Citation Nr: 1120597 Decision Date: 05/26/11 Archive Date: 06/06/11 DOCKET NO. 10-16 378 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUE Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD K. Millikan, Counsel INTRODUCTION The Veteran served on active military duty from April 1967 to December 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a November 2009 rating decision by the Albuquerque, New Mexico, Regional Office (RO) of the Department of Veterans Affairs (VA). FINDING OF FACT The Veteran's service-connected posttraumatic stress disorder (PTSD) is manifested by occupational and social impairment with reduced reliability and productivity due to symptoms such as an anxious mood, extreme hypervigilance, and extreme guardedness, but an appropriate affect, good insight, good judgment, normal speech, and difficulty in establishing and maintaining effective work and social relationships. CONCLUSION OF LAW The criteria for an initial evaluation of 50 percent, but no more, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). REASONS AND BASES FOR FINDING AND CONCLUSION Under 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 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010). 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. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). This notice must be provided prior to an initial RO decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). VCAA notice requirements apply to all five 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication, such as where (1) the claimant demonstrates actual knowledge of the content of the required notice; (2) a reasonable person could be expected to understand from the notice what was needed; or (3) a benefit could not have been awarded as a matter of law. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders/Simmons, 556 U.S. __ (2009). Defective timing may be cured by a fully compliant notice letter followed by a readjudication of the claim. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). But "[i]n cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated-it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled." Dingess/Hartman, 19 Vet. App. at 490; Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007) (noting that once an initial VA decision awarding service connection and assigning a disability evaluation and effective date has been made, section 5103(a) notice is no longer required). Additionally, where service connection has been granted, the claimant bears the burden of demonstrating prejudice from defective notice with respect to downstream elements such as effective dates or disability ratings. Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). Here, the Veteran was sent a letter in February 2009 that provided the required VCAA notice and the Veteran has made no assertions regarding defective notice or resulting prejudice. Accordingly, VA's duty to notify has been satisfied. VA's duty to assist the Veteran has also been satisfied. 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(c)(1)-(3). The Veteran's service treatment records, service personnel records, private medical records, and VA medical records have been obtained. VA provided the Veteran a medical examination in October 2009 that is adequate as it was conducted upon a review of the claims file and addresses the relevant rating criteria and the Veteran's psychiatric symptomatology. In October 2010, the Veteran sent in additional VA medical evidence with a waiver of RO adjudication. See 38 C.F.R. § 20.1304(c) (2010) (holding that any additional pertinent evidence received by the Board that has not already been considered by the RO must be referred to the RO for consideration unless there has been a waiver of such consideration). Additionally, the Veteran provided testimony at an October 2010 Board hearing. There is no indication in the record that additional evidence relevant to the issues decided herein is available and not part of the claims file. See Pelegrini, 18 Vet. App. at 121-22. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 542-43 (2006), aff'd, Mayfield v. Nicholson, 499 F.3d 1317 (2007); see also Dingess/Hartman, 19 Vet. App. at 486. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2010). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2010). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2010). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Board notes, however, that this rule does not apply here, because the current appeal is based on the assignment of an initial rating for a disability following an initial award of service connection for this disability. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Instead, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson, 12 Vet. App. at 126. If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126. For an initial disability rating, VA must consider the severity of the disability during the period for which the veteran is eligible for service connection starting on the date the application was filed. Moore v. Nicholson, 21 Vet. App. 211, 216-17 (2007). Accordingly, here, the relevant time period begins in January 2009. In January 2009 VA medical records, the Veteran reported flashbacks, interrupted sleep, and that he was always on guard. He had been married for 32 years and had no children. He was a photographer by trade. He did not demonstrate suicidal ideations or behavior. In a February 2009 VA record, the Veteran reported anxiety, hypervigilance, intrusive images and memories, sleep problems, a greater need for alcohol to calm himself down, and difficulty concentrating. He also stated he self-isolated and had no friends, although he had a supportive relationship with his wife. Upon examination, there was hyperarousal, slightly pressured speech, and an anxious mood. There was a linear thought process, appropriate thought content, and good insight and judgment. A Global Assessment of Functioning (GAF) score of 61 was assigned, which reflects some mild symptoms, for example depressed mood and mild insomnia; or some difficulty in social, occupational, or school functioning, for example occasional truancy, or theft within the household; but generally functioning pretty well, and has some meaningful interpersonal relationships. See Diagnostic and Statistical Manual of Mental Disorders, 46-47 (4th ed. 1994) (DSM-IV). In March 2009 VA medical records, the Veteran reported difficulty managing his anxiety, tangential speech and thoughts, and problems staying asleep since he retired. He had obsessive thoughts and memories of past trauma, hypervigilance, social isolation, and insomnia. He denied depression. The examiner noted the Veteran had difficulty sitting still, pressured speech, and an anxious mood with no intent to harm self or others. The Veteran was well groomed, alert, fully oriented, pleasant, with a stable mood, appropriate affect, normal perception, organized thought process, intact memory, good insight, and good judgment, and had no delusions or suicidal or homicidal ideations. The GAF score was 70, which contemplates some mild symptoms, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well. See DSM-IV at 46-47. In a June 2009 VA record, the Veteran reported improved mood and less anxiety since he had begun work with his photo studio. He reported some irritability and hypervigilance. He was taking medication. In August 2009 VA medical records, the Veteran reported that he spends 70 to 80 percent of his time obsessively researching the internet for gun control and safety tips, constantly feeling the need to carry a weapon, and has a fair amount of guns and ammunition at home for safety. He had a difficult time leaving the house. He denied suicidal or homicidal ideations and had no feelings of a foreshortened future. He has a difficult time distinguishing between reasonable safety precautions and obsessive safety behaviors. The examiner noted PTSD with active symptoms. There was an anxious mood. The Veteran reported a little bit of repeated disturbing dreams of stressful experiences, avoiding thinking, talking, or having feelings about or talking about the stressful experiences from the past, feeling emotionally numb or being unable to have loving feelings, trouble falling or staying asleep, feeling irritable or having angry outbursts, and difficulty concentrating. He reported a moderate amount of repeated disturbing memories, thoughts, or images of the stressful experience from the past, physical reactions when something reminds him of the stressful experiences from the past, avoiding activities or situations that are reminders of the stressful experience. He reported quite a bit of suddenly acting or feeling as if the stressful experience from the past was happening again, feeling very upset when something reminds him of the stressful experience, trouble remembering important parts of the stressful experience, loss of interest in activities that he used to enjoy, feeling distant or cut off from other people, and feeling jumpy or easily started. He reported being extremely superalert, watchful, or on guard. In a September 2009 VA medical record, the Veteran reported hypervigilance and anxiety. He was not suicidal or homicidal. He was well-groomed and alert, with good eye contact, intact cognitive function, and within normal limits psychomotor functioning, speech, and perception. There was an anxious mood, appropriate affect, and an organized, obsessive, and compulsive thought process. The GAF score was 70, which contemplates some mild symptoms, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. See DSM-IV at 46-47. In September and October 2009 individual therapy sessions, his mood was stable and he was without suicidal or homicidal ideations. An October 2009 VA PTSD examination was conducted. The Veteran reported that he was participating in individual psychotherapy and was taking medication. The Veteran was married in 1971 but that marriage lasted only four years. He married a second time in 1976 and the marriage was fine. They have no children. He has not maintained much of a social life and all his friends are Vietnam veterans. He enjoys photography. The Veteran's occupation was photographer, but he had retired in 2008 due to eligibility due to age or duration of work. The Veteran stated that he continues to be bothered by images of many of the pictures he took during the Vietnam. He also reported sleep disturbance. The examiner found the Veteran clean in appearance and fully oriented, hyperactive, restless, cooperative, and of above-average intelligence. There was unremarkable speech, normal affect, good impulse control, anxious mood, intact attention, rambling thought process, and paranoid ideation, but the Veteran understood the outcomes of behavior. There were no delusions, hallucinations, suicidal or homicidal thoughts, obsessive or ritualistic behaviors, or panic attacks. There was mildly impaired memory. The examiner determined that the Veteran's symptoms were chronic, daily to weekly, and mild to moderate. There was limited social support. Over the past 2 years, the GAF score was 60, which contemplates moderate symptoms, for example, a flat affect and circumstantial speech, or occasional panic attacks, or moderate difficulty in social, occupational, or school functioning, such as having few friends, and conflicts with peers or co-workers. See DSM-IV at 46-47. In a November 2009 statement, the Veteran reported panic attacks, hypervigilance, memory loss, and forgetting to complete tasks. He stated that did not have many friends and did not see his friends often. He moved to the outskirts of town to be away from society, and in the latter part of his career he had difficulty getting along with coworkers. In November and December 2009 VA medical records, there was a stable mood without evidence of suicidal or homicidal ideations. In January 2010 VA records, the Veteran reported hypervigilance, anxiety, and poor sleep. He was not suicidal or homicidal. The examiner found the Veteran well-groomed and alert with normal psychomotor functioning, normal speech, appropriate affect, an organized, obsessive, and compulsive thought process, normal perception, intact cognitive functions, and an anxious and stable mood. A GAF score was 70, which signifies some mild symptoms, for example depressed mood and mild insomnia; or some difficulty in social, occupational, or school functioning, for example occasional truancy, or theft within the household; but generally functioning pretty well, and has some meaningful interpersonal relationships. See DSM-IV at 46-47. In March 2010 VA records, the Veteran stated difficulties with friendships, hypervigilance, not trusting authorities or those around him, and feeling like an outsider. He also reported paranoia. There was an anxious and stable mood, but no evidence of suicidal or homicidal ideations. In an April 2010 statement, the Veteran reported panic attacks more than once a week, which was aided since he moved out to a rural area, memory loss, and suicidal ideation, although not regularly. He stated that he only had three friends, two of which are email friends. In a May 2010 VA record, the Veteran stated he had a great deal of anxiety and was isolative and hypervigilant. He carried a gun at home and rarely came in to town. He reported poor sleep. The examiner found the Veteran well-groomed and alert, with good eye contact, normal speech, appropriate affect, normal perception, intact cognitive functions, an anxious mood, and an organized, obsessive, and compulsive thought process. There were no suicidal or homicidal ideations. The GAF score was 70, which reflects some mild symptoms, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. See DSM-IV at 46-47. In a July 2010 VA medical record, the Veteran reported high levels of hypervigilance and pushing people away. He feels isolated. He contacted a local photography group and was planning some trips with an individual. There was an anxious mood but no evidence of suicidal or homicidal ideations. In an August 2010 VA record, the Veteran reported isolation, marked hypervigilance, and avoidance. There was a stable mood and no suicidal or homicidal ideations. He was being referred for possible medication to aid in reducing paranoia and obsessive thoughts. In an October 2010 VA record, the Veteran reported chronic fears of being vulnerable in public situations and anger at authorities that prohibit citizens from carrying guns in public places. He spends most of his time thinking about protecting himself. He holds people at a distance who do not agree with him and holds back from engaging in enjoyable activities, including participating in outings of a photography club. He continued to experience isolation, fear, and anger. There was an anxious mood and he was irritable. There was no evidence of suicidal or homicidal ideations. In an October 2010 letter, a VA physician stated that the Veteran suffered from PTSD symptoms including excessive hypervigilance and guardedness that interferes with his ability to lead a more productive lifestyle. There was mistrust and isolation that kept him at home. Although the Veteran was an accomplished photographer, it remained difficult for him to engage in any productive activities because of his fear of being attacked. He remained isolated from social activities because he could not accept others that were not as guarded as him. At the October 2010 Board hearing, the Veteran reported panic attacks any time he leaves the house and that he was armed while he was at home. He self-isolates and tries to avoid people. Once per year he went to the Homeowner's Association meeting. His symptoms had worsened after he retired. He lives with his wife, although they do not participate in many activities outside the house. He had readied his jeep for any disaster - it has emergency gear, including shovel, ax, and radio equipment. He had significantly altered the jeep so that it was like his military vehicle in Vietnam. He stated he was constantly on alert and also reported memory loss, obsessional rituals, and irritability. He had every window in his home barred and had a security system. He conducted perimeter checks to include checking that the security system was working. The Veteran stated that he was too law abiding to be homicidal or suicidal, but had road rage and panic attacks. He reported that his biggest symptom was a continuous panic in that he was in ready state of anxiety all the time. He was not taking daily medication, but took it when he went into town. He had no friends, and only associated with people at the VA and the American Legion. He did not take public transportation. The Veteran reported that it was difficult to report the severity of his symptoms at the initial VA examination. The evidence of record supports an initial evaluation of 50 percent, but no more, for the Veteran's PTSD. The level of occupational and social impairment due to a psychiatric disorder is the primary consideration in determining the severity of a psychiatric disorder for VA purposes and not all the symptoms listed in the rating criteria must be present in order for a rating to be warranted. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding that the psychiatric symptoms listed in the rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings). First, the Veteran's GAF scores must be assessed. The GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health - illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quotation omitted). A GAF score is highly probative, as it relates directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). Here, the Veteran's GAF scores were primarily in the 61 to 70 range, which reflects some mild symptoms, for example depressed mood and mild insomnia; or some difficulty in social, occupational, or school functioning, for example occasional truancy, or theft within the household; but generally functioning pretty well, and has some meaningful interpersonal relationships. See DSM-IV at 46-47. In October 2009, a GAF score of 60 was assigned, which contemplates moderate symptoms, for example, a flat affect and circumstantial speech, or occasional panic attacks, or moderate difficulty in social, occupational, or school functioning, such as having few friends, and conflicts with peers or co- workers. See DSM-IV at 46-47. These GAF scores indicate mild to moderate PTSD symptoms and do not definitively support an increased evaluation. For example, a 30 percent evaluation is assigned for PTSD manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, whereas a 50 percent evaluation is manifested by occupational and social impairment with reduced reliability and productivity and difficulty in establishing and maintaining effective work and social relationships. PTSD symptomatology characterized as mild and moderate generally may support either a 30 or 50 percent evaluation. Second, however, all the pertinent evidence of record must be considered and the decision must be based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. The Veteran's PTSD is currently evaluated as 30 percent disabling. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent evaluation is assigned for occupational and social impairment with reduced reliability and productivity due to symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board finds that the Veteran's symptoms more closely approximate the criteria for a 50 percent evaluation. Throughout the time period, the Veteran has consistently demonstrated that although he is well-groomed, alert, and fully oriented, there is also self-isolation, extreme hypervigilance, and extreme guardedness. Although his PTSD manifestations are not well-represented by the list of symptoms in the 50 percent criteria, as he has an appropriate affect, normal speech, above average intelligence, and good insight and judgment, his symptoms cause occupational and social impairment with reduced reliability and productivity and difficulty in establishing and maintaining effective work and social relationships. See 38 C.F.R. § 4.7 (2010) (noting that if two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned). He reported having only a few friends and noted that two of those friends are email friends. He has an inability to maintain friendships with people who are not as guarded or on alert as he is. He has maintained a good relationship with his wife, but they do not participate in many activities and he remains mostly home-bound. The Veteran has reported experiencing panic attacks in November 2009 and April 2010 statement. At the October 2010 hearing, he explained that he was in a constant state of near-panic or fear that required him to be armed at all times and to only travel to places in his car that was specially equipped for disaster. Furthermore, his PTSD is manifested by several representative symptoms as listed in the 50 percent diagnostic criteria, to include memory impairment and an anxious mood. Accordingly, and resolving all reasonable doubt in favor of the Veteran, a 50 percent initial evaluation is warranted. See 38 C.F.R. § 4.3 (2010) (noting that any reasonable doubt is resolved in favor of a veteran). The Board finds that a 70 percent evaluation, however, is not warranted. Although he has reported a near-continuous state of panic, the Veteran does not have deficiencies in most areas with an inability to establish and maintain effective relationships. The examiners consistently noted that although his thought process was obsessive and compulsive, it was also organized and his cognitive functions were intact. He also demonstrated good judgment and impulse control. There was an anxious mood, but the Veteran was able to maintain an effective relationship with his wife and with at least a few friends. Finally, the Veteran's PTSD is not manifested by obsessional rituals that interfere with routine activities, abnormal speech, impaired impulse control, disorientation, or neglect of hygiene. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (noting that a 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships). Accordingly, a 50 percent, but not a 70 percent, initial evaluation is warranted. Consideration has also been given regarding whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2010); 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). An extra-schedular 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. Thun, 22 Vet. App. 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. In this regard, the schedular evaluation in this case is not inadequate. A rating in excess of 50 percent is provided for certain manifestations of the service-connected PTSD but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's PTSD, as the criteria assess various symptomatology and the effects on the Veteran's social and occupational functioning. Accordingly, this appeal need not be referred for consideration of an extraschedular rating. ORDER An initial evaluation of 50 percent, but no more, for service-connected PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs