Citation Nr: 1310495 Decision Date: 03/29/13 Archive Date: 04/09/13 DOCKET NO. 06-37 243A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina THE ISSUE Entitlement to an initial rating in excess of 10 percent for asbestosis. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had active duty service from October 1972 to October 1973. This appeal to the Board of Veterans' Appeals (Board) arose from a July 2006 rating decision in which the RO, inter alia, awarded service connection for asbestosis and assigned an initial, noncompensable rating, effective February 21, 2006.. As the Veteran disagreed with the initial rating assigned following the award of service connection, the Board has characterized this claim in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). During the pendency of the appeal, by rating decision dated in August 2007, the RO granted a 10 percent rating asbestosis, as of February 21, 2006, the effective date of the award of service connection. However, inasmuch as a higher rating is available for asbestosis, and the Veteran is presumed to seek the maximum available benefit for a disability, the claim for a higher rating has remained viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In November 2010 and October 2011, the Board remanded the claim on appeal to the RO, via the Appeals Management Center (AMC) in Washington, D.C, for further action, to include additional development of the evidence. In October 2012, the Board again remanded the claim on appeal to the RO, via the AMC, for further action, to include additional development of the evidence. After completing the requested development, to the extent possible, the RO continued to deny the claim (as reflected in an February 2013 supplemental statement of the case (SSOC)), and returned this matter to the Board for further appellate consideration. A review of the Virtual VA claims processing system reveals VA treatment records dated through February 2013; the February 2013 SSOC notes review of the Veteran's electronic VA treatment records. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim on appeal have been accomplished. 2. From the February 21, 2006 effective date of service connection through December 5, 2011, the Veteran's asbestosis manifested, at worst, a post-bronchodilator FVC (Forced Vital Capacity) of 74 percent of predicted value, but did not manifest an FVC that was 50 to 64 percent of the predicted value, DLCO (SB) (Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method) that was 40 to 55 percent predicted value, or maximum exercise capacity that was 15 to 20 ml/kg in oxygen consumption with cardiorespiratory limitation. 3. Beginning on December 6, 2011, the Veteran's asbestosis manifested, at worst; a post-bronchodilator FVC of 82.4 percent of predicted value, but has not manifested an FVC that was 65 to 75 percent of the predicted value or DLCO (SB) that was 56 to 65 percent of the predicted value. 4. The schedular criteria have been adequate to rate the Veteran's asbestosis at all points to this appeal. CONCLUSIONS OF LAW 1. The criteria for an initial 30 percent rating for asbestosis for the period from February 21, 2006 through December 5, 2011 are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.96, 4.97, 6833 (2012). 2. The criteria for a rating in excess of 10 percent for asbestosis for the period beginning on December 6, 2011 are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.96, 4.97, 6833 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353 - 23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (here, the RO, to include the AMC) . Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. A March 2006 pre-rating letter provided pertinent notice to the Veteran in connection with what was then a claim for service connection for a lung condition due to asbestos exposure. That letter indicated what information and evidence was needed to substantiate the claim, as well as what information and evidence must be submitted by the Veteran and what information and evidence would be obtained by VA. The letter also provided him with general information pertaining to VA's assignment of disability ratings and effective dates in accordance with Dingess/Hartman. After the award of service connection for asbestosis, and the Veteran's disagreement with the initial rating assigned, the August 2012 SSOC set forth applicable criteria for higher ratings for asbestosis (the timing and form of which suffices, in part, for Dingess/Hartman.) Although no notice letter specific to the claim for higher rating for the asbestosis has been provided, on these facts, the absence of such notice is not shown to prejudice the Veteran. As indicated, he has been furnished with notice of the applicable rating criteria, and afforded opportunity to respond. As explained below, there is no indication that there is any outstanding evidence pertinent to the claim. Also, pertinent notice consistent with Pelegrini and certain requirements of Dingess/Hartman has been provided. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter herein decided. Pertinent medical evidence associated with the claims file consists of the reports of the VA examinations, as well as the Veteran's VA treatment records (requested by the Board in its October 2012 remand) and various private treatment records. Also of record and considered in connection with the appeal are various written statements provided by the Veteran and by his representative, on his behalf .The Board finds that no further RO action on this claim, prior to appellate consideration, is required. In a December 2011 letter, the RO informed the Veteran that clarification regarding the contents of specific pulmonary function testing conducted by a private entity was necessary to adjudicate his claim, and requested that he complete an appropriate authorization form (as instructed by the Board in its October 2011 remand however, the Veteran did not respond to this letter. The Board points out that, in order for VA to process claims, individuals applying for VA benefits have a responsibility to cooperate with the agency in the gathering of the evidence necessary to establish allowance of benefits. See Morris v. Derwinski, 1 Vet. App. 260, 264 (1991). Moreover, VA's duty to assist is not always a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991); see Swann v. Brown, 5 Vet. App. 229, 233 (1993). As previously indicated, the RO requested that the Veteran complete an appropriate authorization form to allow VA to seek clarification of specific private testing results in a December 2011 letter. Under these circumstances, the Board finds that, with respect to this request, no further RO action in this regard is required. Also in its October 2012 remand, the Board instructed that a supplemental VA pulmonary opinion was to be obtained to clarify whether the Veteran's manifestations were the result of his service-connected asbestosis or a nonservice-connected pulmonary disorder. The Board further instructed the VA examiner to address the significance of particular pieces of evidence. On remand, a November 2012 VA examiner provided an addendum opinion but did not specifically address the evidence identified by the Board in its remand. However, and as detailed below, the Board has determined that it is not possible, based on the evidence of record, to distinguish the effects of the nonservice-connected disability from those of the service-connected disability, as is attributing all testing results to the service-connected disability. As such, it is not necessary for the VA examiner to address the specific evidence identified by the Board in its October 2012 remand, and the November 2012 VA opinion substantially complies with the Board's remand directives. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO/AMC, the Veteran has been notified and made aware of the evidence needed to substantiate this claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). III. Evaluation of Asbestosis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is entitlement to a higher initial rating assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of 'staged rating' (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson, 12 Vet. App. at 126. The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Under the Diagnostic Code 6833, for asbestosis, manifestations are rated as interstitial lung disease. 38 C.F.R. § 4.97,. The General Rating Formula for Interstitial Lung Disease provides that a 10 percent rating is warranted where the FVC is 75 to 80 percent of predicted value or the DLCO (SB) is 66 to 80 percent of predicted value. A 30 percent rating is warranted if the FVC is 65 to 74 percent of predicted value or the DLCO (SB) is 56 to 65 percent of predicted value. A 60 percent rating is warranted where the FVC is 50 to 64 percent of predicted value; DLCO (SB) is 40 to 55 percent predicted value; or maximum exercise capacity is 15 to 20 ml/kg in oxygen consumption with cardiorespiratory limitation. A 100 percent rating is warranted if the FVC is less than 50 percent of predicted value; DLCO (SB) is less than 40 percent predicted value; maximum exercise capacity is less than 15 ml/kg in oxygen consumption with cardiorespiratory limitation or; cor pulmonale or pulmonary hypertension; or requires oxygen therapy. 38 C.F.R. § 4.97, 6825 to 6833. Post-bronchodilator studies are required when pulmonary function tests (PFTs) are performed for disability evaluation purposes except in instances where the results of pre-bronchodilator PFTs are normal or when the examiner determines that post-bronchodilator studies should not be done. Post-bronchodilator results are to be utilized in applying the evaluation criteria in the Rating Schedule unless the post-bronchodilator results were poorer than the pre-bronchodilator results. The pre-bronchodilator values are to be used for rating purposes in those instances. 38 C.F.R. § 4.96(d)(5). The report of a July 2006 VA pulmonary examination reflects the Veteran's complaints of extertional dyspnea and frequent coughing. He reported that he had smoked two packs of cigarettes per day until last year, when he was diagnosed with pulmonary asbestosis, and that he had decreased his smoking to four or five cigarettes per day. On physical examination, the lungs were without wheezing or rhonchi. An accompanying PFT revealed the FVC to be 93 percent of predicted value. The examiner opined that it was not clear, given the PFT results, whether the Veteran had the stigmata of pulmonary asbestos exposure or actual asbestosis with fibrosis. A December 2006 private PFT revealed the Veteran's FVC to be 79 percent of predicted value and "uncorrected" DLCO to be 54 percent of predicted value; it appears that this testing was conducted pre-bronchodilator. The report of a July 2007 VA pulmonary examination reflects the Veteran's complaints of exertional dyspnea that had worsened since the last examination as well as coughing that was "better." He reported smoking two cigarettes per week. On physical examination, his lungs demonstrated coarse bilateral breath sounds with bilateral end expiratory wheezes and decreased air movement. The examiner opined that the Veteran likely carried the diagnosis of pulmonary asbestosis, which would likely be causing his obstructive ventilatory defect, as the July 2006 VA PFT suggested an obstructive ventilatory defect and the December 2006 private PFT suggested a moderately severe diffusion defect. A December 2007 private PFT revealed the Veteran's post-bronchodilator FVC to be 74 percent of predicted value while uncorrected DLCO was 55 percent. The report of a November 2010 VA pulmonary examination notes the Veteran's complaints of frequent shortness of breath with moderate or heavy exertion and that such episodes of shortness of breath lasted up to one hour. He also reported that he had used inhalers in the past but that they were not helpful. Physical examination found diaphragm excursion and chest expansion to be normal and was negative for abnormal breath sounds, chest wall scarring or a deformity of the chest wall. The examiner noted that the Veteran had failed to appear for his PFT appointment. A January 2012 VA respiratory Disability Benefits Questionnaire (DBQ) reflects the Veteran's reports of frequent shortness of breath with moderate or heavy exertion and that such episodes of shortness of breath lasted up to one hour. He also reported using an inhaler up to four times per day which helped his symptoms. The examiner noted that the result of a January 2011 chest X-ray, which revealed bilateral pleural plaques, and the results of a January 2011 computed tomography (CT) scan, which revealed bilateral pleural plaques without pulmonary fibrosis. Following a review of the Veteran's claims file, the examiner opined that the Veteran's nonservice-connected chronic obstructive pulmonary disease (COPD) affected his PFT results "100 percent" and that the Veteran did not have asbestosis as such a diagnosis must be confirmed by the presence of pulmonary fibrosis on a CT scan as well as other significant imaging findings. However, the examiner did find that the Veteran had asbestos-related pleural disease as evidenced by his bilateral pleural plaques, both calcified and non-calcified. The examiner opined that the Veteran's symptoms of dyspnea on exertion were not caused by his asbestosis-related pleural disease but were caused by his COPD due to tobacco abuse as his PFTs showed improvement with bronchodilation, which occurred only with COPD and not with asbestos-related pleural disease. In addition, the examiner noted that the Veteran had reported symptomatic relief with the use of an inhaler and opined that the use of an inhaler was not effective for asbestosis related pulmonary disease but was effective for COPD. The January 2012 DBQ examiner also noted that she was unable to identify which, if any, of the diffusion tests contained in the December 2007 private PFT report reflected DLCO (SB) testing results, as the report itself did not identify this method of testing. The examiner further opined that it would therefore be pure speculation to presume which, if any, of the December 2007 PFT results represented DLCO (SB) testing results. A February 2012 VA PFT revealed the Veteran's FVC to be 81.4 percent of predicted value and DLCO (SB) to be 39.3 percent. It is not clear whether this testing was conducted post-bronchodilator. The record of a February 2012 VA pulmonary consultation notes that the Veteran's maximum oxygen consumption was 28 m/kg/min. An August 2012 addendum to the January 2012 DBQ indicates that the Veteran's December 6, 2011 PFT results had been incorrectly stated in the previous examination report. The examiner noted that the correct PFT results revealed the Veteran's post-bronchodilator FVC to be 82.4 percent of predicted value. An November 2012 addendum to the January 2012 DBQ includes notes that the examiner had reviewed the Veteran's claims file, recent images and PFTs. The examiner opined that after such a review, she could not say that the Veteran's current pulmonary complaints were in fact due to asbestos exposure and not more likely due to his extensive smoking history. The examiner noted that while the Veteran does have pleural based plaques, he lacked any evidence of pulmonary fibrosis, rendering a diagnosis of pleural asbestosis, not pulmonary asbestosis, appropriate. The examiner further opined that there was no logical evidence presented to change the former medical opinion made by the previous examiner in January 2012. At the outset, the Board notes that, in addition to the Veteran's service-connected asbestosis, the medical evidence also reflects a diagnosis of COPD which, as indicated, has been attributed to the Veteran's smoking history. Where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). Although the January 2012 and November 2012 VA examiners suggested that the Veteran's extertional dyspnea is the result of his nonservice-connected COPD, neither examiner actually distinguished the PFT testing results (which provide the basis for rating the service-connected asbestos) attributable to service-connected and nonservice-connected disability. Hence, the Board has considered all pulmonary testing results in evaluating the Veteran's service-connected asbestosis. As indicated above, for the period prior to December 6, 2011, the Veteran's service-connected asbestosis manifested, at worst, a post-bronchodilator FVC of 74 percent of predicted value, as obtained on December 2007 private PFT. Such results would warrant a 30 percent rating under the General Rating Formula for Interstitial Lung Disease. The Board notes that it is not clear whether the December 2006 private PFT and December 2007 private PFT findings regarding corrected and uncorrected DLCO represented DLCO (SB) findings, and whether they were conducted post-bronchodilator as required by VA regulations, and therefore cannot be considered for rating purposes. See 38 C.F.R. § 4.96(d)(5). A rating in excess of 30 percent for this period is not warranted as the clinical evidence is negative for, and the Veteran has not alleged, that the FVC was 50 to 64 percent of predicted value, that the DLCO (SB) was 40 to 55 percent of predicted value or that maximum exercise capacity was 15 to 20 ml/kg in oxygen consumption with cardiorespiratory limitation. 38 C.F.R. § 4.97, 6733. Beginning on December 6, 2011, the date of a VA PFT, the Veteran's asbestosis manifested a post-bronchodilator FVC of 82.4 percent of predicted value. No DLCO (SB) results were reported for this PFT study. Such results warrant no more than the current 10 percent rating under the General Rating Formula for Interstitial Lung Diseases. A rating excess of 10 percent is not warranted as the clinical evidence is negative for, and the Veteran has not alleged, an FVC of 65 to 75 percent of predicted value or DLCO (SB) of 56 to 65 percent of predicted value. In assessing the severity of the disability under consideration, the Board has considered the Veteran's assertions regarding his symptoms, which he is certainly competent to provide. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of a rating in excess of 30 percent prior to December 6, 2011 or in excess of 10 percent beginning on December 6, 2011 pursuant to any applicable criteria at any point pertinent to this appeal. Additionally, the Board finds that at no pertinent point has the disability under consideration been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The Board notes that although the Veteran has not been provided with the specific provisions of 38 C.F.R. § 3.321(b)(1), the RO explicitly considered whether this disability presented an exceptional or unusual disability picture in an August 2012 SSOC. The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disabilities at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996). Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, supra. In this case, the Board finds that the applicable schedular criteria are adequate to rate the disability under consideration at all points pertinent to this appeal. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than that assigned based on more significant functional impairment. Significantly, there is no medical indication or argument that the applicable criteria are otherwise inadequate to rate the disability. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). As a final point, the Board notes that, although a claim for a total disability rating based on individual unemployability (TDIU) may be raised in the record as a component of a claim for higher rating (see e.g., Rice v. Shinseki, 22 Vet. App. 447 (2009)), here, there is no indication that the Veteran is unemployed, nor is there evidence or argument that the Veteran's asbestosis renders him unemployable. As such, a claim for a TDIU due to asbestosis has not reasonably been raised, and need not be addressed. For all the foregoing reasons, the Board finds that an initial 30 percent, but no higher, rating for asbestosis for the period from February 21, 2006 through December 5, 2011 only is warranted. The Board has applied the benefit-of-the-doubt doctrine in awarding this initial 30 percent rating, but finds that the preponderance of the evidence is against the assignment of a rating in excess of 30 percent prior to December 6, 2011, or in excess of 10 percent beginning on December 6, 2011. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-53 (1990). ORDER An initial 30 percent rating for asbestosis, from February 21, 2006 through December 6, 2011 is granted, subject to the legal authority governing the payment of compensation benefits. A rating for asbestosis in excess of 10 percent for the period beginning on December 6, 2011 is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs