degrees. There was objective evidence of crepitus bilaterally; however, instability and ankylosis was not documented for either knee. Bilateral meniscal tear was noted, as previously identified in a November 2017 MRI. The Veteran reported using a cane, walker, and motorized wheelchair for his bilateral knee disability. Upon review of the evidence of record, the Board finds that from July 22, 2020, a rating in excess of 20 percent is not warranted for the Veteran’s right knee disability. For a rating in excess of 20 percent under DC 5260, the knee must show flexion limited to 15 degrees. Likewise, a rating in excess of 10 percent for the Veteran’s left knee disability is not warranted, or for the right knee prior to July 22, 2020, as he has not had flexion limited to 30 degrees. Neither private nor VA medical evidence indicates that the Veteran experiences limitation of flexion sufficient to warrant a rating in excess of 20 percent or 10 percent, respectively. The Board has also considered the other diagnostic codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). A higher or separate rating is not available under Diagnostic Codes 5256, 5259, 5262, 5263 as the evidence of record indicates the Veteran does not have ankylosis of the right knee, symptomatic removal of the semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. A higher or separate rating under DC 5261 is also not warranted as the evidence of record does not reflect compensable limitation of extension. However, the Board finds a sufficient basis to award a 10 percent rating under DC 5257 for instability. This rating is assigned due to the Veteran's subjective reports. Objectively, the Veteran has been provided with a cane and knee brace to assist with ambulation. As noted earlier, his private treating physician endorsed his use of a motorized wheelchair in October 2019, due to his bilateral knee instability. This evidence supports the assignment of a compensable rating for instability. See English v. Wilkie, 30 Vet. App. 347 (2018). A higher rating is not warranted as objective medical evidence, which is probative, fails to establish clinical findings of severe recurrent subluxation or lateral instability on examination. Clinical testing for instability has largely been negative. The Board finds a sufficient basis to award a 20 percent rating under DC 5258 for the Veteran’s bilateral knee meniscal tear. This rating is assigned in accordance with the November 2017 MRI discussed earlier which found, diffuse complex tear of the macerated medial meniscus with horizontal/radial components in the right knee and a complex tear of the body of the medial meniscus; horizontal tear of the body of the lateral meniscus with parameniscal cysts in the left knee. This evidence supports the assignment of a compensable rating for meniscal tear. See English v. Wilkie, 30 Vet. App. 347 (2018). This is the highest rating allowed under DC 5258. In conclusion, the Board finds that a separate 10 percent rating for bilateral knee instability is warranted effective October 10, 2019, and a 20 percent rating for bilateral knee meniscal tear is warranted effective November 8, 2017. Further, the preponderance of the evidence is against the Veteran’s claim for a higher initial rating prior to July 22, 2020 or a rating in excess of 20 percent thereafter for his right knee patellofemoral syndrome with osteoarthritis. Similarly, the preponderance of the evidence is against a claim for a higher initial rating for the Veteran’s left knee patellofemoral syndrome with osteoarthritis. In denying such the claims, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to TDIU is remanded. The issue of entitlement to TDIU is a component of this appeal consistent with Rice v. Shinseki, 22 Vet. App. 447 (2009) (where there is evidence of unemployability raised by the record during a rating appeal period, the TDIU is an element of an initial rating or increased rating). In light of the Board’s action in granting additional ratings for the service-connected knee disabilities, the issue of TDIU entitlement should be developed and adjudicated by the Agency of Original Jurisdiction (AOJ). This matter is REMANDED for the following action: 1. Contact the Veteran and ask him to submit a VA Form 21-8940 (Veterans Application for Increased Compensation Based on Unemployability). Conduct any additional development deemed necessary. 2. Adjudicate the remanded claim. If the benefit sought on appeal is not granted, the Veteran and his representative should be provided a supplemental statement of the case and an appropriate time period for response. The case should then be returned to the Board for further consideration, if otherwise in order. LLOYD CRAMP Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Telamour, 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.