Citation Nr: 1304047 Decision Date: 02/05/13 Archive Date: 02/08/13 DOCKET NO. 06-21 540 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a gastrointestinal disorder, to include gastroesophageal reflux disease (GERD) and an ulcer. 2. Entitlement to service connection for a migraine headache disorder. 3. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and disorders other than PTSD. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J.B. Freeman, Counsel INTRODUCTION The Veteran served on active duty from February 1989 to April 1990. This matter came before the Board of Veterans' Appeals (Board) on appeal from decisions of March 2005 and April 2007 by the RO in Atlanta, Georgia. The Board remanded the above issues in June 2010 for additional development. They return now for appellate consideration. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. The issue of service connection for an acquired psychiatric disability, to include PTSD and disabilities other than PTSD, 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 currently diagnosed gastrointestinal disability, GERD, was not present during service, has not been continuously present since service, and is not related to her in-service gastrointestinal disturbance treatments in March and June 1990. 2. The Veteran's migraine headache disability was not present during service, has not been continuously present since service, is not related to in-service headache treatment, and was not manifest within one year of separation from service. CONCLUSIONS OF LAW 1. A gastrointestinal disability was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1154(b), 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 2. A migraine headache disability was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1154(b), 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions as to the Veteran's claims for service connection. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA 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. Compliance with the first element requires notice of the five service connection elements: (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. See 38 U.S.C. § 5103(a); see also Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). Prior to initial adjudication of the Veteran's claim, a January 2005 letter fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). This letter did not provide the degree of disability or effective date elements of notice. Since the Board has denied service connection for the gastrointestinal disability and migraine headache claims, any questions as to the appropriate disability rating or effective date to be assigned are rendered moot, and no further notice is needed. See Dingess. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran has at no time referenced outstanding records that she wanted VA to obtain or that she felt were relevant to the claims. A 2009 counseling treatment note indicates that the Veteran applied for VA vocational rehabilitation benefits. Records in the possession of VA facilities that may have an impact on the adjudication of a claim are considered in the constructive possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). VA is generally obligated to associate relevant records with the claims file when aware of the existence of the records. Golz v. Shinseki, 590 F.3d 1371 (Fed. Cir. 2010). The duty to assist is not, however, boundless in scope and relates only to obtaining relevant records. Id. There is no allegation from the Veteran as to how a 2009 application for vocational rehabilitation benefits might substantiate her service connection claims for a gastrointestinal disability or migraine headaches. The Veteran's lay history was obtained during August 2010 examinations. She has not identified any records describing treatment for her gastrointestinal disability or migraine headaches which are not already of record. At best then, the vocational rehabilitation file would include duplicates of her lay history and assertions and her treatment records. The Board also notes that vocational rehabilitation evaluations are generally focused on the present level of impairment and do not provide evaluation of whether a disability may or may not be related to service. See generally 38 C.F.R. Chapter 21, Subchapter A. To the extent those records may be relevant, they are duplicative and need not be associated with the claims file before proceeding to a decision on the gastrointestinal disability or migraine headache claims. See Golz. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006). If VA provides a claimant with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). The Veteran was afforded medical examinations in August 2010 and obtain opinions were obtained as to whether her gastrointestinal disability and/or migraine headaches were the result of service. Supplemental opinions were obtained in March 2011. These opinions were rendered by medical professionals following thorough examinations and interviews of the Veteran and review of the claims file. The examiners obtained accurate histories and listened to the Veteran's assertions. The examiners laid factual foundations and reasoned bases for the conclusions that were reached. Therefore, the Board finds that the examinations are adequate for ratings purposes. See Nieves-Rodriguez. The Board is obligated by law to ensure that the RO complies with its directives; where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). The Board remanded the gastrointestinal disability and migraine headache claims for additional development in June 2010. The Veteran's representative argued in a December 2011 statement that remand for additional compliance with the June 2010 remand instructions was necessary. The representative's argument was premised on the fact that the Board's remand instructed that the Veteran's VA treatment records covering June 2005 and January 2006 for treatment for migraine headaches and a gastrointestinal disability, respectively, be associated with the claims file and that the Veteran be afforded a VA examination in connection with each claim. The specified VA treatment records were obtained. The Veteran was also afforded VA examinations in August 2010 in connection with her claims. The Board has already determined that these are adequate. The Board notes that the representative's argument is that she was not fact seen for examinations but this is a misreading of the claims file. She was not seen for examinations in association with the supplemental opinions which were provided in March 2011, whereas her representative appears to believe that she was never seen for a VA examination. Yet it is well documented that she had already been physical examined in August 2010 and further examination would have been at the discretion of the examiner. The examiners chose not to exercise that discretion, as they clearly could have should an examination have been necessary to provide the requested opinions. The Board finds that the RO complied substantially with June 2010 remand instructions, and further remand for additional development of the prior remand instructions is therefore not warranted. See Stegall. II. Service Connection The Veteran contends that she has a gastrointestinal disability and a migraine headache disability as a result of service. For the reasons that follow, the Board finds that the Veteran's current gastrointestinal disability and her migraine headache disability are not related to service. The Board concludes that service connection is not warranted. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder, there must be competent and credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In the alternative, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and ulcers or other organic diseases of the nervous system (such as migraine headaches) become manifest to a degree of 10 percent within 1 year from 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. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. a. Gastrointestinal Disability The Veteran filed her instant claim in June 2004. She referred to the disability as a stomach disorder. Since the filing of her claim, her VA treatment records have shown treatment for gastrointestinal complaints. These treatment records reflect the Veteran's diagnosis with GERD, as noted in a January 2005 VA treatment record, as well as a January 2006 VA physician's recommendation that she continue taking peptic ulcer medication. The Veteran was seen for an August 2010 VA examination. The examiner indicated that the Veteran bore a current diagnosis of GERD. The examiner also stated that an April 2007 upper GI procedure had revealed a normal esophagus and stomach. The Veteran denied having an ulcer at that time and the examiner concurred. The examiner indicated that, in full awareness of the January 2006 peptic ulcer medication entry, the Veteran did not have and had not had an ulcer. The Board finds that the Veteran has a current disability of GERD but not of an ulcer or any other stomach or intestinal disability. The first element of service connection is established. See Hickson. The Veteran has alleged that she had treatment for the same disability during service. She has not provided a lay description of her symptoms at the time. Her service treatment records bear out some of her contentions. An August 1989 service treatment record documents "possibly ulcer" complaints, with a notation that a diagnosis of peptic ulcer disease should be ruled out. There is no follow-up in the extant service treatment records. Her complaints at that time were that she had stomach pain when eating and had a family history of ulcers. She had lost more than five pounds since entering service. She denied vomiting and dysuria but reported nausea and diarrhea. The Veteran also claimed to be not eating and only taking in liquids but a note indicated that she did have a small amount of formed stool. An upper GI study was recommended. A March 1990 entry shows that the Veteran was seen for a throbbing headache which had persisted for three days. She reported being nauseated and vomiting twice the previous night. She did not have diarrhea, loss of appetite, or stomach cramps. On exam, she had a soft abdomen which was tender. She was diagnosed with a viral syndrome at that time. Her April 1990 separation from service physical examination report shows that her abdomen and viscera were not evaluated. She completed a report of medical history at the time in which she denied any stomach or intestinal complaints. The in-service incurrence event element is well established. See Hickson. The Veteran contends that her present disability is the same as that for which she was treated during service. Her April 2005 Notice of Disagreement and her June 2006 VA Form 9 state the condition persisted since service. Her May 2007 Form 9 states that she was first diagnosed with ulcers/peptic ulcer disease in June 1990 as shown in her service treatment records. The Board notes that the March 1990 entry has a second, June 1990 date at the top of the page, which appears to be from the creation of the microfiche for the document. The entry date is correctly dated in March 1990. With respect to the Veteran's contentions that she has experienced symptoms of gastrointestinal disturbance since service, 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. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). Although the Veteran is competent to give evidence about what she experiences, she is not competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder because she does not have the requisite medical knowledge or training. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Rucker v. Brown, 10 Vet. App. 67, 74 (1997). The only description from the Veteran regarding her current symptoms appears in the August 2010 VA examination report. She stated that she had burps and tasted acid once or twice a day. She was on two medications and had fewer symptoms as a result. The Veteran reported that her psychiatric medication made her not have any appetite for food but she was not losing weight. She denied diarrhea, constipation, history of ulcer, and vomiting blood. She had nausea and increased symptoms when eating greasy or spicy food. The examiner indicated that the Veteran's abdomen was normal on exam. The examiner stated that the present GERD was not at least as likely as not related to service. The examiner found that the in-service complaints were not the same as her current complaints and that the in-service complaints were not GERD or GERD-like. The examiner also reviewed her treatment records for GERD in 2005, for which the Board remanded the claim. The examiner stated that these were likely related to excessive alcohol use at the time. A follow-up opinion was provided in March 2011 that additional evidence did not change the initial opinion. The Board finds that the preponderance of the evidence is against the claim. The Board recognizes that the Veteran is competent to report her own symptoms of gastrointestinal disturbance. Her contention is that her in-service symptoms have continued to the present. The in-service symptoms included stomach pain when eating and nausea (nausea and diarrhea on one occasion and nausea and vomiting on another). At her August 2010 exam, her symptoms did not include stomach pain, vomiting or diarrhea, but did include burping and tasting acid with nausea triggered by eating greasy or spicy food. The August 2010 and March 2011 opinions found these differences to be medically significant, to the point of concluding that the current complaints were not related to in-service complaints. The Board gives greater probative value to the medical opinion that the symptoms do not represent the same underlying disorder. As a result, the Board finds that there has been no continuity of symptomatology since service and that the weight of the probative evidence is against a relationship between the current GERD and service. Without a nexus to service, direct service connection is not warranted. See Hickson. The Board has also considered whether presumptive service connection is warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. GERD is not among those disabilities eligible for presumptive service connection. This is her only diagnosed gastrointestinal disability. Although the Veteran's April 2005 Notice of Disagreement, June 2006 and May 2007 substantive appeals contend that she has an ulcer disability, no such disability has been established on the record. As such, the Veteran cannot benefit from the presumption. As such, the Board finds that the preponderance of the evidence is against the Veteran's gastrointestinal disability claim. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). b. Migraine Headache The Veteran contends that she has had migraine headaches since service. For the reasons that follow, the Board finds that the Veteran did not have a migraine headache disability during service, that a headache disability has not been continuously present since service, that a migraine headache disorder did not manifest within one year of the Veteran's separation from service, and that her currently diagnosed migraine headaches are not otherwise related to her military service. The Board concludes that service connection is not warranted. A January 2005 VA surgical attending note and a June 2005 VA psychiatric treatment record both reflect the Veteran's medical diagnosis with a migraine headache disorder. The current disability element is established. See Hickson. The Veteran contends that she was treated for migraine headaches during service and that they continue to the present. As before, she has not provided a lay description of her symptoms during service. The Veteran's service treatment records show numerous complaints of headaches, but not migraines. In May 1989, the Veteran was treated for headaches for the previous one and a half weeks and complaints of strain while reading. The Veteran was provided an optometry consult and found to be in need of prescription lenses. She was seen again in May 1989 complaining of headaches and was given a diagnosis of muscle contraction headaches. She was seen in November 1989 with sinus pain and congestion. While her complaints included head pain, she was diagnosed with an upper respiratory infection. The Veteran was treated for a throbbing headache which had lasted for three days in March 1990. Based on a full evaluation, she was found to have a viral syndrome. Her April 1990 separation from service physical examination report shows that her neurologic system was normal on exam. She completed a report of medical history at the time which showed that she had headaches two to three times a week due to her eyesight. A note added by the examiner indicates that she had been seen by the optometry service. When a chronic disease is identified in service and at any time after service, service connection will be granted without the need for nexus evidence. Groves v. Peake, 524 F.3d 1306, 1309-10 (Fed. Cir. 2008). The Board emphasizes that the Veteran was not diagnosed with migraine headaches at any time during service. As mentioned, the Veteran is competent to report her experiences. See Jandreau. Although she believes that these incidents were the same disability for which she now receives treatment, the contemporaneous medical evidence conflicts with her assessment. The Veteran is not competent to interpret her symptoms as migraine headaches rather than as muscle contraction headaches or eye strain headaches (as the headaches she was treated for in service were diagnosed). See id. The Veteran has not alleged that any medical professional has told her that her current headaches are the same as those she experienced during service. The Board finds that the current disability is not a chronic disability recurring. Nexus evidence is necessary to establish service connection. See Groves. The Veteran has alleged that her headaches have been continuously present since service in her April 2005 Notice of Disagreement and June 2006 and May 2007 VA substantive appeals. The Veteran is generally competent to report continuity of symptoms since service. She must also do so credibly. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Prior to filing the instant claim, the Veteran sought treatment through VA in October 2001 for headaches. The physician stated that the Veteran had developed several new complaints since her last visit in April 1999, among them chronic headaches of cervical origin. The Veteran reported that they came on with stress and toward the end of her work day. She reported that she had a MRI which was normal through a private provider. At best then, this shows that chronic headaches appeared in April 1999 at the earliest. In this case, however, despite the Veteran's contentions of continuous headaches since service, the evidence does not indicate complaints, treatment or diagnosis of chronic headaches until several years after service. Cf. Buchanan, 451 F.3d at 1336 (holding a lack of contemporaneous medical records may be a fact that the Board can consider and weigh against a veteran's lay evidence, however, the lack of such records does not, in and of itself, render lay evidence not credible); see Maxson v. Gober, 230 F.3d 1330, 1333 (Fed.Cir.2000) (noting that "evidence of a prolonged period without medical complaint" may be considered in determining whether a claimant's condition is related to service). Moreover, this entry is in direct contradiction of her statements in support of her claim. This reduces her credibility significantly. The Board remanded to afford the Veteran a VA examination and opinion as to whether or not her migraine headaches were related to service. She received a thorough examination and interview in August 2010. Her assertions were considered. She described prostrating attacks once or twice a month with vomiting and light sensitivity. She indicated that she took Motrin and Fioricet for her headaches. The examiner concluded that her migraine headaches were not caused by the condition for which she was treated during her active service. The examiner indicated that the Veteran's service treatment records did not document migraine headaches or similar symptoms. The examiner indicated that the headaches had first appeared in 2004 in connection with heavy alcohol consumption. As discussed, the headaches first appeared in 2001. This mistake does not alter the examiner's assessment that the service treatment records did not document migraine headaches or similar symptoms, or that migraine headaches were not diagnosed for a number of years after service. A March 2011 opinion was obtained after considering additional evidence; the examiner concluded that the additional evidence did not alter the opinion. The Board finds that the Veteran's migraine headaches are not related to any incident of service including treatment for unspecified headaches and head pain. The Veteran has different symptoms than during service. Her contemporaneous complaints were not found to be migraine headaches and retrospective review by a VA examiner did not find them to be migraine headaches. Furthermore, her account of continuity of symptoms is not sufficiently credible to establish that symptoms which were eventually diagnosed as migraine headaches had begun in service and continued since that time. The weight of the competent and credible evidence establishes that her migraine headaches did not begin until April 1999 at the earliest. The weight of the competent and credible evidence also establishes that the current disability is not related to her in-service complaints. The Board finds that the Veteran's migraine headaches were not present during service, have not been continuous since service and are not otherwise related to service. The Board concludes that service connection on a direct basis is not warranted. See Hickson. The Board has also considered whether presumptive service connection is warranted. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. As discussed above, the Veteran began having complaints of migraine headaches in 1999, nearly a decade after she separated from service in 1990. The migraine headache disability was not manifest within one year of separation from service. Presumptive service connection is therefore not warranted. As such, the Board finds that the preponderance of the evidence is against the Veteran's migraine headache claim. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Service connection for a gastrointestinal disability, to include GERD and ulcers, is denied. Service connection for a migraine headache disability is denied. REMAND The Board regrets the additional delay but must remand the acquired psychiatric disability claim for additional development. The psychiatric disability claim was remanded in part to obtain a VA examination and opinion as to whether or not a present disability was related to service. The Veteran was seen for an August 2010 examination and a supplemental March 2011 opinion. The examiner indicated that the question could not be resolved without resort to speculation. The examiner stated that it was unclear whether the different diagnoses were attributable to childhood abuse, spousal abuse, or post military stressors such as being arrested and incarcerated, losing her job or financial hardship. While this case was pending before the Board in 2010, the RO conducted development of which the Board was unaware. In particular, the Veteran was seen for counseling by a Dr. S. in March 2009. The treatment records reveal that the Veteran had recently lost her job and had applied for VA vocational rehabilitation benefits. A claim for vocational rehabilitation benefits would include an assessment of whether the Veteran had an employment handicap or serious employment handicap including due to non service-connected disabilities. See 38 C.F.R. §§ 21.40, 21.51, 21.52 (2012). The nature of her acquired psychiatric disability may have been evaluated. This evaluation may provide evidence that allows for a more certain medical opinion in connection with the acquired psychiatric disability claim. VA is required to assist a claimant in obtaining identified records if a reasonable possibility exists that such assistance would aid in substantiating the claim. Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). The Board remands to obtain the Veteran's VA vocational rehabilitation file and to have a supplementary opinion provided for the acquired psychiatric disability claim. Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's VA vocational rehabilitation file, to include any determinations on her claim and supporting medical evidence and evaluation reports. 2. After obtaining the Veteran's vocational rehabilitation file, return the claims file to the examiner who provided the August 2010 VA examination if available. If the examiner is not available, forward the claims file to another appropriate examiner. The examiner should discuss whether any current acquired psychiatric disorder, other than PTSD, at least as likely as not had its onset in-service, and/or is otherwise related to the Veteran's military service. It would be helpful if the examiners would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The examiner should specifically attempt to reconcile the requested opinion with other clinical evidence of record, including post-service records, reflecting complaints and clinical findings of multiple acquired psychiatric illnesses. If the examiner deems further examination necessary, an examination should be scheduled. Additionally, the examiner should provide clear and complete medical reasoning and rational for all requested opinions and findings, which should be set forth in a legible examination report. 3. Then, the RO should readjudicate the claims on the merits. If the benefits sought are not granted, the Veteran and her representative should be furnished a supplemental statement of the case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter 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). ______________________________________________ MATTHEW W. BLACKWELDER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs