Citation Nr: 21030819 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 17-23 423 DATE: May 19, 2021 REMANDED Entitlement to a rating in excess of 10 percent for post-operative osteochondritis dissecans, left knee, is remanded. Entitlement to service connection for a right knee condition, to include as secondary to the service-connected left knee disability, is remanded. Entitlement to service connection for a back condition, to include as secondary to the service-connected left knee disability, is remanded. Entitlement to service connection for a bilateral hip condition (to include bursitis), to include as secondary to the service-connected left knee disability, is remanded. Entitlement to service connection for hypertension, to include as secondary to the service-connected left knee disability, is remanded. Entitlement to service connection for herniated disc neck is remanded. Entitlement to service connection for nerve damage, to include as secondary to the service-connected left knee disability and/or as secondary to a back condition and herniated disc neck, is remanded. Entitlement to service connection for basal cell and squamous cell carcinoma (BCC/SCC) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from April 1985 to April 1986. These matters come before the Board from a July 2013 rating decision in which the Veteran's June 2012 claims for an increased rating for the left knee disability and service connection claims for a back condition, bilateral hip condition, right knee condition, hypertension, herniated disc neck, nerve damage, and BCC/SCC were denied. At a February 2021 hearing, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the proceeding has been associated with the claims file. At the hearing, the Veteran indicated that he has been receiving Social Security Administration (SSA) disability benefits since 2014. No attempts have been made to associate the SSA records with the claims file. As such, upon remand, attempts should be undertaken to obtain the records and add them to the file. Further, VA treatment records in the file date until January 2017. However, the Veteran identified recent relevant treatment by VA providers. As such, updated VA treatment records should be added to the file, as well. 1. Entitlement to a rating in excess of 10 percent for post-operative osteochondritis dissecans, left knee, is remanded. Over the course of the appeal period, the Veteran underwent two VA examinations in July 2013 and December 2015 regarding his left knee. At the hearing, he described worsened symptomology and additional manifestations of his left knee disability occurring since the last evaluation. As such, the Board finds that a new examination is needed to ascertain the current extent and severity of the disability. See Snuffer v. Gober, 10 Vet. App. 400 (1997) (noting that a veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination). Additionally, subsequent to the prior examinations, the Court of Appeals for Veterans Claims (Court) held in Correia v. McDonald, 28 Vet. App. 158 (2016), that the final sentence of 38 C.F.R. 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the Court's holding in Correia established additional requirements for examinations regarding musculoskeletal disabilities. After reviewing the examinations of record, the Board finds that they are incomplete in this regard and requires further medical guidance, in light of the holding in Correia. Additionally, the Court has since stated that flare-ups must be factored into an examiner's assessment of functional loss. Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017). As the previous examination reports do not fully satisfy the requirements of Correia, Sharp, and 38 C.F.R. 4.59, a new examination is needed before a decision may be rendered on the claim. 2. Entitlement to service connection for a right knee condition, to include as secondary to the service-connected left knee disability, is remanded. The Veteran has contended that due to compensation for his service-connected left knee disability, he has developed a right knee condition. He stated that since his in-service left knee injury, he has had to stand with 95 percent of his weight on his right leg. A June 2011 VA treatment record reflected the Veteran's complaint of right knee pain that he believed was from compensating for his left knee disability. Clinicians suspected a meniscus pathology or radicular pain. Radiographs conducted in July 2011 demonstrated mild joint space narrowing. Mild pain, weakness, locking, and giving way were reported. In September 2012, he was diagnosed with a right knee medial meniscus tear and a partial medial meniscectomy was subsequently performed. A VA examination was conducted in July 2013. The examiner determined that the Veteran's right knee condition was less likely than not proximately due to or the result of the left knee condition. VA treatment records supported that the Veteran had an equal cadence gait that would not be expected to produce a flow-through type of injury to the right knee. Evidence instead supported that degenerative change of the right knee was part of normal age progression. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The VA examiner did not address whether the service-connected left knee disability proximately aggravated the Veteran's right knee condition. The Court's holding in El-Amin v. Shinseki, 26 Vet. App. 136 (2013), indicates that in circumstances such as this case, a medical opinion addressing that question should be sought. Accordingly, a new VA examination and opinion are needed before a decision may be rendered on the claim. 38 C.F.R. §§ 3.159, 3.310 3. Entitlement to service connection for a back condition, to include as secondary to the service-connected left knee disability, is remanded. The Veteran has contended that a current back condition is the result of compensation for his service-connected left knee disability. He has stated that he needed to lift objects with his back because his knee could not take the weight and that his antalgic gait further caused his back condition. Private treatment records reflected a complaint of low back pain in June 2009. An MRI conducted in September 2009 demonstrated degenerative disc disease (DDD), facet degenerative change, ligamentum flavum hypertrophy; broad-based disc bulge with an annular tear in the left neural foramen at L4-L5 causing moderate to severe left foraminal narrowing; moderate right foraminal narrowing; and right eccentric and foraminal disc protrusion at L3-L4 resulting in moderate right foraminal narrowing. The Veteran underwent a laminectomy, facetectomy, and foraminotomy in June 2010. A VA examination was conducted in July 2013. The examiner determined that the Veteran's back condition was less likely than not proximately due to or the result of the service-connected left knee disability. The examiner noted that the Veteran endorsed the onset of low back pain around 1999. A May 2010 surgical consult contained no discussion of a relationship to any preexisting conditions. The examiner also stated that private clinicians' 2012 notes did not provide support for a causal relationship. A letter written by one of the Veteran's private treating clinicians in September 2013 noted that he had been her patient since 1986, shortly after discharge. She stated that his left knee pain worsened over the years, resulting in changes to his gait that significantly contributed to serious spinal damage including spinal stenosis. The Board finds that a new VA examination and opinion are needed. The July 2013 opinion did not provide an opinion on causation or aggravation, but merely reflected that medical records in the file did not support a relationship between the conditions. The private opinion did not provide a supporting rationale for the nexus conclusion. As such, a new opinion is needed which provides determinations on both causation and aggravation which are supported by a complete rationale. 4. Entitlement to service connection for a bilateral hip condition (to include bursitis), to include as secondary to the service-connected left knee disability, is remanded. The Veteran has contended that alterations in his gait caused by the service-connected left knee disability have resulted in his current bilateral hip condition. He also stated that his left leg length changed following his last left knee surgery and that the discrepancy between the right and left leg lengths caused hip soreness. A January 2009 private treatment record reflected a post-service injury to the Veteran's left upper leg/hip. In October 2008, an 85-pound object fell from the ceiling of his garage onto his left leg. He immediately believed he had a deep muscle bruise to the quadriceps. However, several months later, he began having pain in his left hip area which was exacerbated when bowling. X-rays were conducted which demonstrated a normal pelvis and left hip. In a February 2011 private treatment record, it was noted that the Veteran had left hip pain and that his limb lengths were equal and he had no limp. Radiographs demonstrated osteoarthritis in the left hip. Trochanteric bursitis was also diagnosed. A therapeutic hip injection was administered. Right hip pain was reported in August 2009. X-rays revealed a normal right hip. In March 2012, x-rays demonstrated mild chronic degenerative changes at the lateral margin of the acetabulum. The Veteran underwent a VA examination in July 2013. The examiner stated that he endorsed hip pain which stemmed from his back condition. He had not had a hip injury. X-rays showing mild DJD were consistent with age-related changes. The examiner determined that the bilateral hip condition was less likely than not proximately due to or the result of the service-connected left knee condition. A January 2017 VA treatment record noted that the Veteran's left leg was longer than his right leg by 3 mm. The Board finds that the current medical opinion of record does not address aggravation and does not contain a complete rationale. As such, a new VA examination and opinion are needed before a decision may be rendered on the claim. 5. Entitlement to service connection for hypertension, to include as secondary to the service-connected left knee disability, is remanded. The Veteran has contended that his currently diagnosed hypertension is either caused or aggravated by pain from his left knee disability. Hypertension was first noted as a diagnosed condition in the Veteran's past medical history in a private March 2004 treatment record. In March 2013, clinicians stated that he had a risk factor of male gender for hypertension and that it was exacerbated by stress. The Veteran's treating clinician submitted a letter in February 2021 which stated that he had a history of hypertension since 1986 when she started treating him She noted that hypertension began when he started experiencing pain from his left knee, arm, and spinal stenosis. She continued that the pain that accompanies these diagnoses can lead to elevated blood pressure results. Pain is one of the biggest factors that can increase a patient's blood pressure. The Board finds that a VA examination and opinion are needed to determine whether the Veteran's hypertension is the result of his service-connected left knee disability. The VA Secretary must provide a VA medical examination when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McClendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Here, the Veteran has a diagnosis of hypertension and there is medical evidence suggesting it may be due at least in part to a service-connected disability. However, the medical opinion of record did not determine that a service-connected disability alone either caused or aggravated the Veteran's hypertension. As such, the Board has insufficient competent medical evidence to make a decision on the claim and a VA examination is needed. 6. Entitlement to service connection for herniated disc neck is remanded. The Veteran has contended that in May 1985, he fell 10 feet onto his neck during a training exercise. He did not seek medical treatment at the time because he did not know that he had injured his neck but he stated that he had concussion symptoms at the time. A May 1985 service treatment record (STR) indicated a complaint of dull, steady temporal/frontal headaches with some radiation to the occipital skull and light sensitivity. Tension headaches were diagnosed. Later May 1985 records contained complaints of continued headaches. The Veteran denied head trauma in the past 72 hours. Clinicians suspected a musculoskeletal etiology or chronic sinusitis. An x-ray revealed mucosal thickening. Mild sinusitis & tension cephalgia were diagnosed. A physical examination conducted as part of a Medical Evaluation Board prior to separation noted that the Veteran's neck was within normal limits. There were no relevant notations on the separation examination and the Veteran himself did not list anything regarding the injury on his separation report of medical history. The first relevant notation in the claims file listed a past medical history of a herniated disc at C3-C4 in a March 2004 private treatment record. In a September 2013 record, the Veteran reported to clinicians that his neck pain began many years ago without a precipitating factor. He had been told many years previously that he had a herniated disc in his neck. A December 2013 record diagnosed symptomatic intervertebral disc herniations at C5-C6 and C6-C7; spinal stenosis in the cervical region; multilevel cervical and lumbar DDD; and cervical radiculopathy. A friend of the Veteran's submitted a letter in February 2021 stating that she spent a lot of time with him during 1985 when they were serving together. The Veteran mentioned several times that he had hurt his neck from a fall he suffered while he was in basic training and there were times where it was obvious that he was in pain. The Board finds that a VA examination and opinion are needed to determine whether the Veteran's current disc herniations are the result of his active service. Although contemporaneous medical records did not document a neck injury, the Veteran and his friend have described an in-service incident and ongoing pain. As such, the Board finds that a medical opinion is needed before a decision may be rendered on the claim. McClendon v. Nicholson, 20 Vet. App. at 81. 7. Entitlement to service connection for nerve damage, to include as secondary to the service-connected left knee disability and/or as secondary to a back condition and herniated disc neck, is remanded. The Veteran has contended that he has nerve damage in his upper and lower extremities that is the result of his active service, specifically to include as secondary to his service-connected left knee disability or his back condition and herniated disc neck condition. An August 2009 private treatment record listed a past medical history of nerve damage. A letter from one of the Veteran's private treating clinicians in November 2009 stated that it was likely that he had soft tissue peripheral nerve damage as a result of his in-service injury to his left knee. He currently had severe neuritic-type pain in the left leg from that injury. Paresthesias from the Veteran's back condition were noted in June 2010. An April 2011 EMG/NCS demonstrated a normal examination of the bilateral lower extremities with no evidence of radiculopathy, plexopathy, focal compression, or polyneuropathy. A June 2011 private treatment record noted radicular symptoms from DJD of the neck at C4-C5 and a VA treatment record stated that he had numbness and referred pain down his lateral thighs from his back condition. At a July 2013 VA back examination, the Veteran had radicular symptoms but radiculopathy was not diagnosed. In September 2013, one of the Veteran's treating clinicians stated that the changes resulting in his gait from his service-connected left knee disability contributed to serious spinal damage including spinal stenosis and nerve damage. He had current constant pain in his legs and numbness in his feet. The Board finds that a VA examination and opinion are needed to determine the etiology of the Veteran's nerve damage. There is medical evidence that it may be related to the service-connected left knee disability. Further, if service connection is warranted for the claimed back condition or the herniated disc neck, an opinion based on a secondary theory of entitlement for those disabilities is needed. 8. Entitlement to service connection for BCC/SCC is remanded. The Veteran has contended that BCC/SCC on his left ear is the result of his active service, specifically to include as due to a sunburn during basic training. He described wearing hats that did not cover his ears and being out in the sun for prolonged periods without sunscreen. A May 1985 STR noted that the Veteran had a mild second degree burn on his left hand. Several days later, a follow-up appointment listed a mild second degree sunburn. The January 1986 separation examination and report of medical history did not reflect any relevant complaints. A biopsy of the Veteran's left ear was conducted in January 2006 which resulted in a diagnosis of BCC. In November 2006, the BCC of the left ear was excised. As there is evidence of a sunburn in service and a later diagnosis of BCC/SCC of the left ear, the Board finds that a VA examination and opinion are needed to determine the etiology of the claimed condition. McClendon v. Nicholson, 20 Vet. App. at 81. The matters are REMANDED for the following action: 1. Contact the Social Security Administration and request copies of the Veteran's complete SSA records, including any administrative decisions on his application for SSA disability benefits and all underlying medical records. 2. Obtain and associate with the claims file any outstanding and relevant records of VA treatment, specifically to include records since January 2017. 3. Schedule the Veteran for a VA examination with an appropriate medical professional to obtain the current extent and severity of his service-connected left knee disability. Following review of the claims file, the examiner should conduct any studies and/or tests deemed necessary (including imaging studies and range of motion testing, which would include pain on both active and passive motion, in weight-bearing and nonweight-bearing, and if possible, with the range of the opposite undamaged joint), and fully describe all symptomology and functional deficits associated with the disability. (a.) The examiner is specifically asked to set forth the extent of any functional loss due to weakened movement, excess fatigability, incoordination, pain on use, swelling, deformity, or atrophy of disuse. (b.) The examiner should elicit information from the Veteran regarding periods of flare-ups and note the severity, frequency, and duration of any such flare-ups. Any additional impairment on use or in connection with flare-ups should be described in terms of the degree of additional range of motion loss. The examiner should specifically describe the severity, frequency, and duration of flare-ups; name the precipitating and alleviating factors; and estimate, per the Veteran, to what extent, if any, such flare-ups affect functional impairment. If the examiner is unable to conduct the required testing or concludes that it is not necessary in this case, he or she should clearly explain why that is so. If the examiner cannot provide additional functional limitation during flare-ups or with repeated use over time in terms of degrees of range of motion, the examiner should provide a medically-based explanation for the inability to do so. (c.) The examiner should specifically indicate the severity of any left knee instability. Throughout the entire appeal period (June 2011 to the present), the examiner should indicate whether any instability, to include as demonstrated on clinical examination and as reported in lay statements, is best described as slight, moderate, or severe. From February 7, 2021, the examiner should indicate whether the Veteran's left knee disability resulted in a diagnosed condition involving the patellofemoral complex with recurrent instability; a sprain, incomplete ligament tear, or complete ligament tear causing persistent instability; or an unrepaired or failed repair of complete ligament tear causing persistent instability. If the Veteran uses an assistive device(s) for ambulation, such device(s) should be identified, and it should be noted whether or not they were prescribed by a medical provider. (d.) The examiner should specifically indicate whether at any time since June 2011 the Veteran has symptomatic or removed semilunar cartilage; whether he had frequent episodes of locking in his left knee; and whether his disability was manifested by effusion in the joints. (e.) Retrospective Opinion: The examiner should review the July 2013 and December 2015 VA examinations and provide a retrospective opinion as to the Veteran's flare-ups based on the aforementioned criteria (see section (b)). If unable to provide a retrospective opinion, the examiner should provide a medically-based explanation for the inability to do so. (f.) A complete and fully explanatory rationale should be provided for any opinion. If any opinion cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, by a deficiency in the record, or because the examiner does not have the needed knowledge or training. 4. Schedule the Veteran for a VA examination with an appropriate medical professional to determine the etiology of any right knee condition. The claims folder should be provided to and reviewed by the examiner. (a.) After a review of the examination findings and the entire evidence of record, the examiner is asked to render an opinion as to whether the Veteran's right knee condition at least as likely as not (probability of 50 percent or greater) is proximately caused or aggravated (i.e., worsened beyond natural progression) by his service-connected left knee disability. If aggravation is found, the examiner should quantify the degree of such aggravation, if possible. (b.) The examiner is asked to specifically address the Veteran's January 2014 statement, April 2017 substantive appeal, and February 2021 hearing testimony and his contention that compensation for the left knee disability resulted in any current right knee condition. The examiner is also asked to address the July 2013 examiner's findings and to reconcile any differences with the conclusions therein. (c.) A complete and fully explanatory rationale should be provided for any opinion. If any opinion cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, by a deficiency in the record, or because the examiner does not have the needed knowledge or training. 5. Schedule the Veteran for a VA examination with an appropriate medical professional to determine the etiology of any back condition. The claims folder should be provided to and reviewed by the examiner. (a.) After a review of the examination findings and the entire evidence of record, the examiner is asked to render an opinion as to whether the Veteran's back condition at least as likely as not (probability of 50 percent or greater) is proximately caused or aggravated (i.e., worsened beyond natural progression) by his service-connected left knee disability. If aggravation is found, the examiner should quantify the degree of such aggravation, if possible. (b.) The examiner is asked to specifically address the Veteran's January 2014 statement, April 2017 substantive appeal, and February 2021 hearing testimony and his contention that compensation for the left knee disability resulted in any current back condition. The examiner is also asked to address the July 2013 examiner's findings and the September 2013 private clinician's letter and to reconcile any differences with the conclusions therein. (c.) A complete and fully explanatory rationale should be provided for any opinion. If any opinion cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, by a deficiency in the record, or because the examiner does not have the needed knowledge or training. 6. Schedule the Veteran for a VA examination with an appropriate medical professional to determine the etiology of any bilateral hip condition. The claims folder should be provided to and reviewed by the examiner. (a.) After a review of the examination findings and the entire evidence of record, the examiner is asked to render an opinion as to whether the Veteran's bilateral hip condition at least as likely as not (probability of 50 percent or greater) is proximately caused or aggravated (i.e., worsened beyond natural progression) by his service-connected left knee disability. If aggravation is found, the examiner should quantify the degree of such aggravation, if possible. (b.) The examiner is asked to specifically address the Veteran's April 2017 substantive appeal and February 2021 hearing testimony and his contention that a difference in gait or leg length caused by the left knee disability resulted in any current bilateral hip condition. The examiner is also asked to address the July 2013 examiner's findings and to reconcile any differences with the conclusions therein. (c.) A complete and fully explanatory rationale should be provided for any opinion. If any opinion cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, by a deficiency in the record, or because the examiner does not have the needed knowledge or training. 7. Schedule the Veteran for a VA examination with an appropriate medical professional to determine the etiology of his hypertension. The claims folder should be provided to and reviewed by the examiner. (a.) After a review of the examination findings and the entire evidence of record, the examiner is asked to render an opinion as to whether the Veteran's hypertension at least as likely as not (probability of 50 percent or greater) is proximately caused or aggravated (i.e., worsened beyond natural progression) by his service-connected left knee disability. If aggravation is found, the examiner should quantify the degree of such aggravation, if possible. (b.) The examiner is asked to specifically address the Veteran's April 2017 substantive appeal and February 2021 hearing testimony and his contention that increased pain from the left knee disability resulted in elevated blood pressure. The examiner is also asked to address the February 2021 private clinician's letter and to reconcile any differences with the conclusions therein. (c.) A complete and fully explanatory rationale should be provided for any opinion. If any opinion cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, by a deficiency in the record, or because the examiner does not have the needed knowledge or training. 8. Schedule the Veteran for a VA examination with an appropriate medical professional to determine the etiology of his herniated disc neck condition. The claims folder should be provided to and reviewed by the examiner. (a.) After a review of the examination findings and the entire evidence of record, the examiner is asked to render an opinion as to whether the Veteran's herniated disc neck condition at least as likely as not (probability of 50 percent or greater) is the result of his active service, specifically to include the May 1985 falling incident. (b.) The examiner is asked to specifically address the Veteran's January 2014 statement, April 2017 substantive appeal, and February 2021 hearing testimony and his contention that a fall during a training exercise injured his neck. The examiner is also asked to consider the February 2021 buddy statement. (c.) A complete and fully explanatory rationale should be provided for any opinion. If any opinion cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, by a deficiency in the record, or because the examiner does not have the needed knowledge or training. 9. Schedule the Veteran for a VA examination with an appropriate medical professional to determine the etiology of any nerve damage condition. The claims folder should be provided to and reviewed by the examiner. (a.) After a review of the examination findings and the entire evidence of record, the examiner is asked to render an opinion as to whether the Veteran's nerve damage at least as likely as not (probability of 50 percent or greater) is proximately caused or aggravated (i.e., worsened beyond natural progression) by his service-connected left knee disability and/or his back condition or herniated disc neck condition. If aggravation is found, the examiner should quantify the degree of such aggravation, if possible. (b.) The examiner is asked to specifically address the Veteran's January 2014 statement, April 2017 substantive appeal, and February 2021 hearing testimony and the November 2009 and September 2013 statements from his private treating clinicians. (c.) A complete and fully explanatory rationale should be provided for any opinion. If any opinion cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, by a deficiency in the record, or because the examiner does not have the needed knowledge or training. 10. Schedule the Veteran for a VA examination with an appropriate medical professional to determine the etiology of his BCC/SCC. The claims folder should be provided to and reviewed by the examiner. (a.) After a review of the examination findings and the entire evidence of record, the examiner is asked to render an opinion as to whether the Veteran's BCC/SCC at least as likely as not (probability of 50 percent or greater) is the result of his active service, specifically to include the documented May 1985 sunburn. (b.) The examiner is asked to specifically address the Veteran's January 2014 statement, April 2017 substantive appeal, and February 2021 hearing testimony and his contention that a sunburn occurred during basic training due to wearing hats that did not cover his ears and being out in the sun for prolonged periods without sunscreen. (c.) A complete and fully explanatory rationale should be provided for any opinion. If any opinion cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, by a deficiency in the record, or because the examiner does not have the needed knowledge or training. 11. After the above development and any additionally indicated development has been completed, readjudicate the issue on appeal. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Rachel E. Jensen, 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.