Citation Nr: 21025749 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 08-32 262 DATE: April 28, 2021 ORDER Entitlement to a 30 percent rating, but not higher, for headaches for the period prior to October 25, 2011, is granted. Entitlement to a rating in excess of 50 percent for headaches as of October 25, 2011, is denied. Entitlement to a 30 percent rating, but not higher, for irritable bowel syndrome for the period prior to October 25, 2011, is granted. Entitlement to a rating in excess of 30 percent for irritable bowel syndrome as of October 25, 2011, is denied. Entitlement to an initial rating in excess of 10 percent for internal hemorrhoids is denied. REMANDED Entitlement to service connection for a right upper extremity neurological disability, to include neuropathy, is remanded. Entitlement to service connection for a left upper extremity neurological disability, to include neuropathy, is remanded. Entitlement to a rating in excess of 10 percent prior to May 24, 2010; in excess of 20 percent as of May 24, 2010, and prior to October 30, 2019; and in excess of 40 percent as of October 30, 2019, for a lumbar spine disability is remanded. Entitlement to a rating in excess of 10 percent prior to May 24, 2010, and in excess of 20 percent as of May 24, 2010, for a cervical spine disability is remanded. Entitlement to an initial rating in excess of 20 percent for a left (minor) shoulder disability is remanded. Entitlement to an initial rating in excess of 10 percent for a right knee disability under Diagnostic Code 5003 is remanded. Entitlement to an initial compensable rating for a right knee disability under Diagnostic Code 5260 is remanded. Entitlement to an initial rating in excess of 10 percent for a left knee disability under Diagnostic Code 5003 is remanded. Entitlement to an initial compensable rating for a left knee disability under Diagnostic Code 5260 is remanded. Entitlement to an initial rating in excess of 10 percent for a right ankle disability is remanded. Entitlement to an initial rating in excess of 10 percent for a left ankle disability is remanded. FINDINGS OF FACT 1. Prior to October 25, 2011, a headache disability was shown to be manifested by migraine headaches occurring either daily or every other day with characteristic prostrating attacks. 2. As of October 25, 2011, a headache disability has been shown to be manifested by no more than frequent migraine headaches with characteristic prostrating attacks of migraine headache pain. The headaches have not been found to result in severe economic inadaptability. 3. Prior to October 25, 2011, irritable bowel syndrome was manifested by alternating diarrhea and constipation with constant abdominal distress. 4. As of October 25, 2011, irritable bowel syndrome was manifested by alternating diarrhea and constipation with constant abdominal distress. 5. Internal hemorrhoids have been shown to be manifested by blood on the toilet tissue and to be no more than mild or moderate in severity. CONCLUSIONS OF LAW 1. The criteria for a 30 percent rating, but not higher, for headaches for the period prior to October 25, 2011, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.124a, Diagnostic Code 8100. 2. The criteria for a rating in excess of 50 percent for headaches as of October 25, 2011, have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.124a, Diagnostic Code 8100. 3. The criteria for a 30 percent rating, but not higher, for irritable bowel syndrome for the period prior to October 25, 2011, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.114, Diagnostic Code 7319. 4. The criteria for a rating in excess of 30 percent for irritable bowel syndrome as of October 25, 2011, have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.114, Diagnostic Code 7319. 5. The criteria for initial rating in excess of 10 percent for internal hemorrhoids have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.114, Diagnostic Code 7336. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 2003 to February 2006. The Veteran appeared at a March 2011 hearing before the undersigned Veterans Law Judge at the Huntington, West Virginia, Regional Office. A hearing transcript is of record. The record shows that the Veteran received a September 2020 Board of Veterans’ Appeals (Board) letter indicating that the Veteran could request a virtual hearing instead of waiting for a travel board hearing. After further review of the record, the Board finds that the Veteran does not have a pending hearing request. The Veteran provided testimony at a hearing with the undersigned Veterans Law Judge. The Board has considered the transcript of that hearing as evidence in this adjudication. Increased Ratings Disability ratings are determined by comparing the Veteran’s current symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Headaches The Veteran asserts that the service connected headaches warrant the assignment of at least a 50 percent rating. A 10 percent rating is warranted for migraines with characteristic prostrating attacks averaging one every two months over the last several months. A 30 percent rating requires characteristic prostrating attacks occurring on an average of once a month over the last several months. A 50 percent rating requires very frequent, completely prostrating, and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. Prior to October 25, 2011 The report of a January 2008 Department of Veterans Affairs (VA) neurological examination states that the Veteran complained of daily headaches which lasted between a few hours and all day. The examiner reported that the Veteran “does seem somewhat light and noise sensitive;” “the headaches are not necessarily prostrating;” and “he is able to continue his activity, but prefers not to.” The examiner diagnosed recurrent headaches. A June 2009 VA treatment record states that the Veteran complained of worsening headaches. At a September 2009 hearing before a VA Decision Review Officer, the Veteran testified that he experienced daily headaches with vision impairment. He stated that prescribed medication did not relieve the headaches. The report of a May 2010 VA neurological examination states that the Veteran complained of progressive worsening headaches. He reported that he had a headache every other day; the headaches had associated light and noise sensitivity and occasional nausea; and “50 percent of the headaches were prostrating and necessitated that he lay down in a dark quiet spot.” The examiner commented that the headaches affected the Veteran’s ability to perform daily activities including chores, exercise, and recreation. At a March 2011 Board hearing, the Veteran testified that he experienced daily headaches which lasted an hour or more; made him sensitive to light and noise; caused him to become nauseous; and required that he isolate himself. Prior to October 25, 2011, a headache disability was shown to manifested by migraine headaches occurring either daily or every other day with characteristic prostrating attacks. Those symptoms merit assignment of at least a 30 percent rating under Diagnostic 8100. The record does not show, and the Veteran has not alleged, that the headaches were very frequent, completely prostrating, or prolonged during the relevant time period. No medical professional concluded that the headaches, alone, were productive of severe economic inadaptability. In the absence of such findings, the Board concludes that a 30 percent rating, and no higher, is warranted for the service connected headache disability for the period prior to October 25, 2011. The Board finds that the preponderance of the evidence is against the assignment of any higher rating. As of October 25, 2011 The report of an October 25, 2011, VA headaches examination states that the Veteran complained of daily headaches with associated blurred vision, light sensitivity, nausea, and “characteristic prostrating attacks of migraine headache pain” more than once a month. The examiner diagnosed migraine headaches. The examiner commented that “headaches cause moderate impairment with physical and sedentary labor due to frequency of the headaches and prostrating nature of the headaches.” An October 2016 VA treatment record states that the Veteran reported that he “often wakes up with a headache.” A November 2016 VA treatment record indicates that the Veteran reported that he “sometimes wakes up with morning headaches.” The report of a November 2019 VA headaches examination states that the Veteran complained of daily headaches. He reported that he experienced constant head pain with light and sound sensitivity and vision changes and characteristic prostrating attacks once every month. The examiner noted that the Veteran did not have “very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability.” The examiner commented that the headaches did not impact the Veteran’s ability to work. As of October 25, 2011, a headache disability has been shown to be manifested by no more than frequent migraine headaches with characteristic prostrating attacks of migraine headache pain. On repeated VA examination, the headaches were not found to be productive of severe economic inadaptability. At the most recent evaluation, the VA examiner expressly concluded that the headaches did not impact the Veteran’s ability to work. The October 2011 VA examination found moderate interference with employment. The Board finds that the current 50 percent rating, the maximum schedular rating under Diagnostic Code 8100, adequately compensates the level of disability associated with the service connected headache disability. Therefore, a rating in excess of 50 percent for headaches is denied. Irritable Bowel Syndrome A 10 percent rating is assigned for moderate irritable bowel syndrome productive of frequent episodes of bowel disturbances with abdominal distress. A 30 percent rating requires severe diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319. Prior to October 25, 2011 The report of an August 2006 VA examination states that the Veteran complained of alternating bouts of diarrhea and constipation with abdominal cramping and pain. He indicated that his weight was stable. At a September 2009 hearing before a VA Decision Review Officer, the Veteran testified that he experienced frequent bowel movements and abdominal cramping and pain. He stated that the gastrointestinal disability significantly interrupted his work activities due to the frequent need to use the restroom. The report of a June 2010 VA gastrointestinal examination indicates that the Veteran complained of having 3 to 10 bowel movements a day with urgency; diarrhea; abdominal cramping and pain; and “no frank bowel incontinence.” The examiner noted that the Veteran denied experiencing constipation or weight loss. The examiner commented that the irritable bowel syndrome affected the Veteran’s ability to perform daily activities including chores, exercise, traveling, and recreation. At a March 2011 Board hearing, the Veteran testified that he experienced diarrhea with five or more bowel movements a day and abdominal cramping. Prior to October 25, 2011, the Board finds that irritable bowel syndrome was manifested by alternating diarrhea and constipation with constant abdominal distress. Those symptoms warrant the assignment of a 30 percent rating under Diagnostic Code 7319. The Board observes that rating is maximum available under the diagnostic code. The Board finds that the preponderance of the evidence is against the assignment of any higher rating. As of October 25, 2011 The report of an October 25, 2011, VA gastrointestinal examination notes that the Veteran reported experiencing recurrent diarrhea with one to six bowel movements a day with associated lower abdominal cramping and bright blood in the stool. The examiner noted that the Veteran experienced seven or more episodes of exacerbation of the irritable bowel syndrome with “at least 12” bowel movements in a day and lower abdominal cramping and no associated weight loss. The examiner commented that “frequent loose bowel movements would cause mild impairment in performing physical labor and would not impair sedentary labor.” A July 2019 VA treatment record states that the Veteran complained of abdominal pain. He reported having one bowel movement every two to three days. The report of a November 2019 VA gastrointestinal examination shows that the Veteran presented a history of “solid food making him sick, cramping diarrhea, and getting constipated now mostly, relieved with bowel movement.” The examiner stated that the irritable bowel syndrome was manifested by alternating diarrhea and constipation; seven or more “episodes of exacerbations and/or attacks of the intestinal condition” in the preceding 12 months; “more constipation than diarrhea currently;” and no associated weight loss. As of October 25, 2011, irritable bowel syndrome has been shown to be manifested by no more than alternating diarrhea and constipation; seven or more “episodes of exacerbations and/or attacks of the intestinal condition” in the preceding 12 months; “more constipation than diarrhea currently;” and no associated weight loss. Those findings fall squarely within the diagnostic criteria for a 30 percent rating under Diagnostic Code 7319. That is the maximum schedular rating for the disability. Therefore, a rating in excess of 30 percent for irritable bowel syndrome is not warranted. The Board finds that the preponderance of the evidence is against the assignment of any higher rating. Internal Hemorrhoids A 10 percent rating is warranted for large or thrombotic, irreducible external or internal hemorrhoids with excessive redundant tissue evidencing frequent recurrences. A 20 percent rating requires hemorrhoids with persistent bleeding and secondary anemia or with fissures. 38 C.F.R. § 4.114, Diagnostic Code 7336. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. At the September 2009 hearing before a VA Decision Review Officer, the Veteran testified that he experienced blood in his stool every time he used the restroom. The report of a June 2010 VA gastrointestinal examination states that the Veteran complained of occasional rectal bleeding and “pain when he has a bowel movement with a formed stool.” On examination, the examiner noted no hemorrhoids were present. The examiner commented that the hemorrhoids did not affected the Veteran’s ability to perform daily activities. At the March 2011 Board hearing, the Veteran testified that the hemorrhoids were productive of daily rectal bleeding and soreness associated with bowel movements. The report of an October 25, 2011, VA rectal examination states that the Veteran reported experiencing recurrent rectal pain with bowel movements and bright blood in the stool. On examination, the examiner noted that no anemia, hemorrhoids, or anal fissures were present. The report of a November 2019 VA rectal examination shows that the Veteran complained of blood on the toilet paper following a bowel movement. The examiner noted mild or moderate internal hemorrhoids, rectal/anal skin tags, and no external hemorrhoids, pain, or anemia. A February 2020 VA gastroenterology evaluation states that the Veteran complained of bright red blood on toilet tissue. The treating VA physician attributed the blood to the service-connected hemorrhoids. The service-connected hemorrhoid disability has been shown to be manifested by mild or moderate internal hemorrhoids, blood on the toilet tissue, and no external hemorrhoids, rectal fissures, or anemia. Those symptoms most closely approximately the criteria for a 10 percent rating under Diagnostic Code 7336. The evidence does not show anemia or fissures. Therefore, an initial rating in excess of 10 percent for internal hemorrhoids is denied. The Board finds that the preponderance of the evidence is against the assignment of any higher rating. REASONS FOR REMAND 1. Entitlement to service connection for a bilateral upper extremity neurological disability is remanded. In October 2018 Remand instructions, the Board requested that the Veteran be “scheduled for a VA neurological examination conducted by a medical doctor to assist in determining the current nature of any identified upper extremity neurological disability and the relationship, if any, to active service or a service connected disability.” The requested VA neurological examination was not scheduled. The Agency of Original Jurisdiction’s compliance with the Board’s remand instructions is neither optional nor discretionary. Stegall v. West, 11 Vet. App. 268 (1998). Therefore, remand is required to schedule an examination. 2. Entitlement to increased ratings for a cervical spine disability and a lumbar spine disability is remanded. The report of an October 2019 VA cervical spine examination states that the Veteran complained of recurrent radiating cervical spine pain. On examination of the cervical spine, the Veteran exhibited a range of motion of forward flexion to 20 degrees, extension to 15 degrees, lateral flexion to 20 degrees, bilaterally, and lateral rotation to 60 degrees, bilaterally; pain with all ranges of motion; pain on weight bearing; and guarding of the cervical spine. The examiner commented that “pain noted on examination and causes functional loss.” The examiner did not identify the degree at which the identified cervical spine pain was exhibited. Because of that deficiency, the Board finds that the October 2019 examination report is of limited probative value. The report of an October 2019 VA lumbar spine examination states that the Veteran complained of recurrent lumbar spine pain. The Veteran clarified that he was unable to get out of bed some days due to the lumbar spine pain. On examination of the lumbar spine, the Veteran exhibited a range of motion of forward flexion to 30 degrees, extension to 10 degrees, lateral flexion to 10 degrees, bilaterally, and lateral rotation to 20 degrees, bilaterally; pain with all ranges of motion; pain on weight bearing; and guarding of the lumbar spine. The examiner commented that “pain noted on examination and causes functional loss” and the Veteran had lumbar spine intervertebral disc syndrome. The examiner did not identify the degree at which the identified lumbar spine pain was exhibited. Because of that deficiency, the Board finds that the October 2019 examination report is of limited probative value. The Board observes that the Secretary of VA has recently amended that portion of 38 C.F.R. Part 4 which pertain to musculoskeletal disabilities. On February 7, 2021, the provisions of 38 C.F.R. § 4.71a, Diagnostic Codes 5242, 5243 addressing degenerative disc disease and intervertebral disc syndrome were amended. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5242, 5243). VA’s duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121 (1991). When VA obtain an evaluations, the evaluation must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, the Board finds that further VA cervical spine and lumbar spine evaluations are needed. Clinical documentation dated after May 2020 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 3. Entitlement to an initial rating in excess of 20 percent for a left (minor) shoulder disability is remanded. The report of an October 2019 VA shoulder examination states that the Veteran complained of recurrent left shoulder pain associated with raising the arm over his head and feeling like the joint was “going out of its socket.” On examination of the left shoulder, the Veteran exhibited a range of motion of flexion to 120 degrees, abduction to 100 degrees, external rotation to 30 degrees, and internal rotation to 30 degrees; pain with all ranges of motion; a passive range of motion of flexion to 130 degrees, abduction to 110 degrees, external rotation to 30 degrees, and internal rotation to 30 degrees; a positive Hawkins’ impingement test; and pain on weight bearing. The examiner commented that “pain noted on examination and causes functional loss” and pain on passive range of motion testing. The examiner did not identify the degree at which the identified left shoulder pain was exhibited. Because of that deficiency, the Board finds that the October 2019 examination report is of limited probative value. The Board observes that the Secretary of VA has recently amended that portion of 38 C.F.R. Part 4 which pertain to musculoskeletal disabilities. On February 7, 2021, the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5201 addressing limitation of arm motion were amended. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5201). Therefore, the Board finds that further VA shoulder evaluation is needed. 4. Entitlement to increased ratings for right and left knee disabilities is remanded. The report of an October 2019 VA knee examination states that the Veteran complained of severe right and left knee pain, locking, and occasional giving out. On examination of the knees, the Veteran exhibited right knee range of motion of 0 to 60 degrees; left knee range of motion of 0 to 60 degrees; pain with all ranges of motion; and pain on weight bearing. The examiner commented that “pain noted on examination and causes functional loss” and pain on passive range of motion testing. The examiner did not identify the degree at which the identified knee pain was exhibited. Because of that deficiency, the Board finds that the October 2019 examination report is of limited probative value. The Board observes that the Secretary of VA has recently amended that portion of 38 C.F.R. Part 4 which pertain to musculoskeletal disabilities. On February 7, 2021, the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5003 addressing degenerative arthritis were amended. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5003). Therefore, the Board finds that further VA knee evaluation is needed. 5. Entitlement to increased ratings for right and left ankle disabilities is remanded. The report of an October 2019 VA ankle examination states that the Veteran complained of right ankle and left ankle pain, popping, and rolling. On examination of the ankles, the Veteran exhibited a right ankle range of motion of dorsiflexion from 0 to 10 degrees and plantar flexion of 0 to 35 degrees; a left ankle range of motion of dorsiflexion from 0 to 10 degrees and plantar flexion of 0 to 25 degrees; pain with all ranges of motion; and pain on weight bearing. The examiner commented that “pain noted on examination and causes functional loss” and pain on passive range of motion testing. The examiner did not identify the degree at which the identified ankle pain was exhibited. Because of that deficiency, the Board finds that the October 2019 examination report is of limited probative value. The Board observes that the Secretary of VA has recently amended that portion of 38 C.F.R. Part 4 which pertain to musculoskeletal disabilities. On February 7, 2021, the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5271 addressing ankle limitation of motion were amended. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5271). Therefore, the Board finds that further VA ankle evaluation is needed. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated any upper extremity neurological disability and the service connected cervical spine, lumbar spine, left shoulder, right knee, right ankle, left knee, and left ankle disabilities. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after May 2020. 3. Schedule the Veteran for a VA neurological examination conducted by a medical doctor to assist in determining the current nature of any identified upper extremity neurological disability and any relationship to active service or a service-connected disability. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all upper extremity neurological disabilities found. If peripheral neuropathy is not identified, the examiner must specifically state that fact and reconcile that with other findings of record. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified upper extremity neurologic disability had its onset during active service or is related to any incident of service. (c) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified upper extremity disability is due to or caused by a service-connected cervical spine disability and the other service-connected disabilities. (d) Opine whether it at least as likely as not (50 percent probability or greater) that any identified upper extremity neurologic disability has been aggravated (increased in severity beyond the natural progress of the disorder) by a service-connected cervical spine disability and the other service-connected disabilities. 4. Schedule the Veteran for a VA spine examination conducted by a medical doctor to assist in determining the severity of cervical and lumbar spine disabilities. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Provide ranges of motion for passive and active motion of the cervical spine and the lumbar spine. The examiner should state whether there is any additional loss of cervical spine and lumbar spine function due to painful motion, weakened motion, excess motion, fatigability, incoordination, or on flare up. The degree of range of motion at which pain is exhibited should be specifically reported. (b) Indicate whether, and to what extent, the Veteran experiences functional loss of the cervical spine and the lumbar spine due to pain or any other symptoms during flare ups or with repeated use. (c) State whether or not there is any ankylosis of the spine or any segment of the spine. (d) Note the frequency and duration of any incapacitating episodes associated with lumbar spine intervertebral disc syndrome. An incapacitating episode is a period of acute signs and symptoms that requires bed rest prescribed by a physician and treatment by a physician. 5. Schedule the Veteran for a VA shoulder examination conducted by a medical doctor to assist in determining the current severity of a left shoulder disability. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Provide ranges of motion for passive and active motion, and for weight bearing and nonweight bearing, of the left shoulder. The examiner should state whether there is any additional loss of left shoulder function due to painful motion, weakened motion, excess motion, fatigability, incoordination, or on flare up. The degree of range of motion at which any pain is exhibited should be specifically reported. (b) Provide an opinion as to the impact of the left shoulder disability on the Veteran’s vocational pursuits. 6. Schedule the Veteran for a VA joint examination to assist in determining the current severity of service connected bilateral knee and bilateral ankle disabilities. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Provide ranges of motion for weight bearing and nonweight-bearing and passive and active motion of the knees and the ankles. The degree of range of motion at which pain is exhibited should be specifically reported. (b) State whether there is any additional loss of knee and ankle function due to painful motion, weakened motion, excess motion, fatigability, incoordination, or on flare up. (c) State whether there is any recurrent lateral instability or subluxation of the right or left knee, and if so the severity of any instability or subluxation. (d) State whether there is ankylosis of the knees or ankles. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. T. Hutcheson, 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.