Citation Nr: 25003469 Decision Date: 03/12/25 Archive Date: 03/12/25 DOCKET NO. 17-56 121A DATE: March 12, 2025 ORDER Entitlement to a separate 30 percent rating, but no higher, is granted for endometriosis from December 12, 2013 under Diagnostic Code (DC) 7269. Entitlement to a rating higher than 30 percent under DC 7615 for bilateral ovarian cysts, ovarian cyst removal, and adhesions is denied. FINDINGS OF FACT 1. From December 12, 2013, the Veteran's endometriosis resulted in chronic pelvic pain that was not controlled by treatment, was unrelated to the menstrual cycle, and was not caused by ovary disease, injury, or adhesions. 2. The Veteran does not have lesions involving the bowel or bladder confirmed by laparoscopy. CONCLUSIONS OF LAW 1. The criteria for a separate 30 percent rating for endometriosis are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.14, 4.116, DC 7629. 2. The criteria for entitlement to an evaluation in excess of 30 percent for bilateral ovarian cysts, ovarian cyst removal, and adhesions from December 12, 2013 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.14, 4.116, DC 7615. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had served honorably on active duty from December 2006 to December 2013. This appeal comes to the Board of Veterans' Appeals (Board) from a rating decision dated February 2014 issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran timely appealed. The appellant testified at an April 2021 video hearing with the undersigned Veterans Law Judge. A transcript of the hearing has been reviewed and associated with the claims file. The Veteran's appeal has previously been before the Board. In June 2021 and August 2022, the Board remanded the Veteran's claim to the Agency of Original Jurisdiction (AOJ) for additional development. In February 2023, the Board denied the issue of entitlement to an evaluation higher than 30 percent for bilateral ovarian cysts, ovarian cyst removal, adhesions, and endometriosis. In compliance with the prior remand directives, VA determined that there were no additional VA treatment records after January 2022 and notified the Veteran in a November 2022 subsequent development letter. That letter also invited the Veteran to provide any details regarding outstanding private treatment records, but she did not respond. The Board finds VA substantially complied with the directive to attempt to obtain outstanding VA and private treatment records. The Veteran appealed the February 2023 denial to the United States Court of Appeals for Veterans Claims (Court). In February 2024, the Court granted a Joint Motion for Remand (JMR) and vacated and remanded the February 2023 Board decision that denied entitlement to an evaluation higher than 30 percent for bilateral ovarian cysts, ovarian cyst removal, adhesions, and endometriosis. In July 2024, the Board remanded the Veteran's claim to the AOJ for additional development consistent with the JMR. The issue has now been returned to the Board for adjudication. Relevant rating criteria The Veteran's bilateral ovarian cysts, ovarian cyst removal, adhesions, and endometriosis are currently rated under 38 C.F.R. § 4.116, DC 7615, for disease, injury, or adhesions of the ovary under the General Rating Formula for Disease, Injury, or Adhesions of Female Reproductive Organs (General Formula). The Veteran seeks a higher rating. The period on appeal begins on December 12, 2013, the date the Veteran was awarded service connection for this disability. The Veteran is already in receipt of the highest evaluation under the General Formula, which applies to Diagnostic Code 7615. See 38 C.F.R. § 4.116. DC 7615 is for disease, injury, or adhesion of the ovary. The General Formula provides a noncompensable rating for symptoms that do not require continuous treatment, a 10 percent rating for symptoms that require continuous treatment, and a 30 percent rating for symptoms not controlled by continuous treatment. The Note to the General Formula provides, "For the purpose of VA disability evaluation, a disease, injury, or adhesions of the ovaries resulting in ovarian dysfunction affecting the menstrual cycle, such as dysmenorrhea and secondary amenorrhea, shall be rated under diagnostic code 7615." Therefore, the Veteran's symptoms caused by disease, injury, or adhesions of the ovaries, and all dysfunction affecting the menstrual cycle caused by disease, injury, or adhesions of the ovaries, are contemplated by her 30 percent rating under DC 7615. The Veteran is also diagnosed with service-connected endometriosis. This diagnosis is rated under DC 7629. 38 C.F.R. § 4.116, DC 7629. Under DC 7629, endometriosis may receive a 10 percent rating for pelvic pain or heavy or irregular bleeding requiring continuous treatment for control; a 30 percent rating for pelvic pain or heavy or irregular bleeding not controlled by treatment; and a 50 percent rating for lesions involving bowel or bladder confirmed by laparoscopy, pelvic pain or heavy or irregular bleeding not controlled by treatment, and bowel or bladder symptoms. Notably, the highest 50 percent evaluation requires all three criteria listed, because the conjunctive "and" is used. See Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007) (use of the conjunctive "and" in a DC means that "all criteria must be must to satisfy" a particular rating). In February 2024, B&M, the firm who represented the Veteran as a Party to the JMR, sent their Rule 33 Summary of Issues (Rule 33 Summary) to the Board, stating VA should consider the legal arguments when it readjudicates the remanded appeal. Notably, B&M is not representing the Veteran before the Board. Further, few of these arguments were agreed to by the Secretary in the JMR. Nonetheless, the Board will address these arguments as contentions raised by the record. In the Rule 33 Summary, B&M asserted that the Board failed to analyze whether the Veteran was entitled to a separate rating for her endometriosis. B&M wrote that even if the Veteran's dysmenorrhea was compensated by her DC 7615 rating, any heavy and abnormal bleeding may still be compensated under DC 7629. Generally, pyramiding, which is the evaluation of the same manifestation under different diagnoses, is to be avoided. 38 C.F.R. § 4.14. However, if a Veteran has separate and distinct manifestations relating to the same injury, she should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). Separate ratings may be assignable under different diagnostic codes where a disability involves distinct conditions. Cullen v. Shinseki, 24 Vet. App. 74, 80-81, 84 (2010). The critical element for separate evaluations is that none of the symptoms for any one of the residuals was duplicative of or overlapping with the symptoms of the other conditions. The pyramiding inquiry does not end with whether two disabilities share a common manifestation. It must also be determined whether that common manifestation would be improperly compensated more than once. Lyles v. Shulkin, 29 Vet. App. 107, 118 (2017). The symptoms of heavy and irregular bleeding constitute dysfunction affecting the menstrual cycle. The Note to the General Formula uses the phrase "such as," making it clear that dysmenorrhea (painful menstrual periods caused by uterine cramps) and secondary amenorrhea (absence of menstruation caused by disease, injury, or adhesions of the ovaries) are just examples of types of menstrual dysfunction. The Board finds that the symptoms of heavy and irregular bleeding constitute dysfunction affecting the menstrual cycle and are, thus, already covered by the General Formula and the Veteran's 30 percent rating under DC 7615. The Board finds that the heavy and irregular would be improperly compensated more than once if it were considered under both DCs 7615 and 7629. The symptom of pelvic pain considered in the 10 and 30 percent ratings under DC 7629 may also be included in the dysmenorrhea considered by DC 7615, to the extent that it is menstrual pain and caused by injury, disease, or adhesions of the ovary. To the extent that the Veteran's pelvic pain is unrelated to the menstrual cycle and not caused by injury, disease, or adhesions of the ovary, it will be discussed later in the Board's analysis. Accordingly, a separate 10 percent or 30 percent rating under DC 7629 would constitute pyramiding for the symptoms of heavy and irregular bleeding, and pelvic menstrual pain. Thus, the Board finds that she cannot receive separate ratings under DC 7629 for these symptoms. Regarding the Veteran's reported bowel symptoms, service connection is already in effect for irritable bowel syndrome (IBS). The Veteran is in receipt of the highest available schedular rating for that disorder under DC 7319, which contemplates symptoms of severe diarrhea, alternating diarrhea and constipation, and abdominal distress. Therefore, the "bowel and bladder symptoms" criterion for a 50 percent rating under DC 7629 cannot be met by any of these bowel symptoms, because that would constitute pyramiding. Based on the foregoing, only 3 paths remain to a separate rating under DC 7629. They require the following criteria to be met: (1) pelvic pain requiring continuous treatment for control, unrelated to the menstrual cycle, and not caused by ovary disease injury, or adhesions (10 percent); (2) pelvic pain not controlled by treatment, unrelated to the menstrual cycle, and not caused by ovary disease injury, or adhesions (30 percent); or (3) lesions involving bowel or bladder confirmed by laparoscopy and pelvic pain not controlled by treatment and bowel or bladder symptoms (excluding IBS, severe diarrhea, alternating diarrhea and constipation, or abdominal distress) (50 percent). Evidence In the September 2014 Notice of Disagreement (NOD), the Veteran wrote that her ovarian cysts caused significant lower abdominal pain that was sharp and dull, intermittent cramping, pain during and after sit-ups, bleeding and inflammation of the cervix, free fluid within the endometrial cavity and cul-de-sac, severe cramping, and other symptoms. She also stated that a pelvic magnetic resonance imaging (MRI) showed ovarian cysts that had increased in size since January 2014. The symptoms and laboratory results caused a final surgical recommendation to remove the cysts. In an August 2017 VA physical therapy (PT) note, the Veteran reported that she had been seen by a private physician and received a diagnosis of adenomyosis. She was undergoing pelvic floor PT. She reported increased abdominal cramps, nausea and bloating during periods but did not know if bloating was related to IBS or menstrual cycle. VA records dated October 2017 document the presence of bladder pain, pain with a full bladder for at least a year, and feelings of urinary pressure in the context of the Veteran's gynecological condition. The assessment was bladder pain likely due to pelvic floor muscle myalgia, and presumed endometriosis versus adenomyosis. Continued pelvic floor PT was advised. In a November 2017 Form 9, the Veteran wrote that medical records showed increasing chronicity and recurring ovarian cysts/cystectomy with painful residuals and scar tissue and continued pain. She wrote that a 30 percent rating would satisfy her appeal because continuous treatment to include two cystectomies, pelvic therapy, and hormones had failed to control the pain caused by the ovarian cysts. A February 2018 VA gynecology note summarized the Veteran's history of bilateral ovarian cysts and pelvic pain. She had undergone two previous surgeries for ovarian cyst removal but the pain continued after the surgeries. The pain was now daily and worse than before. She was experiencing breakthrough heavy bleeding with dysmenorrhea. April 2018 VA treatment records document the Veteran underwent a laparoscopic peritoneal biopsy and hysteroscopy due to chronic pelvic pain "not responsive to medical management." Three surgical biopsies were taken; one of the biopsies showed stage I endometriosis. The surgical report findings included normal appearing bilateral ovaries, uterus, and intrauterine cavity, with no fibroids, polyps, or adhesions. However, the laparoscopy also confirmed the presence of two lesions located in the left posterior and anterior cul-de-sacs. In the April 2021 hearing, the Veteran testified that she had had four surgeries every other year, beginning in 2014 for recurring cysts. The Veteran reported that she experienced persistent, chronic symptoms despite treatment. She described painful periods with heavy bleeding and cramping pains. She stated that she believed her miscarriages were due to her service-connected gynecological condition. She also stated that it affected her ability to become pregnant. In correspondence received in May 2022, the Veteran reported symptoms of pelvic pain, heavy bleeding, irregular bleeding not controlled by treatment, lesions, irritable bowel syndrome, and two miscarriages. Thereafter, in August 2022, the Board remanded the matter for clarification regarding whether the lesions of the anterior and posterior cul-de-sacs involve the bowel or bladder. The examiner was requested to review the VA laparoscopic report from April 2018. The examiner was further directed to provide clarification regarding whether the Veteran had any bladder symptoms related to the service-connected endometriosis. The examiner was requested to review and address the October 2017 VA treatment record. In compliance with that remand directive, VA obtained addendum opinions in November 2022. The examiner opined: "It is less likely than not that the lesions of the anterior and posterior cul-de-sacs approximate lesions involving the bowel or bladder." The examiner explained that the anterior cul-de-sac was at the space between the bladder and the uterus, and the posterior cul-de-sac was at the space between the uterus and the rectum. If there were bladder and bowel involvement of the endometriosis, the examiner stated that would have been clearly reflected on the April 2018 report, but it was not. The examiner also found there were not bowel or bladder symptoms related to endometriosis. The examiner also clarified that the bladder symptoms were not related to endometriosis. The examiner reviewed the relevant evidence, stating that bladder pain and pelvic floor muscle myalgia were noted in October 2017. The examiner further provided that the record did not attribute the bladder pain to endometriosis, but rather stated it was likely from pelvic floor muscle myalgia. Further, an operative report did not mention any bladder involvement of endometriosis and confirmed there were no bladder symptoms from endometriosis. DC 7629 analysis Pelvic Pain The Board finds that the Veteran is entitled to a separate 30 percent rating under DC 7629 for endometriosis because the record shows she had chronic pelvic pain not controlled by treatment, unrelated to the menstrual cycle, and not caused by ovary disease injury, or adhesions. Specifically, medical records show that her pelvic pain did not stop after her ovarian cyst removal surgeries, which leads to the logical conclusion that not all of the pain was caused by those cysts. Further, the pain occurred daily even when she was not menstruating, showing that all the pain was not related to the menstrual cycle. Finally, the pelvic pain was not controlled by treatment or "responsive to medical management." The Veteran has undergone multiple types of treatment for endometriosis pain relief throughout the appeal period but none have been successful. Therefore, the Board grants a 30 percent rating under DC 7269 for endometriosis-related chronic pelvic pain. To this extent, the claim is granted. In the Rule 33 Summary, B&M argued that the November 2022 opinion was inadequate because it did not address whether the Veteran's pelvic floor myalgia was a residual of her service-connected gynecological condition. Myalgia is the medical term for muscle pain, so this argument refers to the symptom of pelvic floor muscle pain. All of the Veteran's chronic pelvic pain, menstrual and non-menstrual, due to endometriosis, ovarian cysts, ovarian cyst removal, and adhesions, is now compensated under her DC 7615 and 7629 ratings. Therefore, this argument is moot. Bowel or bladder lesions The Veteran essentially asserts the cul-de-sac lesions shown on the April 2014 laparoscopy report meet the DC 7629 criteria of lesions involving of the bowel or bladder for a 50 percent rating. See May 2022 correspondence. In the February 2024 JMR, the Parties agreed, in relevant part, that the Board must address whether the November 2022 medical opinion substantially complied with the August 2022 remand instructions. Specifically, "The examiner did not provide a medical opinion as to whether the lesions of the anterior and posterior cul-de-sacs "approximated lesions involving the bowel or bladder." (Emphasis in original.) The August 2022 Board remand directive asked the examiner for "an opinion as to whether the lesions of the anterior and posterior cul-de-sacs approximate lesions involving the bowel or bladder. The examiner is requested to review the VA laparoscopic report from April 2018." The JMR directive is focused on the word "approximate" in the Board's original remand directive. The Board allows that it would have been simpler to ask: "Do lesions of the anterior and posterior cul-de-sacs involve the bowel or bladder?" The word "approximate" is not in the rating criteria and has no legal or practical significance in this case. The 50 percent rating under DC 7629 requires lesions involving the bowel or bladder, period. The clear intent of this remand directive in the context of the claim was to learn whether the lesions noted in the laparoscopic report met the criteria of lesions involving the bowel or bladder for DC 7629 rating purposes. The November 2022 opinion clearly responded to this directive: "It is less likely than not that the lesions of the anterior and posterior cul-de-sacs approximate lesions involving the bowel or bladder." Not only does the opinion use the verbiage that is the focus of the JMR, but it also clearly and sufficiently addresses the essential question of whether the Veteran's lesions involve the bowel or bladder. The examiner clearly reviewed the laparoscopic report as requested, and explicitly defined the locations of the relevant anatomy and lesions, used medical expertise and knowledge of standard medical protocols and procedures, and explained why the absence of relevant notations on the laparoscopy report weighs against finding that bowel and bladder lesions were involved. His rationale is consistent with the evidence of record, complete, persuasive, and probative. Thus, the Board finds there was substantial compliance with the August 2022 remand directive. In the Rule 33 Summary, B&M argued that the November 2022 opinion failed to address this question and failed to provide a reasoned medical explanation for the conclusion that the Veteran's lesions did not approximate lesions of the bowel or bladder. For the reasons given above, the Board rejects this argument. Very significantly, in order to receive the 50 percent rating for endometriosis under DC 7629, the bowel or bladder lesions must be confirmed by laparoscopy. The examiner's opinion is based in part of the fact that the laparoscopy report did not confirm any bowel or bladder lesions. To warrant a rating higher than 30 percent under DC 7629, the evidence must show lesions involving bowel or bladder confirmed by laparoscopy and pelvic pain not controlled by treatment, and bowel or bladder symptoms (excluding IBS, severe diarrhea, alternating diarrhea and constipation, or abdominal distress). Without lesions involving the bowel or bladder confirmed by laparoscopy, a 50 percent rating is unavailable. This is dispositive and it is unnecessary for the Board to analyze whether endometriosis caused bowel or bladder symptoms excluding IBS, severe diarrhea, alternating diarrhea and constipation, or abdominal distress). Based on the foregoing, the Board finds that the probative evidence is neither evenly nor approximately balanced as to whether a 50 percent rating is warranted under DC 7629. Rather, the evidence persuasively weighs against finding lesions involving bowel or bladder confirmed by laparoscopy. The benefit of the doubt doctrine does not apply. 38?U.S.C. §?5107(b), Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (holding the benefit-of-the-doubt doctrine is not for application when the evidence is persuasively for or against the claim). To this extent, the claim is denied. Residuals of Miscarriage The Veteran asserts that two prior miscarriages are due to her service-connected gynecological condition. She seeks additional ratings on this basis for residuals of the miscarriages. Private treatment records show treatment for a miscarriage in December 2020 and treatment for abnormal uterine bleeding in the setting of a prior pregnancy test in June 2021. The June 2021 provider stated the home pregnancy test could have been a false positive or the Veteran could have had a chemical pregnancy. The August 2022 Board remand directed VA to clarify whether the miscarriages were due to the service-connected gynecological condition and if yes, to clarify any residuals of those miscarriages. Specifically, it asked the examiner to provide an opinion regarding whether the Veteran's prior miscarriages were due to the service-connected gynecological condition and, if the examiner determined any miscarriages were due to the service-connected condition, the examiner was asked to further opine whether the Veteran had any residuals of a miscarriage related to the service-connected gynecological condition that manifested during the appeal period. In compliance with that directive, an addendum opinion was obtained in November 2022. In pertinent part, the resulting opinion addressed the relationship between endometriosis and miscarriage. The November 2022 VA examiner opined that the Veteran's miscarriages were unrelated to endometriosis. The examiner reviewed the relevant evidence and explained that chemical pregnancies were caused by chromosomal abnormalities with the developing fetus, and that there was a possibility that the Veteran had a false positive pregnancy test because there had been no confirmation of pregnancy by ultrasound. The examiner also reviewed a medical article summarizing current evidence on the relationship between endometriosis and miscarriage. The examiner wrote, quoting the article: In summary, whilst the randomized controlled trials showed that the treatment of endometriosis had no impact on miscarriage rates, the large population-based databases showed a significant association between the two. It is impossible to make a conclusion on whether endometriosis leads to miscarriages or not. There is therefore a great need for higher quality research in order to help us establish whether endometriosis truly has a part to play in miscarriage. The examiner then explained how the article factored into her opinion: "Medical research shows evidence of association but no evidence of a cause-and-effect relationship between endometriosis leading to miscarriages[;] therefore it is less likely the veteran's endometriosis caused the development of a miscarriage in [her] pregnancy." In other words, the article and medical research described therein does not support a causal relationship between endometriosis and miscarriages. In the absence of medical evidence supporting a causal relationship, the examiner found it was less likely than not. In the Rule 33 Summary, B&M argued that the Board failed to address the probative value of the November 2022 opinion in light of its reliance on a medical article containing "qualifying and contradictory statements." Specifically, the medical literature stated that it was impossible to conclude whether endometriosis causes miscarriages, and that additional research was needed on this issue. The Board finds that the November 2022 VA examiner adequately provided an opinion addressing the relationship between endometriosis and miscarriage based on review of the relevant evidence and her rationale for her conclusions. In this case, the article's statement that it was impossible to conclude whether or not endometriosis leads to miscarriages informed the examiner's opinion because the summary of recent research did not show a causal relationship. In order for the benefit of the doubt doctrine to apply, the evidence must be approximately balanced for and against the claim. For the reasons described above, the article did not establish that endometriosis likely causes miscarriages. Therefore, it is not positive evidence in favor of the claim. For approximate balance to be resolved in the Veteran's favor, there must be some positive nexus evidence to weigh. Neither the Board nor the examiner are expected or able to provide additional medical research on this issue. Both must make determinations on the evidence before them. The examiner, in her medical judgment, saw insufficient affirmative evidence before her to find it at least as likely as not that endometriosis caused miscarriage. The Board finds it is a reasonable conclusion by the examiner that miscarriage is less likely than not due to endometriosis. Thus, the Board finds the November 2022 opinion adequately addressed the relationship between the Veteran's endometriosis and her prior miscarriages. It is probative evidence. In the February 2024 JMR, the Parties also agreed, in relevant part, that the November 2022 VA medical opinion did not comply with the remand directive because it did not mention the Veteran's service-connected bilateral ovarian cysts, which are part of the service-connected gynecological disability. The JMR directed the Board to address whether the November 2022 VA medical opinion substantially complied with its August 2022 remand instructions. Accordingly, in July 2024, the Board remanded the Veteran's claim to obtain a narrow opinion regarding whether the Veteran's prior miscarriages were due to the service-connected bilateral ovarian cysts. If the examiner determined any miscarriages were due to the bilateral ovarian cysts, the examiner was to further opine whether the Veteran had any residuals of a miscarriage related to the service-connected bilateral ovarian cysts that manifested during the appeal period. In compliance with that directive, an examiner provided an opinion in August 2024. When asked whether the Veteran's prior miscarriages were due to the service-connected bilateral ovarian cysts, the examiner wrote, "No." The examiner reasoned, "Ovarian cysts do not represent an established primary etiology of miscarriages in the medical literature." The Board finds there was substantial compliance with the July 2024 remand directives as the August 2024 opinion addressed whether the Veteran's prior miscarriages were due to the service-connected bilateral ovarian cysts and provided a rationale based on medical knowledge of miscarriage etiologies. There is no length or word-count requirement for a rationale to be adequate; it need only "support its conclusion with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Here, there are no contrary opinions to weigh against the August 2024 opinion. Even if there were, the fact that ovarian cysts are not a known primary cause of miscarriages is a complete and clear reason to support the examiner's conclusion that the Veteran's ovarian cysts did not cause her miscarriages. The Board acknowledges the Veteran's testimony and lay evidence of record. The Board has no reason to doubt the Veteran's credibility and that she believes that the lesions she has involve the bowel or bladder and that she believes her two prior miscarriages are due to her service-connected gynecological condition. The Veteran is competent to describe observable symptoms; however, she is not competent to determine whether lesions involve the bowel or bladder or whether her miscarriages were due to her service-connected gynecological condition. The Board finds that the questions of whether lesions involve the bowel or bladder and whether a nexus exists between the service-connected bilateral ovarian cysts, ovarian cyst removal, adhesions, and endometriosis, and the miscarriages, are too complex to be addressed by a layperson. This connection or etiology is not amenable to observation alone. Rather it is a medically complex issue requiring specialized medical education or knowledge, and interpretation of laparoscopic reports. See 38 C.F.R. § 3.159 (a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). Because the Veteran does not have specialized medical training, experience, or knowledge, her opinion, no matter how sincere, is not competent nexus evidence. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Conversely, the November 2022 and August 2024 examiners are competent to do so and have provided adequate opinions supported by medical reasoning. Thus, the medical evidence of record is afforded more probative weight than the lay evidence of record on the questions of whether the Veteran's lesions involve the bowel or bladder and whether a nexus exists between the service-connected bilateral ovarian cysts, ovarian cyst removal, adhesions, and endometriosis, and the miscarriages. In summary, the Board grants a 30 percent rating under DC 7629 for endometriosis and denies a higher rating under DC 7615 for ovarian cysts, ovarian cyst removal, and adhesions. LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.M. 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.