Citation Nr: 21023475 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 14-03 877 DATE: April 20, 2021 ORDER Entitlement to service connection for cervical spine disorder is denied. Entitlement to service connection for lumbar spine disorder is denied. Entitlement to an effective date of November 25, 2014, but no earlier, for the award of service connection for peripheral neuropathy of the left upper extremity is granted, subject to the regulations governing the payment of monetary awards. Entitlement to an effective date of November 25, 2014, but no earlier, for the award of service connection for peripheral neuropathy of the right upper extremity is granted, subject to the regulations governing the payment of monetary awards. Entitlement to an effective date of November 25, 2014, but no earlier, for the award of service connection for peripheral neuropathy of the left lower extremity is granted, subject to the regulations governing the payment of monetary awards. Entitlement to an effective date of November 25, 2014, but no earlier, for the award of service connection for peripheral neuropathy of the right lower extremity is granted, subject to the regulations governing the payment of monetary awards. Entitlement to an initial rating in excess of 20 percent for peripheral neuropathy of the left upper extremity is denied. Entitlement to an initial rating in excess of 30 percent for peripheral neuropathy of the right upper extremity is denied. Entitlement to an initial rating in excess of 20 percent for peripheral neuropathy of the left lower extremity is denied. Entitlement to an initial rating in excess of 20 percent for peripheral neuropathy of the right lower extremity is denied. Entitlement to an effective date of November 25, 2014, but no earlier, for the award of a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted, subject to regulations governing the payment of monetary awards. Entitlement to an effective date of November 25, 2014, but no earlier, for Dependents’ Educational Assistance (DEA) benefits is granted, subject to regulations governing the payment of monetary awards. FINDINGS OF FACT 1. The Veteran’s cervical spine disability was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 2. The Veteran’s lumbar spine disability was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 3. VA received an informal claim of entitlement to service connection for peripheral neuropathy of the upper and lower extremities on November 25, 2014. 4. The Veteran’s peripheral neuropathy of the bilateral upper extremities has been manifested by moderate incomplete paralysis of the radial, median, and ulnar nerves. 5. The Veteran’s peripheral neuropathy of the bilateral lower extremities has been manifested by moderate incomplete paralysis of the sciatic and femoral nerves. 6. Prior to the May 29, 2015 effective date for TDIU, the Veteran’s service-connected disabilities precluded him from securing and maintaining substantially gainful employment consistent with his education and occupational experience, effective November 25, 2014. 7. The Veteran met basic eligibility for DEA on November 25, 2014, the date he has been awarded entitlement to TDIU. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for cervical spine disorder are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 2. The criteria for entitlement to service connection for lumbar spine disorder are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 3. The criteria for an effective date of November 25, 2014 for the award of service connection for peripheral neuropathy of the left upper extremity are met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. § 3.400 (2020). 4. The criteria for an effective date of November 25, 2014 for the award of service connection for peripheral neuropathy of the right upper extremity are met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. § 3.400 (2020). 5. The criteria for an effective date of November 25, 2014 for the award of service connection for peripheral neuropathy of the left lower extremity are met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. § 3.400 (2020). 6. The criteria for an effective date of November 25, 2014 for the award of service connection for peripheral neuropathy of the right lower extremity are met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. § 3.400 (2020). 7. The criteria for an initial rating in excess of 20 percent peripheral neuropathy of the left upper extremity are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8514 (2020). 8. The criteria for an initial rating in excess of 30 percent peripheral neuropathy of the right upper extremity are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8514 (2020). 9. The criteria for an initial rating in excess of 20 percent peripheral neuropathy of the left lower extremity are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Codes 8520, 8521, 8526 (2020). 10. The criteria for an initial rating in excess of 20 percent peripheral neuropathy of the right lower extremity are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Codes 8520, 8521, 8526 (2020). 11. The criteria for an effective date of November 25, 2014 for entitlement to TDIU are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 4.18, 4.19 (2020). 12. The criteria for an effective date of November 25, 2014 for the award of basic eligibility for Dependents’ Educational Assistance benefits are met. 38 U.S.C. §§ 3500, 3501, 3510 (2012); 38 C.F.R. § 21.3021 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from December 1965 to October 1967, including service within the Republic of Vietnam. These matters are before the Board of Veterans’ Appeals (Board) on appeal from June 2015 and February 2016 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in June 2016, September 2017, and October 2020 when the Board remanded the Veteran’s claims currently before the Board for further development. In the February 2016 rating decision, the Agency of Original Jurisdiction (AOJ) awarded entitlement to TDIU and DEA effective May 29, 2015. The Board acknowledges that in March 2016 the Veteran submitted a VA Form 21-0958, Notice of Disagreement (NOD), appealing the effective date assigned for the award of entitlement to TDIU in the February 2016 rating decision. As entitlement to DEA benefits prior to May 29, 2015 is inextricably intertwined with the appeal seeking TDIU prior to May 29, 2015, the Board will address entitlement to an effective date prior to May 29, 2015 for DEA benefits herein. Duties to Notify and Assist VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159 (2020). The Veteran has not raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Accordingly, appellate review may proceed without prejudice to the Veteran with respect to his claims. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service Connection 1. Entitlement to service connection for cervical spine disorder is denied. 2. Entitlement to service connection for lumbar spine disorder is denied. The Veteran generally contends his cervical spine disorder and lumbar spine disorder are related to his service. See VA Form 21-4138, Statement in Support of Claim, dated November 21, 2014. Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. § 1110. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, 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 (Fed. Cir. 2004). Certain chronic diseases (e.g., arthritis) may be presumptively service connected if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 C.F.R. §§ 3.307, 3.309. If a condition listed as a chronic disease in § 3.309(a) is noted during service, but is either shown not to be chronic or the diagnosis could be legitimately questioned, then a showing of continuity of related symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331(Fed. Cir. 2013). The Veteran has current diagnoses of degenerative arthritis of the cervical spine, chronic myositis para cervical spine muscles, and degenerative disc disease as evidenced by the October 2020 VA examination. Regarding the lumbar spine, the Veteran has current diagnoses of degenerative arthritis of the lumbar spine, chronic myositis para lumbar spine muscles, and degenerative disc disease as evidenced by the October 2020 VA examination. The diagnoses of degenerative arthritis of the cervical spine and lumbar spine qualify as a chronic condition under 38 C.F.R. § 3.309(a) as arthritis. However, the disabilities were not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and were not noted in service with attributable continuity of symptomatology. At a September 2016 VA examination, the Veteran reported that his cervical spine pain had its onset when he had cardioversion in July 2015. He reported at an October 2020 VA examination that he had neck pain for several years and the pain was progressively worse. The first evidence of a diagnosis of any cervical spine condition is in a private treatment record from November 2014. The November 2014 private treatment record does not include a discussion of when the Veteran’s cervical spine symptoms began. Furthermore, there is no evidence of a diagnosis of a cervical spine degenerative condition until the September 2016 VA examination, decades after his separation from service and decades outside of the applicable presumptive period. In addition, the Veteran has not reported that he had symptoms of a cervical spine disability in service or during the presumptive period. Hence, a preponderance of the evidence is against a finding that any cervical spine disability manifested to a compensable degree in service or within one year of the Veteran’s service discharge. As such, presumptive service connection for cervical spine disorder as a chronic disease is not warranted. The Board has also considered whether service connection is warranted for his cervical spine disorder based on a continuity of symptomatology theory of entitlement. However, as is noted above, the Veteran has not alleged that his cervical spine symptoms began in service. Furthermore, the Veteran described having cervical spine “for the past several years” at the October 2020 VA examination. Given the absence of the allegation of continuity of symptoms since service, the Board finds that service connection is not warranted based on a continuity of symptomatology theory of entitlement. 38 U.S.C. § 1101(3); 38 C.F.R. § 3.303(b); Walker, 708 F.3d 1331; 3.307, 3.309(a). Regarding the Veteran’s lumbar spine disorder, at an October 2020 VA examination, the Veteran reported that his lumbar spine disorder had its onset several years ago. The first evidence of a diagnosis of any lumbar spine condition is in a private treatment record from November 2014. The November 2014 private treatment record does not include a discussion of when the Veteran’s lumbar spine symptoms began. Furthermore, there is no evidence of a diagnosis of a lumbar spine degenerative condition until the September 2016 VA examination, decades after his separation from service and decades outside of the applicable presumptive period. In addition, the Veteran has not reported that he had symptoms of a lumbar spine disability in service or during the presumptive period. Hence, a preponderance of the evidence is against a finding that any lumbar spine disability manifested to a compensable degree in service or within one year of the Veteran’s service discharge. As such, presumptive service connection for cervical spine disorder as a chronic disease is not warranted. The Board has also considered whether service connection is warranted for his lumbar spine disorder based on a continuity of symptomatology theory of entitlement. However, as is noted above, the Veteran has not alleged that his lumbar spine symptoms began in service. Furthermore, the Veteran described having lumbar spine “for the past several years” at the October 2020 VA examination. Given the absence of the allegation of continuity of symptoms since service, the Board finds that service connection is not warranted based on a continuity of symptomatology theory of entitlement. 38 U.S.C. § 1101(3); 38 C.F.R. § 3.303(b); Walker, 708 F.3d 1331; 3.307, 3.309(a). Service connection for a cervical spine disability and lumbar spine disability may still be granted on a direct basis. As noted above, the record reflects the Veteran has current cervical spine and lumbar spine disabilities. The Board notes that the Veteran has not alleged any specific in-service incident that has caused his current cervical spine or lumbar spine disabilities, however, irrespective of the lack of specific allegations, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s cervical spine and lumbar spine disabilities and an in-service injury, event or disease. 38 U.S.C. § 1110; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. In a November 2014 opinion, Dr. C.M.Q., a private physician, opined that the Veteran’s musculoskeletal disorders are more probable than not secondary to his military service. As Dr. C.M.Q. provided no rationale in support of his opinion, the Board requested VA opinions in the June 2016 Board remand given the inadequacy of the November 2014 opinion. Following a September 2016 VA examination for the Veteran’s cervical spine disorder, the VA examiner opined that the Veteran’s cervical spine degenerative changes and cervical spine muscle spasm were less likely as not incurred in or caused his military service. In support of the opinion, the VA examiner reasoned that the service records are silent regarding any diagnosis or symptoms of degenerative changes or cervical muscle spasm during active service. Following a September 2016 VA examination for the Veteran’s lumbar spine disorder, the examiner opined that the Veteran’s lumbar spine spondylosis was less likely than not incurred in or caused by the Veteran’s service. In support of the opinion, the examiner stated that there is no evidence of any lumbar spine condition during the Veteran’s service or within one year. Furthermore, the examiner stated that the Veteran’s lumbar spine condition is due to the aging process. As the September 2016 opinions did not address the diagnoses of chronic myositis of the cervical spine and lumbar spine, the Board remanded the claims in September 2017 for additional VA opinions that address each of the Veteran’s diagnosed cervical spine and lumbar spine disorders. Following an October 2020 VA examination for the Veteran’s cervical spine and lumbar spine disorders, the VA examiner opined that the Veteran’s degenerative arthritis of the cervical spine, chronic myositis para cervical spine muscles, degenerative disc disease of the cervical spine, degenerative arthritis of the lumbar spine, chronic myositis para lumbar spine muscles, and degenerative disc disease of the lumbar spine are less likely than not manifested during active service or are otherwise etiologically related to his military service. In support of the opinions, the VA examiner noted that the medical records are silent for chronicity of care, complaints and/or treatment related to cervical and lumbar spine conditions during his active service or within 15 years of his separation from service. Furthermore, the VA examiner noted that the conditions are related to the normal aging process. Therefore, given the that the October 2020 VA examiner provided a thorough review of the record, examined the Veteran, took into consideration the Veteran’s prior medical history, and provided a sufficient rationale for the Board to evaluate the claim, the Board gives much probative weight to the October 2020 VA examiner’s opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). While the Veteran believes his cervical spine and lumbar spine disabilities are related to his service, he is not competent to provide a nexus opinion in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the October 2020 VA examiner’s opinion. In summary, the preponderance of the evidence is against a finding that the Veteran’s current cervical spine disability and lumbar spine disability are related to service. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran’s claim for service connection, the benefit-of-the-doubt rule is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App., 49, 53-56 (1990). Earlier Effective Date – Service Connection 1. Entitlement to an effective date of November 25, 2014 for the award of service connection for peripheral neuropathy of the left upper extremity is granted. 2. Entitlement to an effective date of November 25, 2014 for the award of service connection for peripheral neuropathy of the right upper extremity is granted. 3. Entitlement to an effective date of November 25, 2014 for the award of service connection for peripheral neuropathy of the left lower extremity is granted. 4. Entitlement to an effective date of November 25, 2014 for the award of service connection for peripheral neuropathy of the right lower extremity is granted. The Veteran generally contends he is entitled to the award of service connection for peripheral neuropathy of the bilateral upper and lower extremities as of June 10, 2011. See VA Form 21-0958, Notice of Disagreement, dated July 7, 2015. Except as otherwise provided, the effective date of an evaluation and award for pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after a final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Different statutory and regulatory provisions apply depending on whether the claim is an original claim or one for increased compensation. See 38 C.F.R. §§ 3.400(b)(2)(i), 3.400(o)(2). Regulations defining a “claim” were revised, effective March 24, 2015. See 79 Fed. Reg. 57,660 (Sept. 25, 2014). The revision eliminated informal claims and required claims on specific forms. In this case, however, the applicable regulations are those prior to the revision, as the Veteran’s claim for an earlier effective date for his peripheral neuropathy of the bilateral upper and lower extremities stems from the Veteran’s claims that were pending prior to March 24, 2015. As such, the Board will apply the regulations effective prior to March 24, 2015 regarding defining a claim. A specific claim in the form prescribed by the Secretary is necessary for disability benefits to be paid to any individual under the laws administered by VA. 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151. For VA compensation purposes, a “claim” is defined as a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit. 38 C.F.R. § 3.1(p). An informal claim is any communication or action indicating an intent to apply for one or more benefits, and identifying the benefit sought from a claimant, his or her authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris. See 38 C.F.R. § 3.155(a). Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year after the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155(b). Thus, the essential elements for any claim, whether formal or informal, are (1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing. Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). VA must look to all communications from a claimant that may be interpreted as an application or claim for benefits and is required to identify and act on informal claims for benefits. See Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). Secondary service connection is granted for a “disability which is proximately due to or the result of a service-connected disease or injury.” 38 C.F.R. § 3.310(a). “When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition.” 38 C.F.R. § 3.310(a). The “plain meaning of th[is] regulation is and has always been to require VA to afford secondarily service-connected conditions the same treatment (no more or less favorable treatment) as the underlying service-connected conditions for all determinations.” Roper v. Nicholson, 20 Vet. App. 173, 181 (2006). Building on Roper, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) held that “a requirement that a secondary condition ‘be considered a part of [an] original condition’ does not, in our view, establish that the original condition and the secondary condition must receive identical effective dates.” Ellington v. Peake, 541 F.3d 1364, 1369 (Fed. Cir. 2008). “Indeed, a per se rule requiring identical effective dates for primary and secondary conditions would be illogical, given that secondary conditions may not arise until years after the onset of the original condition.” Id. The Federal Circuit concluded that “the effective date for secondary conditions is governed by [38 C.F.R. §] 3.400, which establishes the effective date as the ‘date of receipt of claim, or [the] date entitlement arose, whichever is later.’” Id. The Federal Circuit explained: “[T]his result is consistent with 38 U.S.C. § 5110, the statute which governs the effective date of awards. Section 5110(a) provides generally that ‘[u]nless specifically provided otherwise in this chapter, the effective date of an award based on an original claim... shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor.’ The statute contains no exception to this rule for a claim.” Id. at 1370; see Manzanares v. Shulkin, 863 F.3d 1374 (Fed. Cir. 2017). Turning to the Veteran’s earlier effective date claims, a review of the record illustrates that the Veteran’s first contact with VA reflecting an intent to apply for benefits for peripheral neuropathy of the bilateral upper and lower extremities was on November 25, 2014. A VA Form 21-4138, Statement in Support of Claim, received by VA on November 25, 2014, reflects “[e]nclosed med cert by Dr. M., for . . . s/c for all conditions on pages 3 & 4.” VA received the enclosed medical record from Dr. C.M.Q. on November 25, 2014 that was dated November 21, 2014. However, page 3 of the medical record is missing from the medical record. In a correspondence dated February 19, 2015, VA informed the Veteran that VA received the VA Form 21-4138 claiming service connection for all of the conditions listed on pages 3 and 4 of the medical certificate from Dr. C.M.Q., but that page 3 was lost and conditions 1 to 12 were not available. Furthermore, VA informed the Veteran that VA would continue by addressing only the conditions listed on page 4 if VA did not receive the included VA Form 21-4138 within 30 days listing all of the conditions that the Veteran was claiming service connection for. The Veteran submitted a duplicate VA Form 21-4138, dated November 21, 2014, that VA received on March 4, 2015, referring to the conditions listed on pages 3 and 4 of the medical record from Dr. C.M.Q. The Veteran also submitted the medical record from Dr. C.M.Q. that VA received on March 4, 2015. The additional copy of the record from Dr. C.M.Q. includes pages 3 and 4 and the conditions referenced in the initial VA Form 21-4138 received by VA on November 25, 2014. The Board acknowledges that following the receipt of the November 2014 VA Form 21-4138 and the December 22, 2014 notice to the Veteran, the date the AOJ was made aware of the Veteran’s informal claims, the AOJ did not send the Veteran an application form to the Veteran for execution per VA policy under the claim rules effective prior March 24, 2015. Instead, the AOJ sent a letter to the Veteran in February 2015 informing him to clarify his claims in a VA Form 21-4138 within 30 days of the February 19, 2015 correspondence. Therefore, no formal claim form was necessary as the AOJ accepted the November 25, 2014 VA Form 21-4138 as claims of service connection for diabetic neuropathy of the bilateral upper and lower extremities. As relevant to the earlier effective date claims, page 3 of the record from Dr. C.M.Q. lists “diabetic neuropathy upper/lower limbs.” The AOJ then issued a rating decision in June 2015 awarding service connection for peripheral neuropathy of the bilateral upper and lower extremities effective May 29, 2015. In assigning the effective date of May 29, 2015, the AOJ noted in the rating decision that May 29, 2015 is the date that the medical examination showed diagnoses of diabetic neuropathy of the bilateral upper and lower extremities. Notably, the June 2015 rating decision reflects that the Veteran filed his claim for benefits on November 25, 2014. Thus, the Board concludes that November 25, 2014, the date VA first received the Veteran’s VA Form 21-4138 reflecting an intent to apply for benefits for peripheral c neuropathy of the bilateral upper and lower extremities is the date of the Veteran’s claims. See 38 C.F.R. § 3.155(b). The Board notes that in a September 2014 rating decision, the AOJ awarded service connection for diabetes mellitus associated with herbicide agent exposure effective April 3, 2012. As is noted above, in adjudicating the effective date for the Veteran’s peripheral neuropathy of the bilateral upper and lower extremities the Board is not bound by the effective date for the Veteran’s diabetes mellitus. Prior to the receipt of the Veteran’s VA Form 21-4138 on November 25, 2014, there was no correspondence reflecting an intent to apply for benefits for peripheral neuropathy of the bilateral upper and lower extremities. There is no indication VA received a statement, either orally or via written communication, that indicated an intent to file a claim, prior to November 25, 2014. Therefore, November 25, 2014 is the earliest date that a communication was received expressing an intent to apply for benefits for peripheral neuropathy of the bilateral upper and lower extremities. Regarding the date entitlement arose, the Board notes that the medical record from Dr C.M.Q. dated November 12, 2014 and received initially by VA November 25, 2015, reflects diagnoses of diabetic neuropathy of the upper and lower limbs. Therefore, the June 2015 rating decision that reflects that the May 29, 2015 VA examination report containing diagnoses of diabetic neuropathy of the bilateral upper and lower extremities was the first evidence of diagnoses of diabetic neuropathy of the bilateral upper and lower extremities is an inaccurate depiction of the record, as there is evidence of diagnoses of the conditions as of November 12, 2014 and in the record as of November 25, 2014, when considering the date VA initially received the medical record from Dr. C.M.Q. In addition, the Board notes that the exact date on which entitlement arose need not be ascertained in order to conclude that the November 25, 2014 date selected herein is the earliest possible effective date with regards to the claims of service connection for peripheral neuropathy of the bilateral upper and lower extremities. Even if entitlement arose prior to November 25, 2014, as is indicated by the medical record dated November 12, 2014 and by the July 2015 Notice of Disagreement, then the date of claim would be the later of the two, and hence the correct effective date as provided by 38 C.F.R. § 3.400(b)(2). In sum, the Board finds that the legally correct date of the grant of service connection for peripheral neuropathy of the bilateral upper and lower extremities is November 25, 2014, the date VA first received the Veteran’s informal claim seeking entitlement to service connection for diabetic neuropathy of the bilateral upper and lower extremities. As such, the Veteran’s claim is granted to that extent. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board acknowledges that with respect to a claim for an increased rating for an already service-connected disability, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. 1. Entitlement to an initial rating in excess of 20 percent for peripheral neuropathy of the left upper extremity is denied. 2. Entitlement to an initial rating in excess of 30 percent for peripheral neuropathy of the right upper extremity is denied. The Veteran generally contends he is entitled to increased ratings for ratings for his bilateral upper extremity peripheral neuropathy. See VA Form 21-0958, Notice of Disagreement, dated July 7, 2015. The AOJ has rated the Veteran’s left upper extremity neuropathy at 20 percent for mild incomplete paralysis of the radial nerve and his right upper extremity neuropathy at 30 percent for moderate incomplete paralysis of the radial nerve under Diagnostic Code 8514. 38 C.F.R. § 4.124a. The Veteran is right handed, so his right upper extremity is considered the major upper extremity and his left upper extremity is considered the minor upper extremity. 38 C.F.R. § 4.69. For the major extremity, Diagnostic Code 8514 provides a 20 percent rating for mild incomplete paralysis, a 30 percent rating for moderate incomplete paralysis, and a 50 percent rating for severe incomplete paralysis. A 70 percent rating is assigned where there is complete paralysis of the major extremity. 38 C.F.R. § 4.124a. For the minor extremity, Diagnostic Code 8514 provides a 20 percent rating for mild incomplete paralysis, a 20 percent rating for moderate incomplete paralysis, and a 40 percent rating for severe incomplete paralysis. A 60 percent rating is assigned where there is complete paralysis of the minor extremity. 38 C.F.R. § 4.124a. The rating code provides that the term “incomplete paralysis,” with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type 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 wholly sensory, the rating should be for the mild, or at most, the moderate degree. See Miller v. Shulkin, 28 Vet. App. 376 (2017) (finding that the plain language of the note to § 4.124a contains no mention of non-sensory manifestations and declining to read into the regulation a corresponding minimum disability rating for non-sensory manifestations). The words “mild,” “moderate,” and “severe” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the degree that its decisions are “equitable and just.” 38 C.F.R. § 4.6. It should also be noted that use of descriptive terminology such as “mild” by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 U.S.C. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. Following a review of the evidence, the Board concludes that the evidence most nearly approximates the currently assigned 20 percent rating for the Veteran’s left upper extremity and 30 percent rating for his right upper extremity. The Veteran attended a VA examination in May 2015 for an evaluation of his peripheral neuropathy of the bilateral upper extremities. At the examination, the VA examiner noted the Veteran had moderate incomplete paralysis of the median nerve in the upper extremities. The Veteran’s radial and ulnar nerves were normal bilaterally. The Veteran had decreased sensation in the hand and fingers bilaterally and sensation was normal in the shoulder and inner/outer forearm bilaterally. Position sense and vibration sensation were decreased bilaterally. Deep tendon reflexes were decreased in the brachioradialis bilaterally and normal in in the biceps and triceps bilaterally. The Veteran had reduced grip and pinch strength to 4/5 bilaterally. The Veteran had normal strength in the elbow and wrist bilaterally. He had no muscle atrophy or trophic changes bilaterally. In the bilateral upper extremities, the Veteran reported symptoms of moderate constant pain, moderate paresthesias, and moderate numbness. He described the pain at a 6 out of 10. In addition, he reported that his symptoms were not relieved by daily constant use of tramadol and gabapentin. The examiner noted that the Veteran’s bilateral upper extremity peripheral neuropathy caused no functional impact. The Veteran attended an additional VA examination in September 2016 for an evaluation of his peripheral neuropathy of the bilateral upper extremities. At the examination, the VA examiner noted that the Veteran had mild incomplete paralysis of the radial, median, and ulnar nerves in the upper extremities. The Veteran had normal sensation to light touch/monofilament throughout the upper extremities. Position sense was normal bilaterally and vibration sensation was decreased bilaterally. Deep tendon reflexes were normal throughout the upper extremities. The Veteran had reduced grip and pinch strength to 4/5 bilaterally. The Veteran had normal strength in the elbow and wrist bilaterally. He had no muscle atrophy or trophic changes bilaterally. In the bilateral upper extremities, the Veteran reported symptoms of moderate constant pain, moderate paresthesias, and moderate numbness. In addition, he reported loss of strength in his hands, and he reported treating the pain in his hands with tramadol with some relief of the pain. The examiner noted that the Veteran’s bilateral upper extremity peripheral neuropathy caused functional impact in the form of activities requiring fine motor manipulation using his hands and fingers could require more time to complete since his distal bilateral upper extremity sensation is partially compromised. The Veteran attended a final VA examination in October 2020 for an evaluation of his peripheral neuropathy of the bilateral upper extremities. At the examination, the VA examiner noted that the Veteran had moderate incomplete paralysis of the radial, median, and ulnar nerves in the upper extremities. The Veteran had decreased sensation in the hand and fingers bilaterally and sensation was normal in the shoulder and inner/outer forearm bilaterally. Position sense was normal bilaterally and vibration sensation was decreased bilaterally. Deep tendon reflexes were normal throughout the upper extremities. The Veteran had reduced grip and pinch strength to 4/5 bilaterally. The Veteran had normal strength throughout the upper extremities, no muscle atrophy in the upper extremities, and no trophic changes bilaterally. In the bilateral upper extremities, the Veteran reported symptoms of moderate constant pain, moderate paresthesias, and moderate numbness. In addition, he reported use of naproxen as needed. The examiner noted that the Veteran’s bilateral upper extremity peripheral neuropathy caused no functional impact. The Board has considered the Veteran’s reports of numbness, pain, and tingling in the bilateral upper extremities throughout the appeal period. In addition, the Board acknowledges the Veteran’s report of loss of strength in his hands at the September 2016 VA examination. However, even considering these reports of symptoms, the evidence of record reveals no more than moderate incomplete paralysis. There has been no point throughout the appeal period where a VA examiner has assessed more than moderate incomplete paralysis in any nerve in the upper extremities. Furthermore, the VA examinations reflect that the Veteran has had at least 4/5 strength bilaterally throughout the appeal period. In addition, the findings of decreased sensation in the hand and fingers bilaterally at the May 2015 and October 2020 VA examinations reflect findings of no more than moderate incomplete paralysis. As such, the Board concludes that a preponderance of the evidence is against a finding that the Veteran’s bilateral upper extremity peripheral neuropathy has been manifested by any more than moderate incomplete paralysis. Therefore, the Board finds that a rating in excess of 20 percent is not warranted for the Veteran’s left upper extremity and that a rating in excess of 30 percent is not warranted for the Veteran’s right upper extremity. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt rule is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. 3. Entitlement to an initial rating in excess of 20 percent for peripheral neuropathy of the left lower extremity is denied. 4. Entitlement to an initial rating in excess of 20 percent for peripheral neuropathy of the right lower extremity is denied. The Veteran generally contends he is entitled to increased ratings for ratings for his bilateral lower extremity peripheral neuropathy. See VA Form 21-0958, Notice of Disagreement, dated July 7, 2015. The AOJ has rated the Veteran’s left and right lower extremity peripheral neuropathy at 20 percent for each extremity for moderate incomplete paralysis of the external popliteal nerve under Diagnostic Code 8521. 38 C.F.R. § 4.124a. Diagnostic Code 8521 provides a 20 percent rating for moderate incomplete paralysis and a 30 percent rating for severe incomplete paralysis. A 40 percent rating is assigned where there is complete paralysis of the external popliteal nerve. 38 C.F.R. § 4.124a. Diagnostic Code 8520 provides a 20 percent rating for moderate incomplete paralysis, a 40 percent rating for moderately severe incomplete paralysis, and a 60 percent rating for severe incomplete paralysis. An 80 percent rating is assigned where there is complete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a. Diagnostic Code 8526 provides a 20 percent rating for moderate incomplete paralysis and a 30 percent rating for severe incomplete paralysis. A 40 percent rating is assigned where there is complete paralysis of the quadriceps extensor muscles. 38 C.F.R. § 4.124a. For the reasons that follow, the Board has concluded that the Veteran’s peripheral neuropathy of the bilateral lower extremities is most appropriately evaluated under Diagnostic Code 8520 for incomplete paralysis of the sciatic nerve for the entire appeal period. VA can change the diagnostic code that a particular disability is rated under so long as the rating under that diagnostic code has not been in effect for 20 years. See 38 C.F.R. § 3.951(b); see Murray v. Shinskeki, 24 Vet. App. 420, 425 (2011). VA must explain the change in the diagnostic code. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The May 2015, September 2016, and October 2020 VA examinations and the Veteran’s consistent symptoms throughout the appeal period illustrate the Veteran’s bilateral lower extremity peripheral neuropathy disability affects both the sciatic and femoral nerves. Furthermore, the VA examinations do not illustrate that the external popliteal nerve is affected. Therefore, the Board concludes that Diagnostic Code 8520 best reflects the location of the Veteran’s peripheral neuropathy of the left and right lower extremities. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). Changing the diagnostic code from 8521 to 8520 does not reduce the Veteran’s rating at any time during the appeal period. In addition, using Diagnostic Code 8520 for the sciatic nerve is more beneficial to the Veteran than using Diagnostic Code 8526 for the femoral nerve under 38 C.F.R. § 4.124a, as it provides for greater rating levels if there is further symptom worsening in the future. Accordingly, the Board has changed the Diagnostic Code to 8520 for the bilateral lower extremities for the entire appeal period. Following a review of the evidence, the Board concludes that the evidence most nearly approximates the currently assigned 20 percent rating for each lower extremity. The Veteran attended a VA examination in May 2015 for an evaluation of his bilateral lower extremity peripheral neuropathy. The VA examiner assessed the severity of the incomplete paralysis of the Veteran’s sciatic nerve as moderate bilaterally. The Veteran’s femoral nerve was normal. The Veteran had reduced strength with ankle plantar flexion and ankle dorsiflexion to 4/5 bilaterally. He had normal strength with knee extension and knee flexion bilaterally. Deep tendon reflexes were reduced in the ankle bilaterally and normal in the knee bilaterally. The sensory examination revealed decreased sensation to light touch in in the foot/toes bilaterally. The sensory examination revealed normal sensation to light touch in the knee/thigh and ankle/lower leg bilaterally. Position sense and vibration sensation were decreased bilaterally. The Veteran had no muscle atrophy or trophic changes bilaterally. In the bilateral lower extremities, the Veteran reported symptoms of moderate constant pain, moderate paresthesias, and moderate numbness. He described the pain at a 6 out of 10. In addition, he reported that his symptoms were not relieved by daily constant use of tramadol and gabapentin. The examiner noted that the Veteran’s bilateral lower extremity peripheral neuropathy caused no functional impact. The Veteran attended an additional VA examination in September 2016 for an evaluation of his peripheral neuropathy of the bilateral lower extremities. The VA examiner assessed the severity of the incomplete paralysis of the Veteran’s sciatic and femoral nerves as mild bilaterally. The Veteran had reduced strength with ankle plantar flexion and ankle dorsiflexion to 4/5 bilaterally. He had normal strength with knee extension and knee flexion bilaterally. Deep tendon reflexes were normal throughout the lower extremity bilaterally. The sensory examination revealed decreased sensation to light touch in in the ankle/lower leg and foot/toes bilaterally. The sensory examination revealed normal sensation to light touch in the knee/thigh bilaterally. Position sense was normal bilaterally and vibration sensation was decreased bilaterally. The Veteran had no muscle atrophy or trophic changes bilaterally. In the bilateral lower extremities, the Veteran reported symptoms of moderate constant pain, moderate paresthesias, and moderate numbness. Furthermore, he reported plantar burning pain, and he reported occasional stumbling that he associated with loss of strength in his legs. He reported treating the pain in his legs with tramadol with some relief of the pain. The examiner noted that the Veteran’s bilateral lower extremity peripheral neuropathy caused functional impact in the form of decreased endurance to standing and walking. The Veteran attended a final VA examination in October 2020 for an evaluation of his peripheral neuropathy of the bilateral lower extremities. The VA examiner assessed the severity of the incomplete paralysis of the Veteran’s sciatic and femoral nerves as moderate bilaterally. The Veteran had normal strength throughout the lower extremity bilaterally. Deep tendon reflexes were normal throughout the lower extremity bilaterally. The sensory examination revealed decreased sensation to light touch in in the ankle/lower leg and foot/toes bilaterally. The sensory examination revealed normal sensation to light touch in the knee/thigh bilaterally. Position sense was normal bilaterally and vibration sensation was decreased bilaterally. The Veteran had no muscle atrophy or trophic changes bilaterally. In the bilateral lower extremities, the Veteran reported symptoms of moderate constant pain, moderate paresthesias, and moderate numbness. Furthermore, he reported bilateral plantar burning pain. In addition, he reported use of naproxen as needed. The examiner noted that the Veteran’s bilateral lower extremity peripheral neuropathy caused no functional impact. The Board has considered the Veteran’s reports of numbness and pain in the bilateral lower extremities throughout the appeal period. In addition, the Board acknowledges the Veteran’s report at the September 2016 VA examination of occasionally stumbling due to loss of strength in his legs. However, even considering these reports of symptoms, the evidence of record reveals nor more than moderate incomplete paralysis. There has been no point throughout the appeal period where a VA examiner has assessed more than moderate incomplete paralysis in any nerve in the lower extremities. Furthermore, the VA examinations reflect that the Veteran has had at least 4/5 strength bilaterally throughout the appeal period. In addition, the findings of decreased sensation in the foot/toes bilaterally at the May 2015, September 2016, and October 2020 VA examinations and in the ankle/lower leg at the September 2016 and October 2020 VA examinations reflect findings of no more than moderate incomplete paralysis. As such, the Board concludes that a preponderance of the evidence is against a finding that the Veteran’s bilateral lower extremity peripheral neuropathy has been manifested by any more than moderate incomplete paralysis. Therefore, the Board finds that a rating in excess of 20 percent is not warranted for either lower extremity. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt rule is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. Effective Date – TDIU and DEA 1. Entitlement to TDIU effective November 25, 2014 is granted. The AOJ awarded the Veteran entitlement to TDIU, effective May 29, 2015, the date a VA medical examination showed a diagnosis of bilateral upper and lower extremity peripheral neuropathy. See Rating Decision, dated February 4, 2016. However, prior to the grant of TDIU in the February 2016 rating decision, the Veteran’s claim for TDIU was pending since the August 2011 application for TDIU. In addition, as was noted in the September 2017 Board remand, the Veteran’s claim for an earlier effective date for TDIU was inextricably intertwined with the Veteran’s claims for an earlier effective date for the award of service connection for bilateral upper and lower extremity peripheral neuropathy. As such, the Veteran’s effective date for the Veteran’s TDIU claim may date back prior to the award of the May 29, 2015 effective date. VA will grant TDIU when the evidence shows that the Veteran is precluded, by reason of his service-connected disabilities, from obtaining or maintaining “substantially gainful employment” consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). If there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16(a). Disabilities affecting one or both lower or upper extremities are considered as one disability for the purposes of meeting the 60 percent or 40 percent requirements. Id. Disabilities resulting from one common etiology are also considered as one disability for the purposes of meeting the 60 percent or 40 percent requirements. Id. The established policy of VA reflects that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. Factors such as employment history and educational and vocational attainments are to be considered. Id. For VA purposes, the term “unemployability” is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The Court recently held that “substantially gainful occupation” contains both economic and noneconomic components. Ray v. Wilkie, 31 Vet. App. 58 (2019). The economic component “simply means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. The non-economic component requires consideration of the Veteran’s history, education, skill, and training, and physical and mental ability to perform the activities required by an occupation. Further, the word “substantially” suggests an intent to impart flexibility into a determination of overall employability, as opposed to requiring the appellant to prove that he is 100 percent unemployable. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The central inquiry is “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Following the grant of the earlier effective date of November 25, 2014 herein for the Veteran’s bilateral upper and lower extremity peripheral neuropathy, the Veteran has met the schedular requirements for TDIU as of November 25, 2014 as the Veteran’s combined rating for his service-connected disabilities has been at least 80 percent since November 25, 2014. Although the Veteran does not have one individual disability rated at 40 percent or more, the Veteran meets the schedular requirements of 38 C.F.R. § 4.16(a) because his diabetes mellitus and bilateral upper and lower extremity peripheral neuropathy result from common etiology. When taken together, the disabilities are in excess of 40 percent. Therefore, the Veteran has met the schedular criteria for TDIU since November 25, 2014. 38 C.F.R. § 4.16(a). During this period, the Veteran has also been service-connected for ischemic heart disease with an evaluation of 30 percent. The question remaining is whether the Veteran’s service-connected disabilities (alone) render him incapable of participating in a substantially gainful occupation. Here, the balance of the evidence supports that the Veteran’s service-connected disabilities substantially impacted his ability to secure and engage in types of employment at any exertional level beginning November 25, 2014, the date the Veteran has met the schedular criteria for TDIU after the grants of the earlier effective dates for service connection for bilateral upper and lower extremity peripheral neuropathy. The Veteran’s August 2011 TDIU application reflects that his posttraumatic stress disorder (PTSD) and now service-connected diabetes and heart disabilities preclude him from working. Furthermore, the application reflects the Veteran last worked full time in 2001. The ultimate question of whether a Veteran is capable of securing or following substantially gainful employment is an adjudicatory determination, not a medical one. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376 (2013). Here, following the AOJ awarding TDIU effective the date of the VA examination showing diagnoses of bilateral upper and lower extremity peripheral neuropathy, the Board concludes that given the competent and credible medical evidence showing diagnoses of bilateral upper and lower extremity diabetic neuropathy as of November 2014, the appropriate effective date for the Veteran’s TDIU is November 25, 2014, the date the Veteran met the schedular requirements for TDIU. However, TDIU is denied prior to November 25, 2014 as the record does not support that the Veteran’s service-connected disabilities prior to that date alone precluded employment. Prior to November 25, 2014, the Veteran was service connected for ischemic heart disease at 30 percent and diabetes mellitus at 10 percent, for a combined disability rating of 40 percent. Although the percentage requirements of section 4.16(a) are not met prior to November 25, 2014, total disability ratings for compensation may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Such cases should be referred to the Director, Compensation Service, for extraschedular consideration. 38 C.F.R. § 4.16(b). The Board notes that in November 2014, Dr. C.M.Q. opined that the Board’s service-connected disabilities significantly affect his ability to perform in a competitive work environment. However, the private physician provided no rationale in support of the opinion. Furthermore, the Veteran was not service connected for bilateral upper and lower extremity peripheral neuropathy at the time of the opinion. As such, the Board places little probative weight on the opinion. The Board notes that the Veteran indicated in his August 2011 TDIU application that he became too disabled to work in March 2001. However, the Veteran’s TDIU application reflects that his PTSD in part prevents him from securing or following any substantial gainful occupation, and the Veteran is not service connected for PTSD. In addition, the competent and credible medical evidence of record prior to November 25, 2014 does not support a finding that the Veteran’s service-connected disabilities rendered him unemployable prior to that date, Because a preponderance of the evidence is against a finding that the Veteran was unemployable prior to November 25, 2014 due solely to his service-connected disabilities, referral for an extraschedular evaluation is not warranted for the period prior to November 25, 2014, and the claim is denied prior to that date. 38 C.F.R. § 4.16(b). 2. Entitlement to DEA effective November 25, 2014 is granted. The Board notes that in the instant case, the AOJ has assigned an effective date of May 29, 2014 for the award of Chapter 35 DEA benefits. The date assigned by the AOJ was the same date the AOJ assigned for the award of TDIU. As discussed above, the Board finds that the Veteran is entitled to an earlier effective date of November 25, 2014 for the award of TDIU. Chapter 35 benefits may be awarded effective the date of an award of a permanent and total disability rating but not prior to the award of a permanent and total disability rating. Therefore, the Board concludes the Veteran is entitled to an effective date of November 25, 2014, but no earlier, for the award of entitlement to Chapter 35 benefits. 38 U.S.C. §§ 3501, 3510. M. Mills Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Breitbach, 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.