Citation Nr: 1002138 Decision Date: 01/13/10 Archive Date: 01/22/10 DOCKET NO. 08-19 011 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a duodenal ulcer. 2. Entitlement to service connection for mild ulnar nerve compression at the right elbow (claimed as right arm tingling and numbness). 3. Entitlement to service connection for benign prostatic hypertrophy (claimed as a prostate disability). 4. Entitlement to service connection for chronic obstructive pulmonary disease (COPD). 5. Entitlement to an initial compensable rating prior to December 8, 2008, and to an initial rating greater than 50 percent thereafter, including on an extraschedular basis, for headaches. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from November 1969 to November 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a January 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In a February 2009 rating decision, the RO granted a higher initial 50 percent rating for headaches effective December 8, 2008. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the Veteran's appeal has been obtained. 2. The competent evidence does not demonstrate that the Veteran's current duodenal ulcer, which first manifested decades after service separation, is related to active service. 3. The competent evidence does not demonstrate that the Veteran's current mild ulnar nerve compression at the right elbow (claimed as right arm tingling and numbness) is related to active service. 4. The competent evidence does not demonstrate that the Veteran's current benign prostatic hypertrophy is related to active service. 5. The competent evidence does not demonstrate that the Veteran's current COPD is related to active service. 6. Prior to December 8, 2008, the Veteran's service- connected headaches are manifested by, characteristic prostrating headaches occurring approximately once every two months over several months. 7. Effective December 8, 2008, the Veteran's service- connected headaches have not been manifested by symptoms which interfered markedly with his prior employment or required frequent hospitalization. CONCLUSIONS OF LAW 1. A duodenal ulcer was not incurred in active service nor may it be so presumed. 38 U.S.C.A. §§ 1110, 1112, 1113, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2009). 2. A disability manifested by mild ulnar nerve compression at the right elbow (claimed as right arm tingling and numbness) was not incurred in active service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.304 (2009). 3. Benign prostatic hypertrophy (claimed as a prostate disability) was not incurred in active service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.304 (2009). 4. Chronic obstructive pulmonary disease was not incurred in active service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.304 (2009). 5. Prior to December 8, 2008, the criteria for an initial 10 percent rating for headaches have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.16, 4.124a, Diagnostic Code (DC) 8100 (2009). 6. From December 8, 2008, the criteria for an initial rating in excess of 50 percent, including on an extraschedular basis, for headaches, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.16, 4.124a, Diagnostic Code (DC) 8100 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), 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. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2009). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not accomplished in a timely manner, such error may be cured by issuance of a fully compliant notice followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (holding that the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). Regarding the increased rating claim, the appeal stems from the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA for this issue. Regarding the remaining issues on appeal, the appellant was sent a VCAA notice letter in March 2006 that apprised him of what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. In the instant case, the appellant was never informed of how VA determines disability ratings and effective dates. Because the instant decision denies service connection for all of the Veteran's claimed disabilities, however, no disability rating or effective date will be assigned. Accordingly, any absence of Dingess notice is moot. Therefore, no further development is required regarding the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the service treatment records are silent as to any complaints or treatment for any of the Veteran's claimed disabilities. With respect to the Veteran's claim of entitlement to service connection for a disability manifested by right arm numbness and tingling, it appears that he is seeking service connection for a symptom rather than any underlying disability. The presence of a mere symptom alone, absent evidence of a diagnosed medical pathology or other identifiable underlying malady or condition that causes the symptom, does not qualify as disability for which service connection is available. See generally Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999); vacated in part and remanded on other grounds sub nom., Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). Moreover, the post-service evidence does not indicate any current complaints or treatment referable to a duodenal ulcer, mild ulnar nerve compression at the right elbow, benign prostatic hypertrophy, or COPD until several decades following separation, with no credible statements of continuity of symptomatology to fill that gap in time. Furthermore, the records contains no competent evidence suggesting a causal relationship between any of the Veteran's current disabilities and active service. For all of the above reasons, the evidence does not indicate that the claimed disabilities may be related to active service such as to require an examination even under the low threshold of McLendon. The Veteran also has been provided with examinations which address the current nature and severity of his service-connected headaches. The Board finds that all necessary development has been accomplished and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records as well as post-service reports of VA and private treatment and examination. Moreover, the Veteran's statements in support of the claims are of record. The Board has reviewed such statements carefully and concludes that no available outstanding evidence has been identified. The Board also has perused the medical records for references to additional treatment reports not of record but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection The Veteran contends that he incurred a duodenal ulcer, a disability manifested by right arm numbness and tingling, benign prostatic hypertrophy, and COPD during active service. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including duodenal ulcers, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. The Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for a duodenal ulcer. Despite the Veteran's assertions to the contrary, his service treatment records do not show that he was diagnosed as having a duodenal ulcer during active service. The medical evidence also does not show any diagnosis or manifestation of a duodenal ulcer during the first post-service year (i.e., by November 1972). Thus, the Board finds that service connection for a duodenal ulcer on a presumptive service connection basis is not warranted. See 38 C.F.R. §§ 3.307, 3.309. The Veteran also is not entitled to service connection for a duodenal ulcer on a direct service connection basis. The medical evidence shows that, following service separation in November 1971, the Veteran first was treated for a duodenal ulcer in July 2005, or almost 34 years later, when a VA upper gastrointestinal endoscopy showed one small duodenal ulcer with a clean base. With respect to negative evidence, the fact that there was no record of any complaint, let alone treatment, involving the Veteran's condition for many years is significant. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that it was proper to consider the Veteran's entire medical history, including a lengthy period of absence of complaints). Records dated subsequent to July 2005 do not show any ongoing treatment for a duodenal ulcer. It is acknowledged that the Veteran is competent to report observable symptoms such as stomach pain. Layno v. Brown, 6 Vet. App. 465 (1994). Furthermore, lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, in the present case, to the extent that the Veteran is claiming continuous ulcer symptomatology since active service, he is not found to be credible. Indeed, no symptoms or complaints were recorded in service. Moreover, he did not raise a claim for any of the claimed disorders until 2006, over 30 years following discharge. Had he been experiencing continuous symptoms, it is reasonable to expect that he would have made a claim many years earlier. For these reasons, continuity of symptomatology has not been established, either by the clinical record, or by the Veteran's own statements. Furthermore, none of the Veteran's post-service VA treating physicians have related the Veteran's duodenal ulcer to active service. In summary, absent competent evidence, to include a medical nexus, relating the Veteran's duodenal ulcer to active service, the Board finds that service connection for a duodenal ulcer also is not warranted on a direct basis. The Board also finds that the preponderance of the evidence is against the Veteran's claims of service connection for mild ulnar nerve compression at the right elbow (claimed as right arm tingling and numbness), benign prostatic hypertrophy (claimed as a prostate disability), and for COPD. The Veteran's service treatment records show that he was not diagnosed as having any of these claimed disabilities during active service. The Veteran was treated for upper respiratory infections in November 1970 and June 1971; these problems appear to have been resolved with in-service treatment, however, as further treatment proximate to service is not shown and the Veteran did not raise a claim until decades after discharge. It appears that the Veteran first was treated for mild ulnar nerve compression at the right elbow in July 2008, or almost 37 years after his service separation in November 1971, following his EMG. He first was treated for benign prostatic hypertrophy in December 1997, or more than 26 years after service. He first was treated for COPD in June 2005, or almost 34 years after service. See Maxson, 230 F.3d at 1333. Again, while competent to report a history of continuous symptomatology, such is not found to be credible here, again largely due to his failure to raise his claims until 2006. The post-service VA treatment records also indicate that VA electomyograph (EMG) in July 2008 showed mild ulnar nerve compression at the right elbow. The Board notes that, with respect to his service connection claim for a disability manifested by right arm numbness and tingling, the Veteran appears to be seeking service connection for symptoms rather than for an underlying disability. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999); vacated in part and remanded on other grounds sub nom., Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). The Veteran's post-service VA treatment records show that he currently is being treated for benign prostatic hypertrophy and for COPD. The Veteran's chest x-ray repeatedly was negative for any lung disability, to include COPD, prior to 2005. Moreover, none of the Veteran's post-service VA treating physicians have related his mild ulnar nerve compression at the right elbow, benign prostatic hypertrophy, or COPD to active service. In summary, absent competent evidence, to include a medical nexus, relating the Veteran's mild ulnar nerve compression at the right elbow, benign prostatic hypertrophy, or COPD to active service, or evidence otherwise demonstrating clear continuity of symptomatology, the Board finds that service connection for these disabilities is not warranted. The Board observes that medical evidence generally is required to establish a medical diagnosis or to address questions of medical causation. Lay assertions of medical status do not constitute competent medical evidence for these purposes. Bostain v. West, 11 Vet. App. 124, 127 (1998); Routen v. Brown, 10 Vet. App. 183, 186 (1997). Nevertheless, lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) and Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Veteran has not shown, however, that he has the expertise required to diagnose a duodenal ulcer, mild ulnar nerve compression at the right elbow, benign prostatic hypertrophy, or COPD. Nor is the Veteran competent to offer an opinion regarding any causal relationship between these disabilities and active service. Again, there is no documentation of any injury or findings with respect to these disabilities in service. While the Veteran's contentions have been considered carefully, they are outweighed by the medical evidence of record showing no nexus between any of his claimed disabilities and active service. Higher Initial Rating for Headaches The Veteran finally contends that his service-connected headaches are more disabling than currently evaluated. In general, disability evaluations are assigned by applying a schedule of ratings that represent, as far as can be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2009). Separate diagnostic codes identify the various disabilities and the criteria that must be met for specific ratings. The regulations require that, in evaluating a given disability, the disability be viewed in relation to its whole recorded history. 38 C.F.R. § 4.2 (2009); see Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's service-connected headaches currently are evaluated as noncompensable prior to December 8, 2008, and as 50 percent disabling under 38 C.F.R. § 4.124a, DC 8100. See 38 C.F.R. § 4.124a, DC 8100 (2009). A noncompensable rating is assigned under DC 8100 for headaches with less frequent attacks (meaning, less frequent than that described under the criteria for a 10 percent rating). A 10 percent rating is assigned for headaches with characteristic prostrating attacks averaging one in 2 months over the previous several months. A 30 percent rating is assigned for headaches with characteristic prostrating attacks occurring on an average once a month over the previous several months. A maximum 50 percent rating is assigned under DC 8100 for headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Id. The Board finds that the preponderance of the evidence is against the Veteran's claim for an initial compensable rating prior to December 8, 2008, and an initial rating greater than 50 percent thereafter, including on an extraschedular basis, for headaches, for the reasons discussed below. On VA examination in September 2006, the Veteran complained of experiencing headaches since surgery in 1994. These headaches were present "all the time" and started around his eyes and moved to the top of his head. They also lasted all day. The Veteran stated that, although he could not say how bad his headaches were, when they reached 10/10 on a pain scale, he went to the emergency room and had done so 5 or 6 times in the previous year. He also stated that he had not worked since a July 1980 back injury which required multiple surgeries and rendered him completely disabled from working. He reported experiencing occasional nausea and light sensitivity with his headaches but denied any associated vomiting or sound sensitivity. There were no gross neurological deficits. The impressions were that the Veteran had a headache "almost every day." Again, to achieve a 10 percent rating the evidence must show characteristic prostrating attacks averaging one in 2 months over the previous several months. Here, the Veteran stated at his September 2006 examination that he had 5 or 6 very severe headaches over the past year that required a visit to the emergency room. He is competent to report his observable headache symptomatology. Layno, 6 Vet. App. 465 (1994). Moreover, nothing in the record calls into question his credibility. Thus, based on his credible reports, the evidence shows that he has had essentially one severe, prostrating headache every two months (which would total 6 per year). Accordingly, prior to December 8, 2008, a 10 percent rating for the service-connected headaches is found to be warranted. As there is no showing of characteristic prostrating headaches occurring on an average of once a month, based on the Veteran's own statements raised at the September 2006 examination, the next-higher 30 percent evaluation is not warranted during the period in question. The Board notes that, effective December 8, 2008, the Veteran is in receipt of the maximum 50 percent rating available for headaches under DC 8100. See 38 C.F.R. § 4.124a, DC 8100. It appears that the RO assigned the maximum 50 percent rating based on the results of the Veteran's VA examination on December 8, 2008, when he reported experiencing headaches "most days of the month" and at least 20 days per month. He described his headaches as dull and aching for 5 days a month, severe for 15 days a month, and prostrating for between 10 and 12 of the 15 days a month when they were severe. The Veteran again reported that he had become too disabled to work in July 1980 due to a back injury and subsequent back surgeries. Neurological examination showed that he was alert, responsive, and had an intact memory and orientation. The impression was headaches occurring 20 days per month with 15 days of severe headaches and 10-12 of the 15 days reported as prostrating headaches. The Board must consider whether the Veteran is entitled to consideration for referral for the assignment of an extraschedular rating for his service-connected headaches. 38 C.F.R. § 3.321 (2009); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the Veteran or reasonably raised by the record). The Board notes in this regard that the Veteran currently is in receipt of the maximum schedular rating available for his service-connected headaches effective December 8, 2008. See 38 C.F.R. § 4.124a, DC 8100 (2009). An extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service- connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that schedular evaluations assigned for the Veteran's service-connected headaches are not inadequate in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's service-connected headaches. This is especially true because the 50 percent rating currently assigned for the Veteran's headaches effective December 8, 2008, contemplates severe disability. Moreover, the evidence does not demonstrate other related factors such as marked interference with employment and frequent hospitalization. The Veteran reported at both of his VA examinations in September 2006 and December 2008 that he had been unable to work since a back injury in July 1980 and had been disabled from working since that time due to repeated back surgeries. The Board also notes that the Veteran reported in September 2006 that he had been to a private emergency room (ER) at least 5 or 6 times in the previous year where he received shots to treat his headaches. He did not indicate, and the medical evidence does not show, that he was hospitalized frequently for his service-connected headaches after reporting to the ER. In light of the above, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). As the preponderance of the evidence is against the Veteran's claims, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for a duodenal ulcer is denied. Entitlement to service connection for mild ulnar nerve compression at the right elbow (claimed as right arm tingling and numbness) is denied. Entitlement to service connection for benign prostatic hypertrophy (claimed as a prostate disability) is denied. Entitlement to service connection for COPD is denied. Prior to December 8, 2008, a 10 percent initial rating for headaches is granted, subject to governing criteria applicable to the payment of monetary benefits. From December 8, 2008, an initial rating greater than 50 percent for headaches, including on an extraschedular basis, is denied. ____________________________________________ ERIC S. LEBOFF Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs