Citation Nr: 1314007 Decision Date: 04/26/13 Archive Date: 05/03/13 DOCKET NO. 07-05 848 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for headaches. 2. Entitlement to service connection for an acquired psychiatric disability, to include depression and anxiety. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD H.J. Baucom, Associate Counsel INTRODUCTION The Veteran had service from February 1966 to November 1966. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, which denied service connection for headaches and a nervous condition. The issues have been recharacterized to comport with the evidence of record and the Veteran's contentions in light of Clemons v. Shinseki, 23 Vet. App. 1 (2009). In February 2008 a Board hearing was held at the RO before the undersigned; the transcript is of record. In May 2009 the Board remanded the claim for additional development which has been completed, as discussed further herein. In November 2010 the Board denied the claim. In April 2012 the U.S. Court of Appeals for Veterans Claims (Court) vacated and remanded the November 2010 Board decision based on a Joint Motion for Remand (JMR). In January 2013 the Board remanded the claim for readjudication by the RO. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. The Veteran had multiple concussions prior to entry into active service which was noted on the entry examination along with the Veteran's report of a history of frequent and severe headaches. 2. In August 1966, a Medical Board examination of the Veteran was conducted with a diagnosis of post concussive syndrome that existed prior to service. 3. A September 1966 Service Department Medical Board Report indicated a diagnosis of encephalopathy due to remote trauma with headache; the Medical Board found that the condition was not incurred during service, but rather existed prior to service and was not permanently aggravated by service. 4. Clear and unmistakable (obvious or manifest) evidence demonstrates that a disorder manifested by headaches and nervousness and remote post concussive syndrome existed prior to service. 5. Clear and unmistakable evidence (obvious or manifest) demonstrates that the pre-service disorder manifested by headaches and nervousness, and post concussive syndrome did not undergo a permanent increase in severity during service. 6. The preponderance of the competent and credible evidence shows that any present findings of a headache disorder or a psychiatric disability are not related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for headaches are not met. 38 U.S.C.A. §§ 101(16), 1110, 1116, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303 , 3.304, 3.306, 3.307(a)(6), 3.309(e), 3.310(a) (2012). 2. The criteria for service connection for an acquired psychiatric disability manifested by depression and anxiety are not met. 38 U.S.C.A. §§ 101(16) , 1110, 1116, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303 , 3.304, 3.306, 3.307(a)(6), 3.309(e), 3.310(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance 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. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). A July 2005 letter satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). A March 2006 letter notified the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The issues were subsequently adjudicated in January 2008 statement of the case. The Veteran's service treatment records, VA medical treatment records, and private treatment records have been obtained; he did not identify any additional private or VA treatment records pertinent to the appeal. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The Board has reviewed the Veteran's "Virtual VA" file. The Veteran has not indicated, and the record does not contain evidence, that he is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159 (c) (2). VA examinations were conducted in December 2005, September 2009 and October 2009; the Veteran has not argued, and the record does not reflect, that these examinations were inadequate for rating purposes. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The examinations were adequate as the examiners reviewed the record, evaluated the Veteran and provided opinions as to whether the Veteran's pre existing conditions were aggravated during service. The May 2009 Board remand requested a neuropsychiatric examination which was substantially complied with by two separate examinations, one for psychiatric disorders by a clinical psychologist, and a neurological examination by a physician. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2009) ("substantial compliance" rather than "strict compliance" is required under Stegall) (citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999). There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision at this time. Service Connection In seeking VA disability compensation, a veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A § 1110. "Service connection" basically means that the facts, shown by the evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. Where chronicity of a disease is not shown in service, service connection may yet be established by showing continuity of symptomatology between the currently claimed disability and a condition noted in service. A veteran may also establish service connection if all of the evidence, including that pertaining to service, shows that a disease first diagnosed after service was incurred in service. 38 C.F.R. § 3.303. The Veteran's claim for service connection is based on a claim for aggravation, specifically that he incurred several head injuries prior to service which were aggravated during his active service. A Veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C.A. §§ 1111, 1131, 1132; 38 C.F.R. § 3.304(b). If a preexisting disorder is noted upon entry into service, the veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service- connected aggravation of that disorder. In that case section 1153 applies and the burden falls on the veteran to establish aggravation. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If aggravation is established, the burden shifts to the government to show a lack of aggravation by establishing "that the increase in disability is due to the natural progress of the disease." 38 U.S.C. § 1153; see also 38 C.F.R. § 3.306; Jensen, 19 F.3d at 1417. Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 C.F.R. § 3.306(b). B. Factual Background The Veteran served on active duty from February to November 1966, a period of 9 months. Entrance examination of the Veteran was conducted in September 1965. On the report of medical history the Veteran indicated "yes" to questions which asked if he presently had, or had a history of: dizziness or fainting spells; frequent or severe headache; and, epilepsy or fits. The medical history also noted that the Veteran had "head injuries last four years." The physician's summary also noted "multiple brain concussions - last in [19]65 - no sequelae" On the actual physical examination report, no abnormalities were indicated. However, the examining physician noted a significant medical history of "multiple brain concussions - no apparent sequelae." A February 1966 service department treatment record reveals that the Veteran was seen in the emergency room for complaints of dizziness and headaches within two weeks of entry on active duty. The Veteran reported a history of intermittent dizziness and headaches since 1962. He reported having had multiple recurrent head injuries prior to service. The last one was in an automobile accident in 1964, and he indicated he was unconscious for approximately 5 hours from that injury. He also reported a history of epilepsy in childhood. Neurologic examination was essentially normal and the diagnosis was "possible post concussion syndrome." He was provided Darvon for his headache pain. An April 1966 service treatment record again reveals complaints of headaches and dizziness for which he was again prescribed medication. Another April 1966 service treatment record showed an assessment of muscle tension headaches and he was prescribed Fiorinol to treat the pain. An April 1966 physical profile serial report indicated that the Veteran had a "history of 5 concussions - frequent headaches." He was fit for duty with the restriction of "no strenuous activity, such as judo and strenuous PC." It was recommended that his career field be changed to remove him from the Air Police. Service treatment records dated May and June 1966 reveal that he was seen at the medical dispensary several times for complaints of headaches. A service treatment records entry dated June 1, 1966 indicates that the Veteran had "headaches. Has had 4 concussions - the last 1 year ago. Probably post-concussive syndrome. Says headaches make him very nervous." He was prescribed Librium to treat his symptoms. A treatment note dated June 8, 1966 states that the Veteran reported being "no better. Very nervous. Working in Motor Pool - outside a lot. Very nervous." His prescribed medications were changed at this time. A June 13 treatment note indicated no change and that the Veteran believes that the "pills are making him nervous. Tells me now he was addicted to 'diet pills' about a year ago." Subsequent treatment notes dated in June 1966 show continued complaints of headache and being "nervous." In July 1966, a full neurology evaluation of the Veteran was conducted. The reason for the evaluation request was the Veteran had a "past history of four concussions (the last one a year ago) suffers from severe daily headaches. Had a 'borderline' EEG at Lackland 24 Feb 66. Also complains of a 'nervous problem', probably primary, but maybe secondary to daily headaches." On neurology examination the physician noted the Veteran's history of multiple pre-service head injuries and concussions. The Veteran also reported a history of being told by a physician prior to service that the concussions made him "nervous." The Veteran reported his "headache as being bifrontal and a bit toward the right temporal region. It is present every day and on most days will become quite severe, almost incapacitating the patient." On examination the Veteran was vague in responding to questions and had a somewhat flat affect. No neurologic deficit was found. The neurologist's medical opinion was that the Veteran had post-concussive syndrome and should be separated from active duty. Service treatment records dated in August 1966 reveal that the Veteran was diagnosed with post concussive syndrome and that separation was recommended as the condition existed prior to service (EPTS). In August 1966, a Medical Board examination of the Veteran was conducted. No neurologic or psychiatric abnormalities were noted. However a diagnosis of "post concussive syndrome, EPTS," was indicated. A September 1966 treatment record indicates "anxiety - PE (physical evaluation) Board." A September 1966 service department Medical Board Report indicated a diagnosis of "encephalopathy due to remote trauma, headache." The Medical Board found that the condition was not incurred during service, but rather existed prior to service and was not permanently aggravated by service. A December 2003 private hospital record reveals that the Veteran was treated for a single syncopal episode at that time. This record also noted the recent death of the Veteran's wife. Treatment records dated from 1999 to the present have been obtained from the Veteran's private primary care physician. A May 2005 record indicates that the Veteran reported feelings of depression since the death of his wife approximately one year earlier. An assessment of "depression, new" was made and the Veteran was prescribed Prozac. A January 2007 treatment note indicates that the Veteran reported a problem with chronic headaches. He reported his remote history of concussions and that he was discharged from the military for this and headaches. He reported that he had dull headaches which were now located in the lower part of his neck and upper shoulder area. He reported still missing his deceased wife and that he had insomnia. The assessment was insomnia and chronic headaches. The Board notes that this is the first, and only, record from the Veteran's private primary care provider in which he indicates he has complaints of chronic headaches. This record was made after the Veteran filed his claim for service connection, and notes that the Veteran was awaiting evaluation by VA. Interestingly, a subsequent treatment record dated February 2008, does not indicate and complaints of, diagnosis of, or treatment for headaches. In December 2005, a VA neurology examination of the Veteran was conducted. The examiner noted the Veteran's history of multiple pre-service head injuries and concussions. The Veteran reported having lifelong bifrontal headaches usually in the morning. He reported that the headaches were not accompanied by other symptoms such as nausea, vomiting, or focal neurologic symptoms. The Veteran also reported a history of depression, nervousness, and anxiety. He indicated it was a particular problem during service and has recurred intermittently over his life. The Veteran also reported that he "gets nightmares concerning the service at times." After full examination, the diagnosis was chronic muscle contraction like headaches and a history of anxiety and depression. The examiner noted that the Veteran's anxiety was a significant problem after the concussions and that he may have had a component of post concussion syndrome at that time "but certainly would not have any major residual from that 46 years later." In September 2009, a psychiatric VA examination was conducted by a clinical psychologist. The examiner reviewed the claim file, noting the Veteran's history of pre-service head injuries, concussions. The Veteran reported being treated by a Dr. M prior to military service and after the military as late as the 1980s; on and off for a number of years due to some anxiety/depression symptoms, but the Veteran could not obtain records as the doctor is deceased. The Veteran reported that he did not know why he was anxious or depressed or what triggered it. The Veteran seemed to go through a period of time without any mental health treatment which he estimated to be from the mid 1980s to 2005. The Veteran reported doing better without any significant mental health difficulties and that during that 20 year time he "got straightened out." He reported treatment in 2005 with Prozac for a brief time but he felt he did not need it. The examiner noted the primary care note from 2005 of "depression, new." The examiner noted that primary care records from October 2008 reported the Veteran looked calm and happy though the anxiety was mainly due to normal worry about his sons and their lives. On mental status examination the Veteran's affect ranged from mildly restricted to broader within normal limits. He appeared reasonably calm and in no significant emotional distress. The Veteran reported a history of suicidal feelings about 6 years ago following the death of his wife of 35 years. He denied current symptoms of depression but indicated having a "mid level" of nervousness or anxiety about 25 percent of the time. The examiner noted that this infrequent and mild level of anxiety did not seem to constitute a full blown anxiety disorder, and that his level of reaction seems to be generally within normal limits. The examiner noted the diagnoses of depression and anxiety made in the Veteran's private medical records and indicated that they were made by a primary care provider without full psychiatric work up. The examiner indicated that the Veteran had never been diagnosed with a "true DSM Anxiety Disorder by a mental health professional." The Veteran described some sleep impairment with awakening every few hours. He reported occasion dreams about having to re-enlist, or getting drafted, but the examiner noted that these were not trauma-related dreams. The examiner opined that while the Veteran has some occasional anxiety symptoms, these symptoms are not of a frequency or severity that would meet the criteria for any DSM-IV anxiety disorder. He appeared to have a normal amount of concern and worries over things such as his sons' well being and is periodically frustrated by normal things. The examiner found that no current psychiatric diagnosis was warranted. The examiner found there to be no significant evidence in the claims file that would indicate that any mental health condition began or was exacerbated by military service. In addressing the Veteran's report of treatment for nervousness in service - when he had complained that the pre existing concussions made him nervous - the examiner found that there is no evidence in the file that the Veteran's brief time in the Air Force significantly or permanently aggravated or exacerbated any such pre existing condition. The examiner also noted that the span of 20 years when the Veteran was untreated for any anxiety, from mid 1980s to 2005, further suggested the lack of any relationship to military service in the 1960s. In October 2009 a neurological examination was conducted by a physician. The Veteran reported that he had five concussions while playing football in high school prior to service, and that his headaches got worse during his nine months in service. The Veteran reported seeing a local doctor in his home town from 1966 to the present, and that he had got hooked on Demerol which he has since quit. He reported taking ibuprofen for his headaches, described as a "dull feeling in the frontal area." He reported working for 23 years even though he had headaches. The Veteran reported that he thought his headaches were aggravated by the judo exercises he had to go through on active duty. He reported headaches all the time up to a 9 on a scale of 1 to 10, occasionally a 10, which he treats with ibuprofen and Tylenol. He described his headaches as being a dull frontal pain. Physical examination was normal. A October 2009 MRI of the brain was completely normal. October 2009 x-rays of the skull and chest were normal. October 2009 x-ray of the sinuses showed nasal turbinate engorgement. The examiner noted that chronic nasal turbinate engorgement more likely than not due to allergies, would certainly cause frontal headaches to occur. The examiner found that the Veteran's frontal headaches are not due to any service connected problems. The report of pre-service concussions led to no problems with the brain itself and there was no injury to the brain. The turbinate engorgement noted on the x-rays of the sinuses which would indicate chronic allergy problems which could lead to frontal headaches. A review of the claims folder noted that although his enlistment physical examination mentioned multiple brain concussions with no sequelae, his physical profile was straight 1's which meant there was no abnormality found. He also reported epilepsy or fits that were in a discussion with a physician however there was no indication of any problems with these. The examiner noted the Veteran's frequent inservice reports of headaches that were diagnosed as tension headaches. The examiner also noted that the August 1966 Medical Board showed the Veteran had tension type headaches which occur almost daily and the summary reported "postconcussion syndrome, existed prior to service (EPTS)" with a physical profile of straight 1s, which meant that all the findings, physically, were normal. The examiner found that there was no evidence of any increased difficulty with his condition while on active duty. The examiner opined that it is not likely that any neurological disorder began during service or was caused by any incident in service. The examiner opined that it is not likely that his headache disorder began during service or was caused by any incident of service, but rather was an EPTS condition that continued to affect his service. After review of all the medical records and claims file, the examiner opined that the neurological disorders that pre-existed service did not undergo any permanent increase in the basic level of severity during service. The Veteran has presented numerous statements and testimony with respect to his claims. He filed his present claim in June 2005 on a VA Form 21-526. On this form he specifically indicated nervousness as a symptom of head injury dating back to 1962, which was four years prior to service. He indicated a history of headaches dating back to April 1966, which would place onset of headache symptoms during service. However, this is contradicted by the entrance examination history and service treatment records dated prior to April 1966, which show a history of chronic and severe headaches existing prior to service. In an April 2006 written statement the Veteran reported having "nightmares about being drafted again for service." He indicated his belief that this was a psychiatric disability incurred during service and independent of his pre-service head injuries. The 2009 VA examination found there was no psychiatric disability diagnosed. In February 2008, the Veteran presented sworn testimony at a hearing before the undersigned Veterans Law Judge. He testified that he was not diagnosed with a nervous disorder prior to entry into service. The Veteran stated that his first symptoms of anxiety manifested during service. He testified he was treated for a "nervous condition" from shortly after service until the 1980s, by a private physician, but that those records were unavailable. The Veteran testified that he got daily headaches which were dull. He also testified that his headaches occasionally become severe resulting in dizziness, vomiting, and disorientation approximately twice a month. The Veteran also indicated shoulder pain with his headaches. He indicated that he never lost work because of his headache and that he was presently being treated for headaches by his primary care provider. Following the point at which it is determined that all relevant evidence has been obtained, it is the Board's principal responsibility to assess the credibility, and therefore the probative value of proffered evidence of record in its whole. Owens v. Brown, 7 Vet. App. 429, 433 (1995); see Elkins v. Gober, 229 F. 3d 1369 (Fed. Cir. 2000); Madden v. Gober, 125 F. 3d 1477, 1481 (Fed. Cir. 1997) (and cases cited therein); Guimond v. Brown, 6 Vet. App. 69, 72 (1993); Hensley v. Brown, 5 Vet. App. 155, 161 (1993). In determining whether documents submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511 (1995); see also Pond v. West, 12 Vet. App. 341, 345 (2000) (Observing that in case where the claimant was also a physician, and therefore a medical expert, the Board could consider the appellant's own personal interest); citing Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (holding that while interest in the outcome of a proceeding "may affect the credibility of testimony it does not affect competency to testify." (citations omitted).) A hearing officer may properly consider the demeanor of the witness, the facial plausibility of the testimony, and the consistency of the witness' testimony with other testimony and affidavits submitted on behalf of the veteran." Caluza v. Brown, 7 Vet. App. 498, 511 (1995). The Board finds the Veteran's hearing testimony and written statements with respect to the onset of his symptoms of headaches and nervousness to lack credibility. The Veteran's claim and hearing testimony assert that he had symptoms of nervousness and headaches only upon entry to service. This is in direct contradiction to the history provided on his 1965 entrance examination medical history. It is also contradicted by the history of symptoms he provided in the 2005 VA claim form, and the history he provided during treatment for headaches during active service. C. Analysis With respect to the Veteran's claim for service connection for headaches, the evidence of record clearly and unmistakably establishes that he had multiple concussions prior to entry into active service. These were noted on the entry examination along with the Veteran report of a history of frequent and severe headaches. The August 1966 Medical Board examination report provided a diagnosis of post concussive syndrome that existed prior to service. The September 1966 Service Department Medical Board Report indicated a diagnosis of encephalopathy due to remote trauma with headache. The Service department Medical Board found that the condition was not incurred during service, but rather existed prior to service and was not permanently aggravated by service. The October 2009 VA examiner opined that the Veteran's pre existing headache disorder did not undergo an increase in severity during service. The examiner provided an adequate rationale, by explaining that upon both entry and exit his physical profile was straight 1's, which meant there was no abnormality found, and there was no change whatsoever during service. The examiner also explained that the current MRI of the brain and x-ray of the skull and chest were all normal, indicating no worsening of a headache condition. The examiner also noted that dull frontal headaches could be caused by an allergic reaction, as noted to exist in the sinus x-ray. The October 2009 VA examination report concluded that the Veteran's headache disorder pre-existed service and did not undergo an increase in severity during service. Although the Veteran asserts that he has been treated for daily headaches ever since service, most treatment records prior those of his current physician are unavailable. His current private treatment records, since 2005, only show one instance of a diagnosis of chronic headache which was made when he reported the symptoms in conjunction with his current claim. With this one exception, the Veteran's medical records from his current primary care provider do not show any complaints of, or treatment for headaches. The evidence of record clearly and unmistakably establishes that the Veteran's headaches pre-existed his entry into active military service, as noted upon entry, and did not undergo an increase in severity during service. Accordingly, service connection for headaches is not warranted. With respect to the claim for service connection for a psychiatric disability, the September 2009 VA psychiatric examination report found that the Veteran does not meet the criteria for a current diagnosis of any disability, either anxiety disorder, or depressive disorder. In the absence of proof of present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). To the extent that the Veteran has diagnoses of depression and anxiety in recent private medical records, and was treated with medication, during the pendency of the current claim, service connection may still be warranted. See McClain v. Nicholson, 21 Vet. App. 319 (2007). However, the September 2009 VA examination found that the diagnoses were not in accord with the DSM and were not made by a mental health professional. Moreover, to the extent that the recent private medical records contain diagnoses of depression and/or anxiety, the symptoms are related to more recent precipitating factors such as the death of the Veteran's wife in 2003. The private treatment records do not relate any current psychiatric diagnosis to the Veteran's pre-existing post concussive syndrome or to active service. To the extent that the Veteran claims service connection for "nightmares about being drafted again for service," as a psychiatric disability incurred during service and independent of his pre-service head injuries, the 2009 VA examination report indicated that dreams about having to re-enlist, or getting drafted, were not trauma-related dreams, and do not meet the criteria for the diagnosis of a current psychiatric disability. Clear and unmistakable (obvious or manifest) evidence is against the service connection claims for headaches and a psychiatric disability, to include anxiety and depression; there is no doubt to be resolved; and service connection is not warranted. Gilbert v. Derwinski, 1 Vet. App. at 57-58. ORDER Service connection for headaches is denied. Service connection for an acquired psychiatric disability, to include depression and anxiety, is denied ____________________________________________ MARK W. GREENSTREET Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs