Citation Nr: 23045488 Decision Date: 08/16/23 Archive Date: 08/16/23 DOCKET NO. 19-19 288 DATE: August 16, 2023 ORDER An initial rating in excess of 10 percent for status post bunionectomy and strain of the left foot is denied. An initial rating in excess of 10 percent for status post bunionectomy and strain of the right foot is denied. A separate rating of 10 percent, but no higher, for degenerative joint disease (DJD) of the bilateral first metatarsal phalanges (MTP) joints is granted, subject to the laws and regulations governing the payment of monetary awards. The assignment of a separate rating for left lower extremity neuropathy, evaluated as 10 percent disabling as of January 12, 2023, is proper; the appeal is denied. The assignment of a separate rating for right lower extremity neuropathy, evaluated as 10 percent disabling as of January 12, 2023, is proper; the appeal is denied. FINDINGS OF FACT 1. For the entire appeal period, the Veteran's status post bunionectomy and strain of the bilateral feet have been assigned the maximum schedular rating for such disabilities. 2. For the entire appeal period, the Veteran's DJD of the bilateral first MTP joints has been determined to be a progression of her status post bunionectomy and strain of the bilateral feet, which is manifested by painful motion resulting in functional impairment. 3. As of January 12, 2023, but no earlier, the Veteran's bilateral foot disabilities are manifested by bilateral lower extremity neuropathy resulting in no more than mild incomplete paralysis of the external popliteal (common peroneal) nerves. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for status post bunionectomy and strain of the left foot have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5280. 2. The criteria for an initial rating in excess of 10 percent for status post bunionectomy and strain of the right foot have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5280. 3. The criteria for a separate rating of 10 percent, but no higher, for DJD of the bilateral first MTP joints have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003. 4. The assignment of a separate rating for left lower extremity neuropathy, evaluated as 10 percent disabling as of January 12, 2023, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.120, 4.124a, Diagnostic Code 8521. 5. The assignment of a separate rating for right lower extremity neuropathy, evaluated as 10 percent disabling as of January 12, 2023, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.120, 4.124a, Diagnostic Code 8521. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1980 to March 1991 and February 1999 to April 2011. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in May 2012 by a Department of Veterans Affairs (VA) Regional Office. In April 2022, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In August 2022, the Board remanded the Veteran's claims for higher initial ratings for bilateral foot, status post bunionectomy and strain, with DJD of the bilateral first MTP joints for additional development. While on remand, a March 2023 rating decision assigned separate 10 percent ratings for bilateral lower extremity neuropathy associated with such disabilities as of January 12, 2023. While the Veteran did not appeal with respect to the propriety of the assigned ratings or effective dates for such disabilities, these issues are part and parcel of her claim for higher initial ratings for her bilateral foot disabilities. Therefore, the Board has assumed jurisdiction over such issues and they will be addressed herein. Initial Rating Claims Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history, and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). 1. Entitlement to an initial rating in excess of 10 percent for left foot, status post bunionectomy and strain, with DJD of the left first MTP joint. 2. Entitlement to an initial rating in excess of 10 percent for right foot, status post bunionectomy and strain, with DJD of the right first MTP joint. The basis of disability evaluation 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. 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. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the United States Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). For the entire appeal period stemming from May 1, 2011, the date of service connection, the Veteran is in receipt of 10 percent ratings for her bilateral foot, status post bunionectomy and strain, with DJD of the bilateral first MTP joints, which is the maximum rating under Diagnostic Code 5280. The Board notes that, 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). However, such amendments did not affect the Diagnostic Codes at issue in the instant case. Diagnostic Code 5280 provides a maximum 10 percent rating for operated unilateral hallux valgus with resection of metatarsal head and severe unilateral hallux valgus equivalent to amputation of the great toe. Thus, as the Veteran is in receipt of the maximum schedular rating for her bilateral foot disabilities under Diagnostic 5280, the Board has considered whether higher or separate ratings are warranted under any other potentially applicable diagnostic code. In this regard, the October 2012 VA examiner determined the Veteran's diagnoses of DJD of the bilateral first MTP joints (based on X-ray) were progressions of her service-connected bunionectomies. Diagnostic Code 5003 provides that arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. The Board notes that there are no diagnostic codes specific to range of motion of the toes. In this regard, Diagnostic Code 5003 provides that when limitation of motion due to arthritis is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. In the absence of limitation of motion, Diagnostic Code 5003 provides for a 10 percent rating with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating under Diagnostic Code 5003 requires involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. For the purpose of rating disability from arthritis, multiple involvement of the interphalangeal, metatarsal, and tarsal bones of the lower extremities are considered a group of minor joints. 38 C.F.R. § 4.45. In the instant case, on VA examination in September 2011, the Veteran reported pain on standing and walking; she was able to stand for only 15-30 minutes; and she required the use of shoe inserts that were mildly effective. At the October 2012 VA examination, the Veteran indicated that she experienced constant bilateral great toe pain; she could walk a distance of 1/4 mile and then required a rest break; she used foot cushion inserts in her shoes; she avoided running and could stand stationary for approximately 10 minutes before she had to shift her weight; she was unable to exercise; she avoided stairs; and she had increased pain with activities that required squatting. At the April 2022 Board hearing, she testified that she had to walk on the side or middle of her feet, and experienced pain that required her to buy special shoes and inserts. On VA examination in January 2023, the Veteran reported pain while standing for long periods of time. Additionally, it was noted that her bilateral foot disabilities chronically compromised weight-bearing. Thus, based on the foregoing, the Board finds that a separate rating of 10 percent, but no higher, for DJD of the bilateral first MTP joints associated with the Veteran's status post bunionectomy and strain of the bilateral feet is warranted. In this regard, painful motion of a joint due to arthritis equates to limited motion under Diagnostic Code 5003 and is entitled to at least a compensable rating. See Lichtenfels, 1 Vet. App. at 488; 38 C.F.R. § 4.45(f); 38 C.F.R. § 4.59; Burton, supra; Southall-Normal, supra. Furthermore, the aforementioned symptomatology and resulting functional impairment are not fully contemplated in the currently assigned 10 percent ratings under Diagnostic Code 5280, which only contemplates operated unilateral hallux valgus with resection of metatarsal head and/or severe unilateral hallux valgus equivalent to amputation of the great toe. See 38 C.F.R. § 4.14; Esteban, supra. In this regard, the Board notes that, by the express provisions of Diagnostic Code 5003, separate 10 percent ratings may not be assigned for each of the Veteran's great toes as Diagnostic Code 5003 only allows for a single 10 percent rating for each group of minor joints affected. See Spicer v. Shinseki, 752 F.3d 1367, 1371 (Fed. Cir. 2014) (when Diagnostic Code 5003 is read in view of § 4.45(f), it is clear that Diagnostic Code 5003 requires limitation of motion in two or more interphalangeal joints to warrant a 10 percent rating). Thus, as the evidence only shows arthritic involvement of her left and right first MTP joints, only one minor joint group is affected and, therefore, only one 10 percent rating may be assigned. Further, a 20 percent rating is not warranted under Diagnostic Code 5003 for X-ray findings of arthritis as the Veteran's bilateral foot disabilities do not involve two or more minor joint groups with occasional incapacitating exacerbations. Additionally, other diagnostic codes for foot disabilities are not applicable because the evidence does not demonstrate the presence of such foot disabilities associated with the Veteran's service-connected bilateral foot disabilities. See 38 C.F.R. § 4.71a, Diagnostic Code 5277 (weak foot), Diagnostic Code 5278 (claw foot), Diagnostic Code 5279 (anterior metatarsalgia), Diagnostic Code 5282 (hammer toe), Diagnostic Code 5283 (malunion or nonunion of the tarsal and metatarsal bones). Here, while the October 2012 and January 2023 VA examination reports reflect a diagnosis of pes planus, an April 2023 VA examiner determined that such was not caused or aggravated by the Veteran's service-connected bilateral foot disabilities as pes planus was a separate condition and the two were not interrelated; rather, her pes planus was directly related to her military service as such was noted in her enlistment examination. Further, the Board observes that the Veteran is already in receipt of separate ratings for bilateral pes planus and neuropathy of the bilateral lower extremities, the latter of which was found to be a progression of her service-connected bunionectomies and assigned during the pendency of the appeal and, thus, will be addressed further herein. Moreover, as pertinent to Diagnostic Code 5284, which pertains to other foot injuries, the Court held that when a condition is specifically listed in the rating schedule, it may not be rated by analogy. Copeland v. McDonald, 27 Vet. App. 333, 338 (2015); see also Suttmann v. Brown, 5 Vet. App. 127, 134 (1993) (providing that "[a]n analogous rating... may be assigned only where the service-connected condition is 'unlisted.'"). In Copeland, the Court explicitly rejected the appellant's argument that to rate his disability under Diagnostic Code 5284 for "foot injuries, other," would not be rating by analogy. Rather, the Court held that to do so would ignore the plain meaning of the term "other," and would make the remaining foot-related Diagnostic Codes redundant. Given that the Veteran's bilateral foot disabilities, diagnosed as status post bunionectomy and strain, and DJD of the bilateral first MTP joints, are specifically listed in the rating schedule under Diagnostic Codes 5280 and 5003, respectively, Diagnostic Code 5284 is inapplicable and higher or separate ratings are not warranted under such criteria. 3. Propriety of the assignment of a separate rating for left lower extremity neuropathy, evaluated as 10 percent disabling as of January 12, 2023. 4. Propriety of the assignment of a separate rating for right lower extremity neuropathy, evaluated as 10 percent disabling as of January 12, 2023. Since January 12, 2023, the Veteran has been in receipt of separate 10 percent ratings for neuropathy of the bilateral lower extremities affecting the external popliteal (common peroneal) nerves associated with her bilateral foot disabilities pursuant to Diagnostic Code 8521. In is regard, in peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, a disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. Regulations specifically state that when the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Diagnostic Code 8521 pertains to the external popliteal (common peroneal) nerve and provides that mild incomplete paralysis is rated as 10 percent disabling, moderate incomplete paralysis is rated 20 percent disabling, and severe incomplete paralysis is rated 30 percent disabling. Complete paralysis, described as foot drop and slight droop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes, is rated 40 percent disabling. The words "mild," "moderate," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Additionally, "VA's Adjudication Procedures Manual [M21-1] provides benchmarks for mild, moderate, moderately severe, and severe peripheral nerve conditions," and "[a]lthough the Board is not bound by the M21-1, the standards provided in the M21-1 are 'relevant guidance promulgated for the purpose of facilitating the efficient and proper resolution of claims,' which the Board must consider and address as part of its duty to provide a reasoned explanation for its decision." Chavis v. McDonough, 34 Vet. App. 4, 17-18 (2021) (citing Healey v. McDonough, 33 Vet. App. 321 (2021) and Overton v. Wilkie, 30 Vet. App. 257, 264 (2018)). In this regard, the M21-1 provides that, in cases where a peripheral nerve disability is only manifested by sensory impairment, 38 C.F.R. § 4.124a directs decision makers to assign the evaluation corresponding with the mild or at most the moderate degree of impairment. M21-1, V.iii.12.A.2.b. Such further provides that, to make a choice between mild and moderate, the adjudicator should consider the evidence of record and the following guidelines: " The mild level of evaluation would be more reasonably assigned when sensory symptoms are " recurrent but not continuous " assigned a lower medical grade reflecting less impairment " and/or affecting a smaller area in the nerve distribution. " Reserve the moderate level of evaluation for the most significant and disabling cases of sensory-only involvement. These are cases where the sensory symptoms are " continuous " assigned a higher medical grade reflecting greater impairment, and/or " affecting a larger area in the nerve distribution. The M21-2 also provides general guidelines for each level of incomplete paralysis of the upper and lower peripheral nerves. M21-1, V.iii.12.A.2.c. A "mild" degree of incomplete paralysis is characterized by disability limited to sensory deficits that are lower graded, less persistent, or affecting a small area. A very minimal reflex or motor abnormality potentially could also be consistent with mild incomplete paralysis. "Moderate" is the maximum evaluation available for the most significant cases of sensory-only impairment and is characterized by symptoms described by the claimant and medically graded as significantly disabling and involving a larger area in the nerve distribution. Other sign or symptom combinations that may fall into the moderate category include combinations of significant sensory changes and reflex or motor changes of a lower degree, or motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes (with or without sensory impairment) graded as medically moderate. "Moderately severe" contemplates motor and/or reflex impairment (for example, weakness or diminished or hyperactive reflexes) at a grade reflecting a high level of limitation or disability. Additionally, atrophy may be present; however, for marked muscular atrophy, a rating contemplating severe incomplete paralysis is warranted. "Severe" is characterized by motor and/or reflex impairment (for example, atrophy, weakness, or diminished or hyperactive reflexes) at a grade reflecting a very high level of limitation or disability. Trophic changes may be seen in severe long-standing neuropathy cases. For the sciatic nerve, marked muscular atrophy is expected. Although severe incomplete paralysis cases should show findings substantially less than those for complete impairment of the nerve, the disability picture for severe incomplete paralysis may contain signs or symptoms that resemble some of those expected in cases of complete paralysis of the nerve. Turning to the evidence of record, at a September 2011 VA general medical examination, the examiner indicated that the Veteran had a grossly normal assessment of deep tendon reflexes; normal muscle strength, fine motor control, and muscle tone in her lower extremities; a hypoactive achilles reflex bilaterally; and a normal sensory examination was. Here, the presence of nerve impairment was not noted. Such was also not noted at the October 2012 VA foot examination. However, at the January 12, 2023, VA foot examination, the Veteran reported that she experienced pain in her left foot with numbness starting at her left big toe and extending up the foot. Here, the examiner indicated that her lower extremity peripheral neuropathy was a result of her service-connected bunionectomies. At a corresponding VA peripheral nerves examination, the Veteran reported nerve pain that developed after her bunionectomies. She noted that her surgical site will go numb, she experienced nerve pain which stemmed from her inferior heel and up the calf bilaterally, and such pain continued to get worse over time. The Veteran endorsed mild paresthesias and/or dysesthesias and numbness in her bilateral lower extremities, but denied constant and intermittent pain. Upon physical examination, she had normal muscle strength, normal deep tendon reflexes, and normal sensation. Based on the foregoing, the examiner determined that the Veteran had peripheral neuropathy of the bilateral lower extremities that resulted in mild incomplete paralysis of the external popliteal (common peroneal) nerves. Based on the foregoing, the Board finds that the assignment of separate ratings for neuropathy of the left and right lower extremities, each evaluated as 10 percent disabling as of January 12, 2023, is proper. In this regard, as such nerve impairment was not shown until January 12, 2023, earlier effective dates for such separate ratings are not warranted. Further, as of such date, the Veteran's neuropathy of the bilateral lower extremities was manifested by subjective symptoms of mild paresthesias and/or dysesthesias and numbness without any objective findings. Specifically, muscle strength was normal at 5/5 bilaterally, reflexes were normal at +2 bilaterally, and sensation was normal bilaterally. Accordingly, there is no indication that, as of January 12, 2023, the symptomatology attributable to the Veteran's neuropathy of the bilateral lower extremities exceeded what the Board herein defines as mild as guided by the M21-1. Moreover, in consideration of such subjective symptoms and objective findings, the January 2023 VA examiner found that the Veteran's neuropathy of the bilateral lower extremities resulted in, at most, mild incomplete paralysis of the external popliteal (common peroneal) nerves. Thus, ratings in excess of 10 percent for such disabilities as of January 12, 2023, is not warranted under Diagnostic Code 8521. Other Considerations In reaching its conclusions in the instant case, the Board acknowledges the Veteran's belief that her bilateral foot disabilities are more severe than as reflected by the current assigned disability ratings. In this regard, the Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to describe her symptomatology, she is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (the claimant is not competent to provide evidence as to more complex medical questions). Ultimately, the Board finds the medical evidence in which professionals with specialized expertise examined the Veteran, acknowledged her reported symptoms, and described the manifestations of such disabilities in light of the rating criteria to be more persuasive than her own reports regarding the severity of her disabilities. The Board has also considered whether additional staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected bilateral foot disabilities; however, the Board finds that her symptomatology has been stable throughout the periods on appeal. Therefore, assigning additional staged ratings is not warranted. Furthermore, neither the Veteran nor her representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the initial rating claims adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching the foregoing determinations, the Board has resolved all doubt in the Veteran's favor, which has resulted in the award of a separate rating for DJD of the bilateral first MTP joints associated with her bilateral foot disabilities. However, insofar as the Board has denied higher or separate ratings, the weight of the probative evidence is against such aspects of the Veteran's claims. Therefore, the benefit of the doubt doctrine is not applicable in such regard and her initial rating claims must otherwise be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Koria B. Stanton, 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.