Citation Nr: 1304292 Decision Date: 02/06/13 Archive Date: 02/19/13 DOCKET NO. 04-24 159 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for a right knee disability, to include arthritis. 2. Entitlement to service connection for a left knee disability, to include arthritis. 3. Entitlement to service connection for a right shoulder disability, to include arthritis. 4. Entitlement to service connection for a left shoulder disability, to include arthritis. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The Veteran had active service from July 1990 to August 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2002 rating determination of a Regional Office (RO) of the Department of Veterans Affairs (VA). This appeal was previously before the Board in July 2006, July 2010, and September 2011 when the issues remaining on appeal were remanded for additional development. In April 2006, the Veteran was afforded a travel Board hearing. A transcript of this hearing is of record. The Board finds that there has been substantial compliance with the directives of the Board's remands pertinent to the issues remaining on appeal. In particular, the Board notes that the claims file now contains addenda to the prior pertinent VA examination reports including clarifying findings and an updated medical opinion with adequate discussion of rationale from the specialist involved in the preparation of the prior reports. FINDINGS OF FACT 1. The Veteran's right knee disability was not manifested during active duty service or for many years thereafter, nor is it otherwise related to such service. 2. The Veteran's left knee disability was not manifested during active duty service or for many years thereafter, nor is it otherwise related to such service. 3. The Veteran's right shoulder disability was not manifested during active duty service or for many years thereafter, nor is it otherwise related to such service. 4. The Veteran's left shoulder disability was not manifested during active duty service or for many years thereafter, nor is it otherwise related to such service. CONCLUSIONS OF LAW 1. A right knee disability was not incurred in or aggravated by the Veteran's active duty service, nor may it be presumed to have been incurred in such service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. A left knee disability was not incurred in or aggravated by the Veteran's active duty service, nor may it be presumed to have been incurred in such service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 3. A right shoulder disability was not incurred in or aggravated by the Veteran's active duty service, nor may it be presumed to have been incurred in such service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 4. A left shoulder disability was not incurred in or aggravated by the Veteran's active duty service, nor may it be presumed to have been incurred in such service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (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). Duty to Notify Upon receipt of a complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 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 v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant with proper notice by letter dated in August 2006. Any deficiency in the timing of this notice was remedied by readjudication of each issue in a subsequent supplemental statement of the case as recently as in November 2012. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notification complied with the specificity requirements of Dingess v. Nicholson, 19 Vet. App. 473 (2006) identifying the five elements of a service connection claim; and Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of her claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist VA has obtained service and VA treatment records and assisted the Veteran in obtaining evidence including private medical evidence. VA has assisted the Veteran in successfully obtaining records in the custody of the Social Security Administration (SSA) which are available for review in the claims-file. VA has afforded the Veteran appropriate VA examination and medical opinions in connection with the issues as evidenced by the VA examination reports and addenda dated in October 2007, September 2010, October 2011, and October 2012. The Board finds that the VA examination reports, having been amended with addenda in accordance with the Board's prior remand directives, now provide adequate and probative evidence sufficiently addressing the issues on appeal. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file, and the Veteran and her representative have not contended otherwise. VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claims at this time. Analysis This appeal involves a claim of entitlement to service connection for disabilities of the shoulders and the knees. Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury or disease in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Additionally, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Where the record contains both positive and negative evidence, it is the responsibility of the Board to weigh the credibility and probative value of the medical opinions, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one medical opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995); see also Wensch v. Principi, 15 Vet. App. 362, 368 (2001) (it is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons and bases for doing so). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A veteran is competent to describe symptoms that he or she experienced in service or at any time after service when the symptoms he or she perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (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.); Layno, 6 Vet. App. at 469-71 (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness, but lay testimony is not competent to prove a particular injury or illness); see Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr, 21 Vet. App. 303 ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Also, a veteran as a lay person is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the lay person is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F. 3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a lay person is competent to identify the medical condition; he or she is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). The Board notes that it has reviewed all of the evidence in the Veteran's claims file (including in "Virtual VA," VA's electronic database storage) with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. The Board finds that service connection is not warranted with regard to any disability of the shoulders or the knees in this case because the preponderance of the evidence is against finding that any such disability manifested during service, manifested within a year following service, or is otherwise etiologically linked to service. The Veteran's service treatment records are silent as to any suggestion of treatment or diagnosis of any injury or disability of either knee or shoulder. The Veteran's July 1991 service separation medical examination report shows that a trained medical professional determined that the Veteran was clinically normal with no pertinent abnormalities including specifically with regard to upper and lower extremities. The attached medical history questionnaire shows that the Veteran herself expressly denied having ever had "swollen or painful joints," "arthritis." "painful or 'trick' shoulder or elbow," or "'trick' or locked knee." In sum, the Veteran's service treatment records indicate that neither trained medical professionals nor the Veteran herself believed that she had any chronic disability of either shoulder or either knee during service. The Board finds that the service treatment records present competent probative evidence that the Veteran did not have any pertinent disability or injury involving either shoulder or either knee during her active duty military service. The Veteran contends that she currently suffers from chronic disability of the bilateral knees and shoulders due to significant lifting and straining associated with her responsibilities during active duty service. The Veteran has acknowledged that she was not diagnosed with her claimed disabilities in any of these joints during service, but recalls the onset of non-disabling pain during that time. The Veteran has testified, including at her Board hearing in April 2006, that she first sought medical treatment for any pertinent symptomatology associated with these claims "around '96," or approximately 4 to 5 years following her separation from service. The Veteran contends that her current disabilities of the shoulders and knees are a result of the aggregated stress of significant lifting activity and straining of her joints during performance of service duties, and she denies (including in her Board hearing testimony) any specific particular injury event during service. The Board notes that the Veteran is competent to provide lay testimony of her recollection of significant lifting and straining during service, and the Veteran has been afforded VA examination and medical opinion to address the question of whether any current disability of the shoulders or knees is etiologically linked to her physical duties during service. The October 2007 VA examination report presents a number of current clinical findings along with diagnoses of "bilateral shoulder strain" and "patellofemoral syndrome of both knees." The report further contains imaging studies interpreted to show left shoulder soft tissue calcification located superior to the acromium process which "is probably posttraumatic." The October 2007 VA examination report shows that the Veteran has current diagnosed disabilities of the shoulders and knees, but does not address the question of the claimed etiological link between such disabilities and military service. In accordance with the Board's July 2010 remand, a new September 2010 VA examination report was obtained from the same examiner who authored the October 2007 report. Unfortunately, after careful consideration, the Board concluded that reliance upon the September 2010 VA examination report would also not be adequate to permit the fully informed appellate review in accordance with the purpose of the Board's July 2010 remand. In short, the September 2010 VA examination report failed to present a rationale for its conclusion that "any relationship to symptoms in service is purely speculative," and also made reference to entries allegedly in the service treatment records that the Board found were not actually contained in the service treatment records. The September 2010 VA examination report contained no medical conclusion suggesting any support for the Veteran's claims, and the negative conclusion was not presented with an adequate rationale to permit the Board to view the evidence as probative. In September 2011, the Board remanded the case once again for the purpose of obtaining an adequate medical opinion addressing the service connection issues. During the processing of the remand, the September 2010 VA examination report was amended by an October 2011 addendum and then an October 2012 addendum. The latter addendum was prepared after the Veteran failed to report for a new VA examination, and was authored by the same orthopedist involved with the October 2007 and September 2010 VA examination reports; the October 2012 VA examiner documented the Veteran's failure to report on a form dated in October 2012. The October 2011 addendum from a VA physician's assistant opines that "[i]t is less likely than not that the veteran's bilateral shoulder condition diagnosed as bilateral shoulder strain and patellofemoral syndrome of both knees are related to duties during her military service." The examiner expressly cited that the service treatment records "did not show treatment for these complaints," and explained that "[a]fter review of all available evidence of medical records" the evidence did not support finding "nexus of symptoms or treatment" between the current problems and her military service. The medical opinion identifies that the etiology of the disability is more likely linked to a significant increase in weight since her discharge from service. Subsequently, the Veteran failed to report for a new VA examination and the claims file was forwarded to a specialist, the same orthopedist involved in the October 2007 and September 2010 VA examination reports, for review and a clarifying opinion. The orthopedist's October 2012 addendum stated that the claims-file was reviewed, to include the October 2011 opinion, and the orthopedist acknowledged that there was "no treatment in service." The orthopedist expressed the opinion that "it is less li[k]ely that the current complaints of shoulders and knees are d[ue] to the complaints of shoulders and bilateral knee pain in service so long ago, but rather natural age progression." The Board finds that the VA examination report opinion, as amended and revised, now presents probative evidence indicating that the Veteran's current disabilities of the bilateral shoulders and knees are unlikely to be etiologically linked to the Veteran's military service. The VA opinion is presented by a competent medical professional (with input from additional medical professionals) informed by review of claims-file, the pertinent medical history, and acknowledges the Veteran's lay testimony concerning recollections of in-service strain and symptoms in her joints. The amended opinion cites the nature of the current disabilities and their consistency with likely etiologies that are not linked to military service (weight gain and aging) together. This rationale presented by competent medical professionals informed of the pertinent facts and contentions is persuasive, especially considered together with the fact that the Veteran's service separation examination report shows that neither trained medical professionals nor the Veteran herself believed that she had any disability of the shoulders or knees during service. Significantly, there is no competent medical opinion of record contrary to that presented by the VA examination reports. There is no medical opinion of record indicating that the Veteran's current shoulder and knee disabilities are etiologically linked to her military service. There is no competent medical evidence of record otherwise contradicting any element of the analysis of the VA medical opinion, and the evidence of record does not contradict the factual predicates of the VA medical opinion. The Board finds that the competent evidence in this case weighs against a finding of any medical nexus between any current shoulder or knee disability and the Veteran's service. The Veteran's testimony otherwise raises the contention that she has experienced the symptoms of her current chronic shoulder and knee disabilities since the time of her active duty service with continuity through the present. As discussed above, the Veteran's service treatment records indicate that she did not have any complaints nor medically detected diagnoses of any disability of the shoulders or knees during service. The Veteran now contends, including in her April 2006 Board hearing testimony, that she experienced shoulder and knee symptoms during service but did not report the symptoms due to concerns about how she would be perceived as weak: "I never wanted to show my weakness because we were supposed to be in the military and withstand anything...." To the extent that the Veteran has testified that she concealed or declined to report significant symptoms of shoulder and knee disability during service for the purpose of maintaining an appearance of toughness during military duty, the Board finds that this testimony is not credible in light of the information of record. The Veteran expressly denied any pertinent symptoms or problems of the shoulders or knees at the time of her service separation examination; this is precisely the time that a Veteran would be expected to disclose significant symptomatology that had developed during previous duty. Trained medical professionals examined her at the time of her separation and also found no suggestion of disability of the shoulders or knees. Moreover, the Veteran's own testimony at her Board hearing indicates that she first sought medical attention "around '96," or approximately 4 or 5 years after the conclusion of her active duty military service. In light of the contemporaneous evidence and the Veteran's own contemporaneous statements indicating no symptoms or disabilities of the shoulders or knees during service, and in light of the several year gap (acknowledged by the Veteran) between the conclusion of her service and the first instance of her seeking medical treatment for any shoulder or knee problems, the Board finds that the Veteran's testimony concerning a continuity of symptomatology from service onward to the present is not credible. As the Veteran's lay testimony is the only evidence of record indicating a continuity of pertinent symptomatology, and as this lay testimony is not credible in light of the other evidence of record, there is no probative evidence of record showing a continuity of pertinent symptomatology to support a grant of service connection in this appeal. Rather, the more credible and contemporaneous evidence showing no pertinent symptomatology or disability during active duty service or for several years afterwards is the probative evidence concerning this question. The preponderance of the probative evidence is against finding a continuity of pertinent symptomatology from the time of service. The preponderance of the probative evidence is also against finding that any current chronic shoulder or knee disability is otherwise etiologically linked to military service. Accordingly, the Board finds that service connection is not warranted for any shoulder or knee disability in this case. The Board also finds that service connection is not warranted on a presumptive basis as the probative evidence weighs against finding that any arthritis of any claimed joint manifested to a compensable degree within one year of discharge from service. In this regard, the Board again notes the probative evidence showing no chronic disability or symptoms at the time of the Veteran's separation and the Veteran's acknowledgment in recent testimony (during her Board hearing) that she first sought medical consultation for any of these issues several years following service. This evidence suggests that there was no compensable manifestation of arthritis in any of these joints within a year of service, and there is no credible evidence indicating pertinent manifestations during the one-year presumptive period following service. Conclusion The Board finds that the preponderance of the evidence is against the claims of entitlement to service connection for disability of either shoulder or either knee. In reaching this decision, the Board has reviewed the entirety of the evidence of record but finds that there is no other evidence of record which probatively contradicts the findings presented in the most probative evidence discussed above. The Board acknowledges that the claims-file contains a quantity of other documents, but none of the information in these records substantially supports the Veteran's claims or otherwise contradicts the evidence deemed to be most probative in the discussion above. Here, the evidence does not support finding that the Veteran's current disabilities of the shoulder or knees are related to her military service. The Veteran has been afforded a VA examination with adequate medical reports and opinions in connection with these claims; the evidence (as amended) now provides clear findings and conclusions with persuasive rationale weighing against the claims. The reports' pertinent findings and opinions are uncontradicted by the rest of the competent evidence of record. No medical professional has provided any opinion indicating that the Veteran's claimed disabilities of the shoulders and knees are related to her military service. The Board acknowledges that service connection may indeed be granted when a chronic disease or disability is not present in service, but there is evidence of continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). As discussed above, and in accordance with Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006), the Board concludes that the lay evidence presented by the Veteran concerning continuity of symptoms since service does not provide a persuasive basis to award service connection in this case because such testimony in this regard is not credible. As discussed above, contemporaneous medical evidence shows clearly that neither the Veteran nor trained medical professionals believed that the Veteran had pertinent symptoms or disabilities during service or at separation; there is also no suggestion of medical consultation for any claimed disability until several years after separation (a timeline acknowledged by the Veteran in her Board hearing testimony). Any contention of continuity of symptomatology in this case is viewed as a self-interested statement in pursuit of monetary benefits, contradicted by probative contemporaneous evidence, and not credible. The Board finds that there is no credible evidence in this case establishing continuity of pertinent symptomatology for any shoulder disability or knee disability from the time of active duty military service. The Board acknowledges the Veteran's belief that her claimed disabilities are related to her military service. However, there is no evidence of record showing that the Veteran has the specialized medical education, training, and experience necessary to render a competent medical opinion as to the diagnosis and etiology of a disability. Espiritu v. Derwinski, 2 Vet. App. 492 (1992); 38 C.F.R. § 3.159(a)(1). Consequently, the Veteran's own assertions as to diagnosis and etiology of a disability have no probative value. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). See also Robinson v. Shinseki, 312 Fed. Appx. 336 (Fed. Cir. 2009) (non-precedential) (confirming that, in some cases, lay evidence will be competent and credible evidence of etiology). However, a determination concerning the possibility of a causal relationship between military service and a chronic disability which the evidence shows did not manifest until some time after such service requires specialized training, and may therefore not be established by lay opinions on etiology. As the preponderance of the evidence is against the Veteran's claims of entitlement to service connection for shoulder disabilities and knee disabilities, the benefit-of-the-doubt rule does not apply and these claims are denied. See 38 U.S.C.A § 5107. ORDER The appeal is denied as to all issues. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs