Citation Nr: 21022958 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 12-35 497 DATE: April 19, 2021 ORDER Entitlement to a rating in excess of 30 percent for right knee meniscectomy residuals, prior to January 13, 2009, is denied. Entitlement to a separate 10 percent rating, but not higher, for a right knee limitation of motion with arthritis, pursuant to Diagnostic Code 5003, as of January 7, 2008, but not earlier, and prior to January 13, 2009, is granted. Entitlement to a separate 10 percent rating, but not higher, for a right knee disability, based on genu recurvatum of the right knee pursuant to Diagnostic Code 5263, as of January 7, 2008, but not earlier, and prior to January 13, 2009, is granted. Entitlement to a rating in excess of 30 percent for right total knee arthroplasty residuals, from March 1, 2010, to February 28, 2017, is denied. Entitlement to a rating in excess of 60 percent for right total knee arthroplasty residuals, as of March 1, 2017, is denied. FINDINGS OF FACT 1. Prior to January 13, 2009, a right knee disability was manifested by pain and discomfort; it was not manifested by flexion limited to 60 degrees or less for an objectively sustained period, extension limited to 5 degrees or greater for an objectively sustained period, ankylosis, dislocated semilunar cartilage, or impairment of the tibia and fibula. 2. Effective January 7, 2008, the evidence of record shows genu recurvatum of the right knee, which is not shown as of January 13, 2009. 3. Effective January 7, 2008, the evidence of record shows noncompensable limitation of motion of the right knee with X-ray evidence of arthritis, which is not shown as of January 13, 2009. 4. On January 13, 2009, the Veteran had a total right knee arthroplasty. 5. From March 1, 2010, to February 28, 2017, the Veteran’s right total knee arthroplasty residuals were productive of intermediate residual pain. 6. Effective March 1, 2017, the Veteran’s right total knee arthroplasty residuals were manifested by chronic residuals of a prosthetic replacement of the right knee joint consisting of severe painful motion or weakness in the affected knee. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 30 percent for right knee meniscectomy residuals, prior to January 13, 2009, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Codes 5055, 5256-5263. 2. Resolving reasonable doubt in favor of the Veteran, the criteria for a separate 10 percent rating, but not higher, for right knee genu recurvatum, effective January 7, 2008, but not earlier, have been met.   38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5263. 3. Resolving reasonable doubt in favor of the Veteran, the criteria for a separate 10 percent rating, but not higher, for right knee arthritis with noncompensable limitation of motion, effective January 7, 2008, but not earlier, and prior to January 13, 2009, have been met.   38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5003. 4. The criteria for entitlement to a rating in excess of 30 percent for right total knee arthroplasty residuals, from March 1, 2010, to February 28, 2017, have not been met. 38 U.S.C. § § 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055. 5. The criteria for entitlement to a rating in excess of 60 percent for right total knee arthroplasty residuals, as of March 1, 2017, have not been met. 38 U.S.C. § § 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1977 to June 1978. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a May 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. In March 2017, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record. In October 2017, June 2019, and February 2021, the Board remanded these claims to the Agency of Original Jurisdiction for additional action. Increased Rating Disability ratings are based on VA’s Schedule for Rating Disabilities. 38 C.F.R. Part 4. Separate Diagnostic Codes identify various disabilities and the criteria for a specific percentage rating to be assigned for that disability. The percentage ratings represent as far as practicably can be determined the average impairment in earning capacity due to a service-connected disability. 38 U.S.C. § 1155. A rating is assigned by comparing the extent to which a Veteran’s service-connected disability impairs the ability to function under the ordinary conditions of daily life, as demonstrated by the Veteran’s symptomatology, with the criteria for the percentage ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.10; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Examination reports must be interpreted, and if necessary reconciled, into a consistent picture so that the rating may accurately compensate the elements of disability present. 38 C.F.R. § 4.2. If two ratings are potentially applicable, 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. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Board must determine the probative weight to be assigned among evidence in a case, and to state reasons or bases for favoring one opinion over another. Winsett v. West, 11 Vet. App. 420 (1998). If all the evidence is in relative equipoise, reasonable doubt shall be resolved in the Veteran’s favor, and the claim should be granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. If the preponderance of the evidence is against the claim, the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Rating a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint. 38 C.F.R. §§ 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). 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 on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, the regulations state that the functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. When rating the joints, inquiry will be directed as to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. 38 C.F.R. § 4.45. The intent of the 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. The rating of the same disability under different diagnostic codes, known as pyramiding, must be avoided. However, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259 (1994). Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5256, a 40 percent rating is warranted for ankylosis in flexion between 10 degrees and 20 degrees. A 50 percent rating is warranted for ankylosis in flexion between 20 degrees and 45 degrees. A 60 percent rating is warranted for extremity unfavorable ankylosis in flexion at an angle of 45 degrees or more. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Diagnostic Code 5257 provides that a 10 percent rating is warranted for slight recurrent subluxation or lateral instability of a knee. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe knee impairment with recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Subluxation of the patella is the incomplete or partial dislocation of the knee cap. Rykhus v. Brown, 6 Vet. App. 354 (1993). Under Diagnostic Code 5260, a 10 percent rating is assigned for limitation of flexion of the knee to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating is assigned for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a 10 percent rating is assigned for limitation of extension of the knee to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating is assigned for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Pursuant to Diagnostic Code 5262, a 30 percent rating is warranted when there is malunion of the tibia and fibula, with marked knee or ankle disability. A schedular maximum 40 percent rating is warranted when there is nonunion of the tibia and fibula, with loose motion requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. The words slight, moderate, and severe as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. In addition, separate ratings may be assigned for compensable limitation of both flexion and extension, or for limitation of motion and instability or subluxation of the knee, or meniscal pathology. However, a separate rating can only be assigned where additional compensable symptomatology is shown that is not duplicative of that used to assign another rating. 38 C.F.R. § 4.14; VAOPGCPREC 09-04 (2004), 69 Fed. Reg. 59990 (2004);VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98 (1998), 63 Fed. Reg. 56704 (1998); Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). Diagnostic Code 5003 provides 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. When limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a 10 percent rating is generally for application. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. A rating for arthritis cannot be combined with a rating based on limitation of motion of the same joint. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under Diagnostic Code 5055, a 30 percent rating is the minimum possible rating assigned following total knee replacement. A 60 percent rating is warranted for a total knee replacement with chronic residuals consisting of severe painful motion or weakness in the affected extremity. A 100 percent rating is warranted for one year following implantation of the prosthesis. Intermediate degrees of residual weakness, pain, or limitation of motion (a level of disability in between those contemplated by the 30 and 60 percent ratings) are to be rated by analogy to Diagnostic Codes 5256, 5261, or 5262. 38 C.F.R. § 4.71a, Diagnostic Code 5055. The Veteran filed an increased rating claim on January 1, 2008. Excluding the periods of the temporary 100 percent rating following right knee surgery, the Veteran is currently assigned a 30 percent rating for residuals of right meniscectomy status post total knee arthroplasty (TKA) under Diagnostic Code 5055 prior to March 1, 2017, and a 60 percent rating, effective March 1, 2017. The Veteran contends that a right knee disability is more severe than that represented by the assigned ratings. A July 2007 X-Ray found bilateral knee degenerative changes, more severe on the right than the left. No other abnormalities were noted. A December 2007 MRI found complete cartilage loss with degenerative tear involving the medial femorotibial compartment, ganglion posterior to the PCL and MCL ganglion, small joint effusion, and tricompartmental degenerative changes. A December 2007 physical therapy evaluation describes the Veteran as complaining of right knee pain. The Veteran was noted as having full range of motion to 91 degrees flexion, limited by pain. Sensation and strength were within functional limits and the Veteran did not experience point tenderness. The Veteran had mild edema and clicking but did not experience instability. At a January 2008 VA examination, the Veteran complained of right knee pain. The Veteran did not have right knee ankylosis, deformity, giving way, episodes of dislocation or subluxation, or flare ups. The Veteran experienced instability, locking, pain, stiffness, weakness, and effusion. Range of motion was, at worst, 0 to 70 degrees of flexion and 90 to -5 degrees of extension. During the examination, the Veteran stated that the knee was unstable when standing for any length of time or when walking for any distance. That caused the Veteran to feel like the right knee would give out. The Veteran also expressed difficulty rising from a seated position. In a June 2008 outpatient consultation report, the Veteran complained of right knee pain, worse with standing, walking, and any movement. The Veteran wore a brace when working. Range of motion was noted as being to -5 degrees of extension and to 110 degrees of flexion. The Veteran stood with marked varus alignment of the right knee, but the knee was stable to varus and valgus stress. The examiner diagnosed severe arthritis of the medial compartment of the right knee with varus alignment. On January 13, 2009, the Veteran had a total right knee arthroplasty. A May 2010 primary care note shows the Veteran complaining of right knee pain and swelling. The Veteran was noted having swelling diffusely and tenderness on palpation along the medial aspect. X-Ray found total knee arthroplasty, with no loosening of the prothesis. There was no recent fracture, dislocation, or significant interval change. At an April 2011 VA examination, the Veteran complained of intermittent pain, that was constant on some days. The pain was brought on by walking, standing, and weather exposure. The Veteran had right knee deformity, tenderness, stiffness, weakness, guarding of movement, and decreased speed of joint motion. The Veteran did not have right knee ankylosis, instability, giving way, incoordination, episodes of dislocation or subluxation, locking episodes, effusions, flare ups, crepitus, or effusion. Range of motion was, at worst, 0 to 85 degrees in flexion and to 0 degrees extension. In a January 2012 orthopedic surgery outpatient note, the Veteran complained of right leg pain that occasionally radiated down to his toes. No instability was noted in the knee. The right knee incision was described as well healed without evidence of infection. Range of motion was 0 to 120 degrees, stable to varus and valgus stress in flexion and extension. The extremity was distally neurovascularly intact. In a January 2013 orthopedic surgery outpatient note, the Veteran denied experiencing right knee pain. The right knee incision was described as well healed without evidence of infection. Range of motion was 0 to 120 degrees, stable to varus and valgus stress in flexion and extension. The extremity was distally neurovascularly intact. Recent X-Ray films were reviewed and showed excellent alignment without evidence of complication. No instability was noted. In a January 2014 orthopedic surgery outpatient note, the Veteran complained of right knee pain but was noted as doing well. The Veteran had some difficulty getting up from a seated position. The right knee incision was described as well healed without evidence of infection. Range of motion was 0 to 120 degrees, stable to varus and valgus stress in flexion and extension. The extremity was distally neurovascularly intact. Recent X-Ray films were reviewed and showed excellent alignment without evidence of complication. No instability was noted. In a January 2015 orthopedic surgery outpatient note, the right knee incision was described as well healed without evidence of infection. Range of motion was 0 to 120 degrees, stable to varus and valgus stress in flexion and extension. The extremity was distally neurovascularly intact. Recent X-Ray films were reviewed and showed excellent alignment without evidence of complication. No instability was noted. During a March 2017 Board hearing, the Veteran stated that the right knee condition had greatly worsened since an April 2011 VA knee examination. The Veteran stated that he experienced daily pain with flare-ups and swelling. He occasionally used a cane to help with balance. The Veteran also stated that he had difficulty walking long distances, standing, and that his knee gave out when the pain was severe, approximately one to two times a week, especially when walking stairs. He also acknowledged that his knees locked up, roughly two years ago. The Veteran was prescribed Percocet for pain. A May 2018 X-Ray found a right total knee arthroplasty with an intact prosthesis. There was no evidence of loosening or periprosthetic fracture identified. Alignment was anatomic. Soft tissues were unremarkable. The Board notes that, in a previous June 2019 Remand, the Board found a December 2017 VA knee examination to be inadequate for rating purposes. Thus, the December 2017 VA examination will not be considered in adjudication of this claim. During VA examination in January 2020, the Veteran described experiencing flare-ups of right knee pain during cold and damp weather and with increased activity. The Veteran was noted as having right knee flexion to, at worst, 90 degrees and extension to 0 degrees. The Veteran did not have additional functional loss of range of motion after repeated use or during a flare-up. The Veteran was not noted as having muscle atrophy, loss of strength, ankylosis, joint instability, or recurrent patellar dislocation in the right knee. The Veteran occasionally used a cane to assist in normal mode of locomotion. In support of the claim, the Veteran has also submitted several self- written statements, and statements from friends and family, detailing the effects of the right knee disability on his life. 1. Entitlement to a rating in excess of 30 percent for right knee meniscectomy residuals, prior to January 13, 2009. 2. Entitlement to a separate 10 percent rating, but not higher, for genu recurvatum of the right knee pursuant to Diagnostic Code 5263, as of January 7, 2008, and prior to January 13, 2009. Prior to January 13, 2009, the Veteran appears to be in receipt of a 30 percent rating pursuant to Diagnostic Code 5257 for severe recurrent right knee instability based on meniscal pathology, range of motion, pain, instability, and arthritis. The Board notes that a 30 percent rating is the maximum schedular rating assignable under Diagnostic Code 5257, for recurrent subluxation or lateral instability of the knee. Therefore, no higher rating can be assigned pursuant to 5257. Prior to January 13, 2009, the Board finds that the preponderance of the evidence is against the assignment any higher rating under Diagnostic Code 5260 for limitation of flexion of the right knee.  The evidence does not show limitation of flexion to 45 degrees in the right knee, prior to January 13, 2009, or that any pain or other functionally limiting factors limited flexion to 45 degrees. Therefore, an increased rating for limitation of flexion is not warranted as the contemporaneous evidence of record does not warrant a rating in excess of 0 percent in the right knee. The Board further finds that the preponderance of the evidence is against the assignment of a compensable rating under Diagnostic Code 5261 for limitation of extension of the right knee. The evidence does not show that Veteran’s right knee disability has been manifested by limitation of extension to 10 degrees or worse commensurate with a 10 percent rating. Therefore, a higher or separate rating for limitation of extension is not warranted as the contemporaneous evidence of record does not warrant an increased rating in the right knee. Prior to January 13, 2009, the Board finds that Diagnostic Codes 5256 (ankylosis of the knee) and 5262 (nonunion or malunion of the tibia and fibula) are not applicable, as the medical evidence does not show that the Veteran has those conditions in the right knee. The Board finds that a separate rating is not warranted for meniscal pathology pursuant to Diagnostic Codes 5258, as the evidence shows the Veteran did not have any dislocated semilunar cartilage in the right knee during the course of this appeal. To the extent that the meniscal pathology results in pain or limitation of motion, that symptomatology has been considered in assigning ratings pursuant to Diagnostic Code 5257. To assign a separate rating for that symptom under the diagnostic criteria for meniscus impairment would constitute impermissible pyramiding. 38 C.F.R. § 4.14. The disability was rated for meniscectomy prior to January 13, 2009. However, the evidence shows that the main symptomatology was instability which has been rated under Diagnostic Code 5257. The Board finds that the evidence does not show other symptoms of meniscectomy which could warrant the assignment of a separate rating. However, the Board finds that a separate 10 percent rating, but not higher, is warranted as of January 7, 2008, but not earlier, and prior to January 13, 2009, pursuant to Diagnostic Code 5003. The evidence shows a noncompensable level of limitation of motion prior to January 13, 2009, with X-ray evidence of arthritis. However, the Board finds that as of January 13, 2009, a 100 percent rating was assigned and the 10 percent rating pursuant to Diagnostic Code 5003 must be discontinued. When that 100 percent rating was discontinued on March 1, 2010, the Board finds that the knee disability should be rated pursuant to Diagnostic Code 5055, and the continuance of the rating under Diagnostic Code 5003 is not appropriate as the replacement results in the removal of the arthritis of the knee joint, and the symptoms are properly rated under Diagnostic Code 5055. In reaching the foregoing conclusions, the Board has considered the evidence of functionally limiting factors caused by limitation of motion due to painful motion, excess motion, weakened motion, fatigability, incoordination, and flare up. Deluca v. Brown, 8 Vet. App. 202 (1995). While the Veteran has shown objective evidence of pain throughout the appeal, the record does not show that his pain has resulted additional functional limitation consistent with a higher disability rating. Accordingly, the Board finds that, prior to January 13, 2009, the preponderance of the evidence is against the assignment of any higher or additional separate rating for the right knee disability, other than right knee genu recurvatum which will be discussed below. Therefore, the claim for an increased rating, prior to January 13, 2009, must be denied. Gilbert v. Derwinski,1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to a rating in excess of 30 percent for right total knee arthroplasty residuals, from March 1, 2010, to February 28, 2017. 4. Entitlement to a rating in excess of 60 percent for right total knee arthroplasty residuals, as of March 1, 2017. On January 13, 2009, the Veteran had a total right knee arthroplasty. The Board has reviewed the Veteran’s medical records and finds that, from March 1, 2010 to February 28, 2017, the Veteran’s symptomatology most closely approximates a 30 percent rating under Diagnostic Code 5055. Under Diagnostic Code 5055, a knee disability may be considered by analogy under Diagnostic Codes 5256 (ankylosis), 5261 (limitation of extension), or 5262 (impairment of tibia and fibula). From March 1, 2010 to February 28, 2017, the medical records are negative for any evidence to support ankylosis, impairment of the tibia and fibula, or compensable limitation of extension. The Veteran has never been found to have ankylosis, impairment of the tibia or fibula, or to have limited extension worse than to 0 degrees. The record also does not demonstrate chronic residuals consisting of severe painful motion or any weakness in the right knee, prior to March 1, 2017. Therefore, increased ratings are not available under the applicable Diagnostic Codes. Effective March 1, 2017, the Veteran is assigned a 60 percent disability rating for status post total right knee arthroplasty pursuant to Diagnostic Code 5055. The Board notes that a 60 percent rating is the maximum schedular rating assignable under Diagnostic Code 5055, after the one year following replacement, which has expired. The Board also notes that the 60 percent rating is the equivalent of an amputation rating for the right knee, so no higher rating can be assigned. Accordingly, the Board finds that, throughout the period of appeal, the preponderance of the evidence is against the assignment of any higher or additional separate rating for the right knee disability. Therefore, the claim for an increased rating must be denied. Gilbert v. Derwinski,1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to a separate 10 percent rating, but not higher, for genu recurvatum of the right knee pursuant to Diagnostic Code 5263, as of January 7, 2008, and prior to January 13, 2009. An April 2008 outpatient consultation note shows the Veteran experiencing right knee marked varus alignment of his right knee that was stable to varus and valgus stress. Therefore, resolving all benefit of the doubt in favor of the Veteran, the Board finds that Veteran is entitled to a 10 percent rating commensurate with the criteria set forth in Diagnostic Code 5263 for rating genu recurvatum which is acquired, traumatic, and with weakness and insecurity in weight-bearing objectively demonstrated, effective January 1, 2008, the date the claim for an increased rating was first filed. A 10 percent rating is the only rating available under Diagnostic Code 5263. Therefore, no higher rating under Diagnostic Code 5263 is warranted. The Board finds that the preponderance of the evidence is against the assignment of any rating higher than 10 percent or any earlier effective date for the separate rating, as that is the highest schedular rating available for genu recurvatum. That 100 percent rating is discontinued as of January 13, 2009, when a 100 percent rating was assigned for knee replacement. As of March 1, 2010, when the 100 percent rating was discontinued, the Board finds that the rating for genu recurvatum is no longer warranted because the evidence shows that following insertion of prosthesis, the knee was in good alignment, to include the January 2013 VA examination noting that X-rays showed that the prosthesis was in good alignment and subsequent reviews showing good or excellent alignment. Therefore, the Board finds that the rating for genu recurvatum was no longer warranted after replacement by prosthesis and should be discontinued as of January 13, 2009. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mondesir, Eric 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.