Citation Nr: 1314281 Decision Date: 04/30/13 Archive Date: 05/15/13 DOCKET NO. 11-09 571 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Sioux Falls, South Dakota THE ISSUE Entitlement to service connection for a low back disability. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Megan C. Kral, Associate Counsel INTRODUCTION The Veteran had active duty service from January 1951 to December 1954. This matter came to the Board of Veterans' Appeals (Board) on appeal from a December 2009 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). This matter was remanded in July 2012 and February 2013 for further development. A review of the record shows that the RO has complied with all remand instructions by taking appropriate action to obtain VA treatment records, providing a VA examination, and issuing a supplemental statement of the case. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran testified at a hearing before the Board in April 2012. As was previously noted in the July 2012 remand, the Veteran's claim of service connection for a low back disability was denied in an August 1955 rating decision, the Veteran did not perfect an appeal in the matter, and the RO has characterized the matter as a claim to reopen; however in April 1956 (within one year of the rating decision) the Veteran, through his representative, submitted two letters from his physicians which note that he did not complain of back pain prior to service. When new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). Hence, based on the application of 38 C.F.R. § 3.156(b), the Board finds that submission of these letters was new and material evidence considered to have been filed in connection the original pending claim, that kept the August 1955 rating decision from becoming final. See Young v. Shinseki, 22 Vet. App. 461, 469 (2009). In light of the foregoing, the Board will reconsider the claim on the merits; the issue has been characterized accordingly. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran has a congenital defect of the low back. 2. The low back complaints and symptoms during service were acute in nature and did not result in a chronic low back disability; there was no superimposed low back injury during service; a separate low back disability was not manifested during service or for many years thereafter, nor is a separate low back disability otherwise causally or etiologically related to service. CONCLUSION OF LAW A low back disability was not incurred in or aggravated by active military service, and may not be presumed to have been so incurred. See 38 U.S.C.A. §§ 1110, 1112, 1113, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the Veteran of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the Veteran and what part VA will attempt to obtain for the Veteran. 38 U.S.C.A. § 5103(a); 38 C.F.R § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Duty to Notify The record shows that in a November 2009 VCAA letter, the Veteran was informed of the information and evidence necessary to warrant entitlement to the benefit sought on appeal. The Veteran was also advised of the types of evidence VA would assist him in obtaining as well as his own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet. App. 183(2002); Charles v. Principi, 16 Vet. App. 370 (2002). The United States Court of Appeals for Veterans Claims' decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that a VCAA notice as required by 38 U.S.C. § 5103(a), must be provided to a Veteran before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. In the present appeal, as the Board has found the August 1955 rating decision never became final, it was impossible to provide notice to the Veteran prior to the initial unfavorable decision, because the VCAA was not enacted at the time. However, notice errors 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) (where notice was not provided prior to the AOJ's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the AOJ) see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). In this case, VA's duty to notify was satisfied by letter sent to the Veteran in November 2009, prior to the readjudication of the Veteran's claim. Further, the notice requirements apply to all five elements of a service connection claim: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the Veteran was provided with notice of what type of information and evidence was needed to substantiate the claim for service connection. Further, the November 2009 letter gave notice of the types of evidence necessary to establish a disability rating and effective date for the disabilities appeal. In sum, the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist Furthermore, the Board finds that there has been compliance with the assistance provisions set forth in the law and regulations. The record in this case includes service treatment records, private medical records, and VA examination reports. The Veteran was afforded VA examinations in February 2011, August 2012, and again in March 2013 in compliance with the February 2013 Board remand. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Board finds that the March 2013 VA examination report contains sufficiently specific clinical findings and informed discussion of the facts of record to provide probative medical evidence adequately addressing the issue decided below. The examination report obtained contains sufficient information to decide the issue on appeal. See Massey v. Brown, 7 Vet. App. 204 (1994). Thus, the Board finds that a further examination is not necessary. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c)(4). No additional pertinent evidence has been identified by the Veteran. The Board notes there is evidence of record that indicates the Veteran sought treatment with Dr. Skjefte, a private chiropractor. In December 2010, VA sent the Veteran a letter requesting he provide a signed authorization to allow VA to secure the records of Dr. Skjefte. The Veteran failed to respond. The Court has held that the duty to assist is by no means a one-way street, and a Veteran's obligation to provide certain facts, in this case by submission of consent forms, is not an impossible or onerous task. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). No further action is necessary. 38 C.F.R. § 3.159 . For all the foregoing reasons, the Board concludes that VA's duties to the Veteran have been fulfilled with respect to the issue on appeal. Legal Criteria The Veteran claims entitlement to service connection for a disability featuring pain of the lower back. The Veteran was diagnosed with sacrolization of the 5th lumbar vertebra, which is a congenital defect. 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 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 Veteran's 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). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Board notes that is has reviewed all of the evidence in the Veteran's claims file, as well as in "Virtual VA" (VA's electronic data storage system), with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000)(VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ('although interest may affect the credibility of testimony, it does not affect competency to testify'). A veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination 'medical in nature' and is capable of lay observation). Congenital or developmental defects are not diseases or injuries in the meaning of applicable legislation for disability compensation purposes. 38 C.F.R. §§ 3.303(c), 4.9. VA's General Counsel has held, however, that service connection may be granted for diseases (but not defects) of congenital, developmental or familial origin if the evidence as a whole shows that the manifestations of the disease in service constituted 'aggravation' of the disease within the meaning of applicable VA regulations. VAOPGCPREC 82-90 (July 18, 1990); 38 C.F.R. §§ 3.303(c), 3.306. According to the VA General Counsel 's opinion, although service connection cannot be granted for a congenital or developmental defect, such a defect can be subject to superimposed disease or injury, and if that superimposed disease or injury occurs during military service, service connection may be warranted for the resultant disability. VAOPGCPREC 82-90. The Board notes that the presumption of soundness does not apply to congenital defects because such defects are not considered diseases or injuries within the meaning of the statutes. See Quirin v. Shinseki, 22 Vet. App. 390, 396-97 (2009); see also Terry v. Principi, 340 F.3d 1378, 1386-86 (Fed. Cir. 2003); Winn v. Brown, 8 Vet. App. 510, 516 (1996). Factual Background The January 1951 enlistment examination was negative for a back disability. Service treatment records noted treatment for low back pain. In May 1954 the Veteran complained of low back pain. In June 1954, the Veteran reported low back pain as a result of carrying a heavy steam tank. The initial diagnosis was chronic myositis of the lumbosacral spine. However, an x-ray taken at this time, revealed a 2-3 cm rounded density in relation to the body of the L4. The examiner noted that a congenital abnormality was suspected, but admitted the Veteran into the hospital for further study. On admission, the Veteran was suspected to have a tumor. The Veteran was hospitalized until July 1954, without additional complaint. In September and October 1954, the Veteran was again treated for low back pain. In November 1954, x-rays showed an irregular spherical 2x2 cm bony growth to the left and anterior to interspace between the bodies of the fourth and fifth lumbar vertebrae. An osteoma of the lumbar vertebrae was diagnosed. The Veteran's service separation examination was negative for a back disability, but noted that the Veteran was hospitalized in June 1954 for observation for back trouble. Following service separation, in March 1955, an x-ray of the Veteran showed sacrolization of the 5th lumbar vertebra. In March 1955, in support of his initial appeal, the Veteran stated that his back ached. He underwent a VA examination at this time. The examiner diagnosed the Veteran with a developmental defect of the lumbar spine. The Veteran began treatment with a VA medical center (VAMC) in 2001. However, the VAMC treatment records showed the Veteran never complained of, was never treated for, or diagnosed with low back pain or a low back disability. Treatment records from October 2001 indicated the Veteran ambulates with a steady gait. Annual visits from 2003 through 2005 showed the Veteran ambulates with a steady gait and has functional range of motion of the cervical, thoracic, and lumbar spine. VA treatment records from 2008 and 2009 also indicated the Veteran ambulates with a steady gait. In November 2010, Dr. Skjefte, a chiropractor, reported the Veteran began treatment for low back pain in February 2007. It was noted that the Veteran's pain improved with treatment, and the Veteran returned periodically for treatment. As discussed above, these treatment records have not been provided. Dr. Skjefte opined that the Veteran has a permanent condition which will not change and will continue to bother him for the rest of his life. Based on a collected history, Dr. Skjefte also opined that the Veteran suffered an injury in 1954 which led to his chronic back pain. The Veteran was afforded a VA examination in February 2011. On examination, the Veteran reported that he had no pain in the back, and that his pain comes and goes, but was not currently bothering him. The Veteran reported he had no pain when standing straight, and has never been incapacitated because of his back. The Veteran reported flare-ups when twisting or trying to pick something up, however, on examination he demonstrated going down to one knee to pick something up. The Veteran denied stiffness, fatigue, spasm, weakness, decreased motion, numbness, foot drop, and bowel or bladder complaints. The examiner noted he walked unaided and without a back brace. The Veteran reported treatment by a chiropractor, but no hospitalizations or injections. On examination, the examiner noted the Veteran's gait was stable, he was able to get in and out of the chair multiple times, and while sitting in the chair he was able to demonstrate raising both legs greater than 90 degrees straight out. The examiner noted he had no paraspinal or spinal tenderness, normal curvature although some prominence in the lumbar spine region. The examiner diagnosed the Veteran with sacralization of the L5 vertebrae. The examiner opined that the sacralization of the L5 vertebrae was a congenital defect. The examiner opined that it was less likely as not that there was aggravation of the sacralization of the L5 vertebrae while in service. In August 2012, an x-ray of the lumbar spine showed, grade 1 anterolisthesis at L4-L5, mild multilevel degenerative disc disease seen throughout the lumbar spine, no significant intervertebral disc space narrowing, mild endplate concavity suggestive of osteoporosis, and facet arthropathy seen at L3-L4, L4-L5, and L5-S1. The Veteran was diagnosed with mild lower lumbosacral spondylosis and grade 1 anterolisthesis at L4-L5. The Veteran underwent a second VA examination in August 2012. Here the examiner noted the Veteran was diagnosed with myositis in 1954, which was resolved. The examiner noted he reviewed the Veteran's claims file and post-service treatment records. He reported that there was no record of treatment for back pain in the eleven years the Veteran sought treatment from VA, and back pain was not included in his VA problem list. The examiner noted the Veteran reported that he could not "do anything". Range of motion was tested, the examiner noted that there was no objective evidence of painful motion seen. The examiner noted there was no tenderness or pain to palpation and there was no guarding or muscle spasm. Muscle strength, deep tendon reflexes, and sensation to touch were all normal. There was no evidence of radiculopathy or other neurological abnormalities. The examiner noted there was no functional impairment and the low back condition did not impact the Veteran's work. The examiner opined that the Veteran's sacralization of the L5 vertebrae is of congenital origin (defect) and it is less likely his back complaints are due to a "congenital disease". The examiner relied on an article from the Asian Spine Journal from June 2008 in finding that spondylolosthesis, spondylosis, DDD, and facet arthoropathy are not caused by, or secondary to or aggravated by congenital sacralization. The examiner further opined that the radiological findings in an 84 year old individual certainly could cause back pain, but would be consistent with normal aging process and also consistent with someone who did physical labor during their adult life. The examiner noted, the Veteran was physically active and it did not appear there were any functional limitations to his subjective complaint of back pain. In September 2012, VA treatment records again showed the Veteran ambulates with a steady gait. Pursuant to the Board's most recent remand, the Veteran was afforded another VA examination in February 2013. The examiner provided a detailed history of the Veteran's in-service treatment, and noted that on examination, the Veteran was having a pain level of 10/10, but reported that he does not take pain medication. The report noted that the Veteran showed no limp or weakness of his back, and that he ambulated and moved out of a chair without problem. The Veteran reported that he was not supposed to bend from the waist, and that he may end up in a wheelchair if he makes the wrong movement or even slightly injuries his back. The examiner noted that recent x-rays showed grade 1 anterolisthesis at L4-L5, mild multilevel degenerative disc disease seen throughout the lumbar spine, no significant intervertebral disc space narrowing, mild endplate concavity suggestive of osteoporosis, and facet arthropathy or degenerative changes seen at L3-L4, L4-L5, and L5-S1. The Veteran stated that his back bothered him since "then" (presumably since service) but that it got better, but that it continued to bother him for awhile or about five years after his period of service. On examination he reported low back pain on a constant pain scale between 8-10, and he cannot take his mind off the pain. He reported seeing a chiropractor, osteopath, and had acupuncture. There was mild tenderness of the L4 to L5 paralumbar region, but no guarding or muscle spasm reported. Strength, sensation and reflex testing were all normal. There was no evidence of radiculopathy. The examiner opined that the sacralization of the 5th lumbar vertebrae is a congenital defect and not a congenital disease. The examiner stated that the condition is less likely than not incurred in or caused by the claimed in-service injury. The examiner noted that there is no medical syndrome or disease that causes sacralization of a vertebrae. It is one of the several minor congenital abnormalities that may exist at the lumbar spine or at the end of the lumbosacral junction. Most are asymptomatic. They include facet joint asymmetry, variations in the number of lumbar vertebrae, spina bifida occulta, and transitional lumbosacral vertebrae being some of the more common variations. Only the transitional vertebra appears to be possibly related to low back pain according to Practical Orthopedics, 6th edition. Examples of transitional vertebra include lumbarization of S1 or sacralization of L5. Treatment is usually conservative. The examiner further opined, that the Veteran denied having any back symptoms prior to his period of service, and then had a brief flare up of pain during May and June of 1954 consisting of low back pain while he was doing heavier lifting. There was no history of injury to his low back. His separation examination included a normal extremity and back examination with no back complaints. When asked if the Veteran had any other low back disabilities, besides the sacralization, the examiner noted that there were no other diagnoses of any other back condition noted during his period of service. The examiner noted he was seen for acute lumbar strain, or myositis, and was treated conservatively. His service treatment records clearly show that his symptoms improved and that after each episode of pain, that he became pain free. There was no evidence of a chronic low back condition at the time of his separation from service. As to the current symptoms, the examiner opined that his current symptoms began recently, and there was no evidence of a medical nexus or link between the onset of his acute back pain in May and June of 1954 with his recent diagnosis of back pain as made by his chiropractor in 2007. The examiner found there was no evidence in service of a chronic back condition. Further, there was no history of a nexus between the Veteran's acute back pain in service with his recent lumbar spine x-rays that indicated mild lower lumbosacral spondylosis and grade 1 anterolisthesis at L4-L5. The examiner continued to opine that the Veteran worked as both a farmer and welder after his period of service, and it is more likely than not, at age eighty-three, his back complaints and present arthritis are related to general aging. Analysis The evidence of record clearly shows that the Veteran has a congenital defect of the low back. In this regard the November 1954 and March 1955 diagnosed sacaralization of the lumbar spine; and the medical evidence persuasively shows that this is a congenital defect. As noted above, service connection may not be granted for a congenital defect. 38 C.F.R. §§ 3.303(c), 4.9. The only way service connection may be established is if there is a superimposed, or separate, low back disability which is causally related to service. The Board must therefore consider whether the Veteran suffered a superimposed disease or injury of the lower back during his military service. The Veterans service treatment records indicate that before the congenital defect was detected by x-ray in 1954, the Veteran was treated for acute lumbar strain, or myositis. Service treatment records also show that the Veteran's condition improved and was resolved prior to the Veteran's discharge. Both the 2012 and 2013 VA examiners are of the opinion that the Veteran's back strain resolved with conservative treatment while the Veteran was in-service. Therefore, there is no evidence of a chronic or recurrent disability. Significantly, the record shows the Veteran did not seek treatment for low back pain until 2007, fifty-three years after he was separated from service. The Board finds that this lengthy period without treatment weighs heavily against the claim. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (service incurrence may be rebutted by the absence of medical treatment of the claimed condition for many years after service). Finally, there is no probative medical opinion of record which relates the etiology of any current back disability to any occurrence or onset during military service. Although in the 2010 opinion of Dr. Skjefte related the Veteran's low back pain to an in-service injury, the Board finds this opinion to be of little probative value. Specifically, it is not determined whether Dr. Skjefte has reviewed the Veteran's claims file or any contemporaneous treatment records, Dr. Skjefte does not provide a diagnosis, and even Dr. Skjefte reported that the Veteran's pain is transient and resolved with treatment. The more probative evidence of record includes, the VA examinations, in which the examiner reviewed the Veteran's treatment history, the radiological studies, discussed the lack of contemporaneous treatments, and provided a rationale, which specifically discussed how the Veteran's age, previous occupation as a farmer and welder, and not his active duty service affected his lower back. The Board acknowledges the Veteran's contentions that he has a low back disability as a result of his active duty. However, the medical evidence of record does not support this contention. The Veteran can attest to factual matters of which he had first-hand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Thus, he is competent to describe experiencing back pain during service and periodically thereafter. However, the Veteran, as a lay person has not been shown to be competent to offer opinions on complex medical questions, such as whether a current back disability can be related to pain suffered approximately fifty-three years ago. See Jandreau, 492 F.3d at 1377 (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). While the Veteran is competent to report what comes to him through his senses, he does not have medical expertise. See Layno v. Brown, 6 Vet. App. 465, 469-470 (1994). Even considering the Veteran's lay testimony with regard to the matters it is competent to address, the most probative evidence weighs against the claim of entitlement to service connection in this case. Competent medical evidence is required to establish an etiological nexus between a claimed disability and military service. In this case, the Board finds that the preponderance of the probative evidence of record weighs against finding any such nexus with regard to the claimed low back disability. In sum, the Board is compelled to conclude that the preponderance of the evidence is against the Veteran's claim. As such, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for a low back disability must be denied. See 38 U.S.C.A §5107; Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). ORDER Entitlement to service connection for a low back disability is not warranted. The appeal is denied. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs