Citation Nr: 1308028 Decision Date: 03/11/13 Archive Date: 03/20/13 DOCKET NO. 09-04 576 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for degenerative disc disease of the cervical spine. 2. Entitlement to service connection for headaches, to include as secondary to degenerative disc disease of the cervical spine. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Prem, Counsel INTRODUCTION The Veteran served on active duty from July 1969 to October 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from June 2008 and August 2009 rating decisions by a Regional Office (RO) of the Department of Veterans Affairs (VA). This matter was previously before the Board in September 2010. At that time, the cervical spine claim was reopened and both issues were then remanded for further development. The Veteran presented testimony at a Board hearing in May 2010. A transcript of the hearing is associated with the Veteran's claims folder. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Degenerative disc disease of the cervical spine was not manifested during the Veteran's active duty service or for many years after service, nor is it otherwise related to service. 2. Chronic headaches were not manifested during the Veteran's active duty service or for many years after service, nor are they otherwise related to service, to include as secondary to a service connected disability. CONCLUSIONS OF LAW 1. Degenerative disc disease of the cervical spine was not incurred in or aggravated by the Veteran's active duty service, nor may it be presumed to have been incurred in or aggravated by such service. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. Chronic headaches were not incurred in or aggravated by the Veteran's active duty service; nor are they secondary to a service connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Notify 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). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent letters in April 2008 and June 2009 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. The letters also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record, including testimony provided at a May 2010 Board hearing before the undersigned. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection 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 suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 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). Additionally, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet.App. 439 (1995). Degenerative disc disease of the cervical spine At the Veteran's May 2010 Board hearing, he testified that during service, he worked as a maintenance mechanic. This involved working on vehicles at different angles (sometimes working upside down). He testified that he had problems with his neck during service, and that he sought treatment on one occasion, but was only given pain pills. He stated that following service, he noticed neck symptoms in 1987 or 1988. He did not know that his neck problems were associated with the work he did in the Air Force. The Board notes that the service treatment records fail to reflect any findings attributable to a neck or cervical spine disability. He sought treatment on one occasion, in July 1969, for sharp, shooting headaches. He had no joint or muscle pain at that time. He was diagnosed with an upper respiratory infection. His separation examination in September 1970 reflects normal findings. The service treatment records also contain a September 1970 Report of Medical History in which the Veteran denied any back trouble, arthritis, or swollen or painful joints. In a September 2009 statement in support of the claim (VA Form 21-4138), he stated that he did not complete either the separation examination report or the Report of Medical History. Post-service, x-rays taken in December 2003 reflect multilevel degenerative changes of the cervical spine with bilateral neural foraminal narrowing and multilevel degenerative disc disease. A February 2004 MRI also showed multi-level degenerative changes throughout the cervical spine. The Veteran submitted an April 2004 correspondence from Dr. M.F.H. She stated that she was the Veteran's primary care physician at the Minneapolis VA Medical Center. She stated that the Veteran had a 25-30 year history of progressive neck pain and stiffness. She noted the December 2003 x-rays and the February 2004 MRI. She noted the Veteran's current symptoms of constant severe neck pain; interrupted sleep as a result of neck pain; cracking, crunching, and locking of the neck; bilateral shoulder pain radiating into the arms; and numbness and tingling in his fingers. She noted that the Veteran did not have any other medical conditions and did not have degenerative changes in other joints. She opined that the Veteran's disability "is likely due to years of repetitive trauma predisposed by hereditary influences." The Veteran also submitted an April 2008 correspondence from a private chiropractor J.G.M. He stated that the Veteran suffered an injury to his cervical spine while working as a mechanic from 1969-1971 in the U.S. military. He noted the Veteran's subjective symptoms, including cervical stiffness, shoulder pain, cervical crepitation. Objectively, there was reduced range of motion positive cervical compression test, etc.). He opined that the Veteran suffered an 85 percent permanent partial disability to his cervical spine as a result of the 1969-1971 injuries. A May 2008 MRI reflects diffuse degenerative changes of the cervical spine with areas of spinal canal narrowing, as well as neural foraminal narrowing/stenosis. The Veteran submitted June 2009 correspondence from Dr. J.H., who examiner him in June 2009. He stated that the Veteran was in the military from 1969-1971 and that during this time, he began experiencing headaches and neck pain. He stated that the Veteran did not have any such pain prior to service and that such pain had become progressively more severe since service. He noted the physical examination findings of loss of motion, decreased light touch sensation in the cervical spine, and muscle spasm. He stated that in his professional opinion, the Veteran's disabilities were as likely as not related to service, where the Veteran began experiencing neck pain and headaches while working as a mechanic. Dr. J.H. stated that the Veteran likely endured multiple minor traumas to his cervical spine while working under various vehicles, which contributed to his current state. The Veteran underwent a VA examination in February 2011. The examiner reviewed the claims file in conjunction with the examination. The Veteran stated that he began experiencing headaches and neck pain in service, but he did not report any specific injury to the head or neck. He stated that during service, he did a lot of twisting around and working upside down. After service, he worked as a janitor for 10 years and then drove a truck until 2002. He had not been pain free in his neck since service, and his symptoms had progressively worsened since his discharge. The examiner summarized the evidence in the claims file, including the opinions of Dr. M.F.H, J.M., and Dr. J.H. He conducted a thorough physical examination. He diagnosed the Veteran with cervical spine degenerative changes. He opined that the Veteran's cervical disability was not related to military service, reasoning that there was no medical evidence of any injury during service, and the Veteran's separation examination reflects normal findings. He stated that a review of the peer reviewed medical literature did not show that a mechanic is at increased risk for developing cervical spine degenerative changes. He acknowledged that two chiropractors opined that the disability was due to military service, but he observed that neither opinion was supported by a rationale or medical evidence to support it. He stated that flexion, extension, side bending, rotation of the cervical spine, or holding the cervical spine in one position for extended periods of time does not cause, contribute to, or enhance progression of degenerative changes of the cervical spine. Analysis With respect to the question of entitlement to service connection on a presumptive basis, while current degenerative disease of the cervical spine is established, there is no competent medical evidence of arthritis within one year of the Veteran's separation from active duty service, as required for service connection under 38 C.F.R. § 3.307(a). Thus, service connection under the presumptive provisions of 38 C.F.R. §§ 3.307 and 3.309 is not warranted. In support of his claim for service connection, the Veteran contends that he had neck problems during service. In this regard, he is competent to describe symptoms of back pain. 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 v. Brown, 6 Vet. App. 465, 469-71 (1994) (lay testimony is competent as to symptoms, 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). In evaluating the credibility of the Veteran's claims of continuous neck symptoms since service, the Board notes the gap of more than three decades between the Veteran's separation from service and the first documented treatment for a neck disorder. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. However, such absence of documented treatment, in and of itself, is not a basis for discrediting his lay statements of continuity. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Thus, the Board must consider the totality of the record, and not just the absence of clinical treatment, in weighing the Veteran's statements asserting continuity of symptomatology. In this case, the Veteran himself testified that he began to notice neck symptoms in 1987 or 1988. Consequently, he has been somewhat inconsistent with regard to contentions of continuity of symptomatology. It is noted that a January 2004 treatment report reflects a history of neck pain for several years but the Veteran did not appear to attribute his neck pain to service at that time. To the contrary, the Veteran specifically testified that he did not associate his neck problems to service when he first noticed them. Additionally, it is noted that the Veteran did not file a claim for service connection for a neck disability until 2004, many decades after he separated from service. Had he been experiencing chronic neck problems since service it would be reasonable to expect that he would have filed a claim sooner. For the above reasons continuity of symptomatology is not demonstrated here, either by the clinical record or by the Veteran's own statements. As noted above, service connection is not warranted in this case on the basis of continuity of symptomatology. However, if the competent medical evidence indicates that the current neck disorder is related to the Veteran's active service, then an award of service connection would be appropriate. In that vein, the Veteran has submitted correspondence from Dr. M.F.H, J.M., and Dr. J.H, and he underwent a February 2011 VA examination. Dr. J.H. and J.M. opined that the Veteran's cervical spine disability is related to service. By contrast, the February 2011 VA examiner opined that it is not due to service. Dr. M.F.H. did not specifically relate the disability to service. She stated that it was due to years of repetitive trauma predisposed by hereditary influences. She did not state that the years of repetitive trauma were incurred in service; however, she did state that the Veteran had a 25-30 year history of cervical spine symptoms. The Court has held that the Board must determine how much weight is to be attached to each medical opinion of record. See Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one medical professional's opinion over another, depending on factors such as reasoning employed by the medical professionals and whether or not, and the extent to which, they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). Adequate reasons and bases, in short, must be presented if the Board adopts one medical opinion over another. In assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. 444, 448-9 (2000). In some cases, the physician's special qualifications or expertise in the relevant medical specialty or lack thereof may be a factor. In every case, the Board must support its conclusion with an adequate statement of its reasoning of why it found one medical opinion more persuasive than the other. There are substantial and significant factors which favor assigning more probative weight to the February 2011 VA medical opinion as compared to the opinions of the private physicians in this case. The Veteran's service treatment records, including his separation examination, showed no complaints, symptoms, diagnoses, or treatment of arthritis or degenerative joint disease. The records also failed to show any specific treatment for a neck injury. Furthermore, there are no medical records for many years after service that show any neck disability, to include degenerative changes of the cervical spine. It does not appear that Dr. M.F.H, J.M., and Dr. J.H had access to the Veteran's claim file. If they did, they did not so specify, nor did they address the findings contained therein. In this regard, the Board recognizes that a lack of review of a VA claims file does not render a medical opinion incompetent. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Rather, the focus is not on whether the clinician had access to the claims file, but instead on whether the clinician was "informed of the relevant facts" and medical history in rendering a medical opinion. Id. The Court has held that VA cannot reject a medical opinion simply because it is based on a history supplied by the Veteran and that the critical question is whether that history was accurate. Kowalski v. Nicholson, 19 Vet. App. 171 (2005); see, e. g., Coburn v. Nicholson, 19 Vet. App. 427, 432 (2006) (reliance on a Veteran's statement renders a medical report incredible only if the Board rejects the statements of the Veteran). In this case, the opinions of the examiners are predicated on the Veteran's reports of cervical spine symptoms that began in service and that have been continuous since service. None of the examiners recognized that there were no findings of neck pain during service or for many years after service. The examiners failed to comment on the normal separation examination and the fact that the Veteran admitted at his May 2010 hearing that he began to notice symptoms in 1987 or 1988, over 15 years after separation from service. Looking at each opinion individually, Dr. M.F.H. did not specifically state that the Veteran's cervical spine disability was due to service. She stated that it was due to "years of repetitive trauma predisposed by hereditary influences." The Board notes that the Veteran was only in service for one year and three months. Consequently, it appears that Dr. M.F.H. was unaware of the time the Veteran spent in service or was referencing years of post service traumas. If she was referring to post service trauma, then the opinion does not weigh in the Veteran's favor. If she was referring to "years" spent in service, then she was clearly unaware of the amount of time the Veteran spent in service. Coupled with the fact that she failed to note that there were no findings of neck pain during service (to include at the separation examination) or for many years after service, and the fact that the Veteran himself admitted to first noticing symptoms in 1987 or 1988, all indicate that the examiner was not privy to an accurate history provided by the Veteran. Likewise, chiropractor J.G.M. stated that the Veteran suffered an injury to his cervical spine working as a mechanic from 1969-1971 while service in the U.S. military. However, the service treatment records contain no records of such an injury. Moreover, the Veteran stated at his February 2011 VA examination that he could not recall any specific injury. In J.G.M.'s conclusion, he opined that the Veteran suffers an 85 percent permanent partial disability to his cervical spine as a result of the 1969-1971 injuries (plural). J.G.M.'s opinion appears to be predicated on the Veteran having sustained multiple injuries during service, despite the fact that none are noted in the service treatment records, and the Veteran himself admitted that he could not recall any specific injury. Finally, Dr. J.H. also stated that the Veteran experienced neck pain and headaches during service, despite the fact that no such neck pain is noted in the service treatment records. He opined that the Veteran likely endured multiple minor traumas to his cervical spine while working under various vehicles. He provided no rationale for this opinion. He failed to address the possibility that the Veteran could have sustained minor traumas to his cervical spine in the three decades after service as opposed to the 15 months spent in service. On the other hand, the February 2011 VA examiner did have access to the Veteran's claims file. Moreover, he provided an accurate summary of both the service treatment records and the post service treatment records. He noted the lack of medical findings in the service treatment records, and opined that the Veteran's cervical spine disability was not related to military service. His opinion was supported by the medical evidence (or lack thereof) in the claims file; and he further noted that review of the peer reviewed medical literature does not show that a mechanic is at increased risk for developing cervical spine degenerative changes. He also noted that flexion, extension, side bending, rotation of the cervical spine, or holding the cervical spine in one position for extended periods of time does not cause, contribute to, or enhance progression of degenerative changes of the cervical spine. The Board finds the opinion of the VA physician to be persuasive evidence. Indeed, it was based on a review of the record and was offered following a physical evaluation of the Veteran. Moreover, it was accompanied by a clear rationale. For the forgoing reasons, the Board finds the opinion of the February 2011 VA examiner to be more probative than the other medical opinions. The Veteran himself believes that his current neck disorder is related to service. However, while he is competent to describe symptoms of neck pain and reduced range of motion, he has not demonstrated the expertise generally required to opine on causation. Indeed, in this case, the question of etiology extends beyond an immediately observable cause-and-effect relationship, such as a fall leading to a broken leg. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau)). Here, degenerative disease of the cervical spine is not a simple medical condition that the Veteran can identify based on visual observation or by any other of the senses. In sum, his statements as to etiology in this case are not competent and therefore lack probative value. The Board finds the Veteran's testimony regarding his current symptoms to be credible. However, the Board finds his assertion that he did not complete the September 1970 Report of Medical History to be not credible. The handwriting is consistent with that of the Veteran's other correspondence. Likewise, the signature is consistent with the Veteran's signature on other documents in the claims file. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for entitlement to service connection for degenerative disc disease of the cervical spine must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Headaches The Veteran has claimed entitlement to service connection for headaches, to include as secondary to his cervical spine disability. Since the Board has determined that entitlement to service connection for a cervical spine disability is not warranted, there is no basis upon which to grant service connection for headaches on a secondary basis. Consequently, the Board turns its attention to whether service connection is warranted on a direct basis. The Board notes that the Veteran sought treatment for sharp, shooting headaches in July 1969. He had no joint or muscle pain at that time and he was diagnosed with an upper respiratory infection. There were no additional findings attributed to headaches. The service treatment records include a normal separation examination. They also include a Report of Medical History dated September 1970 (in conjunction with separation from service), in which the Veteran denied that he had frequent or severe headaches, or a history of any head injury. The Veteran underwent a VA examination in June 2009. The examiner reviewed the claims file in conjunction with the examination. The Veteran reported that his headaches began in 1969 and progressively worsened over time. He had been receiving treatment since 1987 and he took Tylenol with Codeine on a daily basis, with some mild benefit. The examiner noted the Veteran's single complaint of headaches during service and the final diagnosis of upper respiratory infection. Following an examination of the Veteran, the examiner opined that the Veteran's headaches were not the result of military service. She based her opinion on the fact that there was no medical evidence of an ongoing headache condition during service. She opined that the Veteran's headaches were more likely related to his cervical spine disability. The Veteran underwent another VA examination in February 2011. The examiner reviewed the claims file in conjunction with the examination. The Veteran reported that initially, he had 2-3 headaches per month. At the time of the examination, he reported having them 2-3 times per week. He described them as similar to migraine headaches. On a severity scale of 1-10, he reported them to be approximately a 6. The headaches lasted 2-3 hours and did not radiate. He did not feel that they were associated with stress. When he experienced a headache, he would take Tylenol and codeine, and lie down until the headache went away. He did not report any visual changes, vomiting, peripheral neuropathies, or dizziness. The examiner opined that the headaches were not related to service. He reasoned that there was only one incident of a headache in service, and that the Veteran denied headaches at separation from service. He also stated that the description of the headaches provided by the Veteran was not consistent with those that result from degenerative changes in the cervical spine. He noted that although mechanics may have exposure to bright lights or noise that could cause headaches, the headaches would resolve when the initiating event was removed, and it would not be expected to cause long term residuals. He stated that there was no peer reviewed medical literature that shows that mechanics are at increased risk for headaches. The Board acknowledges that the VA examiners are not in complete agreement regarding the cause of the Veteran's headaches. The June 2009 examiner opined that the headaches were related to the Veteran's cervical spine disability. The February 2011 examiner reached the opposite conclusion. However, the Board notes that neither of the examiners opined that the headaches were directly related to service. Consequently, neither of the opinions is favorable to the Veteran so long as the cervical spine disability is not service connected. Moreover, the opinions of record, and particularly the more recent February 2011 opinion considered the entire record and was accompanied by a clear rationale. While the opinion was based in part on the absence of documented in-service treatment, aside from one isolated report, the examiner went on to provide other reasons for his negative response, to include a literature review and an explanation of why the work environment of a mechanic would not be expected to result in long-term residual headaches. Thus, the opinion is found to be highly probative. Moreover, no other competent medical evidence attributes the Veteran's current headache disorder to active service. In the absence of medical evidence reflecting chronic headaches during service or for decades after service, and the lack of a competent medical opinion linking headaches to service, the Board finds that a preponderance of the evidence weighs against the Veteran's claim. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for entitlement to service connection for headaches (to include as secondary to degenerative disc disease of the cervical spine) must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). ORDER Entitlement to service connection for degenerative disc disease of the cervical spine is denied. Entitlement to service connection for headaches, to include as secondary to degenerative disc disease of the cervical spine, is denied. ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs