Citation Nr: 0903052 Decision Date: 01/28/09 Archive Date: 02/09/09 DOCKET NO. 02-16 131 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office and Insurance Center in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to an initial compensable rating for bilateral pes planus. 2. Entitlement to an initial compensable rating for herpes simplex of the lip for the period prior to November 23, 2006, and in excess of 10 percent for the period beginning November 23, 2006. ATTORNEY FOR THE BOARD Timothy D. Rudy, Associate Counsel INTRODUCTION The veteran served on active duty from April 1981 to April 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2001 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, in which, inter alia, service connection was granted for bilateral pes planus and for herpes simplex of the lip and non-compensable disability ratings were awarded for both, each effective May 1, 2001. Subsequently, the case was transferred to the RO in Philadelphia, Pennsylvania. The Board remanded these issues for further development in June 2004, October 2005, June 2007, and February 2008. During development, the veteran's noncompensable rating for herpes simplex of the lip was increased to 10 percent, effective from November 23, 2006. As that award was not a complete grant of benefits, and the appellant is presumed to be seeking the maximum available benefit, the Board has characterized the appeal as encompassing the matters set forth on the preceding page. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35, 38 (1993). In a signed letter dated November 2008, the veteran complained of a miscalculation in awarded back pay. This matter is referred to the RO. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claims herein decided has been accomplished. 2. Bilateral pes planus is presently manifested by a mild foot deformity; with the feet resting in a calcaneus stance only a slight valgus position of the heels is revealed with only a mild and medial bowing of the Achilles tendon. 3. Prior to November 23, 2006, the veteran's herpes simplex of the lip was manifested by infrequent flare-ups, no functional impairment, no disfiguration, and no use of topical therapies. 4. Beginning November 23, 2006, the veteran's herpes simplex of the lip was manifested by active pathology and the use of an antiviral drug therapy. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for bilateral pes planus are not met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2008); 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5276 (2008). 2. The criteria for an initial compensable rating for herpes simplex of the lip for the period prior to November 23, 2006, and in excess of 10 percent for the period beginning November 23, 2006, are not met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2008); 38 C.F.R. § 4.118, Diagnostic Code 7806 (effective prior to August 30, 2002; effective from August 30, 2002; and effective from October 23, 2008) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) and as interpreted by the United States Court of Appeals for Veterans Claims (the Court), have been fulfilled by information provided to the veteran in letters from the RO dated in July 2004, November 2005, and March 2006. These letters notified the veteran of VA's responsibilities in obtaining information to assist the veteran in completing his claims, and identified the veteran's duties in obtaining information and evidence to substantiate his claims. Thereafter, the claims were reviewed and a supplemental statement of the case was issued in August 2008. (See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006), Dingess/Hartman v. Nicholson, 20 Vet. App. 473 (2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006)). The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008, removing the sentence in subsection (b)(1) stating that VA will request the claimant provide any evidence in the claimant's possession that pertains to the claim. Subsection (b)(3) was also added and notes that no duty to provide § 5103(a) notice arises "[u]pon receipt of a Notice of Disagreement" or when "as a matter of law, entitlement to the benefit claimed cannot be established." 73 Fed. Reg. 23,353-23,356 (Apr. 30, 2008). During the pendency of this appeal, the Court in Dingess/Hartman found that the VCAA notice requirements applied to all elements of a claim. An additional notice as to these matters was provided in the March 2006 correspondence. The Board acknowledges a recent decision from the Court that provided additional guidance regarding the content of the notice that is required to be provided under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) in claims involving increased compensation benefits. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). In that decision, the Court stated that for an increased compensation claim, 38 U.S.C.A. § 5103(a) requires, at a minimum, that VA notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Further, if the diagnostic code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), VA must provide at least general notice of that requirement to the claimant. Id. However, in the case of an increased initial rating claim, no duty to provide the notice described 38 C.F.R. § 3.159(b)(1) of this section arises upon receipt of a Notice of Disagreement. Therefore, regarding an initial increased rating for both disabilities under appeal here, the requirements outlined in Vazquez-Flores are not applicable. Instead, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found--a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The notice requirements pertinent to the issues on appeal have been met and all identified and authorized records relevant to these matters have been requested or obtained. The Board finds that the available medical evidence is sufficient for an adequate determination. There has been substantial compliance with all pertinent VA laws and regulations and to move forward with these claims would not cause any prejudice to the appellant. Laws and Regulations Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2008). The Court has held that a claim for a higher rating when placed in appellate status by disagreement with the original or initial rating award (service connection having been allowed, but not yet ultimately resolved), remains an "original claim" and is not a new claim for an increased rating. See Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the pendency of the appeal, a practice known as "staged" ratings. Id. at 126. It is the responsibility of the rating specialist to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2008). Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses are prohibited. 38 C.F.R. § 4.14 (2008). The Court has held that where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence is required. Grottveit v. Brown, 5 Vet. App. 91 (1993); see also Espiritu v. Derwinski, 2 Vet. App. 492 (1992). VA is free to favor one medical opinion over another provided it offers an adequate basis for doing so. See Owens v. Brown, 7 Vet. App. 429 (1995). When there is a question as to which of two evaluations to apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7 (2008). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3 (2008). Pes Planus The veteran's bilateral pes planus, or flatfeet, is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5276 (2008). 527 6 Flatfoot, acquired: Pronounced; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances: Bilateral 50 Unilateral 30 Severe; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities: Bilateral 30 Unilateral 20 Moderate; weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral 10 Mild: symptoms relieved by built-up shoe or arch support 0 38 C.F.R. § 4.71a, Diagnostic Code 5276 (2008) During a January 2001 VA medical examination, mild bilateral pes planus was noted. Objectively, the veteran had a normal gait, posture and balance. He was able to rise on his heels and toes and stand and hop on one foot without evidence of increased discomfort. No swelling or inflammation was reported. The veteran underwent a VA podiatry examination in November 2004. He complained of being flat-footed and having calluses at pressure points on his feet. After a long day his feet had a dull, achy, throbbing-type of pain at the midfoot plantarly and sometimes at the dorsal left midfoot. The pain was worse with prolonged standing and walking. Post service he had a job where he spent 90 percent of his day at a desk, and 10 percent on hard concrete tile floors. Objectively, there was no weakness, stiffness, swelling, heat, redness, fatigability, and no lack of endurance noted. It also was noted that the veteran did not use, and did not need, crutches, braces, a cane, or corrective shoes. On physical examination, no bunions or hammertoes were observed. There was a mild medial arch when nonweight bearing. Weight bearing revealed a mild pes planus foot type, bilaterally, and a mild forefoot and midfoot malalignment. There was no pain on manipulation of the forefoot, bilaterally. A resting calcaneus stance position revealed a slight valgus position, bilaterally, with a mild medial bowing of the Achilles tendon. There was no pain on manipulation of the Achilles tendon, bilaterally. When the bilateral rear foot was placed in a neutral calcaneal stance position, the heel was in a perpendicular position to the ground and the Achilles was not medially bowed. The veteran could rise to his toes, bilaterally, without pain and did resupinate. He had no complaints of pain along the plantar fascia. There also was no pain on palpation along the plantar fascia. He could rise to his heels without bilateral pain. A normal heel-to-toe gait pattern was noted and his shoe gear revealed no abnormal shoe wear pattern. Callosities not characteristically associated with pes planus also were noted. The examining podiatrist diagnosed mild bilateral pes planus. During an April 2006 VA podiatry examination, the veteran reported that he had received no additional foot treatment and had trimmed his own calluses. He complained that the calluses were pressure points that hurt him. He had more foot pain with a lot of walking and long periods of standing. On the day of examination there was a mild amount of pain on direct plantar palpation of the bilateral fifth metatarsal head callosities. There was no weakness, stiffness, heat, redness, fatigability and no lack of endurance observed. He did not use or need crutches, braces, a cane or corrective shoes. Physical examination revealed no functional loss related to his anatomical condition. There was no evidence that range of motion or function was additionally limited by pain, weakness or lack or endurance on repetitive use. A mild foot deformity, corresponding to the current diagnosis of a mild bilateral pes planus, was noted with the feet resting in a calcaneus stance revealing only a slight valgus position of the heels with only a mild and medial bowing of the Achilles tendon. The veteran's shoe gear revealed no abnormal shoe wear pattern. A normal heel-to-toe gait was noted as well as calluses not characteristic of associated ples planus. Mild bilateral pes planus was diagnosed. During a January 2007 VA diabetic foot examination, it was noted that the veteran had calluses on the lateral aspect of the ball of each foot and corns were noted on the plantar surface of the left foot. July 2007 and February 2008 VA podiatry clinic records noted that the veteran had no bilateral hallux abducto valgus, bunions, hammertoes, foot infections, or bony prominences. Based on the evidence of record, the Board finds that the criteria for a compensable rating for bilateral pes planus have not been met. In this matter, the Board finds the results of the November 2004 and April 2006 VA examinations persuasive. The examiner (the same podiatrist for each examination) reviewed all of the veteran's medical records, interviewed the veteran, and performed all necessary tests. She provided adequate reasons and bases for her opinions. The Board observes that there is no evidence of a moderate flatfoot condition or weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, and pain on manipulation and use of the feet, bilateral or unilateral, throughout the period of appeal. Therefore, a compensable rating is not warranted. See 38 C.F.R. § 4.71a, Diagnostic Code 5276 (2008). Herpes of the lip At the time of the grant of service connection, the veteran's herpes simplex of the lip disability was rated under 38 C.F.R. § 4.118, Diagnostic Code (DC) 7806, used to evaluated eczema, and DC 7899, used to evaluate skin disorders not otherwise listed in the rating schedule. Regulations for the evaluation of skin disabilities were revised effective on August 30, 2002 and again on October 23, 2008; however, the regulation revision of October 23, 2008, is applicable to claims received on or after that date. Pursuant to VAOPGCPREC 7-2003, where the law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to the appellant normally applies, absent Congressional intent to the contrary. 780 6 Eczema: Ratin g With ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant 50 With exudation or itching constant, extensive lesions, or marked disfigurement 30 With exfoliation, exudation or itching, if involving an exposed surface or extensive area 10 With slight, if any, exfoliation, exudation or itching, if on a nonexposed surface or small area 0 38 C.F.R. § 4.118, Diagnostic Code 7806 (effective prior to August 30, 2002) 780 0 Burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck: Ratin g With visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. 80 With visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement 50 With visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement 30 With one characteristic of disfigurement 10 Note (1): The 8 characteristics of disfigurement, for purposes of evaluation under Sec. 4.118, are: * Scar 5 or more inches (13 or more cm.) in length. * Scar at least one-quarter inch (0.6 cm.) wide at widest part. * Surface contour of scar elevated or depressed on palpation. * Scar adherent to underlying tissue. * Skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.). * Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.). * Underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.). * Skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Note (2): Rate tissue loss of the auricle under DC 6207 (loss of auricle) and anatomical loss of the eye under DC 6061 (anatomical loss of both eyes) or DC 6063 (anatomical loss of one eye), as appropriate. Note (3): Take into consideration unretouched color photographs when evaluating under these criteria. Note (4): Separately evaluate disabling effects other than disfigurement that are associated with individual scar(s) of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, under the appropriate diagnostic code(s) and apply § 4.25 to combine the evaluation(s) with the evaluation assigned under this diagnostic code. Note (5): The characteristic(s) of disfigurement may be caused by one scar or by multiple scars; the characteristic(s) required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008) 780 4 Scars, superficial, painful on examination 1 0 Note (1): A superficial scar is one not associated with underlying soft tissue damage. Note (2): In this case, a 10-percent evaluation will be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable evaluation. (See Sec. 4.68 of this part on the amputation rule.) 38 C.F.R. § 4.118, Diagnostic Code 7804 (effective August 30, 2002) 780 4 Scar(s), unstable or painful: Ratin g Five or more scars that are unstable or painful 30 Three or four scars that are unstable or painful 20 One or two scars that are unstable or painful 10 Note (1): An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2): If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3): Scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008) 780 6 Dermatitis or eczema. Ratin g More than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period 60 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period 30 At least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period 10 Less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12- month period 0 Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2008) During a January 2001 VA examination on the eve of discharge from service, the veteran gave a history of recurrent herpes simplex or cold sores of the lip. Topical preparations aided in his recovery. On objective examination of the face, no rashes, lesions or inflammation were noted. The mouth was without inflammation, lesion or deformity. The diagnosis was recurrent herpes simplex (cold sores) or the lip. The veteran underwent a VA examination in November 2004. He told the examiner that he developed herpes simplex type 1 on the left side of the chin about 1995. Subsequently, he has had problems three to four times a year with flare-ups taking between 10 to 14 days to heal. Treatment consisted solely of topicals. The veteran never took oral medications for this condition. He complained of a lot of discomfort when the cold sores flared up, principally burning and itching and some disfiguring scaling. Usually there is some healing with hyperpigmentation. There was no herpes simplex activity on the date of examination. The veteran denied any functional impairment from the problem. He also denied any professional treatment for the herpes simplex since his military discharge. On physical examination, there was clear skin noted about the mouth and no current evidence of a herpes simplex infection. The scarred areas of the face, accounting for 15 percent of the veteran's exposed skin, also were noted, but these findings are associated with the veteran's service-connected acne vulgaris and not with his cold sores of the lip. The examiner diagnosed a history of herpes simplex virus, type 1, in the perioral area with no current activity. The veteran underwent a VA dermatology examination in April 2006. He told the examiner that after he first developed this condition in 1995 he would have a flare-up about twice a year for approximately a week before healing. The lesions had never been cultured when active. When the lesions occurred, there was tingling and burning of the affected area, but no dysfunction of the mouth. However, this activity had diminished over time. His last flare-up was noted in 2002. It also was noted that, since discharge, the veteran had used an over-the-counter agent (Bacitracin ointment), but had not been seen in a medical facility for treatment. At the time of this examination he applied nothing to his lips on a regular basis. On physical examination, the skin was entirely clear and there was no evidence of the herpes simplex of the lip disability. Post acne scars and hyperpigmentation of the face and other parts of the body were not associated with the veteran's service-connected herpes simplex of the lip. The examiner specifically noted in his diagnosis of a history of herpes simplex virus infection, probably type 1, of the perioral area, that it was currently not active and not disfiguring. On November 23, 2006, the veteran was seen at a VA medical facility for treatment of active pathology of his herpes simplex. Color photographs of his mouth area were taken. The VA physician prescribed Zovirax cream, for application three times a day, and Zovirax tablets, 800 mg five times a day. Based upon the evidence of record, the Board finds that from the time service connection was granted for herpes simplex or cold sores for the lip until the skin regulations were changed on August 30, 2002, there was no competent medical evidence in the claims file that would entitle the veteran to a compensable rating under the pre-2002 skin regulations found at the former version of Diagnositic Code 7806. For the period from August 30, 2002 until November 23, 2006, the criteria for only a noncompensable rating for dermititus or eczema under Diagnostic Code 7806 is warranted. The Board finds the results of the November 2004 and April 2006 VA examinations persuasive. The examiner (the same dermatologist for each examination) reviewed all of the veteran's medical records, interviewed the veteran, and performed all necessary tests. He provided adequate reasons and bases for his opinions. In addition, there is evidence in the record to support the staged increased rating to 10 percent beginning November 23, 2006. As noted above, on that date the veteran was treated at a VA facility for an active outbreak of his herpes simplex of the lip. He was prescribed antiviral medication in both cream and tablet form. He also provided color photographs of the perioral area which are found in the claims file. The Board finds that this evidence shows the use of an intermittent systemic therapy to warrant an increase to a 10 percent disability rating. However, there is no evidence in the record that this or any similar therapies were to be constant, near constant, or to exceed a period of six weeks, which are required for a rating higher than 10 percent under the provisions of Diagnostic Code 7806. Further, there is no competent medical evidence in the claims file associating any of the veteran's scars from his service- connected acne with his service-connected herpes simplex of the lip. Therefore, potentially higher ratings for human scars available under the former and current skin regulations found at 38 C.F.R. § 4.118 cannot avail the veteran. In conclusion, a compensable rating is not warranted for the veteran's herpes simplex of the lip for the period prior to November 23, 2006, and a rating in excess of 10 percent is not warranted for the period beginning November 23, 2006. See 38 C.F.R. § 4.118, Diagnostic Code 7806 (2008). Conclusion The Board acknowledges the veteran's contentions that his disabilities at issue in this appeal are more severely disabling. However, the veteran is not a licensed medical practitioner and is not competent to offer opinions on questions of medical causation or diagnosis. See Grottveit, 5 Vet. App. 91; see also Espiritu, 2 Vet. App. 492. The Board also finds that there is no evidence of any unusual or exceptional circumstances, such as marked interference with employment or frequent periods of hospitalization, related to these disabilities on appeal that would take the veteran's case outside the norm so as to warrant an extraschedular rating. Consequently, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996). When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The preponderance of the evidence is against these claims. ORDER Entitlement to an initial compensable rating for bilateral pes planus is denied. Entitlement to an initial compensable rating for herpes simplex of the lip for the period prior to November 23, 2006, and in excess of 10 percent for the period beginning November 23, 2006, is denied. ____________________________________________ RENÉE M. PELLETIER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs