Citation Nr: 1031328	
Decision Date: 08/19/10    Archive Date: 08/24/10

DOCKET NO.  06-37 760	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Nashville, 
Tennessee


THE ISSUES

1.  Entitlement to service connection for a heart condition 
claimed as abnormal electrocardiogram (EKG).

2.  Entitlement to service connection for a right ankle disorder.


REPRESENTATION

Appellant represented by:	Veterans of Foreign Wars of the 
United States


WITNESS AT HEARING ON APPEAL

Appellant




ATTORNEY FOR THE BOARD

Emily B. Joyner, Counsel


INTRODUCTION

The Veteran served on active duty from July 1981 to July 1985.  
He also had Reserve service on and off from August 1985 to June 
2004.  In 1993 he had 39 days of inactive duty training and 13 
days of active duty training points.  Thereafter, he was recalled 
to active duty and served from June 17, 2004 to August 13, 2004.

This matter comes before the Board of Veteran's Appeals (Board) 
on appeal from a May 2005 rating decision by the Department of 
Veterans Affairs (VA) Regional Office (RO) in Nashville, 
Tennessee which denied the claims on appeal.

The Veteran testified before the undersigned Veterans Law Judge 
at a hearing held at the Central Office in June 2007.  A 
transcript of this hearing is associated with the claims file.

When the case was last before the Board in September 2007, the 
Board granted service connection for a lumbar spine disorder and 
remanded the claims for entitlement to service connection for 
hypertension, a heart disorder claimed as abnormal EKG, sinus 
disorder, right ankle disorder and left ankle/foot disorder.  
Thereafter, in a January 2010 rating decision, the RO granted 
service connection for hypertension, chronic sinusitis, and a 
left ankle and foot condition.  As such, the only issues 
currently before the Board are the two issues listed on the title 
page of this decision.






FINDINGS OF FACT

1.  A heart condition was not present during service or within 
one year of discharge therefrom, and any currently diagnosed 
heart disorder is not etiologically related to active service.  

2.  The competent evidence of record reflects that it is at least 
as likely as not that the Veteran's right ankle disorder was 
incurred during the Veteran's active duty for training in 1993.  


CONCLUSIONS OF LAW

1.  A heart disorder was not incurred or aggravated during active 
service, and the incurrence or aggravation of a heart disorder 
during such service may not be presumed.  38 U.S.C.A. §§ 1101, 
1110, 1112, 5103, 5103A, 5107 (West 2002 
& Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 
(2009).

2.  Resolving reasonable doubt in the Veteran's favor, a right 
ankle disorder was incurred during active service.  38 U.S.C.A. 
§§ 1101, 1110, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 
38 C.F.R. §§ 3.102, 3.159, 3.303 (2009).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Duties to Notify and Assist

Review of the claims folder reveals compliance with the Veterans 
Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. § 5100 et seq. 
See 38 C.F.R. 
§§ 3.102, 3.156(a), 3.159, 3.326(a).  Proper VCAA notice must 
inform the claimant of any information and 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 U.S.C.A. § 5103(a); C.F.R. § 3.159(b)(1).  Pelegrini 
v. Principi, 18 Vet. App. 112 (2004).

In Pelegrini, the United States Court of Appeals for Veterans 
Claims (Court) held that VCAA notice, as required by 38 U.S.C. § 
5103(a), must be provided to a claimant before the initial 
unfavorable adjudication by the RO.

The Court has also held that the VCAA 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.  
Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).  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.  Additionally, this notice must inform a claimant 
that a disability rating and an effective date for the award of 
benefits will be assigned if service connection is awarded.  Id.

The Board notes that in letters dated in January 2005, January 
2007, and March 2008, the RO and the Appeals Management Center 
(AMC) provided notice to the Veteran regarding what information 
and evidence is needed to substantiate his claims, as well as 
what information and evidence must be submitted by the Veteran 
and the types of evidence that will be obtained by VA.  
Additionally, the January 2007 notice letter informed the Veteran 
as to disability ratings and effective dates.

Because the notice pursuant to Dingess came after the initial 
adjudication of the claim, the timing of the notice did not 
comply with the requirement that the notice must precede the 
adjudication.  The timing deficiency was remedied by the fact 
that the Veteran's claims were readjudicated by the AMC in March 
2010, after proper VCAA notice was provided and after the Veteran 
had an opportunity to respond.  Mayfield v. Nicholson, 444 F.3d 
1328 (2006).  The Board concludes that the duty to notify has 
been met.

The record also reflects that VA has made reasonable efforts to 
obtain relevant records adequately identified by the Veteran.  
Specifically, the information and evidence that have been 
associated with the claims file include the Veteran's service 
treatment records, VA treatment records and VA examination 
reports, and private medical evidence.  Also of record and 
considered in connection with the appeal are various written 
statements submitted by the Veteran and his representative.

A remand by the Board confers on the claimant, as a matter of 
law, the right to compliance with the remand orders.  Stegall v. 
West, 11 Vet. App. 268, 271 (1998).  In this regard, the Board is 
satisfied as to compliance with the instructions from its 
September 2007 remand.  Specifically, the RO was instructed to 1) 
ask the Veteran to identify all health care providers who have 
treated him for his disabilities at issue and obtain records from 
the identified providers; 2) provide the Veteran with VA 
examinations to determine the extent, nature and etiologies of 
the disabilities; 3) and verify various periods of service.  The 
Board finds that the RO has complied with these instructions and 
that the VA examination reports substantially complies with the 
Board's September 2007 remand instructions. Stegall v. West, 11 
Vet. App. 268 (1998).

As discussed above, the Veteran was notified and aware of the 
evidence needed to substantiate his claims, the avenues through 
which he might obtain such evidence, and the allocation of 
responsibilities between himself and VA in obtaining such 
evidence.  The Veteran was an active participant in the claims 
process, identifying pertinent medical evidence and submitting 
evidence.  Thus, he has been provided with a meaningful 
opportunity to participate in the claims process and has done so.  
Any error in the sequence of events or content of the notice is 
not shown to have any effect on the case or to cause injury to 
the Veteran.  Therefore, any such error is harmless and does not 
prohibit consideration of this matter on the merits.  See 
Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also 
ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998).



Governing Laws and Regulations for Service Connection Claims

Service connection may be established for a disability resulting 
from disease or injury incurred in or aggravated by service.  38 
U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303.  Evidence of 
continuity of symptomatology from the time of service until the 
present is required where the chronicity of a condition 
manifested during service either has not been established or 
might reasonably be questioned.  38 C.F.R. § 3.303(b).  
Regulations also provide that service connection may be granted 
for any disease diagnosed after discharge, when all the evidence, 
including that pertinent to service, establishes that the 
disability was incurred in service.  38 C.F.R. § 3.303(d).

To establish service connection for an injury, the Court 
generally requires a veteran to show (1) medical evidence of a 
current disability, (2) medical or lay evidence of in- service 
incurrence or aggravation of an injury, and (3) medical evidence 
of a nexus between the claimed in-service injury and the present 
disability.  Dalton v. Nicholson, 21 Vet. App. 23, 36 (2007).  In 
cases where the veteran cannot establish some of these elements, 
a veteran can instead establish continuity of symptomatology.  38 
C.F.R. § 3.303(b); Barr v. Nicholson, 21 Vet. App. 303, 307 
(2007).  To establish continuity of symptomatology, the Veterans 
Court requires a veteran to show "(1) that a condition was 
'noted' during service, (2) evidence of postservice continuity of 
the same symptomatology, and (3) medical or lay evidence of a 
nexus between the present disability and the postservice 
symptomatology."  Barr, 21 Vet. App. at 307.  Lay evidence can be 
competent and sufficient to establish a diagnosis of a condition 
when (1) a layperson is competent to identify the medical 
condition, (2) the layperson is reporting a contemporaneous 
medical diagnosis, or (3) lay testimony describing symptoms at 
the time supports a later diagnosis by a medical professional.

"Status as a 'veteran' is one of the five elements of a claim for 
service- connection benefits."  Dingess v. Nicholson 19 Vet. App. 
473, 484 (2006).

A "veteran" is a person who served in active military, naval, or 
air service.  38 U.S.C.A. § 101(2) (West 2002).  Pursuant to 38 
U.S.C.A. § 101(24), " 'active military, naval, or air service' 
includes active duty, any period of active duty for training 
[ACDUTRA] during which the individual concerned was disabled or 
died from a disease or injury incurred in or aggravated in line 
of duty, and any period of inactive duty training [INACDUTRA] 
during which the individual concerned was disabled or died from 
an injury incurred in or aggravated in line of duty."  38 
U.S.C.A. § 101(24).  Put another way, service connection may be 
granted for disability resulting from disease or injury incurred 
in or aggravated while performing active duty for training, or 
for injury incurred during inactive duty training.

Veterans are presumed to be in sound medical condition at the 
time of entry into service except for defects actually noted when 
examined for entry into service.  This presumption of soundness 
can be rebutted by clear and unmistakable evidence that the 
disability existed prior to service and was not aggravated by 
service.  38 U.S.C.A. § 1111; 38 C.F.R. § 3.304.

A preexisting disease or injury will be considered to have been 
aggravated by active service where there is an increase in 
disability during such service, but this presumption of 
aggravation can be rebutted by clear and unmistakable evidence 
that the disability was not aggravated by active service.  38 
U.S.C.A. § 1153; 38 C.F.R. § 3.306.

In this regard, service connection can be established for a 
disability which preexisted service, but was permanently 
aggravated thereby.  A pre-existing disease or injury will be 
found to have been aggravated by service only if the evidence 
shows that the underlying disability underwent an increase in 
severity; the occurrence of symptoms, in the absence of an 
increase in the underlying severity, does not constitute 
aggravation of the disability.  Davis v. Principi, 276 F.3d 1341, 
1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a).  Evidence of the 
veteran being asymptomatic on entry into service, with an 
exacerbation of symptoms during service, does not constitute 
evidence of aggravation.  Green v. Derwinski, 1 Vet. App. 320, 
323 (1991).  If the disorder becomes worse during service and 
then improves due to in-service treatment to the point that it 
was no more disabling than it was at entrance into service, the 
disorder has not been aggravated by service.  Verdon v. Brown, 8 
Vet. App. 529 (1996).

In Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004), the United 
States Court of Appeals for the Federal Circuit (Federal Circuit 
Court) held that the correct standard for rebutting the 
presumption of soundness requires that VA show by clear and 
unmistakable evidence that (1) the appellant's disability existed 
prior to service and (2) that the preexisting disability was not 
aggravated during service.  Generally, a preexisting injury or 
disease will be considered to have been aggravated by active 
service where there was an increase in disability during such 
service, unless there is a specific finding that the increase in 
disability was due to the natural progress of the disease; 
however, aggravation may not be conceded where the disability 
underwent no increase in severity during service on the basis of 
all the evidence of record pertaining to the manifestations of 
the disability prior to, during and subsequent to service.  38 
U.S.C.A. § 1153; 38 C.F.R. § 3.306.  See also VAOPGCPREC 3-2003.

Moreover, where a veteran served continuously for ninety days or 
more during a period of war, or during peacetime service after 
December 31, 1946, and valvular heart disease becomes manifest to 
a degree of 10 percent within one year from the date of 
termination of such service, such disease shall be presumed to 
have been incurred in service, even though there is no evidence 
of such disease during the period of service.  This presumption 
is rebuttable by affirmative evidence to the contrary.  
38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309.  

Except as otherwise provided by law, a claimant has the 
responsibility to present and support a claim for benefits under 
laws administered by the Secretary.  The Secretary shall consider 
all information and lay and medical evidence of record in a case 
before the Secretary with respect to benefits under laws 
administered by the Secretary.  When there is an approximate 
balance of positive and negative evidence regarding any issue 
material to the determination of a matter, the Secretary shall 
give the benefit of the doubt to the claimant.  38 U.S.C.A. § 
5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 
53 (1990).  To deny a claim on its merits, the evidence must 
preponderate against the claim.  Alemany v. Brown, 9 Vet. App. 
518, 519 (1996), citing Gilbert, 1 Vet. App. at 54.

Analysis

The Board has reviewed all the evidence in the appellant's claims 
file.  Although the Board has an obligation to provide adequate 
reasons and bases supporting this decision, there is no 
requirement that the evidence submitted by the appellant or 
obtained on his behalf be discussed in detail.  Rather, the 
Board's analysis below will focus specifically on what evidence 
is needed to substantiate the claim and what the evidence in the 
claims file shows, or fails to show, with respect to the claim.  
See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and 
Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000).

I.  Heart Condition Claimed as Abnormal EKG

The Veteran claims that he is entitled to service connection for 
a heart disability because he had two bad EKGs in service.  The 
first abnormal EKG was in April 2001 and the second abnormal EKG 
was in May 2004.  

A review of the service treatment records from the Veteran's 
first period of service reflect that in November 1984 while being 
treated for a viral upper respiratory infection he was noted to 
have tachycardia on examination of the heart.  The service 
treatment records do not reflect that he was diagnosed with any 
heart disorder during his first period of service.

Between his first period and second period of active service, in 
May 2004, an EKG revealed sinus bradycardia.  A past history of 
bradycardia was also noted.

The report of a September 2008 VA examination report notes that 
in 2004 during the Veteran's National Guard service, a pre-
deployment physical examination revealed that EKG results were 
abnormal.  The examiner opined that the EKG in question revealed 
only sinus bradycardia.  Another EKG revealed only a non-specific 
ST segment abnormality.  The Veteran was entirely asymptomatic.  
However, because of this and his other conditions, he was not 
deployed with his unit.  He was not referred to a cardiac 
specialist and he had no cardiac testing performed.  He received 
no treatment for this EKG finding.  He occasionally has an 
episode of dizziness lasting 30 minutes.  He denied syncope, 
chest pain, palpitations, shortness of breath, and dyspnea.  
Cardiac examination was normal.  A November 2007 EKG was normal.  
An October 2008 EKG revealed sinus bradycardia, otherwise normal.  
The diagnosis was sinus bradycardia, asymptomatic, without 
effects on daily activities.  

A February 2009 addendum to the September 2008 VA examination 
report notes that the Veteran does not have any significant heart 
disease.  The examiner opined that the Veteran has mild, 
asymptomatic, intermittent, sinus bradycardia, which is not a 
pathophysiological condition or diagnosis.  Instead, it is a 
normal physiological variation and has not been shown to be 
responsible for any symptoms on the testing performed.  Testing 
has not revealed any SA Node disease that could be responsible 
for the sinus bradycardia.  There was no prolonged cardiac rhythm 
pauses on testing.  The Veteran is on medications for his 
service-connected conditions that could be responsible for his 
sinus pauses.  There is no aggravation of this condition due to 
military service.  The examiner further stated that the Veteran 
has very mild hypertensive heart disease that is only manifested 
by mild left ventricular hypertrophy that manifests itself on an 
echocardiogram.  There are no clinical symptoms from this 
condition, nor is there any functional disability due to this 
condition.  The condition is not physiologically important; it is 
a mild laboratory abnormality only.  The baseline heart disease 
without regard to aggravation by military service cannot be 
determined by available records.  It is the examiner's opinion 
that the amount of aggravation of this condition by military 
service is trivial.  The Veteran has no coronary artery disease, 
valvular heart disease, pericardial heart disease, low output 
congestive heart failure, high output congestive heart failure, 
cardiomyopathy, congenital or acquired cardiac shunts, 
obstructive hypertrophic heart disease, rheumatic heart disease, 
other heart disease (due to sexually transmitted disease (STD) or 
parasites), or pulmonary artery disease.

After reviewing the evidence of record, the Board finds that 
service connection is not warranted for a heart disorder claimed 
as abnormal EKG.  In this regard, the Board notes that no heart 
disorder was diagnosed during any period of service.  The 
"abnormal" EKGs actually displayed no evidence of any heart 
disease, and as such, no diagnosis was made.  In addition, no 
diagnosis of any heart disorder was made in the year following 
the first period of service or the second period of service.  
Moreover, there is no evidence showing that any currently 
diagnosed heart disorder is etiologically related to any period 
of service, or that any currently diagnosed heart disorder was 
aggravated during the Veteran's second period of active service.  

Specifically, the Veteran underwent a thorough VA cardiac 
examination in September 2008 in order to answer these very 
questions.  The report of this examination is very clear.  In 
sum, the Veteran currently has no symptomatic heart disorder, and 
any heart condition that he has, namely sinus bradycardia, is 
unrelated to any period of active service, to include based upon 
aggravation.  (The Veteran is already compensated for his 
service-connected hypertension.)  Notably, the February 2009 VA 
examination addendum clearly lists the heart diseases that the 
Veteran does not have; he does not have coronary artery disease, 
valvular heart disease, pericardial heart disease, low output 
congestive heart failure, high output congestive heart failure, 
cardiomyopathy, congenital or acquired cardiac shunts, 
obstructive hypertrophic heart disease, rheumatic heart disease, 
other heart disease (from an STD or a parasite), or pulmonary 
artery disease.  Instead, he has mild, asymptomatic, intermittent 
sinus bradycardia, which is not a pathophysiological condition or 
diagnosis; it is merely a normal physiological variation that 
does not cause any symptoms.  The examiner stated that this 
condition causes no symptoms or functional disability.  It is 
merely a laboratory abnormality that is not etiologically related 
to active service, and any aggravation of such condition by 
service is trivial.  

In essence, the evidence linking a heart disability to service is 
limited to the Veteran's own statements.  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.  38 
U.S.C.A. 
§ 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 
1372 (Fed. Cir. 2007); see 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).  Although the 
Veteran is competent to report that he has experienced heart 
symptoms since military service, the evidence fails to support 
his recollections.  As noted above, service treatment records 
make no mention of a heart disorder.  Further, no heart disorders 
were evident when he was examined for service separation for any 
period of service.  Sinus bradycardia is not a pathophysiological 
condition or diagnosis, and the only medical opinion on point 
indicates that it is not caused by or a result of service, nor 
was it aggravated by military service.  In this regard, the 
presumption of in-service incurrence is not for application.  38 
U.S.C.A. §§ 1101, 1112(a)(1); 38 C.F.R. §§ 3.307(a)(3), 3.309.  

As such, service connection is not in order for a heart 
condition.  In making this determination, the Board has 
considered the provisions of 38 U.S.C.A. § 5107(b), but there is 
not such a state of approximate balance of the positive evidence 
with the negative evidence to otherwise warrant a favorable 
decision.

II.  Right Ankle Disorder

The Veteran contends that he is entitled to service connection 
for a right ankle disorder because he hurt his right ankle while 
on active duty for training with the National Guard in July 1993.  
He claims that he has had problems with the ankle ever since 
then.  He also testified that he reinjured the ankle when he was 
recalled to active duty in 2004.

A review of the service treatment records from the Veteran's 
first period of service reflect that in October 1981 the Veteran 
was treated for complaints of pain in the right foot.  The 
service treatment records do not reflect that he was diagnosed 
with any right ankle disorder during his first period of service.

Records after his second period of active service from June 2004 
to August 2004 reflect that the Veteran was treated in March 2007 
for problems with both ankles.  X-rays showed degenerative 
changes in both feet and ankles.  A June 2007 VA podiatry note 
indicates that the Veteran complained of pain in the right ankle 
after walking all day.  The Veteran indicated that the right 
ankle had been painful for five years.  The impression was 
degenerative joint disease of the right ankle, talar fracture, 
and hypertrophied navicular.  

A September 2008 VA examination report notes that the Veteran 
sprained his right ankle playing basketball while on two weeks 
active duty.  He had pain and reduced range of motion.  No 
fracture was revealed by X-rays.  When he returned home, he went 
to his primary care physician and received an ace bandage, pain 
medications, nonsteroidal anti-inflammatories, and was told to 
rest.  He got worse.  He then sought treatment through VA and 
received orthotic inserts for his shoes, an ankle brace, and pain 
medications.  This did not help.  A June 2007 X-ray revealed 
degenerative/traumatic arthritis, a talar fracture, and navicular 
hypertrophy of the right ankle.  He underwent corrective surgery 
for this condition in December 2007.  His pain improved.  The 
examiner opined that the degenerative/traumatic arthritis and 
talar fracture of the right ankle was not caused by or a result 
of the Veteran's first period of active service because the 
service treatment records from that period of service do not 
reflect any right ankle injury.  There is also no evidence 
showing that the right ankle injury occurred in the first year 
after discharge from the first period of service.  There is no 
documented evidence that the right ankle injury occurred or was 
aggravated by the second period of active military service 
between June 17, 2004 and August 13, 2004.  The examiner noted 
that by the Veteran's own verbal account, his initial right ankle 
injury occurred while on two weeks active military duty training 
with the National Guard in 1993.  Although the examiner could not 
find documentation of this injury, the examiner felt that the 
story is believable and credible.  

The Veteran's service personnel records reflect that he served on 
active duty for training for 13 days during 1993.  He also served 
on inactive duty training.  In light of this information and the 
VA examiner's opinion that the Veteran's version of his right 
ankle injury during such service is credible and believable, the 
Board finds that the evidence is in favor of the Veteran's claim 
for service connection for a right ankle disorder.  In this 
regard, the Board acknowledges the Court's recent holdings 
affirming the ability of lay statements to establish the 
occurrence of an in-service injury even in the absence of 
contemporaneous documentation.  See Davidson v. Shinseki, 581 
F.3d 1313, 1316 (Fed. Cir. 2009), (a lay statement can be 
sufficient to show that a disability began in service); Buchanan 
v. Nicholson, 451 F.3d 1331, 1337 (2006) (VA cannot determine 
that lay evidence lacks credibility merely because it is 
unaccompanied by contemporaneous medical evidence of the in-
service event); see also Jandreau v. Nicholson, 492 F.3d 1372, 
1376-77 (Fed. Cir. 2007) (lay evidence can be competent and 
sufficient to establish a diagnosis of a condition when (1) a 
layperson is competent to identify the medical condition, (2) the 
layperson is reporting a contemporaneous medical diagnosis, or 
(3) lay testimony describing symptoms at the time supports a 
later diagnosis by a medical professional).

Based on the above, and resolving all doubt in the Veteran's 
favor, service connection for a right ankle disorder is granted.  
See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102.


ORDER

Service connection for a heart condition claimed as abnormal EKG 
is denied.

Service connection for a right ankle disorder is granted.



____________________________________________
A. BRYANT
Veterans Law Judge, Board of Veterans' Appeals




 Department of Veterans Affairs