Citation Nr: 1300617 Decision Date: 01/08/13 Archive Date: 01/16/13 DOCKET NO. 10-35 588 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to an initial rating in excess of 20 percent for diabetes mellitus. 2. Entitlement to an initial compensable rating for obstructive sleep apnea. 3. Entitlement to an initial compensable rating for hypertension. 4. Entitlement to an initial compensable rating for gastroesophageal reflux disease (GERD). 5. Entitlement to an initial rating in excess of 10 percent for a disability of the thoracolumbar spine. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD N. Holtz, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1989 to May 2009. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah Because the current appeal was processed as part of the Virtual VA system, any future consideration of this appellant's case should take into consideration the existence of this electronic record. It is noted that a claim for a total rating based on individual unemployability was raised during the course of this appeal. That claim was denied by rating action of July 2011 and the Veteran was provided notice of that denial in October 2011. The record before the Board contains an Informal Hearing Presentation where his representative recites the appellant's earlier contention that he is unemployable, but does not contain a disagreement with the July 2011 rating. As, that issue is not before the Board at this time. The issue of entitlement to an initial rating in excess of 10 percent for a thoracolumbar spine disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's diabetes mellitus requires insulin, metformin, and a regulated diet, but the Veteran has not been instructed to restrict his activities by a medical professional. 2. The Veteran's obstructive sleep apnea is mild and productive of snoring, but does not cause persistent daytime hypersomnolence. 3. The Veteran's hypertension requires continuous medication for control, but his diastolic pressure is not predominantly over 100 mmHg, his systolic pressure is not predominantly over 160 mmHg, and he does not have a history of diastolic pressure over 100 mmHg. 4. The Veteran's GERD causes heartburn on average less often than one time per week, but is not productive of dysphagia, pyrosis, or regurgitation, or other symptomatology. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.31, 4.119, Diagnostic Code (DC) 7913 (2012). 2. The criteria for an initial compensable rating for sleep apnea have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.31, 4.97, Diagnostic Code 6847 (2012). 3. The criteria for an initial compensable rating for hypertension have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.31, 4.104, Diagnostic Code 7101 (2012). 4. The criteria for an initial compensable evaluation for GERD have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.27, 4.31, 4.114, DC 7346 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist 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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). The Veteran's appeal concerns the initial evaluations assigned following grants 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. Dunlap v. Nicholson, 21 Vet. App. 112, 117 (2007). Therefore, no further notice is needed under VCAA. VA has fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate his claims for increased initial ratings. The claims file contains the Veteran's service treatment records, as well as post-service reports of VA treatment and medical examination. Moreover, the Veteran's statements in support of the claim are of record, as are those of his representative. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified with respect to the issues being adjudicated. 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 claims adjudicated in this decision. 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 these claims. 38 C.F.R. § 3.159(c). Initial Rating Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where service connection has been granted and the assignment of an initial evaluation is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-26 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function, however, will be expected in all instances. 38 C.F.R. § 4.21. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. In making all determinations, the Board must fully consider the lay assertions of record. Buchanan, 451 F.3d at 1335. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a). Thus, a layperson is competent to report on the onset and continuity of his symptomatology. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (holding that a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the medical issue is within the competence of a layperson, (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. See Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). For instance, a lay person may speak to etiology in those limited circumstances where a nexus is obvious merely through observation, such as a fall leading to a broken leg. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) Where there is conflicting medical evidence, the Board may not ignore or disregard any medical professional's opinion, but may favor one medical opinion over by providing an adequate statement of reasons or bases. Owens v. Brown, 7 Vet. App. 429, 433 (1995). A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Thereafter, the Board's duty is to assess the credibility of all material. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995). 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. Diabetes Mellitus The RO assigned an initial rating of 20 percent for the Veteran's diabetes mellitus. For the next higher rating, 40 percent, the evidence would have to demonstrate that the Veteran required insulin, a restricted diet, and a regulation of activities. 38 C.F.R. § 4.119, Diagnostic Code (DC) 7913. A rating in excess of 40 percent would require ketoacidosis or hypoglycemic reactions. "Regulation of activities" has been defined as the situation where the Veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,446 (May 7, 1996) (defining "regulation of activities," as used by VA in DC 7913). Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360 (2007). Although as shown in the examination reports from the March 2009 pre-separation examination, and the two October 2010 VA examinations (October 6th and 25th), the Veteran does require insulin and a regulated diet to control his diabetes (in addition to metformin), that treatment regimen only qualifies him for a 20 percent rating. He indicated on his August 2010 VA Form 9 Substantive Appeal that he required regulation of activities, but the evidence shows that any such regulation of activities has not been medically prescribed. At both of his general medical examinations in October 2010, he denied having been informed by a medical professional that he needed to regulate his activities to treat his diabetes, and there is no other medical evidence to suggest that he had been. Further, his representative acknowledged in correspondence dated in April 2012 that the Veteran's activities have not been regulated. As the Veteran is a layperson, his August 2010 statement concerning regulation of activities is insufficient to warrant a 40 percent rating for diabetes. Id. at 364. Therefore, he does not meet the criteria for a 40 percent rating, and has not at any stage of the appeal period. 38 C.F.R. § 4.119, DC 7913; Fenderson, 12 Vet. App. at 125-26. The Veteran indicated at his October 6, 2010 examination that he had experienced hypoglycemia or ketoacidosis, but that the reactions did not require hospitalization, and that he required "monthly or less often" visits to a diabetic care provider. Notably, he indicated on his medical history at his October 2010 eye examination that he had experienced a hypoglycemic episode. His service treatment records show that he had two hypoglycemic episodes shortly after his diabetes diagnosis, but that medication prevented subsequent episodes. At his pre-separation examination, he denied a history of hypoglycemic reactions, a statement that appears to be inaccurate. There is no evidence that he experienced post-service hypoglycemic episodes, a fact consistent with his denial of experiencing those episodes at the October 25, 2010 examination. Thus, the evidence also does not support a 60 percent or higher rating for diabetes. Id. The Board also finds that there is no evidence to suggest that the Veteran warrants separate ratings for any other diabetes-related disabilities (the issue of hypertension is addressed separately, below). Note (1) to DC 7913 provides that compensable complications of diabetes will be evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Non-compensable complications are considered part of the diabetic process. Other than his service-connected hypertension, there is no evidence that the Veteran has any other complications of diabetes mellitus. At his October 2010 examinations, he denied symptoms of other diabetic complications, including peripheral vascular disease, neurovascular disease, peripheral neuropathy, diabetic nephropathy, and skin disorders. At his October 6, 2010 general medical examination, and at his October 2010 eye examination, he indicated that he experienced blurry vision when his glucose levels were high. The optometrist who provided the eye examination determined that he did not experience diabetic retinopathy or any other diabetes-related eye symptomatology. The Board acknowledges the Veteran's lay association between his blurry vision and his blood sugar levels, but such a determination requires medical expertise; the Veteran is not competent to associate any vision symptomatology with his diabetes. See Jandreau, 492 F.3d at 1376-77. Sleep Apnea The Veteran is assigned an initial noncompensable evaluation for service-connected obstructive sleep apnea. In order to warrant a compensable rating, the evidence would have to show that he experienced persistent daytime hypersomnolence; under those circumstances, a 30 percent rating would be applicable. 38 C.F.R. § 4.97, DC 6847. A rating higher than 30 percent requires that the Veteran be prescribed the use of a continuous airway pressure (CPAP) machine, or other more severe symptoms, including chronic respiratory failure or that he required a tracheostomy. Id. There is some evidence to suggest that the Veteran has experienced daytime hypersomnolence, but nothing to suggest that the hypersomnolence is persistent. In April 2010, his representative characterized his hypersomnolence as "intermittent daytime hypersomnolence," and acknowledged that his daily activities were not affected by sleep apnea symptoms. Throughout his post-service records, there are two instances where the Veteran identified hypersomnolence. The first documentation of possible hypersomnolence is found in the report of the October 6, 2010 general medical examination. In describing his symptoms, the Veteran stated that in the past, he had loud snoring that caused intermittent daytime fatigue, but that since he lost weight to treat his diabetes, his snoring had lessened. Prior to a physical examination, and based on the Veteran's stated history, the examiner noted that daytime hypersomnolence was a "possible related symptom." Following examination, however, the examiner diagnosed the Veteran with mild obstructive sleep apnea that was improving with intentional weight loss, and that did not affect his usual daily activities. The second reference to hypersomnolence is from the October 2010 eye examination, in which the Veteran listed hypersomnolence in his medical history. When describing his symptoms to the October 25, 2010 examiner, he indicated that he snored while sleeping, but that his snoring had decreased as he lost weight. He no longer identified hypersomnolence as a symptom of his condition. The examiner characterized the Veteran's disability as "mild obstructive sleep apnea," without the use of a CPAP machine, and noted that there were no effects on his usual daily activities. The fact that both of the October 2010 examiners who provided opinions concerning the Veteran's sleep apnea found that there was no effects on usual daily activities strongly correlates with a finding that to the extent the Veteran experienced daytime hypersomnolence, it was not persistent. While the Veteran may have experienced intermittent daytime hypersomnolence in the past, the evidence does not suggest that it has been persistent. Even were he continuing to experience intermittent hypersomnolence, such would not warrant a 30 percent rating. 38 C.F.R. § 4.97, DC 6847. There is no evidence of the use of a CPAP machine, or that the Veteran has had other more severe symptomatology addressed by the higher potential ratings under DC 6847. The Veteran's claim for a compensable initial rating for his obstructive sleep apnea must be denied, and staged ratings are not warranted. Id.; Fenderson, 12 Vet. App. at 125-26. Hypertension The Veteran is rated at noncompensable for hypertension. A compensable rating for hypertensive vascular disease requires diastolic pressure predominantly 100 mmHg or more, or systolic pressure predominantly 160 mmHg or more, or that the claimant have a history of diastolic pressure predominantly 100 mmHg or more and require continuous medication for control. 38 C.F.R. § 4.104, DC 7101. Higher ratings would be based on higher blood pressure readings. Id. The Veteran does not meet the criteria for a compensable rating for hypertension. The evidence does not reflect any systolic readings over 160 mmHg, much less consistent readings of that magnitude. Although he has one in-service diastolic reading of 128/102 mmHg from May 1999, the records do not reflect that his diastolic blood pressure is predominantly 100 mmHg or more. Recent blood pressure readings support a finding that the Veteran's hypertension does not warrant a compensable rating. On October 6, 2010, his blood pressure, over three readings, was measured as 120/80 mmHg, 118/80 mmHg, and 120/80 mmHg. On October 25, 2010, his blood pressure was measured as 105/65 mmHg, 100/60 mmHg, and 100/60 mmHg. A January 2011 reading was 107/75 mmHg. Although he is on lisinopril to lower his blood pressure, his hypertension could warrant a compensable rating, even though his current diastolic reading is not predominantly 100 mmHg or more, if he has a history of diastolic pressure predominantly 100 mmHg or more. The records do not reflect such a history. His service treatment records show the reading of 128/102 mmHg in May 1999, many years prior to his hypertension diagnosis, but other than that reading, his records show consistent diastolic readings ranging between 70 mmHg and 95 mmHg. Based on the evidence of record, the Veteran's hypertension disability does not warrant a compensable rating at any time during the appeal period. Id.; Fenderson, 12 Vet. App. at 125-26. Gastroesophageal Reflux Disease The Veteran also has a noncompensable initial rating for gastroesophageal reflux disease. Under the rating formula for GERD (hiatal hernia), a 30 percent evaluation is assigned for persistently recurrent epigastric distress, with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health; a minimum 10 percent evaluation is warranted for two or more symptoms for the 30 percent evaluation for a hiatal hernia, of less severity. A 60 percent evaluation is assigned for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptoms combinations productive of severe impairment of health. 38 C.F.R. § 4.114, DC 7346. The evidence of post-service symptomatology does not warrant an initial compensable rating, or staged ratings, for the Veteran's GERD disability. It is apparent that in 2007, while he was still in service and before he began taking medication, the Veteran experienced both heartburn and regurgitation, as described in the March 2009 pre-separation examination report. When he started on Zantac, his symptoms came under control. The Board acknowledges that had that symptomatology continued post-service, he would warrant a 10 percent rating. Id. At his October 6, 2010 examination, the Veteran denied regurgitation, dysphagia, vomiting, hematemesis, and melena. He stated that the frequency of his heartburn was "days to months," and that he experienced heartburn "[less] than weekly." He was on daily Zantac, which worked well. The examiner diagnosed the Veteran with chronic, stable GERD that caused mild effects on feeding. The Veteran's October 25, 2010 examination report showed that the Veteran had a history of regurgitation, but did not indicate that such symptomatology continued. Presently, the Veteran denied vomiting, dysphagia, and esophageal distress, but indicated that he had heartburn weekly. The examiner diagnosed the Veteran with intermittent heartburn associated with GERD, which did not affect his usual daily activities. The totality of the evidence demonstrates that since service, the Veteran's GERD has been manifested by heartburn occurring weekly or less often. He has not had other symptoms post-service, and his GERD is well-controlled by medication. Without evidence of two or more of the 30 percent rating criteria symptoms, an initial compensable rating is not warranted. Id. There is also no support for staged ratings. Fenderson, 12 Vet. App. at 125-26. In reaching the conclusions above the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b). Extraschedular Considerations Pursuant to 38 C.F.R. § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242, 244 (2008). If the evidence raises the question of entitlement to an extraschedular rating, 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 a claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom., Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Under the approach prescribed by VA, 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. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). There is no allegation or evidence of exceptional factors with regard to any of the issues adjudicated in this appeal. The symptoms of the Veteran's disabilities are as described above. All of the Veteran's symptomatological manifestations, including for his diabetes, sleep apnea, hypertension, and GERD, are considered by the various rating criteria for those disabilities. Each of the diagnostic codes for the disabilities on appeal has multiple levels of higher rating criteria that the Veteran does not meet. There is no suggestion that the rating schedule for these disabilities is inadequate in light of the evidence presented to the Board. Further, the Veteran has not been hospitalized as a result of his disabilities. To the extent that these disabilities interfere with the Veteran's ability to maintain employment, as the Veteran indicated in his notice of disagreement, the matter is being remanded for consideration of whether a total disability rating based on individual unemployability is warranted; the Board notes, however, that the evidence of record reflects a voluntary retirement, unrelated to the Veteran's disabilities. As such, referral for consideration of an extraschedular evaluation is not warranted. 38 C.F.R. § 3.321(b)(1). ORDER Entitlement to an initial rating in excess of 20 percent for diabetes mellitus is denied. Entitlement to an initial compensable rating for obstructive sleep apnea is denied. Entitlement to an initial compensable rating for hypertension is denied. Entitlement to an initial compensable rating for gastroesophageal reflux disease is denied. REMAND The Veteran's claim for an initial rating in excess of 10 percent for a thoracolumbar disability must be remanded for additional records. As noted by the Veteran's representative, there are chiropractic treatment records the agency of original jurisdiction (AOJ) relied on (as indicated in the July 22, 2011 record in Virtual VA labeled "CAPRI") that are not included in the Virtual VA file. Such records must be made available to the Board under VA's duty to assist. 38 U.S.C.A. § 5103A(c) (West 2002). In addition, from the note showing these records, it appears that some of them are dated before certification of the matter to the Board. Those records should be reviewed by the RO initially, and will be as the case undergoes the development below. Accordingly, the case is REMANDED for the following actions: 1. Obtain and associate with the claims file any pertinent records adequately identified by the Veteran, including any ongoing VA treatment records. The chiropractic notes referred to should be specifically obtained, as should any subsequent VA treatment notes. If the Veteran identifies private medical treatment, request that he provide a completed release form (VA Form 21-4142) authorizing VA to request copies of any private treatment records relevant to his claimed conditions. After the Veteran has signed the appropriate releases, those records not already associated with the claims file should be obtained and associated therewith. All attempts to procure any outstanding treatment records should be documented in the claims file. If records identified by the Veteran cannot be obtained, a notation to that effect should be included in the claims file and the Veteran and his representative should be notified of unsuccessful efforts in this regard, in order to allow her the opportunity to obtain and submit those records for VA review. 2. After all available records are obtained, readjudicate the Veteran's claim for an increased initial rating for a thoracolumbar spine disability. If findings on records obtained suggest that additional examination is indicated, such examination should be scheduled in accordance with applicable procedures. If the claim remains denied, the RO/AMC should issue an appropriate supplemental statement of the case and provide the Veteran and his representative the opportunity to respond. Thereafter, return the case to the Board if in order. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs