Citation Nr: 0815172 Decision Date: 05/08/08 Archive Date: 05/14/08 DOCKET NO. 05-08 687 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to service connection for gastroesophageal reflux disease (GERD). 2. Entitlement to service connection for irritable bowel syndrome (IBS). 3. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for paranoid schizophrenia. 4. Entitlement to an increased disability rating for service-connected post-traumatic stress disorder (PTSD), currently evaluated as 30 percent disabling effective November 6, 2000. 5. Entitlement to a compensable initial disability rating for service-connected constipation secondary to medications prescribed for service-connected PTSD, currently evaluated as noncompensably (0 percent) disabling effective May 8, 2002. REPRESENTATION Veteran represented by: John S. Berry, Esq. Berry & Kelly ATTORNEY FOR THE BOARD J. Alsup, Associate Counsel INTRODUCTION The veteran served on active duty from February 1977 to October 1979. This matter comes before the Board of Veterans' Appeals (the Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. Procedural history An unappealed February 1996 rating decision denied the veteran's November 1995 claim for entitlement to service connection for paranoid schizophrenia. The veteran's claims for entitlement to service connection for GERD, PTSD and paranoid schizophrenia were denied in a September 2001 rating decision. The veteran's April 2002 claims for entitlement to service connection for IBS and a sleep disorder were denied in a June 2003 claim. The veteran disagreed and timely appealed the issues of entitlement to service connection for PTSD, GERD, IBS, constipation and whether new an material evidence sufficient to reopen a claim for entitlement to service connection for paranoid schizophrenia. A March 2004 rating decision granted service connection for PTSD evaluated as 30 percent disabling effective November 6, 2000, and entitlement to service connection for constipation evaluated as noncompensably (0 percent) disabling effective May 8, 2002. The veteran disagreed with the assigned disability ratings and timely appealed. Issue not on appeal As noted above, the veteran's claim for entitlement to service connection for a sleep disorder was not addressed in a July 2003 notice of disagreement (NOD). The record does not include any NOD addressing the issue. Thus, the issue of entitlement to service connection for a sleep disorder is not in appellate status and will not be addressed any further herein. See Archbold v. Brown, 9 Vet. App. 124, 130 (1996) [pursuant to 38 U.S.C.A. § 7105(a), the filing of a notice of disagreement initiates appellate review in the VA administrative adjudication process, and the request for appellate review is completed by the claimant's filing of a substantive appeal after a statement of the case is issued by VA]. The issues of entitlement to an increased disability rating for service-connected PTSD and constipation are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A preponderance of the competent medical and other evidence supports a conclusion that the veteran's GERD is unrelated to his active military service. 2. A preponderance of the competent medical and other evidence supports a conclusion that the veteran has no diagnosis of IBS. 3. In an unappealed February 1996 rating decision, the RO denied the veteran's claim for entitlement to service connection for paranoid schizophrenia. 4. Evidence submitted since the February 1996 rating decision is not new and material and is not so significant that it must be considered in order to fairly decide the merits of the veteran's claim of entitlement to service connection CONCLUSIONS OF LAW 1. Entitlement to service connection for GERD is not warranted. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303 (2007). 2. Entitlement to service connection for IBS is not warranted. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303 (2007). 3. The February 1996 rating decision denying the veteran's claim of entitlement to service connection for paranoid schizophrenia is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 3.104, 20.1103 (2007). 4. Since February 1996, new and material evidence has not been received, and so the previously denied claim of entitlement to service connection for paranoid schizophrenia is not reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran essentially contends his GERD and IBS were incurred in or aggravated by active duty service. In addition, the veteran seeks to reopen his claim for entitlement to service connection for paranoid schizophrenia, contending that he has submitted new and material evidence in support of that claim. The Board will first address preliminary matters and then render a decision as to all three issues. Duties to notify and assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). As to VA's duty to notify, this appeal arises from the veteran's disagreement with the denial of service connection for GERD and IBS, and the denial to reopen a claim for service connection for paranoid schizophrenia for lack of new and material evidence. In this case, the RO provided the appellant with notice in November 2002, June and November 2003, October 2005 and July 2007. Notice requirements with respect to the content of the notice were met in this case. The RO informed the veteran in the notice letters about the information and evidence that is necessary to substantiate his claims for service connection in letters dated November 2002 and June and November 2003. Specifically, the veteran was informed that the evidence must show a current disability, an in-service incurrence or aggravation of a disability, and medical evidence of a nexus between a current disability and an in-service incurrence or aggravation of a disability. Additionally, the January 2005 statement of the case (SOC) notified the veteran of the reasons for the denial of his application and, in so doing, informed him of the evidence that was needed to substantiate his claim. With regard to the issue of whether new and material evidence has been submitted, the Board notes that in Kent v. Nicholson, 20 Vet. App. 1 (2006), the Court of Appeals for Veterans Claims (Court) specifically addressed VCAA notice requirements in the context of a veteran's request to reopen a previously and finally denied claim. The Court found that VA must notify a claimant of the evidence and information that is necessary to reopen the claim, and must provide notice that describes what evidence would be necessary to substantiate the element or elements required to establish service connection that were not found in the previous denial. The veteran in this case was informed of what evidence was needed to establish new and material evidence in the June and November 2003 letters. The notices also informed the veteran of the meaning of the terms "new" and "material," and informed him of the basis for the prior denial for service connection. The Board observes that the RO essentially used language that substantially follows the regulatory language of 38 C.F.R. § 3.156, set forth below. In addition, with relation to the service connection claims, the RO notified the veteran in that reasonable efforts would be made to help him obtain evidence necessary to support his claim, including that VA would request any pertinent records held by Federal agencies, such as military records, and VA medical records. The veteran was also informed that a medical examination would be provided or that a medical opinion would be obtained if it was determined that such evidence was necessary to make a decision on his claim. Finally, in the July 2007 notice letter, the RO informed the claimant to submit any evidence in his possession that pertains to the claim. Thus, because each of the four notice requirements has been fully satisfied in this case, any error in not providing a single notice to the appellant covering all content requirements is harmless error. Further, during the pendency of this appeal, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473, noted above, which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service- connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Additionally, this 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. Id. In the present appeal, the veteran was provided specific notice of how VA determine a disability rating and an effective date in a letter dated March 2006. In addition, the duty to assist the appellant has also been satisfied in this case. The veteran's service medical records as well as all available VA treatment records are in the claims file and were reviewed by both the RO and the Board in connection with his claim. The RO also obtained Social Security Administration (SSA) records that pertained to his claim. He veteran was also afforded VA examinations in February 2004 and September 2007 in connection with his claims. VA has further assisted the veteran and his representative throughout the course of this appeal by providing them with a SOC, which informed them of the laws and regulations relevant to the veteran's claim. For these reasons, the Board concludes that VA has fulfilled the duty to assist the veteran in this case. With regard to the claim to reopen entitlement to service connection for paranoid schizophrenia, VA's statutory duty to assist a claimant in the development of a previous finally denied claim does not attach until the claim has been reopened based on the submission of new and material evidence. However, once a claim is reopened, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the veteran's claim for a benefit under a law administered by VA, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. See 38 U.S.C.A. § 5103A (West 2002). The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2007). The record reveals that the veteran waived his right to a hearing before a Veterans Law Judge. See February 2005 VA Form 9. The Board will therefore proceed to a decision on the merits. 1. Entitlement to service connection for gastroesophageal reflux disease (GERD). 2. Entitlement to service connection for irritable bowel syndrome (IBS). Because the issues present similar facts and identical law, they will be addressed in the same analysis. Relevant law and regulations Service connection - in general A disability may be service-connected if it results from an injury or disease incurred in, or aggravated by, military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2007). In order to establish service connection for the 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). Analysis The Board will address each Hickson element as to each issue in turn. With regard to element (1), the Board observes that a February 2004 VA examiner diagnosed the veteran with GERD. Thus, element (1) is satisfied as to GERD. However, the same examiner did not make a diagnosis of IBS. Instead, the examiner stated that ". . . at this time the veteran does not appear to meet the diagnostic criteria for irritable bowel syndrome." The Board notes that service connection presupposes a current diagnosis of the claimed disability. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Thus, without a current diagnosis, the veteran's claim for entitlement to service connection for IBS fails to satisfy Hickson element (1). The claim is not warranted. With regard to element (2) as to both GERD and IBS, the Board notes that the veteran's service medical records do not indicate that the veteran complained of or sought treatment for GERD or IBS during his active duty. Moreover, the record does not contain evidence showing that the veteran had GERD or IBS within a year of his discharge. Thus, element (2) is not met as to either issue. For the sake of completeness, the Board will briefly address the remaining Hickson element. See Luallen v. Brown, 8 Vet. App. 92, 95-6 (1995), citing Holbrook v. Brown, 8 Vet. App. 91, 92 (1995) [the Board has the fundamental authority to decide a claim in the alternative]. With regard to element (3), medical evidence of a nexus between the claimed in-service disease or injury and the current disability, the February 2004 examiner noted that the veteran's GERD disorder was "less likely than not related to military service." There is no other medical opinion regarding nexus. Thus, element (3) is not met, and service connection for GERD fails on this basis as well. With regard to IBS, it follows that there can not be a nexus between a non-existent current disability and no in-service disability. For those reasons, the Board finds that entitlement to service connection for GERD and IBS is not warranted. (CONTINUED ON NEXT PAGE) 3. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for paranoid schizophrenia. Relevant law and regulations Service connection - in general A disability may be service-connected if it results from an injury or disease incurred in, or aggravated by, military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2007). Notwithstanding the above, service connection may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. See 38 C.F.R. § 3.303(d) (2007); Cosman v. Principi, 3 Vet. App. 303, 305 (1992). Service connection may also be granted on a presumptive basis for certain chronic disabilities, including psychoses, when manifested to a compensable degree within the initial post service year. See 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2007). In order to establish service connection for the 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). Finality/new and material evidence In general, Board decisions are final. 38 U.S.C.A. § 7104 (West 2002); 38 C.F.R. § 20.1100 (2007). Pursuant to 38 U.S.C.A. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. The Board notes that the definition of material evidence was revised in August 2001 to require that the newly submitted evidence relate to an unestablished fact necessary to substantiate the claim and present the reasonable possibility of substantiating the claim. See 66 Fed. Reg. 45,620, 45,630 (Aug. 29, 2001) [codified at 38 C.F.R. § 3.156 (2006)]. This change in the law pertains only to claims filed on or after August 29, 2001. Because the veteran's claim to reopen was initiated in April 2002, the claim will be adjudicated by applying the revised section 3.156. The revised regulation provides that new evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, related to an unsubstantiated fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. See 38 C.F.R. § 3.156(a) (2007). An adjudicator must follow a two-step process in evaluating previously denied claims. First, the adjudicator must determine whether the evidence added to the record since the last final decision is new and material. If new and material evidence is presented or secured with respect to a claim that has been finally denied, the claim will be reopened and decided upon the merits. Once it has been determined that a claimant has produced new and material evidence, the adjudicator must evaluate the merits of the claim in light of all the evidence, both new and old, after ensuring that the VA's statutory duty to assist the appellant in the development of his claim has been fulfilled. See 38 U.S.C.A. § 5108 (West 2002); Elkins v. West, 12 Vet. App. 209 (1999); Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). There must be new and material evidence as to each and every aspect of the claim that was lacking at the time of the last final denial in order for there to be new and material evidence to reopen the claim. See Evans v. Brown, 9 Vet. App. 273 (1996). Analysis As indicated in the Introduction, the RO denied the veteran's claim for service connection for paranoid schizophrenia in a February 1996 rating decision which was not appealed by the veteran. That decision is final. See 38 U.S.C.A. § 7105(b)(2)(c) (West 2002); 38 C.F.R. §§ 3.104, 20.1103 (2007). The veteran now seeks to reopen his claim. The "old" evidence The relevant evidence of record at the time of the February 1996 decision included the veteran's service medical records, which do not contain any references to any psychological disabilities. The record also contained evidence of psychological treatment in the form of a March 1987 report (8 years after service) stating that the veteran was seen by the MHC of Mid-Iowa in the past, and had received services from the University of Iowa in the past. The March 1987 report indicates the veteran was diagnosed "various diagnoses . . . including schizophrenia, paranoid subchronic" in March 1986. The February 1996 rating decision As noted above, the RO denied the veteran's November 30, 1995, claim in a February 1996 rating decision. The rating decision indicated the RO considered the evidence described above and that the RO found that the veteran had not submitted evidence to show an in-service injury or incurrence of a disease, or within one year of his discharge from active duty. The veteran was informed of the decision in a letter dated February 1996. Additionally submitted evidence Evidence submitted since the February 1996 rating decision includes a VA treatment records; March, April, June, July and September 2003, and January 2004 treatment records from the Richmond Center; and, a diagnostic evaluation by Dr. J.T. and other treatment records from Greeley M.C. dated September and October 2003. The record since February 1996 also includes many statements made by the veteran indicating his diagnoses of paranoid schizophrenia, his symptomatology, and the effect it has had on his employability and his daily life. The record also includes several records from Iowa correctional facilities, including medical records. Discussion The veteran contends that service connection should be granted for his currently diagnosed paranoid schizophrenia disorder because it was purportedly exhibited during his active duty service. In essence, the claim has been denied by the RO in the past because of a lack of Hickson elements (2) and (3), evidence of in-service disease or injury and medical nexus evidence. For reasons explained immediately below, new and material evidence supportive of those two elements is still lacking. As explained above, the veteran's claim for service connection for a paranoid schizophrenia may only be reopened if he submits new and material evidence. See 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a) (2007). The crux of this inquiry is whether the additional evidence raises "a reasonable possibility of substantiating the claim." Manifestly, it does not. The only Hickson element established as of the February 1996 rating decision was element (1), evidence of a current disability. The recent medical evidence merely reflects further treatment of the veteran's well-documented psychiatric disabilities. Accordingly, such evidence is cumulative in nature and cannot serve to reopen the claim. See Cornele v. Brown, 6 Vet. App. 59, 62 (1993); Mintz v. Brown, 6 Vet. App. 277, 280 (1994) [medical evidence that merely documents continued diagnosis and treatment of disease, without addressing the crucial matter of medical nexus, does not constitute new and material evidence]. With regard Hickson element (2), evidence of in-service disease or injury, the evidence of record considered by the RO in February 1996 does not establish that the veteran suffered from any psychiatric disease during service or within the one year presumptive period after service. No competent evidence added to the record since the February 1996 rating decision supports the veteran's contention that he had a mental disability in service. The veteran's own recent statements to that effect are reiterative of statements he made in support of his initial claim, and are therefore not new. See Reid v. Derwinski, 2 Vet. App. 312, 315 (1992). Because new and material evidence has not been received as to this crucial element, the veteran's claim to reopen fails on this basis alone. See Elkins, supra. Similarly, regarding element (3), medical nexus, nothing has been added to the record that supports a nexus between the veteran's military service and his current mental disability. The veteran himself continues to contend that his current paranoid schizophrenia disorder is related to his military service. Such statements are reiterative of those made in connection with his claims made in 1995, and 2001. Moreover, it is now well established that lay persons without medical training, such as the veteran, are not qualified to render medical opinions regarding the etiology of disorders and disabilities. In Moray v. Brown, 5 Vet. App. 211, 214 (1993), the Court specifically stated that lay persons are not competent to offer medical opinions and that such evidence does not provide a basis on which to reopen a claim for service connection. In Routen v. Brown, 10 Vet. App. 183, 186, (1997), the Court again noted that "[l]ay assertions of medical causation cannot suffice to reopen a claim under 38 U.S.C. 5108." Thus, new and material evidence has not been received as to element (3), as well as element (2), and the veteran's attempt to reopen the claim fails on this basis as well. In short, none of the newly received evidence, aside from the veteran's repeated contentions, addresses the key questions of whether the veteran incurred paranoid schizophrenia during service or within the one year presumptive period, and whether there is a nexus between any such condition and the veteran's current psychiatric disability. Conclusion In summary, for reasons and bases expressed above the Board finds that no new and material evidence has been added to the record as to either of the two critical elements which were lacking at the time of the RO's February 1996 rating decision. The additional evidence consists only of treatment records indicating that the psychiatric disability still exists; and the veteran's reiterations of his previous contentions, which had been considered and rejected by the RO in February 1996. The additional evidence does not raise a reasonable possibility of substantiating the claim on the merits. See 38 C.F.R. § 3.156 (2006). In the absence of such evidence, the veteran's claim may not be reopened. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000), [a veteran seeking disability benefits must establish a connection between the veteran's service and the claimed disability]. The benefits sought on appeal remain denied. ORDER Entitlement to service connection for GERD is denied. Entitlement to service connection for IBS is denied. New and material evidence not having been received, the veteran's claim of entitlement to service connection for a paranoid schizophrenia disorder disability is not reopened. The benefit sought on appeal remains denied. REMAND 4. Entitlement to an increased disability rating for service-connected post-traumatic stress disorder (PTSD), currently evaluated as 30 percent disabling effective November 6, 2000. 5. Entitlement to a compensable initial disability rating for service-connected constipation secondary to medications prescribed for service-connected PTSD, currently evaluated as noncompensably (0 percent) disabling effective May 8, 2002. The Board finds that the medical evidence of record does not permit a fully informed evaluation of the veteran's claims for increased disabilities for PTSD and constipation. Specifically, the medical evidence does not distinguish to what degree the veteran's psychiatric problems are caused by his service- connected PTSD vis-à-vis other, non service- connected conditions, in particular paranoid schizophrenia. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) [the Board is precluded from differentiating between symptomatology attributed to service-connected disability and non service-connected disability in the absence of medical evidence which does so]. For example, the veteran is reported to have auditory hallucinations. It is unclear whether that symptomatology is attributable to the veteran's diagnosed paranoid schizophrenia or to PTSD. The Board seeks a medical opinion that can, to the extent practicable, clarify this and similar issues. See also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) [the duty to assist includes "the conduct of a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one"]. Similarly, the service-connected constipation is secondary to medications taken for the veteran's psychiatric disability and disorders. The record is unclear whether the medications causing constipation are prescribed for the veteran's service-connected PTSD or for the non-service-connected paranoid schizophrenia, or both. Accordingly, the case is REMANDED for the following action: 1. VBA should arrange for a psychologist to review the veteran's VA claims folder, including this Remand decision. The reviewing examiner should, to the extent practicable, determine which of the veteran's psychiatric symptoms are attributable to PTSD and which are attributable to paranoid schizophrenia. The reviewing psychologist should determine, to the extent practicable, the degree and extent of disability caused by PTSD, and what impact that disability has on the veteran's ability to function under the ordinary conditions of daily life including employment. Appropriate diagnostic testing should be undertaken, as deemed necessary by the examiner, and the examiner should specifically comment on the validity of the test results. The reviewing psychologist's written report shall be associated with the veteran's VA claims folder. 2. VBA should arrange for a psychiatrist to review the veterans VA claims folder, including this Remand decision. The examining psychiatrist should determine, to the extent practicable, which medications are prescribed for treatment of the veteran's service-connected PTSD, and describe which symptoms the medications are prescribed to treat. The examining psychiatrist should further determine, to the extent practicable, which medications are prescribed for treatment of the veteran's non-service- connected paranoid schizophrenia, and further describe which symptoms such medications are prescribed to treat. Finally, the reviewing examiner shall provide an opinion which, if any, of the prescribed medications can be associated with the veteran's service-connected constipation disability. The reviewing psychiatrist's written report shall be associated with the veteran's VA claims folder. 3. Following the completion of the foregoing, and after undertaking any additional development which it deems to be necessary, VBA should then readjudicate the veteran's claims of entitlement to an increased disability rating for service- connected PTSD and of entitlement to a compensable rating for service-connected constipation. If the benefits sought on appeal remain denied, in whole or in part, VBA should provide the veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ______________________________________________ FRANK J. FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs