Citation Nr: 1122934 Decision Date: 06/15/11 Archive Date: 06/28/11 DOCKET NO. 09-06 854 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for post traumatic stress disorder (PTSD) prior to June 5, 2009. 2. Entitlement to a rating in excess of 70 percent from June 5, 2009 for PTSD. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Heather M. Gogola, Counsel INTRODUCTION The Veteran served on active duty from January 1944 to March 1946. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Board notes that the issues initially certified to the Board included the issue of entitlement to an earlier effective dated prior to June 5, 2009 for a 70 percent rating for PTSD. However, as this issue is incorporated with the claim for an initial rating in excess of 30 percent, the Board has incorporated the issue of entitlement to an effective date for a 70 percent rating for PTSD prior to June 5, 2009, into the Veteran's claim for an initial rating in excess of 30 percent for PTSD. FINDINGS OF FACT 1. Prior to June 5, 2009, the impairment from the Veteran's service-connected PTSD most nearly approximated an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to symptoms. 2. From June 5, 2009, the impairment of the Veteran's service-connected PTSD most nearly approximated deficiencies in most areas, such as work, family relations, judgment, thinking or mood, due to symptoms, without total social and occupational impairment. CONCLUSIONS OF LAW 1. Prior to June 5, 2009, the criteria for an initial rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.126, 4.130, Diagnostic Code 9411 (2010). 2. From June 5, 2009, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.126, 4.130, Diagnostic Code 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2010), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2010), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is specifically to inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Although the regulation previously required VA to request that the claimant provide any evidence in the claimant's possession that pertains to the claim, the regulation has been amended to eliminate that requirement for claims pending before VA on or after May 30, 2008. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was provided complete VCAA notice by letter mailed in July 2007, prior to the originating agency's initial adjudication of the claim for service connection for PTSD. In addition, the Veteran's service treatment records as well as pertinent post-service treatment records have been obtained, and VA examinations have been provided. Further regarding the duty to assist, the Veteran's statements in support of the claim as well as a transcript of a hearing before the undersigned Veterans Law Judge are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also 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 claim. 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 claim. 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). Accordingly, the Board will address the merits of the claim. Legal Criteria Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2010). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When evaluating a mental disorder, the VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. VA shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Under 38 C.F.R. § 4.130, Diagnostic Code 9411, PTSD is rated under the General Rating Formula for Mental Disorders. A 100 percent evaluation is warranted for total occupational and social impairment, due to symptoms such as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting himself or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to symptoms such 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 or hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 50 percent evaluation is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms 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 (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 30 percent evaluation is warranted for occupational and social impairment with decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events. In addition, 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(b) (West 2002); 38 C.F.R. § 4.3 (2010). Background By a July 2008 rating decision, the RO granted service connection and assigned a 30 percent rating, effective July 2007. The Veteran disagreed, asserting his PTSD warranted a higher rating. In a June 2009 supplemental statement of the case (SSOC), the RO granted an increased rating to 50 percent, effective June 5, 2009. A September 2009 SSOC granted an increased rating of 70 percent, effective June 5, 2009. The Veteran chose to continue his appeal, asserting that his PTSD warranted a higher rating. He also asserted that the 70 percent rating should be effective prior to June 5, 2009. The Veteran submitted records from the Vet Center dated August 2005 to June 2007. An August 2005 social survey indicated that the Veteran had never been married but did have two long-term relationships. The first lasted until his significant other died. He described his current relationship as an excellent relationship. The Veteran also described himself as getting along well with others. The Veteran endorsed symptoms including panic attacks, occasional flashbacks, and trying to avoid negative things. The Veteran was able to keep his focus during the day. The examiner noted that the Veteran was neat and clean in appearance, with good hygiene and relevant, coherent and spontaneous speech. Memory was within normal limits and thinking tended to be concrete. The Veteran's significant other indicated that the Veteran has always seemed a little nervous. A diagnosis of anxiety disorder not otherwise specified was provided. Records dated April to July 2007 indicated symptoms of anxious and depressed mood. The Veteran reported not having a close friend since the war and stated that he had never been close with the two women he shared his life with. He also reported a need for constant activity in order to prevent intrusive thoughts. An April 2007 evaluation indicated that the Veteran's anxiety had persisted. The Veteran again reported needing to keep himself busy to control his intrusive thoughts. The Veteran stated that he got along well with people, but aside from his family, he did not have close friends. The Veteran also had suicidal thoughts at times but no plans. The psychologist noted that the Veteran's affect was sad, and mood was anxious and depressed. Speech was spontaneous, relevant and coherent, and hygiene was good. Group Counseling notes dated November 2005 to April 2007 indicated that the Veteran endorsed symptoms of re-experiencing combat -related trauma, avoidance, hyper arousal, depression, anger management, and anxiety. Diagnoses of PTSD were noted. VA treatment records dated May to June 2007 indicate that the Veteran endorsed symptoms of nightmares once or twice a month, a panic attack, crying several times a week, ruminating about the war, inability to remember aspects of his active service, and trouble sleeping. The Veteran's affect was moderately blunted and he was mildly to moderately depressed on a chronic basis. Memory was good and there were no signs of psychotic ideation. The Veteran reported an occasional thought of suicide but would never consider following through. The psychiatrist noted that the Veteran seemed to be suffering from delayed PTSD. A follow-up June 2007 record noted that the Veteran was vastly improved after starting medications that helped with his sleep and mood. An August 2007 Vet Center record noted that the Veteran was a master of denial, and the psychologist noted that the Veteran's affect and statements did not accurately reflect how he was doing. The Veteran avoided strong feelings by pushing himself physically, and had recently had to slow down. In an August 2007 statement, the Veteran reported sleep disturbances during which he kicked holes in sheetrock walls during a nightmare. A September 2007 VA treatment record indicated that the Veteran had marked improvement in depression several months prior after starting medication, but currently appeared to be slipping back into his depression. An October 2007 VA treatment record noted that the Veteran was treated for PTSD symptoms including nightmares, crying, being isolated from his family, and hypervigilence. The Veteran was afforded a VA examination in May 2008. The Veteran reported a good relationship with his girlfriend. The Veteran reported symptoms including nightmares two to three times a week, intrusive thoughts, occasional flashbacks, mild to moderate social anxiety, some degree of social avoidance, and some hypervigilence, as well as reported suicidal ideation about three to four years ago, but without plan. The Veteran did not have any problems with anger or impulse control. Mental status examination revealed that the Veteran's appearance, attitude, and behaviors were within the normal limits. Eye contact was good, speech was relevant, coherent and productive. Thought processes were rational and goal directed. Insight and judgment were good. There was no evidence of hallucinations, delusions, mania, psychosis, obsessions, compulsions, or ritualistic behaviors. Short term memory and concentration skills were intact. Mood was pleasant and euthymic and affect was appropriate with the full range noted. The examiner noted that the Veteran's symptoms were consistent with a diagnosis of chronic and currently mild to moderate PTSD. The examiner provided a diagnosis of chronic, mild to moderate PTSD, and assigned a global assessment of functioning (GAF) of 67. The examiner noted that the Veteran did not reveal any marked impairments regarding the Veteran's basic competence for maintaining himself independently and that his current level of personal and social adjustment is mildly to moderately impaired due to his PTSD. An August 2008 letter from the Vet Center indicated that the Veteran participated in individual and group therapy. The psychologist noted that the Veteran had PTSD symptoms including intrusive thoughts, avoidance of reminders of the war, social isolation, nightmares causing sleep disturbances, constantly being on guard, and difficulty concentrating. The Veteran reported anger at times and needing to be careful not to lose his temper. The psychologist opined that the Veteran had severe chronic PTSD that impaired his ability to live a rewarding life. A statement received from the Veteran in April 2009 indicated that he was no longer physical able to keep himself busy due to physical problems and as a result began having terrible nightmares, panic attacks, and sleep disturbances. He also stated that he had memory problems, particularly that he would forget something if he did not write it down. A May 2009 letter from R.W., MD, indicated that the she saw the Veteran for a physical in 2005 at which point the Veteran reported severe anxiety since World War II. By May 2006 the Veteran had insight into his PTSD and had been enrolled with the VA and Vet Center. The physician stated that the Veteran still experienced violent behavior at night, sleepwalking, nightmares, and continued to isolate himself from others. A May 2009 VA treatment record indicated complaints of nightly nightmares. Affect was mildly blunted but the Veteran did not appear to be morbidly depressed, helpless or hopeless. He denied any current suicidal ideation. The psychiatrist noted mild memory problems. In June 2009, the Veteran was afforded another VA PTSD examination by the same examiner who performed the May 2008 examination. The Veteran reported PTSD symptoms including nightmares three to four times a week, flashbacks two to three times a month, daily intrusive thoughts, moderate to at time severe social anxiety, hypervigilence including making frequent checks of windows and doors at home, recurring episodes of frustration and anger, moderate to severe sleep disturbance, severe startle response, marked anhedonia, irritability, and anxiety. The examiner noted that the Veteran's symptoms had recently increased due to the Veteran's retirement and decreased physical activities which prevent him from keeping as busy as before, which was the Veteran's way of keeping his symptoms at bay. Mental status examination revealed a fully cooperative Veteran with good hygiene, and good eye contact. Speech was mildly pressured, which the examiner attributed to anxiety, but was otherwise relevant, coherent, and productive. Thought processes were rational and goal directed. There was no evidence of hallucinations, delusions, specific obsessions, compulsions, phobias, or ritualistic behaviors. The Veteran did struggle with short-term memory and concentration. The examiner opined that the Veteran's PTSD symptoms did cause recurring disruptions in his capacity to focus and concentrate. Mood was tense and anxious throughout the examination and affect was somewhat constricted, but otherwise appropriate. There was no evidence of suicidal or homicidal ideation. The examiner opined that the Veteran had undergone a clear increase in PTSD symptoms since his last examination and that his current evaluation was consistent with a diagnosis of chronic and moderate to, in some areas, severe PTSD. A GAF score of 52 was provided. Vet Center records dated July 2009 indicated that the Veteran complained of nightly nightmares followed by ruminations on his war experiences, as well as intrusive thoughts. He had frustration in his inability to communicate with others. The Veteran also reported having suicidal ideation. Mood was anxious and depressed. The psychologist noted that the Veteran's symptoms made him unable to sustain gainful employment. Subsequent Vet Center records dated through October 2009 noted symptoms including fatigue, nightmares, and intrusive thoughts. An October 2009 record noted that the Veteran's PTSD alone was severe enough to preclude him from gainful employment. Additionally, the counselor noted that the Veteran displayed anxious and depressed mood, and sad affect. A January 2010 VA treatment record noted continued complaints of nightmares and intrusive thoughts related to PTSD, as well as depression and memory problems. The Veteran also reported difficulty sleeping. Mood was depressed and the physician noted anhedonia. Affective range was good and there was no overt psychosis. Judgment and insight were adequate to provide informed consent for treatment. The Veteran denied hallucinations, delusions, homicidal thoughts, suicidal thoughts or intent. A diagnosis of PTSD and major depression were provided and a GAF score of 50 was assigned. The Veteran was afforded a hearing before the undersigned Veterans Law Judge in May 2011. The Veteran testified that in the last eight to ten years he'd been having PTSD symptoms and felt that the severity of his symptoms had been the same since he initially filed a claim for PTSD in July 2007. Analysis With respect to the period prior to June 5, 2009, the evidence shows that the Veteran's PTSD was characterized primarily by nightmares two to three times a week, occasional flashbacks, intrusive thoughts, mild to moderate social anxiety, some degree of social avoidance, and some hypervigilence. The Veteran consistently reported a good relationship with his current, long-term girlfriend but no close friends, and did not report any symptoms of anger or impulse control. Vet Center records as well as the May 2008 VA examiner noted that the Veteran reported some occasional suicidal ideation without plan or intent. The May 2008 VA examiner stated that there was no evidence of any marked impairments in the Veteran's basic competence for maintaining himself independently and that his current level of personal and social adjustment was mildly to moderately impaired due to his PTSD. An August 2008 Vet Center letter noted some complaints of difficulty concentrating and a May 2009 VA record noted some mild memory problems. Repeated examinations revealed no evidence of circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; or impaired abstract thinking. Overall, prior to June 5, 2009, the Veteran's speech was clear and coherent, and thought processes and content were normal. Judgment and insight were good. There was no evidence of hallucinations, delusions, obsessive, compulsive, or ritualistic behaviors and impulse control was good. Short term memory and concentration skills were intact, and as such, there was no evidence for memory loss including the names of close relatives, own occupation or his own name. There were occasional suicidal thoughts, but as of the May 2008 VA examination, the Veteran denied any suicidal ideation. While the August 2008 Vet Center record indicated that the Veteran reported feeling angry and feeling the need to control his temper at times, there was no evidence of unprovoked irritability with periods of violence. In summary, prior to June 5, 2009, the impairment from the Veteran's service-connected PTSD most nearly approximated an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to symptoms. The criteria for an initial rating in excess of 30 percent for PTSD have not been met prior to June 5, 2009. Regarding the period from June 5, 2009, the June 2009 VA examiner noted that the Veteran's PTSD symptoms had clearly increased in severity since his last VA examination. The examiner opined this was due to the Veteran's retirement as well as decreased physical activities which deprived the Veteran of his coping with his PTSD symptoms by keeping busy. From June 5, 2009, the Veteran's PTSD symptoms were characterized by nightmares at least three to four times a week, flashbacks, daily intrusive thoughts, moderate to severe social anxiety, hypervigilence, recurring episodes of frustration and anger, moderate to severe sleep disturbance, severe startle response, memory and concentration problems, marked anhedonia, irritability, and anxiety. Vet Center records dated July and October 2009 noted some suicidal ideation, and the psychologist opined that the Veteran's PTSD symptoms precluded him unable to sustain gainful employment. Moreover, the June 2009 VA examiner indicated an increase in severity of PTSD symptoms at the June 2009 examination in comparison to the previous May 2008 examination. Repeated examinations revealed no evidence of 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; or neglect of personal appearance or hygiene. Overall, from June 5, 2009, the Veteran had good hygiene and good eye contact. Speech was mildly pressured, but otherwise relevant, coherent and productive. Thought processes were rational and goal directed. Judgment and insight were adequate. There was no evidence of hallucinations, delusions, obsessive, compulsive, or ritualistic behaviors. Short term memory and capacity for concentration were disrupted by the Veteran's PTSD symptoms. Mood was tense and affect was somewhat constricted. The June 2009 VA examination found no evidence of suicidal or homicidal ideation. GAF scores were assigned in May 2008 (67), June 2009 (52), and January 2010 (50). However, GAF scores alone do not provide a basis for the assignment of a higher disability rating for PTSD. According to the Fourth Edition of American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a GAF score is a scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental-health illnesses. The GAF score and the interpretation of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). The GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). GAF scores between 41 and 50 are indicative of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores between 51 and 60 are indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores between 61 and 70 are indicative of some mild symptoms (e.g. depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful relationships. For the most part, the GAF scores assigned in this case are consistent with the Board's determinations. To the extent that they are not, the Board has found the specific findings and history noted in the reports to be more persuasive than the GAF scores. During the period prior to June 5, 2009, almost all of the symptoms associated with the Veteran's PTSD are contemplated by the criteria for a rating of 30 percent. For the period beginning June 5, 2009, none of the symptoms associated with a 100 percent rating has been demonstrated. Throughout the period of this claim, the Veteran has maintained some social interactions, particularly with his current, long-term girlfriend. During the period prior to June 5, 2009, while the Veteran stated he did not have close friends, he reported that he got along well with others. Additionally, the May 2008 VA examiner stated that the Veteran's current level of personal and social adjustment was only mildly to moderately impaired due to his PTSD. In summary, from June 5, 2009, the impairment of the Veteran's service-connected PTSD most nearly approximated deficiencies in most areas, such as work, family relations, judgment, thinking or mood, due to symptoms, without total social and occupational impairment. The criteria for a rating in excess of 70 percent for PTSD have not been met from June 5, 2009 . The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Shinseki, F.3d 1366 (Fed. Cir. 2009). Here, as discussed above, the rating criteria for the disabilities at issue reasonably describe the Veteran's disability level and symptomatology. Thus, as the Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate, and no referral for an extraschedular evaluation is required. Id. In light of the foregoing, the Board finds that the preponderance of the evidence is against the claim for an initial rating in excess of 30 percent for PTSD prior to June 5, 2009. The preponderance of the evidence is also against the claim for a rating in excess of 70 percent for PTSD from June 5, 2009. In making this determination, the Board considered the benefit-of-the-doubt doctrine but finds that it is inapplicable. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to an initial rating in excess of 30 percent for PTSD prior to June 5, 2009, is denied. Entitlement to a rating in excess of 70 percent from June 5, 2009, is denied. ____________________________________________ MICHAEL MARTIN Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs