Citation Nr: 22011607 Decision Date: 03/01/22 Archive Date: 03/01/22 DOCKET NO. 18-03 197 DATE: March 1, 2022 ORDER A rating in excess of 10 percent for a right knee disorder is denied. A separate 20 percent rating for right knee status post meniscectomy with episodes of popping, swelling and pain is granted, subject to the rules and regulations governing the award of monetary benefits. Service connection for sleep apnea is denied. REMANDED Entitlement to service connection for a left shoulder disorder is remanded. Entitlement to service connection for a fibromyalgia condition, to include a condition of the cervical spine, bilateral elbow, and mid-back, is remanded. Entitlement to service connection for a right ankle disorder, to include right calcaneal spur, is remanded. Entitlement to service connection for a left ankle disorder, to include left calcaneal spur, is remanded. FINDINGS OF FACT 1. The Veteran's right knee disorder has been manifested by no more than pain with limitation of flexion to 100 degrees, limitation of extension to 0 degrees, and status post meniscectomy with episodes of popping, swelling, and pain. 2. The preponderance of the evidence is against a finding that the Veteran's sleep apnea had its onset in or is related to his active duty service or is proximately due to or aggravated by his service-connected posttraumatic stress disorder (PTSD). CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for a right knee disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5260. 2. The criteria for a separate 20 percent rating, but no higher, for right knee status post meniscotomy with episodes of popping, swelling and pain have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, DC 5258. 3. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1980 to January 1988. In August 2019, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. In December 2019, the Board remanded the current claims for additional development. Included in the December 2019 decision was the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), which the Board also remanded as inextricably intertwined with the other issues remanded therein. While that appeal was pending, the Regional Office (RO) issued an August 2020 rating decision that granted entitlement to TDIU for the period from January 4, 2019, and continued an appeal for the denial of TDIU prior to January 4, 2019. The RO indicated in the August 2020 rating decision that the effective date of January 4, 2019, had been assigned based upon the date the Veteran's employment ended on January 3, 2019. Thereafter, the Veteran withdrew the appeal as to entitlement to a TDIU for the period prior to January 4, 2019. The Board withdrew that appeal in a December 23, 2021 decision. Accordingly, that issue is no longer on appeal. Regarding the claims for service connection for right and left ankle disorders, the Board notes that is how the claim was originally filed. However, during the June 2020 VA examination, the VA examiner did not provide any diagnoses for the left and/or right ankle disorders and instead found evidence of bilateral calcaneal spurs. Thus, while the Veteran did not file a claim for service connection for calcaneal spurs, pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Board has expanded the claim to include any residuals he might be experiencing. 1. Entitlement to an increased disability rating for the right knee disorder. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. It is important that when evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements must be considered. See 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). Consideration must also be given to weakened movement, excess fatigability and incoordination. 38 C.F.R. § 4.45. It is the intent of the schedule to recognize painful motion with joint or periarticular pathology as productive of disability. It is also the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. In spite of these regulatory changes, the criteria for evaluating the knee under DCs 5260/5261 (for limitation of flexion/extension) or 5258 (for cartilage, semilunar problems) have not been changed. Under DC 5260 for limitation of flexion, knee flexion limited to 60 degrees is noncompensable, flexion to 45 degrees warrants a 10 percent rating, flexion to 30 degrees warrants a 20 percent evaluation, and flexion to 15 degrees warrants a 30 percent evaluation. 38 C.F.R. § 4.71a. Under DC 5261 for limitation of extension, a noncompensable evaluation is assigned for extension limited to 5 degrees, 10 percent for extension limited to 10 degrees, 20 percent for extension limited to 15 degrees, 30 percent for extension limited to 20 degrees, 40 percent for extension limited to 30 degrees, and 50 percent for extension limited to 45 degrees. For rating purposes, normal range of motion of the knee is from 0 to 140 degrees. See 38 C.F.R. § 4.71a, Plate II. Under DC 5258, a 20 percent rating is warranted for episodes of "locking," pain, and effusion into the joint. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit-of-the doubt in resolving each such issue shall be given to the veteran. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. In September 2015, the Veteran underwent a VA examination to evaluate his right knee disorder. The Veteran reported symptoms of knee popping, shooting pain across the kneecap, buckling, swelling, and constant pain. The examiner diagnosed degenerative joint disease of the right knee and documented no range of motion loss. The examiner also indicated that there was pain noted on examination, but it did not result in functional loss. The examiner documented tenderness of the right knee, pain with weight bearing, and crepitus. The examiner indicated the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repeated use over time or with flareups. The examiner also indicated she was unable to say without mere speculation as to whether pain, weakness, or incoordination significantly limited functional ability with repeated use over a period of time or with flareups. The examiner noted there was no impact on the Veteran's ability to perform occupational tasks. In August 2019, at a hearing before the Board, the Veteran testified that his right knee disorder caused shooting/stabbing pain, numbness, instability/give way, and swelling and he occasionally wore a knee brace. In June 2020, the Veteran most recently underwent a VA examination to evaluate his right knee disorder. The Veteran reported symptoms of buckling, swelling, and flareups consisting of stabbing/radiating pain. The Veteran also reported functional loss consisting of being able to walk a block, stand 10 minutes, and inability to run, climb stairs, or kneel. The examiner documented range of motion as follows: flexion at 100 degrees and extension at 0 degrees. Pain was noted on flexion but did not result in or cause functional loss. There was pain with active range of motion, but no pain with weight bearing and nonweight bearing. Passive range of motion was not performed because it was determined to be dangerous. There was tenderness to palpation of the medial knee. There was no additional range of motion loss on repetitive use testing. The Veteran was being examined immediately after repetitive use over time and pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time. The examiner indicated the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flareups. The examiner also noted that based on examination of the Veteran, review of the available records/history, and clinical experience there was no basis to offer any additional range of motion loss with repetitive use or during flareups. There was no joint instability and no meniscal condition, except for a meniscectomy that occurred in 1986. The Veteran utilized a brace for his knee and a walker for his lumbar spine. The Veteran's contemporaneous VA treatment records reflect chronic right knee pain and utilization of a right knee brace. Based on the foregoing, the Board finds that the criteria have not been met for an increased rating for the right knee disorder pursuant to DCs 5260/5261 (for limitation of flexion/extension). The evidence does not show limitation of flexion to 30 degrees or less or limitation of extension to 15 degrees or more (i.e., the criteria for a higher 20 percent rating). Accordingly, a rating in excess of 10 percent for a right knee disorder is not warranted. However, the Board finds that the evidence is at least in equipoise as to whether a separate 20 percent rating is warranted under DC 5258. As noted above, a rating under DC 5258 provides for a 20 percent rating for episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. While the VA examiners of record have not found a meniscal condition, the evidence of record shows that the Veteran's right knee is status post meniscectomy and there is evidence of pain, popping, and effusion. Accordingly, the criteria for a separate initial 20 percent rating under DC 5258 are met. See Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that that ratings under DC 5257, 5260, and 5261 do not necessarily preclude ratings under DCs 5258 and 5259). A 20 percent rating is the highest rating available under DC 5258. Therefore, a higher rating may not be assigned. The Board has also considered whether separate ratings are available under DCs 5256 for ankylosis; 5259 for symptomatic removal of the semilunar knee cartilage; and 5262 for impairment of the tibia and fibula; and 5263 for genu recurvatum. However, these DCs do not apply, as the record does not show that these symptoms and/or diagnoses for these conditions were present. The Board acknowledges the Veteran's reports of knee instability and give way. See May 2017 Correspondence and August 2019 Board Hearing Transcript. The Board also notes that the Veteran utilizes a knee brace. Significantly, however, the VA examinations of record did not demonstrate patellar subluxation/instability, lateral instability, or a complete or incomplete ligament tear to meet the established criteria for a separate compensable rating under DC 5257. See 38 C.F.R. § 4.71a. The Board acknowledges that VA examinations must 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. 38 C.F.R. § 4.59; Correia v. McDonald, 28 Vet. App. 158 (2016). The Board has further considered the United States Court of Appeals for Veterans Claims (Court's) holding in Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), addressing 38 C.F.R. § 4.40, which states that a VA examiner must "express an opinion on whether pain could significantly limit functional ability" and the examiner's determination in such regard "should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups." The Board has carefully considered the VA examinations of record and whether they complied with Correia and Sharp, and the Board finds that the most recent June 2020 VA examination complied with these requirements. The Board also notes that, to the extent that the previous examination findings of record relative to the right knee are not completely in compliance with Correia and/or Sharp, the Board finds that remand for additional examination/opinion would serve no useful purpose. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). This is because any retrospective opinion would merely impose an additional burden on VA with no benefit flowing to the Veteran, as VA would be asking an examiner to speculate as to the pre-June 2020 ranges of motion. 2. Entitlement to service connection for sleep apnea. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). There are three requirements to establish service connection: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Although all of the evidence must be reviewed, only the most salient evidence must be discussed. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Persuasive or unpersuasive evidence must be identified, however, and reasons must be provided for rejecting favorable evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994), Wilson v. Derwinski, 2 Vet. App. 614 (1992); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Both medical and lay or non-medical evidence may be discounted in light of its inherent characteristics and relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). When there is an approximate balance of positive and negative evidence, the claimant must be afforded the benefit of the doubt. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The record establishes that the Veteran has a diagnosis of sleep apnea. Such evidence is sufficient to meet element (1) for establishing service connection on a direct and secondary basis. However, service treatment records do not document complaints, findings or treatment for sleep apnea. Moreover, postservice treatment records only show diagnosis and treatment for sleep apnea as early as August 2006 and do not include any opinions concerning the etiologic relationship of that disability to the Veteran's service. Neither the Veteran nor his representative has offered any specific contentions as to how they believe the Veteran's sleep apnea is directly related to his active duty service. Thus, while there is competent medical evidence of a current disability, there is no indication in the record that the Veteran's sleep apnea had its onset in or was caused/aggravated by service. Consequently, a VA examination regarding direct service connection is neither necessary nor warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Accordingly, the weight of the evidence against finding that a medical nexus exists between the Veteran's OSA and his military service and entitlement to service connection for sleep apnea on a direct basis is denied. The Board notes, however, that it is the Veteran's primary contention that his sleep apnea is related to his service-connected PTSD. The question of whether his sleep apnea is etiologically related to his PTSD was initially addressed in July 2017 VA medical opinion. The VA examiner reviewed the claims file and opined that the Veteran's sleep apnea was less likely than not caused by or proximately due to his PTSD. The examiner explained that while PTSD was a well-known etiological cause for insomnia, it was not an established cause of sleep apnea, per medical literature. In December 2019, the Board found that while the July 2017 VA examiner had provided an opinion as to whether the Veteran's sleep apnea was caused by his PTSD, the examiner did not address whether his PTSD had aggravated his sleep apnea and remanded the claim for another VA medical opinion. In compliance with the Board's December 2019 remand directives, a February 2020 VA medical opinion was obtained. The examiner indicated that the current level of severity for the Veteran's sleep apnea was not greater that the baseline level of severity. In June 2020, another VA medical opinion was obtained to provide further clarification as to whether the Veteran's PTSD had aggravated his sleep apnea. The examiner indicated that despite the Veteran's diagnosis of PTSD in 2015/2016 there was no evidence of worsening sleep apnea and no noted changes in the Veteran's CPAP since the diagnosis of PTSD. It was noted that the Veteran continued to have moderate to severe sleep apnea with CPAP 9 to 15 cm H2O. Accordingly, the examiner opined the current level of severity for the Veteran's sleep apnea was not greater than the baseline level of severity and there was no aggravation beyond the natural progression. The Board assigns the above medical opinions significant probative value, as the VA examiners based their opinion on their knowledge and skill as medical providers and a thorough review of the Veteran's claims file. There is no competent evidence to the contrary. The Board acknowledges the Veteran's general contention that his sleep apnea is related to his service-connected PTSD. However, he is not competent to provide such a nexus opinion, as such issue is medically complex and requires knowledge of the interaction between multiple organ systems in the body. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the July 2017 and June 2020 VA examiners' negative nexus opinions. The Board also acknowledges the articles cited to by the Veteran that suggest an association between PTSD and OSA. See October 2019 Correspondence. These articles indicate that Veterans with PTSD are at higher risk for obstructive sleep apnea. These articles also indicate that PTSD and sleep apnea are shared by many patients because they both affect sleep and the quality of life of the affected subjects. The Board notes, however, that this evidence merely suggests that sleep apnea is associated with a higher prevalence of psychiatric comorbid conditions, not that the Veteran's psychiatric problems have a causal effect on sleep apnea. As indicated by the July 2017 VA examiner, both PTSD and sleep apnea affect the Veteran's ability to sleep. However, the evidence in this case does not establish that the Veteran's sleep apnea is otherwise etiologically linked to PTSD or worsened by it. Based on the foregoing, the Board concludes that the evidence weighs persuasively against the Veteran's secondary service connection claim for sleep apnea. As outlined, the record does not support a causal nexus between the Veteran's sleep apnea and his service-connected PTSD. The July 2017 and June 2020 VA examiners adequately found that the Veteran's sleep apnea was not related to or aggravated by his service-connected PTSD. There is no competent contrary evidence, to include any medical opinions, of record. As such, entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD, is denied. REASONS FOR REMAND 1. Entitlement to service connection for a left shoulder disorder is remanded. In December 2019, the Board remanded this claim for a VA examination to assess the etiology of the Veteran's left shoulder disorder. This resulted in a June 2020 VA examination and medical opinion where the examiner rendered a negative nexus opinion. The examiner explained that, while the Veteran reported injuring his left shoulder in a motor vehicle accident (MVA) in 1987, the November 1987 service separation examination was negative, and the current findings were consistent with natural aging and not related to a MVA in service. Since the June 2020 VA examination was performed, however, the Veteran submitted relevant evidence from February 1990, only a few years after his separation from service, indicating that he had limited range of motion of the left shoulder with previous ligament damage. As this evidence was available to the June 2020 VA examiner, the Board finds that the current evidence is insufficient to adequately adjudicate the Veteran's claim. Accordingly, remand is warranted for a new VA medical opinion consistent with the directives herein. 2. Entitlement to service connection for a fibromyalgia condition to include a condition of the cervical spine, bilateral elbow, and mid-back is remanded. In December 2019, the Board remanded this claim for a VA examination to assess the etiology of the Veteran's claim of fibromyalgia. The Board specifically instructed that the examiner should opine as to whether any current fibromyalgia condition or other condition that was manifested by chronic pain of the cervical spine, bilateral elbows, and/or mid-back pain at least as likely as not (i.e., a 50 percent or greater degree of probability) had its onset in service or was otherwise related to service. In June 2020, the RO procured a VA medical opinion from an appropriate VA examiner. The examiner rendered a negative nexus opinion and indicated there was no specific diagnosis for fibromyalgia, but there were positive findings consistent with a known history of degenerative joint disease of the neck, low back, and left shoulder. The examiner, however, did not indicate whether the Veteran's diagnoses for the cervical spine and/or low back were otherwise related to service as requested by the Board. As a result, the Board finds there has not been substantial compliance with the previous remand. Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, remand is warranted for a new VA medical opinion consistent with the directives herein. 3. Entitlement to service connection for bilateral ankle disorders, to include bilateral calcaneal spurs are remanded. In June 2020, the RO also procured a VA medical opinion to address the etiology of the Veteran's ankle disorders. The VA examiner rendered a negative nexus opinion and explained that current radiographs show bilateral calcaneal spurs, and such condition was a primary disease process and was not caused or aggravated beyond its natural progression by the right knee condition. This rationale, however, is deficient because the examiner did not provide an explanation as to why a primary disease process, such as calcaneal spurs, could not be caused or aggravated by the Veteran's right knee disorder. This explanation also does not take into account the July 2017 positive nexus opinion that indicates that a disability of the opposite joint is a common cause of pathology in the contralateral joint. Accordingly, the Board finds the June 2020 VA medical opinion insufficient for adjudication purposes and remand is warranted for a new VA medical opinion consistent with the directives herein. The matters are REMANDED for the following actions: 1. Obtain a VA medical opinion from an appropriate examiner to determine the nature and etiology of the Veteran's left shoulder disorder. The claims folder (including a copy of this remand) must be provided to and reviewed by the examiner. The examiner should opine as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's left shoulder disorder had its onset in or is otherwise related to the Veteran's active duty service. In rendering the above opinion, the examiner must specifically consider and discuss the Veteran's statements that he injured his left shoulder when he was in a MVA in 1987 and the treatment records from February 1990 indicating that the Veteran had limited range of motion of the left shoulder with previous ligament damage. The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 2. Obtain a VA medical opinion from an appropriate examiner to determine the nature and etiology of the Veteran's claim for a fibromyalgia condition to include a condition of the cervical spine, bilateral elbow, and mid-back. The claims folder (including a copy of this remand) must be provided to and reviewed by the examiner. The examiner should opine as to whether any current fibromyalgia condition or other condition that is manifested by chronic pain of the cervical spine, bilateral elbows, and mid-back pain at least as likely as not (i.e., a 50 percent or greater degree of probability) had an onset in service, or is otherwise related to service, to include the MVA in 1987. The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 3. Obtain a VA medical opinion from an appropriate examiner to determine the nature and etiology of the Veteran's bilateral ankle disorders (to include calcaneal spurs). The claims folder (including a copy of this remand) must be provided to and reviewed by the examiner. The examiner should opine as to whether any current left and/or right ankle disability (to include calcaneal spurs) is at least as likely as not (i.e., a 50 percent or greater degree of probability) related to, caused by, or aggravated by the service-connected right knee disability. In rendering this opinion, the examiner should note the significance, if any, of the positive opinion provided by the VA examiner in July 2017. The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. A. ISHIZAWAR Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Metzner, Paul 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.