Citation Nr: 0813124 Decision Date: 04/21/08 Archive Date: 05/01/08 DOCKET NO. 04-20 750 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for residuals of frozen feet. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Jeanne Schlegel, Counsel INTRODUCTION The veteran had active military service from April 1953 to April 1955. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. This claim was previously before the Board in September 2006 at which time it was remanded for both due process concerns and for additional evidentiary development, to include affording the veteran a VA examination. The actions requested in that remand have been undertaken, and the case has returned to the Board for appellate consideration. In December 2007, the veteran and his representative requested that the case be advanced on the docket. In March 2008, the Board granted the veteran's motion to advance this case on the docket based on a finding of good cause. See 38 C.F.R. § 20.900(c) (2007). FINDINGS OF FACT The competent evidence fails to demonstrate that claimed residuals of frozen feet, to include current foot/leg neuropathy, initially diagnosed decades after the veteran's discharge from service, are related to the veteran's active duty service. CONCLUSION OF LAW Residuals of frozen feet were not incurred in or aggravated by the veteran's active duty service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's Duties to Notify and Assist Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002). VA must request that the claimant provide any evidence in the claimant's possession that pertains to a claim. 38 C.F.R. § 3.159 (2007). See also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). Initially, the Board observes that the veteran's service medical records may not be entirely complete in this case. Even prior to the enactment of the Veterans Claims Assistance Act of 2000, the United States Court of Appeals for Veterans Claims (Court) had held that in cases where the veteran's service medical records were unavailable/incomplete, through no fault of the veteran, there was a "heightened duty" to assist the veteran in the development of the case. See generally McCormick v. Gober, 14 Vet. App. 39, 45-49 (2000); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board notes that the RO has requested additional service medical records and service personnel records to no avail. As it appears that repeated attempts to obtain additional service medical records has been undertaken without success, the Board believes that VA has no further duty to assist in this regard. After careful review of the claims folder, the Board finds that letters dated in March 2003, June 2004 and June 2006 fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). These letters advised the veteran what information and evidence was needed to substantiate the claim decided herein and what information and evidence must be submitted by him, namely, any additional evidence and argument concerning the claimed condition and enough information for the RO to request records from the sources identified by the veteran. In this way, he was advised of the need to submit any evidence in his possession that pertains to the claim. He was specifically told that it was his responsibility to support the claim with appropriate evidence. Finally the letters advised him what information and evidence would be obtained by VA, namely, records like medical records, employment records, and records from other Federal agencies. The Board notes that the 2004 and 2006 letters were sent to the veteran after the June 2003 adjudication of the claim. Although these letters were not sent prior to initial adjudication of the appellant's claim, this was not prejudicial to him, since a duty to assist letter had been issued prior to the adjudication of the claim, and the claim was readjudicated after the issuance of the 2004 and 2006 letters in supplemental statements of the case (SSOCs) provided to the appellant in December 2005 and July 2007. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). Further, through his statements, the veteran has demonstrated his understanding of what is necessary to substantiate his claim, i.e., any notice defect was cured by the veteran's actual knowledge. See Sanders v. Nicholson, 487 F.3d. 881 (Fed. Cir. 2007; see also Simmons v. Nicholson, 487 F.3d 892 (Fed. Cir. 2007). In any event, the Board finds that a reasonable person could be expected to understand from the notice what was needed to substantiate the claim and thus the essential fairness of the adjudication was not frustrated. Id. As such, the Board concludes that, even assuming a notice error, that error was harmless. See Medrano v. Nicholson, 21 Vet. App. 165 (2007); Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006). During the pendency of this appeal, on March 3, 2006, the Court issued a decision in Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006), which held that the VCAA notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The October 2006 letter provided such notice. In light of the above, the Board finds that all notices required by VCAA and implementing regulations were furnished to the veteran and that no useful purpose would be served by delaying appellate review to send out additional VCAA notice letters. The Board finds that VA has also fulfilled its duty to assist the veteran in making reasonable efforts to identify and obtain relevant records in support of the veteran's claim and providing a VA examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(4)(i) (2007). In this regard, the veteran's available service medical records are associated with the claims folder, and he has been fully informed that these records may be incomplete due to a fire and cannot be reconstructed. Relevant VA and non-VA treatment records have also been associated with the file. The veteran has not identified any additional relevant, outstanding records that need to be obtained before deciding his claim and indicated in October 2006 that he had no additional evidence to provide for the record. VA examinations were provided in conjunction with the veteran's claim in 2007. Under the circumstances of this case, "the record has been fully developed," and "it is difficult to discern what additional guidance VA could have provided to the veteran regarding what further evidence he should submit to substantiate his claim." Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Therefore, the Board is satisfied that VA has complied with the duty to assist requirements of the VCAA and the implementing regulations and the record is ready for appellate review. Factual Background The veteran filed a service connection claim for residuals of frozen feet in February 2003, indicating that this condition initially arose while serving on active military duty in Korea. The veteran's DD Form 214 shows that completed a course of study in cooking at food service school and shows that he was assigned to the 622d Military Police Company. His awards included a Korean Service Medal. The service medical records (SMRs) show that upon enlistment examination of January 1953, clinical evaluation of the feet was normal. The veteran was treated for left elbow problems in May 1953 and for epigastric discomfort in May 1954. The April 1955 separation examination report revealed that clinical evaluation of the feet and lower extremities was normal, and there was no information provided in the area of the report addressing defects or diagnoses. The service medical records were negative for documented complaints, treatment or a diagnosis relating to the feet or lower extremities. The veteran filed a compensation claim in April 1962, indicating that he had been treated for a stomach condition during service in Korea in 1954. Private medical statements dated in May and June 1962 are negative for any mention of a history of frostbite/cold injury in service or for complaints relating to the feet or legs. The veteran underwent a VA examination in April 1962 at which time he had no complaints related to the feet or lower extremities and musculoskeletal evaluation to include the feet, was normal. The veteran also failed to complain of any foot/leg problems on VA examinations conducted in June 1967 and June 1972. VA medical records include a psychiatric progress note dated in August 2000 which indicates that the veteran served in the Korean War and received a Combat Infantryman Badge. The entry indicated that while the veteran was stationed in Korea, he was subjected to extremely low temperatures and sustained frostbite of the legs and feet. It was reported that since that time, he had experienced symptoms of muscle twitching and cramping of the lower legs. Diagnoses which included leg cramps, possibly due to neurovascular injury due to frostbite, were made by the psychiatrist. A VA general medical note dated later that same day in August 2000 revealed that the veteran was scheduled to undergo lab testing in conjunction with his complaints of severe leg cramps. The assessments included leg cramps, most likely secondary to osteoarthritis. A psychiatric progress note dated in June 2001, shows that the veteran gave a history of frostbite of both lower extremities during the Korean War (described as a combat veteran) with symptoms of recurrent pain of the legs and feet since that time. The psychiatrist observed that this was quite a common problem with many veterans who served in North Korea and suffered from hypothermia of the lower extremities and being in cold wet trenches and noted that this causes permanent neurovascular changes. The psychiatrist commented that due to this experience, the veteran should probably be service connected for this. The diagnoses included restless leg syndrome and status post frostbite injuries which occurred while stationed in Korea during the Korean War, with probable peripheral neuropathy and trophic changes due to frostbite. The veteran was seen by VA in August 2001 to undergo testing in conjunction with his complaints of muscle cramps. It was noted that most of the blood work was negative. Objective examination revealed spasms in the leg muscles bilaterally. Muscle cramps were diagnosed, and it was stated that the veteran would start on Thiamine and was already taking Clonazepam. A neurology consultation was recommended. An entry dated in September 2001 indicates that the veteran had been found to have both thrombocytopenia and leukopenia. When seen by VA in March 2002, it was noted that the veteran continued to have muscle cramps and that EMG testing which had been done had revealed possible demarginating disease. A July 2002 VA record states that the veteran had a history of cramping dating back 25 years, worse with activity. It was noted that EMG and nerve conduction studies (NCS) done in March 2002 were abnormal, consistent with a sensory and motor polyneuropathy with axonal and demyelinating features, without evidence of a primary myopathic process. An assessment of cramps with neuropathy and possible myokymia was made, of unsure etiology. A request for information from VA to the National Personnel Records Center for the veteran's personnel file was made in March 2003. A response was received in May 2003 indicating that these records were fire related and could not be obtained and the information requested could not be reconstructed. Service connection for residuals of frozen feet was denied in a June 2003 rating action. In his Notice of Disagreement received in August 2003, the veteran reported that, in approximately February 1953, he was on guard duty in rice paddies with his boots filled with water. He reported that he was off duty entirely for 3 days and was put on light duty for 2 weeks thereafter. He indicated that treatment was received at a field station sometime between January and April 1953. Morning reports received in January 2004 show that the veteran's service in Korea began in mid-February 1954 and failed to reveal any sick, injury or hospitalization reports. In a substantive appeal received in May 2004, the veteran reported that it was in approximately February 1954 that he sustained frostbite/frozen feet when he was on guard duty in rice paddies and his boots filled with water. He again reported that he was off duty entirely for 3 days and was put on light duty for 2 weeks thereafter. He also indicated that he sought treatment at the VAMC in Waco, Texas, in 1955 or 1956 and was treated by Dr. R.D. during the 1970's. The record contains a private medical statement, dated in July 2004, from Dr. R.D. The doctor confirmed that he had treated the veteran for foot problems prior to 1980, described as treatment for the effects of frozen feet which were obtained during military service in Korea. It was reported that he was treated by Dr. R.D. for some time and referred for specialty consultation. In July 2004, VA received a response from the VAMC in Waco, Texas, indicating that the veteran's medical records were created in March 1982 and contained one note. Correspondence from NPRC dated in March 2006 indicated that it had no records for the veteran and that some service records may have been lost in a fire and could not be reconstructed. A VA examination was conducted in January 2007. The veteran complained of decreased sensation in the feet, constant and progressive, over the years. Physical examination revealed no alteration of the skin and circulation intact. Range of motion of the ankles and toes was within normal limits. X- ray films of the feet revealed no abnormality or evidence of arthritis of degenerative joint disease. A VA neurological evaluation was conducted in February 2007 and the claims folder was reviewed. The veteran reported sustaining a frostbite injury to his feet in 1954 during service in Korea. The veteran reported having symptoms of cramping, numbness and tingling since that time, getting progressively worse. Physical examination revealed decreased sensory ability in the lower extremities. Nerve conduction studies of the lower extremities were consistent with polyneuropathy. An impression of peripheral neuropathy was made. The examiner observed that the veteran had clinical, as well as electrophysiological, evidence of peripheral neuropathy and was not diabetic. The examiner noted that he was unable to find a SMRs showing treatment or hospitalization for frostbite injury. The examiner opined that if the veteran had cold injuries to the feet and legs, then it was possible that his neuropathy was related to these injuries and explained that frostbite and cold injuries could cause large and small nerve fiber damage. Legal Analysis In a case such as this where it appears that veteran's service medical records are incomplete, the Board's obligation to explain its findings and conclusions, and to consider carefully the benefit-of-the-doubt rule, is heightened. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991); Pruitt v. Derwinski, 2 Vet. App. 83, 85 (1992). The Board must point out; however, the O'Hare precedent does not raise a presumption that the missing medical records would, if they still existed, necessarily support the veteran's claim. Case law does not establish a heightened "benefit of the doubt," only a heightened duty of the Board to consider the applicability of the benefit of the doubt, to assist the claimant in developing the claim, and to explain its decision when the veteran's medical records have been destroyed. See Ussery v. Brown, 8 Vet. App. 64 (1995). Similarly, the case law does not lower the legal standard for proving a claim for service connection, but rather increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the appellant. Russo v. Brown, 9 Vet. App. 46 (1996). The Board has thoroughly reviewed all the evidence in the appellant's claims folders. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis herein focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish direct service connection for a claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The veteran generally contends that cold weather and temperatures to which he was exposed while serving in Korea caused the currently claimed residuals of frozen feet. Initially, the Board notes that a VA medical dated in August 2000 indicates that the veteran served in the Korean War and received a Combat Infantryman Badge, and other records mention that he participated in combat. For injuries or disease which are alleged to have been incurred in combat, 38 U.S.C.A. § 1154(b) provides a relaxed evidentiary standard of proof to determine service connection. Collette v. Brown, 82 F.3d 389 (Fed. Cir. 1996); Gregory v. Brown, 8 Vet. App. 563 (1996). However, in this case, no evidence of record, including the DD Form 214, reflects that the veteran received a CIB or otherwise establishes that the veteran engaged in combat during his period of active duty service, to include service in Korea. Accordingly, the provisions of 38 U.S.C.A. § 1154(b), are not applicable in this case. There is no question in this case that the veteran has a current diagnosis, primarily assessed as sensory and motor polyneuropathy, affecting the feet/lower extremities. The critical inquiry is whether this currently manifested condition is in any way etiologically related to service. The available SMRs dated during the veteran's period of service contain no documentation of complaints, treatment or a diagnosis related to the feet or lower extremities. However, affording the benefit of the doubt in favor of the veteran, the Board finds his statements to the effect that the temperatures in Korea were low/cold and that he served on guard duty in boots filled with water to be credible. The Board also finds credible the veteran's statements to the effect that he sought treatment during service for symptoms of frostbite/frozen feet/cold injury, although undocumented in the SMRs. However, the Board does not find credible the veteran's account that he was hospitalized for 1 to 2 weeks for this condition during service. In this regard, those statements are not found credible in that the veteran has not been able to provide the dates of that treatment, and the time period that he has provided between January 1953 and April 1953, was even prior to his enlistment into service, and well before his assignment in Korea, which did not begin until mid-February 1954. Moreover, the separation examination report, which would normally document such treatment failed to note any such hospitalization or any clinical abnormality of the feet or lower extremities. Even presuming that a cold injury occurred during service as reported, the record must also include competent medical evidence to substantiate that this injury resulted in a currently manifested and/or chronically existing disability. See Hickson, 12 Vet. App. at 253. In this case, as previously noted the record does in fact contain the separation examination conducted in April 1955, just prior to the veteran's discharge from service, which is entirely negative for any clinical abnormality of the feet or lower extremities was normal and there was no information provided in the area of the report addressing defects or diagnoses. In addition, VA examination reports and post-service medical statements dated from 1955 to 1972, fail to mention any cold injury in service or any symptomatology of the feet and lower extremities. Post-service, it was not until 2000, about 45 years after the veteran was discharged from service, that medical records initially document the veteran's report of a cold injury in service and complaints relating to the feet/lower extremities. Since that time, the veteran's symptomatology of the feet/lower extremities has been diagnosed as polyneuropathy and restless leg syndrome. In 2000 a VA psychiatrist provided a diagnosis which included leg cramps, possibly due to neurovascular injury due to frostbite. Later, in 2001, the same VA psychiatrist diagnosed restless leg syndrome and status post frostbite injuries and opined that these occurred while the veteran stationed in Korea during the Korean War, with probable peripheral neuropathy and trophic changes due to frostbite. The opinions provided by the VA psychiatrist in 2000 and 2001 are not considered to be probative in this case. Initially, the opinions were based solely on a history (unsubstantiated by any documented evidence) provided by the veteran. Moreover, it is clear that no medical records were reviewed in conjunction with rendering these opinions, nor was the veteran even clinically evaluated (orthopedically or neurologically) in conjunction with rendering both the diagnoses and the medical opinions. Moreover, the psychiatric incorrectly stated on both occasions that the veteran was a combat veteran, which is not established in this case. Similarly, the private medical statement of Dr. R.D. dated in July 2004 is not considered to be probative in this case. The doctor confirmed that he had treated the veteran for foot problems prior to 1980, described as treatment for the effects of frozen feet which were obtained during military service in Korea. As to this evidence, the file contains no medical records indicative of treatment relating to the feet/lower extremities at any time prior to 2000. However, even if Dr. R.D. treated the veteran from 1975 forward, this was still more than 20 years after the veteran's discharge from service. Moreover, again the opinion appears to be based solely on a history (unsubstantiated by any documented evidence) provided by the veteran. There is no indication that any medical records were reviewed in conjunction with rendering this opinion, and there was no information provided reflecting that the veteran was clinically evaluated in conjunction with rendering medical opinion. Finally, a VA examiner in 2007 diagnosed peripheral neuropathy, but noted that he was unable to find a SMR showing treatment or hospitalization for frostbite injury. The examiner opined that, if the veteran had cold injuries to the feet and legs, then it was possible that his neuropathy was related to these injuries and explained that frostbite and cold injuries could cause large and small nerve fiber damage. The use of the words "possible", "may" or "can be", as in this case, makes a doctor's opinion speculative in nature. See Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus). See also Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor's statement framed in terms such as "could have been" is not probative); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) ("may or may not" language by physician is speculative). Therefore, the Board finds the VA examiner's opinion to be of low probative value due to its speculative nature. In this case, no probative or competent evidence has been presented which establishes that the veteran's post-service foot/lower extremity symptomatology, primarily manifested by neuropathy, is etiologically related to service or has chronically existed since service. Supporting medical evidence is required in the circumstances presented in this case. See Voerth v. West, 13 Vet. App. 117, 120-1 (1999) (holding that there must be medical evidence on file demonstrating a relationship between the veteran's current disability and the claimed continuous symptomatology, unless such a relationship is one as to which a lay person's observation is competent). A prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury a disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Concerning this evidentiary gap between active service and the earliest mention of any cold injury in service and related symptomatology in 2000, existing for more than 4 decades after the veteran's discharge from service, the Board notes that the absence of evidence constitutes negative evidence tending to disprove the claim that the veteran sustained a cold injury in service which resulted in chronic disability or persistent symptoms thereafter. See Forshey v. West, 12 Vet. App. 71, 74 (1998), 38 U.S.C.A. § , 284 F.3d 1335, 1358 (Fed. Cir. 2002) (noting that the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact); see also 38 C.F.R. § 3.102 (noting that reasonable doubt exists because of an approximate balance of positive and "negative" evidence). Thus, the lack of any objective evidence of continuing complaints, symptoms, or findings related to the feet/lower extremities for decades after service is itself evidence which tends to show that a disorder of the feet/lower extremities did not have its onset in service or for many years thereafter. Additionally, the veteran did not report having residuals of a cold injury either to the Veterans Benefits Administration (VBA) or to his health care providers until 2000 and did not file his initial claim until 2003, more than four decades after service. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the veteran). Not only may the veteran's memory be dimmed with time, but self interest may play a role in the more recent statements. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest may affect the credibility of testimony); cf. Pond v. West, 12 Vet. App. 341, 346 (1999). The veteran maintains that his currently diagnosed conditions of the feet/lower extremities are etiologically related to service, to include a cold injury reportedly sustained therein. However, the Board notes that where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1991). Since the record does not reflect that the veteran possesses the medical training and expertise necessary to render a diagnosis concerning an eye disorder, his lay statements are of no probative value in this regard (as to the matter of causation/etiology). See Heuer v. Brown, 7 Vet. App. 379, 384 (1995) (citing Grottveit v. Brown, 5 Vet. App. 91, 93 (1993)). Thus, with consideration of the veteran's service medical records, to include a 1955 separation report which was negative for any clinical abnormality of the feet or lower extremities and failed to mention any treatment for a cold injury; the length of time following service prior to any reference to a cold injury in service and recorded complaints allegedly related thereto, and the absence of any competent and probative medical opinion establishing a causal link to the veteran's service, the Board finds that the preponderance of the evidence is against the veteran's claim of service connection for residuals of frozen feet. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to service connection for residuals of frozen feet, is denied ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs