Citation Nr: 1312802 Decision Date: 04/17/13 Archive Date: 05/02/13 DOCKET NO. 10-05 524 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to an initial evaluation in excess of 50 percent for a major depressive disorder. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and Family ATTORNEY FOR THE BOARD H. Bunker, Associate Counsel INTRODUCTION The Veteran had active duty service from March 1994 to March 1997. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision by the, Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma, which granted service connection for a depressive disorder and assigned a 50 percent disability rating and denied entitlement to a TDIU. The Veteran testified at a Board hearing before the undersigned Acting Veterans Law Judge in June 2011; a transcript of that hearing is associated with the claims file. The case was brought before the Board in March 2012, at which time the claims were remanded to allow the Agency of Original Jurisdiction (AOJ) to further assist the Veteran in the development of his appeal, to include affording the Veteran new VA examinations. The Veteran was afforded VA examinations in April 2012 for his claims and to determine if a TDIU was warranted. Therefore, the Board finds that there has been substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (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). In a March 2012 decision the Board denied entitlement to an evaluation in excess of 50 percent for the Veteran's depressive disorder from May 8, 2007 to June 24, 2008. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In November 2012 the Court endorsed a Joint Motion for Remand (JMR) vacating the Board's denial of an increased rating from May 8, 2007 to June 24, 2008 and remanding the matter for further proceedings. Accordingly, the issue of an initial evaluation in excess of 50 percent for a depressive disorder, as of May 8, 2007 is again before the Board for the entire appeal period. FINDINGS OF FACT 1. As of May 8, 2007 the Veteran's depressive disorder has been manifested by depression, anxiety, suicidal ideations, and the inability to establish and maintain effective relationships. 2. The competent evidence of record indicates the Veteran's service-connected disabilities render him unable to secure or follow substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an evaluation of 70 percent, but no higher, for a depressive disorder have been met as of May 8, 2007. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9434 (2012). 2. The criteria for assignment of a TDIU have been met as of May 8, 2007. 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to review the entire record, the Board does not have to discuss each piece of evidence reviewed. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists which does not satisfactorily prove or disprove the claim. Reasonable doubt is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Prior to the initial rating decision in this matter, a May 2007 letter informed the Veteran of all five elements of service connection, gave examples of the types of evidence the Veteran could submit in support of his claim, and provided notice of the Veteran's and VA's respective responsibilities for obtaining such evidence. Therefore, the duty to notify has been satisfied. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also Goodwin v. Peake, 22 Vet. App. 128, 136 (2008) (holding that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service- connection claim has been proven and thus section 5103(a) notice is no longer required because the purpose that the notice is intended to serve has been fulfilled). The Veteran has not alleged that VA failed to comply with the notice requirements of the VCAA, and he was afforded a meaningful opportunity to participate effectively in the processing of his claim, and has in fact provided additional arguments at every stage. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005). The notice required by 38 U.S.C.A. § 5103(a) should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). That was done in this case. The Veteran's service treatment records and VA treatment records are in the file. The Veteran has not indicated that there are any additional outstanding records to be obtained. The duty to assist with obtaining medical records has been satisfied. 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. The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. The Veteran was afforded a VA medical examination in June 2008 and April 2012 for his depressive disorder claim. These opinions were rendered by medical professionals following a thorough examination and interview of the Veteran and review of the claims file. The examiners obtained an accurate history. The examiners provided a detailed conclusion for the conclusions that were reached. Therefore, the Board finds that the examinations are adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In light of the foregoing, all relevant facts have been adequately developed to the extent possible; no further assistance to the Veteran in developing the facts pertinent to the issue on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Increased Rating The Veteran's depressive disorder has been rated 50 percent disabling. The Veteran contends that a higher rating is warranted. For the reasons discussed below, the Board finds that a 70 percent evaluation, but no higher, is warranted as of May 8, 2007. Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 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. The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). In Fenderson v. West, 12 Vet. App. 119 (1999), the Court held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. In Fenderson, the Court also discussed the concept of the "staging" of ratings, finding that in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a Veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Fenderson at 126-28; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). Under 38 C.F.R. § 4.130, Diagnostic Code 9434, a 70 percent disability evaluation is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. Id. As evidenced by use of the phrase "such symptoms as," followed by a list of examples, this list of symptoms in the rating criteria is meant to be mere examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet App 436, 442-3 (2002). However, if the evidence shows the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the Diagnostic Code, the appropriate equivalent rating will be assigned. Mauerhan, at 443. The Federal Circuit Court has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). The mental status findings in the claims file indicate the Veteran's judgment and insight were generally appropriate over the appeal period. At his June 2008 VA examination the Veteran had abnormal orientation to time in that he did not know the day, date, or month. His communication and speech were within normal limits. In an August 2009 VA treatment record the Veteran was oriented times four, although he was noted to have a lot of difficulty maintaining coherence at his appointment. At his April 2012 VA examination the examiner found the Veteran had impaired abstract thinking and a flattened affect. There has been no evidence throughout the appeal of gross impairment in the Veteran's thought process or communication which could warrant a higher rating. The Veteran reported some memory loss at his June 2008 VA examination. He described it as forgetting names, directions, and recent events. The Veteran also reported mild memory loss at his April 2012 VA examination. Neither the Veteran nor a VA or private treatment provider has indicated that the Veteran has memory loss so severe he cannot remember the names of his close relatives, his own occupation, or his own name, which could warrant a higher rating. At his June 2008 VA examination the Veteran reported that he felt depressed, angry, irritated, frustrated, anxious, and nervous. The Veteran reported anxiety attacks which occurred more than once per week. The Veteran was diagnosed with anxiety in an August 2009 treatment record. The Veteran reported feelings of depression, anxiety, and anger in a June 2011 VA treatment record. See also January 2010 VA treatment record. The Veteran's wife reported that she believed most of his symptoms were situational based on work. However, even after resigning from work in a July 2011 VA treatment record the Veteran reported that he still had agitation and anxiety at times. At his June 2011 Board hearing the Veteran testified that he had a short temper. The Veteran's wife testified that the Veteran was undergoing therapy to help control his coping skills, breathing, and staying calm. The Veteran also reported daily panic attacks at his April 2012 VA examination. These symptoms have been taken into account in the 70 percent evaluation. At his June 2008 VA examination the Veteran denied suicidal or homicidal ideations. In June 2011 the Veteran was hospitalized with depressive symptoms and homicidal ideations towards his boss. He reported that he did not think he would hurt the boss, but that he could not trust himself. Following an overnight hospitalization he reported no homicidal or suicidal ideations. The Veteran has also reported suicidal ideations, but that he did not have an active intent or plan. See June 2011 VA treatment record. In a later June 2011 treatment record he reported some thoughts of hurting others, but that he had no intent to act on them. At his April 2012 VA examination he was noted to have suicidal ideations. The Veteran has consistently reported suicidal ideations over the appeal period, but there has been no evidence of intent, plan, or attempted suicide. The Veteran has also reported intermittent homicidal ideation. These symptoms were taken into account with the current 70 percent evaluation. The Veteran has not shown that he is in persistent danger of hurting himself or others, which could warrant a higher evaluation. With regard to social impairment, at his June 2008 VA examination the Veteran reported that he had a good relationship with his wife and children. In a May 2009 VA psychiatric evaluation the Veteran reported that he had no interest in making friends and that he kept to himself. He did not participate in groups or organized clubs or got to local bars or restaurants. He also reported no hobbies. He reported working part time because he could not maintain full time positions. At his June 2011 Board hearing he also testified that he withdrew from people. He testified that he only went out when his wife forced him to go out. In July 2011 the Veteran reported that he had been forced to resign from his job. At his April 2012 VA examination the examiner determined that the Veteran had occupational and social impairment with deficiencies in most areas. The Veteran reported limited contact with extended family and friends. He also reported a strained relationship with his daughter and wife, which included a separation period from his wife in the previous year. The Veteran reported one responsibility which was picking his daughter up from school. The Veteran's wife stated that he had to be reminded of things daily. The April 2012 examiner did differentiate that the Veteran's major depressive disorder was causing occupational and social impairment with regard to reduced productivity in work, difficulty concentrating, indecisiveness, inadequate sleep, and feelings of failure. His major depressive disorder also caused withdrawal from others. This was differentiated from his panic disorder which caused him to not leave the house. The Board observes that a higher rating is not warranted because the competent evidence of record does not demonstrate that the Veteran's symptomatology more closely approximates a 100 percent evaluation. The Veteran denied hallucinations and delusions in a June 2008 VA examination report. There is no evidence to the contrary. If apparent, these symptoms could be evidence that a higher rating is warranted. In a January 2010 VA treatment record the Veteran was well groomed. However, the Veteran's wife stated that he needed to be reminded of personal hygiene issues at times. See April 2012 VA examination report. The Board takes into account all the evidence of record when determining the appropriate rating, instead of relying on a single symptom. At his June 2008 VA examination the Veteran denied obsessional rituals, but at his June 2011 Board hearing the Veteran testified that he had obsessional rituals in his life such as needing things to be in specific places. The Board has also taken this into account in determining that a 70 percent evaluation is warranted. The Board also acknowledges that the Veteran suffers from symptoms not covered under Diagnostic Code 9434. For instance, in a January 2010 treatment record the Veteran was tearful and apologetic for his lack of emotional control. The Veteran has reported feelings of worthlessness and low energy as well. See e.g., April 2012 VA examination reports. However, all of the Veteran's symptoms have been taken into account when determining the most appropriate evaluation. Also of record are the Veteran's GAF scores. GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders contemplates that the GAF scale will be used to gauge a person's level of functioning at the time of the evaluation (i.e., the current period) because ratings of current functioning will generally reflect the need for treatment or care. The Board notes that while GAF scores are probative of the Veteran's level of impairment, they are not to be viewed outside the context of the entire record and they will not be relied upon as the sole basis for an increased rating. At his June 2008 VA examination he was assigned a GAF score of 55. At his April 2012 VA examination the Veteran was assigned a GAF score of 45. A GAF score of 41-50 is assigned for serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job. GAF scores ranging between 51 and 60 indicate some moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Taking into account the Veteran's depressive disorder symptoms, including social impairment, suicidal ideation, and depression, the Veteran has been assigned GAF scores corresponding with moderate and severe symptoms. The Board observes that the Veteran's depressive disorder has been rated as 70 percent disabling as of May 8, 2007. As such, the moderate and severe GAF scores are appropriate for this time period. The Board has considered the requirement of 38 C.F.R. § 4.3 to resolve any reasonable doubt regarding the level of the Veteran's disability in his favor. The Board concludes that the objective medical evidence and the Veteran's statements regarding his symptomatology show disability that warrants the assignment of a 70 percent rating as of May 8, 2007. See 38 C.F.R. § 4.7. In addition to the medical evidence, the Board has considered the Veteran's statements in support of his claim. The Veteran, as a layman, is competent to report on that as to which he has personal knowledge, such as anxiety, social impairment, suicidal ideation, and irritability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); and 38 C.F.R. § 3.159(a)(2). Since his allegations of these particular symptoms appear to be uncontradicted, even by medical findings of record, the Board also finds them to be credible and, thus, probative. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Rucker v. Brown, 10 Vet. App. 67 (1997) (indicating his competency to make these proclamations must be distinguished from the weight and credibility of his lay testimony, which are factual determinations going to the ultimate probative value of this evidence). On the other hand, as a layman, without the appropriate medical training and expertise, the Veteran is not further competent to provide a probative (persuasive) opinion on a medical matter, especially the severity of his depressive disorder in relation to the applicable rating criteria. An examiner, including the VA compensation examiners, takes into consideration the Veteran's subjective complaints, his social and occupational history, and the results of the objective mental status evaluation in determining the overall severity of his depressive disorder. This determination is multi-factorial, not just predicated on lay statements and other testimony, rather, all of the relevant medical and other evidence. The Federal Circuit Court has recognized the Board's 'authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence.' Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Overall, the Board concludes that the evidence discussed above supports no more than a 70 percent rating for the Veteran's depressive disorder as of May 8, 2007. In reaching its decision, the Board considered the benefit-of-the-doubt rule. However, the preponderance of the evidence is against a higher evaluation and therefore, it does not apply. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Extra-Schedular Consideration There is no evidence of exceptional or unusual circumstances to warrant referring these claims for extra-schedular consideration. 38 C.F.R. § 3.321(b)(1). The Court has clarified the analytical steps necessary to determine whether referral for extra-schedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a determination of whether the evidence presents such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, there must be a determination of whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms". Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating under 38 C.F.R. § 3.321(b)(1). The Board finds no such evidence in this particular instance, however. The Veteran's complaints related to his major depressive disorder are considered under the appropriate diagnostic code. His primary symptoms are depression and social impairment. But all of his symptoms are accounted for in the regular schedular rating criteria. According to 38 C.F.R. § 4.1, generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. Indeed, in Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993), the Court reiterated this, noting the disability rating, itself, is recognition that industrial capabilities are impaired. As the assigned schedular evaluation for the service-connected depressive disorder is adequate, referral for an extra-schedular rating is unnecessary. Thun, supra. Furthermore, there is no evidence of any exceptional or unusual circumstances, such as frequent hospitalizations, suggesting he is not adequately compensated for this disability by the regular Rating Schedule. His evaluation and treatment for this disability has been entirely on an outpatient basis, not as an inpatient, much less frequent inpatient. So extra-schedular referral is not warranted under the circumstances presented. See Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); and VAOPGCPREC 6-96 (August 16, 1996). TDIU The Veteran contends that his service-connected disabilities are of such severity that they render him unemployable and in turn entitle him to a TDIU. For the reasons that follow, the Board concludes that a TDIU is warranted. Entitlement to a TDIU requires the presence of impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. Consideration may be given to the veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2012). In reaching such a determination, the central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The law provides that a total disability rating may be assigned where the schedular rating is less than total, when the person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16(a). As discussed above, the Veteran is entitled to a 70 percent disability rating for a major depressive disorder as of May 8, 2007. He is also service connected for vertigo, evaluated as 30 percent disabling, tinnitus, evaluated as 10 percent disabling, bilateral hearing loss, bilateral ear scars, and bilateral ear disabilities, all noncompensably rated. The Veteran's service-connected depressive disorder at 70 percent disabling meets the criteria for schedular consideration of TDIU. Id. Thus, the Veteran is eligible to receive TDIU benefits. The Veteran reports that he has been too disabled to work since August 2011, when he stopped working from his part time positions. See April 2012 VA examination report. There is no evidence of record to indicate that the Veteran has worked since leaving his previous part time position. At his May 2009 VA psychiatric examination the Veteran reported that he only worked part time because he had not been able to maintain a job full time with his physical disabilities. At his June 2011 Board hearing the Veteran testified that he had to miss work because his depression was worsening. At his April 2012 VA examination for scars the examiner determined the Veteran's scars did not prohibit him from maintaining substantially gainful employment. The Veteran's hearing loss, tinnitus, and inner ear disabilities did not prohibit him from maintaining substantially gainful employment, although it was noted he had difficulty standing and sitting due to his inner ear disability. However, the examiner opined that the Veteran was capable of performing sedentary employment. At his April 2012 VA examination the Veteran reported that he had not worked since August 2011 and prior to that he was working part time. He said he had received feedback that he was "not mentally stable." The examiner ultimately concluded that the Veteran's severe major depressive disorder limited his ability to maintain gainful employment. In light of the evidence above, the Board finds that the Veteran's service-connected disabilities, specifically his depressive disorder, render him totally disabled and incapable of gainful employment. Notably, there is no evidence of record to the contrary. As such, a total disability rating based on individual unemployability is warranted. See 38 U.S.C.A. § 5107(b); Gilbert, supra. ORDER Entitlement to an evaluation of 70 percent, but no higher, is granted, effective May 8, 2007 for depression, subject to the laws and regulations governing monetary awards. Entitlement to a TDIU is granted, effective May 8, 2007. ____________________________________________ ROBERT E. O'BRIEN Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs