Citation Nr: 1314419 Decision Date: 05/01/13 Archive Date: 05/15/13 DOCKET NO. 09-26 191 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to an initial compensable disability rating for a heart condition from December 16, 2005 to November 17, 2006, and a rating in excess of 60 percent from April 1, 2007 to December 27, 2008. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) prior to December 28, 2008. ATTORNEY FOR THE BOARD Jason A. Lyons, Counsel INTRODUCTION 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 & Supp. 2012). The Veteran served on active duty from October 1940 to October 1942 and from January 1951 to February 1969, including service in the Republic of Vietnam. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico which, in relevant part, granted the Veteran's claim for service connection for a heart condition with the following rating assignments: a noncompensable (0 percent) disability rating, effective December 16, 2005; a 100 percent schedular rating from November 18, 2006; and a 60 percent disability rating from April 1, 2007. The Veteran appealed from this initial assignment of disability compensation. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (when a veteran appeals the initial rating for a disability, VA must consider the propriety of a "staged" rating based on changes in the degree of severity of it since the effective date of service connection). The case was previously before the Board in May 2012, at which time it was remanded for further development. Subsequently, in November 2012 the RO awarded the Veteran's a 100 percent schedular rating for his heart disease, effective December 28, 2008. The RO also awarded a TDIU effective from December 28, 2008. In the rating decision, the RO (via the Appeals Management Center (AMC)) erroneously stated that this represented a full grant. As the Veteran was not assigned a 100 percent schedular rating for the entire appellate period, the issue for an increased rating for a heart condition remained on appeal (as captioned on the title page). The Board again remanded this claim in February 2013, for issuance of a Supplemental Statement of the Case (SSOC) addressing the outstanding time periods for consideration of a higher disability rating, and the matter has since returned for further appellate review. Presently, the Board observes that there is an additional claim presented on appeal of entitlement to a TDIU prior to December 28, 2008, regarding which the Board now formally takes jurisdiction. The RO/AMC's November 2012 rating decision did grant a TDIU, effective December 28, 2008. This notwithstanding, there remains the question of entitlement to that benefit before December 2008, as the TDIU claim had been pending prior to then (see September 2007 deferred rating decision, recognizing TDIU claim raised by evidence of record). Moreover, the Veteran's TDIU claim is a component of the increased rating issue that is already before the Board, as a heart condition has been identified as the primary service-connected disability underlying occupational limitation. Thus, the Board assumes jurisdiction over the TDIU claim. See VAOPGCPREC 6-96 (Aug. 16, 1996). See also Rice v. Shinseki, 22 Vet. App. 447 (2009). FINDINGS OF FACT 1. From the December 16, 2005 effective date of service connection to November 17, 2006, the Veteran's heart condition required continuous medication. 2. From April 1, 2007 to December 27, 2008, this condition did not involve chronic congestive heart failure; a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. 3. From April 1, 2007 to December 27, 2008, the Veteran was incapable of maintaining gainful employment due to his heart condition. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria are met to establish an initial 10 percent rating for a heart condition from December 16, 2005 to November 17, 2006. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.3, 4.7, 4.10; 4.104, Diagnostic Code 7005 (2012). 2. The criteria are not met for a rating in excess of 60 percent for a heart condition from April 1, 2007 to December 27, 2008. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.3, 4.7, 4.10; 4.104, Diagnostic Code 7006 (2012). 3. Resolving reasonable doubt in the Veteran's favor, the criteria are met for a TDIU from April 1, 2007 to December 27, 2008. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.15, 4.16, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist the Claimant The Veterans Claims Assistance Act, codified at 38 U.S.C.A. §§ 5100, 5102, 5103A, 5107, 5126 (West 2002 & Supp. 2012), prescribes several requirements as to VA's duty to notify and assist a claimant with the evidentiary development of a pending claim for compensation or other benefits. Implementing regulations were created, codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326 (2012). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must inform the claimant of any information and evidence (1) that is necessary to substantiate the claim; (2) that the claimant is expected to provide; and (3) that VA will seek to provide on the claimant's behalf. See also Pelegrini v. Principi, 18 Vet. App. 112, 120-121 (2004) ("Pelegrini II"). A regulatory amendment effective for claims pending as of or filed after May 30, 2008 removed the requirement that VA specifically request the claimant to provide any evidence in his or her possession that pertains to the claim. 73 Fed. Reg. 23,353-56 (Apr. 30, 2008), later codified at 38 CFR 3.159(b)(1) (2012). With regard to the claim for a TDIU prior to December 28, 2008, the Veteran was provided adequate notice by letters dated in November 2007, November 2008, and August 2009. As to the claim on appeal for a higher initial evaluation for a service-connected heart condition, the requirement of VCAA notice does not apply. Where a claim for service connection has been substantiated and an initial rating and effective date assigned, the filing of a Notice of Disagreement (NOD) with the RO's decision as to the assigned disability rating does not trigger additional 38 U.S.C.A. § 5103(a) notice. The claimant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to either of these "downstream elements." See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). See also Dunlap v. Nicholson, 21 Vet. App. 112, 119 (2007). This is the case here, in that the claim for service connection for a heart condition has been substantiated, and no further notice addressing the downstream disability rating requirement is necessary. Regardless, the Veteran was provided adequate notice by means of letters dated in January 2006, November 2006, and November 2008. The RO (including through the AMC) has taken appropriate action to comply with the duty to assist the Veteran through obtaining VA outpatient treatment records. The Veteran has also undergone several VA Compensation and Pension examinations. See 38 C.F.R. §4.1 (for purpose of application of the rating schedule accurate and fully descriptive medical examinations are required with emphasis on the limitation of activity imposed by the disabling condition). The RO/AMC further complied with the terms of the prior Board remand by adjudicating the claim for increase for all remaining relevant timeframes for which the maximum schedular benefit had not been awarded, followed by issuance of a SSOC on this matter. In furtherance of his claim, the Veteran has provided several statements. He did not request the opportunity for a hearing in this matter. The record as it stands includes sufficient competent evidence to decide the claim. Under these circumstances, no further action is necessary to assist the Veteran. In sum, the record reflects that the facts pertinent to the claim being decided have been properly developed and that no further development is required to comply with the provisions of the VCAA or the implementing regulations. That is to say, "the record has been fully developed," and it is "difficult to discern what additional guidance VA could [provide] to the appellant regarding what further evidence he should submit to substantiate his claim." Conway v. Principi, 353 F. 3d. 1369 (Fed. Cir. 2004). Accordingly, the Board will adjudicate the claim on the merits. Background and Analysis Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. § 4.1 (2012). Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Where the veteran appeals the rating initially assigned for the disability, after already having established service connection for it, VA must consider the propriety of a staged rating that is indicative of changes in the severity of the course of his disability over time. In Fenderson v. West, 12 Vet. App. 119 (1999), the Court recognized a distinction between a veteran's dissatisfaction with an initial rating assigned following a grant of service connection and a claim for an increased rating of a service-connected disorder. In the case of the assignment of an initial rating for a disability following an initial award of service connection for that disability (the circumstances of the present appeal), separate ratings can be assigned for separate periods of time based on the facts found - "staged" ratings. See Fenderson, supra, at 125-26. Under Diagnostic Code 7006, for a myocardial infarction, a 100 percent rating is assigned during and for three months following myocardial infarction, documented by laboratory tests. Thereafter, with history of documented myocardial infarction, a 10 percent rating is warranted where a workload of greater than seven METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is warranted where there is a workload of greater than five METs but not greater than seven METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. An evaluation of 60 percent is assigned for more than one episode of acute congestive heart failure in the past year; or where a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; where there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A higher 100 percent disability evaluation is warranted for chronic congestive heart failure, or where a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or where there is left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104. A note to the rating criteria defines one "MET" (metabolic equivalent) as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. In addition to the preceding rating criteria, VA revised that portion of the Rating Schedule for evaluation of specified cardiovascular disorders, to consist of those rated under Diagnostic Codes 7000 through 7007, 7011, and 7015 through 7020, effective from October 6, 2006. See 71 Fed. Reg. 52,459-60 (Sept. 7, 2006); codified at 38 C.F.R. § 4.100. The revised regulation contains the following new provisions: (1) In all cases, whether or not cardiac hypertrophy or dilatation (documented by electrocardiogram, echocardiogram, or X-ray) is present and whether or not there is a need for continuous medication must be ascertained. (2) Even if the requirement for a 10 percent rating (based on the need for continuous medication) or a 30 percent rating (based on the presence of cardiac hypertrophy or dilatation) is met, MET testing is required except when there is a medical contraindication; when the left ventricular ejection fraction has been measured and is 50 percent or less; when chronic congestive heart failure is present or there has been more than one episode of congestive heart failure within the past year; and when a 100 percent evaluation can be assigned on another basis. (3) If left ventricular ejection fraction (LVEF) testing is not of record, evaluation should be based on alternative criteria unless the examiner states that the LVEF test is needed in a particular case because the available medical information does not sufficiently reflect the severity of the veteran's cardiovascular disability. The Veteran filed the original claim for service connection for a heart condition, from which this increased initial rating claim stems, on December 16, 2005. As indicated, the RO has already granted a 100 percent disability evaluation for a heart condition, though exclusive of the time periods from December 16, 2005 to November 17, 2006, when a noncompensable rating was in effect; and from April 1, 2007 to December 27, 2008, when a 60 percent rating applied. Thus, these two remaining timeframes are the only remaining rating periods for the Board's consideration. Evidence of record since the date of claim indicates a December 2006 private physician's correspondence indicating that the Veteran underwent hospitalization from November 18, 2006 to December 1, 2006 following a myocardial infarction. Thereafter, the Veteran underwent a July 2007 VA Compensation and Pension examination. He reported frequent dizziness without loss of consciousness, and dyspnea to great exertion, but denied chest pain. There was a history of myocardial infarction. There was no history of trauma to the heart, cardiac neoplasm, congestive heart disease, rheumatic heart disease, hypertensive heart disease, syphilitic heart disease, endocarditis, or pericarditis. There was continuous medication required. There was daily fatigue and dizziness, dyspnea on moderate exertion, and recent episodes of syncope, the last one in November 2006. There was no reported chest pain since the previous year. A physical exam was completed. It was found that exercise testing was medically contraindicated because of an abnormal baseline EKG. Estimated level of activity consisted of more than three METs up to 5 METs. The Veteran reported dyspnea when bathing. There was some left ventricular dysfunction, with ejection fraction measured at 35 percent. Heart size was larger than normal, with moderate heart enlargement on echocardiogram. The diagnosis given was "coronary artery disease, post myocardial infarction November 2006, heart failure (ejection fraction 35 percent)." Having reviewed the foregoing, the Board ascertains the basis to award an initial 10 percent evaluation for a heart condition from December 16, 2005 to November 17, 2006. In this regard, the Board observes that the Veteran's July 2007 VA examination established a very thorough medication regimen of about fix to six different prescription drugs taken intended for cardiovascular functioning. Given the long-term history of arteriosclerotic heart disease in this case, it would seem likely that the Veteran was taking at least one of these medications continuously between December 2005 and November 2006. The Board will resolve reasonable doubt in his favor on this point. See 38 C.F.R. § 4.3. While the Veteran experienced the myocardial infarction that is the basis for service connection in November 2006, presumably his existing heart disease would be service-connected as well, under Diagnostic Code 7005 for arteriosclerotic heart disease. See generally, Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992) (an alternative diagnostic code than that applied by the RO may be appropriate under the circumstances, and where a claim is evaluated under this criteria, the VA adjudicator should explain the basis for this determination). See also Butts v. Brown, 5 Vet. App. 532, 538 (1993). Under Diagnostic Code 7005, as with Diagnostic Code 7006, a 10 percent evaluation may be assigned where continuous medication is required for treatment purposes. The basis for this increase having been noted, there are no clinical findings that otherwise support a higher rating, inasmuch as there was no pertinent medical evidence during this time period, and the Board's review is constrained by the record before it. Accordingly, a 10 percent initial evaluation, and not higher, for a heart condition from December 16, 2005 to November 17, 2006 is deemed warranted. Regarding the remaining time period under review, from April 1, 2007 to December 27, 2008, the Board does not find that an evaluation in excess of the existing 60 percent rating is warranted. Pursuant to Diagnostic Code 7006, a 100 percent evaluation is assigned for chronic congestive heart failure, or where a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or where there is left ventricular dysfunction with an ejection fraction of less than 30 percent. See 38 C.F.R. 4.104. In this instance, none of the aforementioned precipitating conditions are met. The Veteran did not have congestive heart failure, estimated exercise tolerance exceeded three METs, and left ventricular ejection fraction exceeded 30 percent. The objective criteria for assignment of a 100 rating on a schedular basis not having been met, the claim for increase beyond 60 percent for a heart condition from April 1, 2007 to December 27, 2008 must be denied. Meanwhile, aside from the VA rating schedule, the potential application of other provisions of Title 38 of the Code of Federal Regulations has also been considered, including 38 C.F.R. § 3.321(b)(1), which provides procedures for assignment of an extraschedular evaluation. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). In Thun v. Peake, 22 Vet. App. 211 (2008), the Court articulated a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation is found inadequate because it does not contemplate the claimant's level of disability and symptomatology, the Board must determine whether the claimant's disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors, 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 extraschedular rating. In this case, there initially is no basis to find that the Veteran's heart condition presents such an exceptional disability picture that the applicable schedular criteria are inadequate, particularly as the rating criteria are thorough, and he does not manifest or describe symptomatology outside of those criteria. Essentially, the rating criteria premised upon structural and functional components of the cardiovascular system fairly accounts for nearly all of the Veteran's symptoms as presented, including from his descriptions upon VA examination. To the extent the Veteran has distinct overall functional limitation, this has been recognized through testing mechanisms such as exercise tolerance testing and left ventricular ejection fraction percentage designed to give as objective assessment of functional limitation as possible. Thus, the Board cannot conclude that the Veteran's condition is consistent with an exceptional disability picture as to render the schedular rating criteria inadequate. The first stage of the standard for determining availability of an extraschedular rating not having been met, the potential application of the next two steps becomes a moot issue. In the absence of the evidence of such factors, the Board is not required to remand this case to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For these reasons, the Board is granting in part the claim for increased rating for the initial time period from December 16, 2005 to November 17, 2006, and denying the claim for the remaining time period from April 1, 2007 to December 27, 2008. This determination takes into full account the potential availability of "staged rating" based upon incremental increases in severity of service-connected disability during the pendency of the claim under review. To the extent any higher level of compensation is sought, the preponderance of the evidence is against the claim, and under these circumstances the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. See also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). TDIU Total disability ratings are authorized for any disability or combination of disabilities provided the schedular rating is less than total, where the disabled person is unable to secure and maintain substantially gainful employment because of the severity of his service-connected disabilities. If there is only one such disability, it must be ratable at 60 percent or more. Provided instead, there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional service-connected disability to bring the combined rating to at least 70 percent. 38 C.F.R. §§ 4.15, 4.16 (2012). If the claimant does not meet the minimum percentage rating requirements of § 4.16(a) for consideration of a TDIU, he or she may still be entitled to the benefit sought where the circumstances of the case present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards to warrant a TDIU on an extraschedular basis. See 38 C.F.R. § 4.16(b) (2012). In Bowling v. Principi, 15 Vet. App. 1, 10 (2001), the U.S. Court of Appeals for Veterans Claims (Court), citing its decision in Floyd v. Brown, 9 Vet. App. 88, 94-97 (1995), held that the Board cannot award a TDIU under 38 C.F.R. § 4.16(b) in the first instance because that regulation requires that the RO first submit the claim to the Director of the Compensation and Pension Service for extraschedular consideration. While the procedures for assignment of a total disability rating on an extraschedular basis would require referral to the RO for further disposition, where the record does not contain evidence that would render such claim plausible the Board may deny entitlement to an extraschedular evaluation in the first instance. VAOPGCPREC 6-96 (Aug. 16, 1996); see also Floyd, supra. The degree of impairment in occupational functioning that is generally deemed indicative of unemployability consists of a showing that the Veteran is "[in]capable of performing the physical and mental acts required by employment," and is not based solely on whether the Veteran is unemployed or has difficulty obtaining employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Rather, the record must demonstrate some factor which takes the claimant's situation outside the norm of such a case, since the VA rating schedule already is designed to take into consideration impairment that renders it difficult to obtain and keep employment. Id. See also 38 C.F.R. §§ 4.1, 4.15. In evaluating a claim for a TDIU, the central inquiry is whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Other factors that may receive consideration in determining whether a Veteran is unemployable include his employment history, level of education and vocational attainment. See 38 C.F.R. § 4.16(b); see also Ferraro v. Derwinski, 1 Vet. App. 326, 331-32 (1991). By comparison, the impact of any nonservice-connected disabilities, or the Veteran's age, are not factors taken into consideration for this purpose. 38 C.F.R. §§ 3.341, 4.16, 4.19. In addition, "marginal employment" shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). See Faust v. West, 13 Vet. App. 342, 355 (2000). Rather, the Court has accepted the definition of substantially gainful employment as that "at which non-disabled individuals earn their livelihood with earnings comparable to the particular occupation in the community where the Veteran resides." Moore (Robert) v. Derwinski, 1 Vet. App. 356, 358 (1991), citing to VA Adjudication Procedure Manual, M21-1 MR, Part IV, Subpart ii, Chapter 2 (December 13, 2005) (previously cited at M21-1, Part IV, paragraph 7.09). See also Ferraro, 1 Vet. App. at 332 (determining that substantially gainful employment suggests "a living wage"). The Board finds that the criteria for a TDIU are met for the time period from April 1, 2007 to November 17, 2006. The Veteran is already rated at 60 percent for a heart condition during this timeframe, and thereby meets the preliminary schedular standard for a TDIU. See 38 C.F.R. § 4.16(a). The dispositive question becomes whether he is incapable of maintaining substantially gainful employment as due to service-connected disability. There is a VA medical opinion which provides enough of a basis to conclude that the answer to this inquiry is in the affirmative, that of the July 2007 VA examiner, stating: "The conditions diagnosed, including his service-connected heart condition, represent complete occupational disability, and are both very limiting in terms of the Veteran's ability to move independently out of home premises, requiring him being transported by family and being accompanied. He would be unable to live alone, as he is unable to perform any household duties and even personal activities of daily living are done with great difficulty, requiring personal assistance frequently." Whereas the VA examiner refers to more than one underlying diagnosis, as indicated, practically speaking the only diagnosis given pursuant to the examination was a heart condition. There is sufficient linkage between service-connected disability and lack of employment capacity, and therefore a basis to grant a TDIU from April 1, 2007 to December 27, 2008, based on the time frame described by the July 2007 VA examination report. Prior to April 1, 2007, the Veteran did not meet the criteria for a TDIU rating under 38 C.F.R. § 4.16(a) and his case does not warrant referral for extraschedular consideration under 38 C.F.R. § 4.16(b). While the Veteran's heart disease and hearing loss undoubtedly caused some impairment, the evidence did not show that they precluded him from obtaining and maintaining substantially gainful employment prior to April 1, 2007. ORDER An initial 10 percent disability rating for a heart condition from December 16, 2005 to November 17, 2006 is granted, subject to the law and regulations governing the payment of VA compensation benefits. A rating in excess of 60 percent from April 1, 2007 to December 27, 2008 is denied. A TDIU for the time period from April 1, 2007 to December 27, 2008 is granted, subject to the law and regulations governing the payment of VA compensation benefits. ____________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs