Citation Nr: 1314740	
Decision Date: 05/03/13    Archive Date: 05/15/13

DOCKET NO.  08-26 229A	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Jackson, Mississippi


THE ISSUES

1.  Whether new and material evidence has been received to reopen a claim of service connection for a right shoulder disability.

2.  Whether new and material evidence has been received to reopen a claim of service connection for a cardiac disability (claimed as chest pain).

3.  Whether new and material evidence has been received to reopen a claim of service connection for a right knee disability.

4.  Entitlement to service connection for a left knee disability.

5.  Entitlement to service connection for a back disability.

6.  Entitlement to service connection for bilateral hearing loss.

7.  Entitlement to service connection for a psychiatric disability, to include depressive disorder and posttraumatic stress disorder (PTSD), to include as secondary to service-connected disabilities.
8.  Entitlement to service connection for a bilateral hip disability, to include as secondary to bilateral knee disabilities.

9.  Entitlement to a rating in excess of 20 percent for residuals of a rotator cuff tear of the left shoulder with degenerative joint disease and impingement.

10.  Entitlement to a temporary total rating under 38 C.F.R. § 4.30 (2012) based upon convalescence for residuals of a rotator cuff tear of the left shoulder with degenerative joint disease and impingement.

11.  Entitlement to a total disability rating based on individual unemployability (TDIU).  

12.  Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance of another person or on account of being housebound.

13.  Entitlement to a certificate of eligibility for specially adapted housing or a special home adaptation grant.


WITNESS AT HEARING ON APPEAL

The Veteran


ATTORNEY FOR THE BOARD

B. Elwood, Associate Counsel


INTRODUCTION

The Veteran served on active duty from February 1974 to March 1975.

These matters initially came before the Board of Veterans' Appeals (Board) from March and May 2007, November 2008, and July 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi.  

In the March 2007 decision, the RO denied entitlement to a certificate of eligibility for specially adapted housing or a special home adaptation grant.  In the May 2007 decision, the RO denied entitlement to a rating in excess of 20 percent for residuals of a rotator cuff tear of the left shoulder with degenerative joint disease and impingement.  In the November 2008 decision, the RO denied the Veteran's petition to reopen claims of service connection for atypical chest pain, bilateral Osgood Schlatter's disease, a back injury with degenerative disc disease, bilateral hearing loss, and a nervous condition as new and material evidence had not been submitted, denied entitlement to service connection for schizophrenia and a bilateral hip disability, denied entitlement to a TDIU, and denied entitlement to SMC based on the need for regular aid and attendance of another person or on account of being housebound.  In the July 2009 decision, the RO denied entitlement to service connection for right shoulder arthritis.

The Veteran testified before the undersigned at a November 2011 videoconference hearing at the RO.  A transcript of the hearing has been associated with his claims folder.

In April 2012, the Board granted the Veteran's motion to advance this appeal on its docket pursuant to 38 C.F.R. § 20.900 (c) (2012).  38 U.S.C.A. § 7107 (a)(2) (West 2002).

In April 2012, the Board granted the petitions to reopen the claims of service connection for a left knee disability, a back disability, bilateral hearing loss, and a psychiatric disability and remanded the underlying claims as well as the other claims currently on appeal for further development.

The Board notes that the issues on appeal pertaining to the Veteran's right knee disability and cardiac disability (claimed as chest pain) were previously characterized as solely entitlement to service connection for a right knee disability and chest pain by the Board in its April 2012 decision and remand.  However, a claim of service connection for a right knee disability was denied in a May 2003 Board decision.  Also, a claim of service connection for a cardiac disability was denied by the agency of original jurisdiction (AOJ) in an unappealed April 2004 rating decision.

Where the claim in question has been finally adjudicated by the AOJ or the Board, the statutes make clear that the Board must initially determine whether new and material evidence has been submitted with regard to the claims of service connection for right knee and cardiac disabilities.  Only where the Board concludes that new and material evidence has been received does it have jurisdiction to consider the merits of the claims.  Thus, despite the prior characterizations of the right knee and cardiac issues on appeal, the Board has recharacterized the issues as stated above.

In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claims.  The documents in this file have been reviewed and considered as part of this appeal.

The issues of entitlement to service connection for bilateral hearing loss, a psychiatric disability, and a bilateral hip disability, entitlement to an increased rating for the service-connected left shoulder disability, entitlement to a temporary total rating under 38 C.F.R. § 4.30 based upon convalescence for the service-connected left shoulder disability, entitlement to a TDIU, entitlement to SMC based on the need for regular aid and attendance of another person or on account of being housebound, and entitlement to a certificate of eligibility for specially adapted housing or a special home adaptation grant are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC.





FINDINGS OF FACT

1.  The Veteran's claims of service connection for a right shoulder disability and a right knee disability were denied in a May 2003 Board decision as the disabilities did not have their onset in service and were not otherwise related to a disease or injury in service.

2.  The Veteran's claims of service connection for a right shoulder disability and a right knee disability were again denied in rating decisions dated in April 2004 and July 2005 as new and material evidence had not been submitted; the Veteran did not appeal these determinations and new and material evidence was not received within a year of their issuance.

3.  The Veteran's claim of service connection for a cardiac disability was denied in the April 2004 rating decision as the disability did not have its onset in service and was not otherwise related to a disease or injury in service; the Veteran did not appeal this determination and new and material evidence was not received within a year of its issuance.

4.  Evidence received since the April 2004 and July 2005 RO decisions includes information that was not previously considered, but which does not relate to an unestablished fact necessary to substantiate the claims of service connection for a right shoulder disability, a right knee disability, and a cardiac disability, the absence of which was the basis of the previous denials.

5.  The Veteran's left knee disability clearly and unmistakably pre-existed his entry into active service, but the evidence is not clear and unmistakable that the disability was not aggravated in service.

6.  The Veteran's current left knee disability is the result of an in-service injury.

7.  The Veteran's current back disability did not have its clinical onset in service, was not exhibited within the first post service year, and is not otherwise related to active duty.  
CONCLUSIONS OF LAW

1.  The Board's May 2003 decision and the RO's April 2004 and July 2005 decisions that denied the claims of service connection for a right shoulder disability, a right knee disability, and a cardiac disability are all final.  38 U.S.C.A. §§ 7104(b), 7105 (West 2002); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 19.32, 20.200, 20.302, 20.1100(a), 20.1103 (2012).

2.  The evidence received since the April 2004 decision is not new and material and, therefore, insufficient to reopen the claim of service connection for a cardiac disability.  38 U.S.C.A. §§ 5107(b), 5108 (West 2002); 38 C.F.R. § 3.156(a).

3.  The evidence received since the July 2005 decision is not new and material and, therefore, insufficient to reopen the claims of service connection for a right shoulder disability and a right knee disability.  38 U.S.C.A. §§ 5107(b), 5108; 38 C.F.R. § 3.156(a).

4.  The Veteran's current left knee disability was incurred in service.  38 U.S.C.A. §§ 1110, 1111, 1137, 1153, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.304(b), 3.306(a) (2012).

5.  The Veteran's current back disability was not incurred or aggravated in service and may not be presumed to have been incurred therein.  38 U.S.C.A. §§ 1101, 1110, 1112, 1113(b), 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307(a), 3.309(a) (2012).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance.  38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012).

As the Board is granting the claim of service connection for a left knee disability, the claim is substantiated and there are no further VCAA duties as to this issue. Wensch v. Principi, 15 Vet App 362, 367-68 (2001); see also 38 U.S.C.A. § 5103A(a)(2) (Secretary not required to provide assistance "if no reasonable possibility exists that such assistance would aid in substantiating the claim"); VAOPGCPREC 5-2004; 69 Fed. Reg. 59989 (2004) (the notice and duty to assist provisions of the VCAA do not apply to claims that could not be substantiated through such notice and assistance).

With respect to the petitions to reopen the claims of service connection for a right shoulder disability, a right knee disability, and a cardiac disability and the claim of service connection for a back disability, under the VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim.  Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b).

The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim.  Those five elements include: 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/Hartman v. Nicholson, 19 Vet. App. 473 (2006).

In the context of a petition to reopen, the Court has held that VCAA notice (1) must notify a claimant of the evidence and information that is necessary to reopen the claim and (2) must notify the claimant of the evidence and information that is necessary to establish entitlement to the underlying benefit sought by the claimant.

The Court elaborated that the VCAA requires, in the context of a claim to reopen, that VA look at the bases for the denial in the prior decision and to respond with a notice letter that describes what evidence would be necessary to substantiate the element or elements required to establish service connection that were found insufficient in the previous denial.  Therefore, the question of what constitutes material evidence to reopen a claim of service connection depends on the basis on which the prior claim was denied.  Kent v. Nicholson, 20 Vet. App. 1 (2006).

In letters dated in August 2008 and June 2012, the RO informed the Veteran of dates and the correct bases of the previous denials of his claims of service connection for a right shoulder disability, a right knee disability, and a cardiac disability (identified as chest pain).  The Veteran was also informed of the appropriate definitions of new and material evidence and of the evidence needed to substantiate the underlying claims, on both a direct and secondary basis, in these letters.  The August 2008 and June 2012 letters thereby met some of the requirements of Kent.

There was a timing deficiency in that the June 2012 letter was sent after the initial adjudication of the petition to reopen the claims of service connection for a right shoulder disability and a right knee disability.  This timing deficiency was cured by readjudication of the claims in a November 2012 supplemental statement of the case.  Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007).  

In a pre-adjudication letter dated in February 2009, the RO notified the Veteran of the evidence needed to substantiate his claim of service connection for a back disability, on both a direct and secondary basis.  The August 2008 and February 2009 letters also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist him in obtaining and the evidence it was expected that he would provide.  Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002).

The claimant's Veteran status has been substantiated.  He was notified of all other elements of the Dingess notice, including the disability rating and effective date elements of his claims, in the August 2008 and February 2009 letters.  

The August 2008 and June 2012 letters did not meet all of the requirements of Kent to the extent that they provided the incorrect dates of the most recent denials of the claims of service connection for a right shoulder disability, a right knee disability, and a cardiac disability.  These letters referred to May 1993 and July 1994 denials of claims pertaining to atypical chest pain, rather than the April 2004 rating decision which denied the claim.  Also, the June 2012 letter referred to April 2004 and July 2009 denials of claims of service connection for a right shoulder disability and a right knee disability, respectively, rather than the July 2005 decision which denied the claims.  

The Veteran was notified of the correct date for the previous denial of the claim of service connection for a right knee disability in a November 2010 statement of the case.  Such a post-decisional document could not serve to provide legally compliant VCAA notice.  Mayfield v. Nicholson, 444 F.4d 1328 (2006).  It should, however, have served to put the Veteran on notice as to what evidence was required and he had years within which to submit additional evidence and argument. 

To the extent that the Veteran was not provided with pre-adjudication notice of some of the correct information required by Kent, prejudicial error occurs in the context of VCAA notice only when such error affects "the essential fairness of an adjudication" or "has the natural effect of producing prejudice."  Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007).  Appellants must generally identify "with considerable specificity": (1) how the VCAA notice was defective and (2) how the lack of notice and evidence was prejudicial or affected the essential fairness of the adjudication.  Id.  See also Shinseki v. Sanders, 129 S.Ct. 1696 (2009).  

Actual knowledge of the correct dates of the previous denials of the claims of service connection for a right shoulder disability, a right knee disability, and a cardiac disability has been demonstrated as the Veteran had been sent copies of the actual April 2004 and July 2005 rating decisions which denied these claims.  Moreover, as explained above, he received the correct date of the most recent denial of the claim of service connection for a right knee disability in the November 2010 statement of the case.  Thus, no showing of prejudice has been made in this case.

The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim.  38 U.S.C.A. § 5103A; 38 C.F.R. 
§ 3.159(c), (d).  This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim.  38 C.F.R. § 3.159(c)(4).  

The Court has held that the provisions of 38 C.F.R. § 3.103(c)(2) (2012) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked.  Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam).

At the Veteran's November 2011 hearing, the undersigned identified the issues on appeal (including entitlement to service connection for a cardiac disability and arthritis of various joints) and asked the Veteran about the history of his claimed disabilities.  Further, the Veteran provided testimony as to the symptoms and history of his claimed disabilities and has submitted additional evidence throughout the claim period, thereby demonstrating actual knowledge of the ability to identify and submit additional relevant evidence.  Also, the Board subsequently remanded the claims of service connection for a right shoulder disability, a cardiac disability, a right knee disability, and a back disability to provide additional notice and obtain additional evidence (i.e. opinions as to the etiology of the Veteran's current right knee and back disabilities) suggested by the hearing testimony.  The duties imposed by Bryant were thereby met.

To the extent that any Bryant notice may have been inadequate, this was effectively cured by actual knowledge of the issues on appeal (as evidenced by the Veteran's receipt of statements of the case dated in November 2010 and May 2011 and a November 2012 supplemental statement of the case) as well as his contentions made during the November 2011 hearing.

VA obtained the Veteran's service treatment records, pertinent service personnel records, and all of the identified relevant post-service VA treatment records and private medical records.  In addition, the Veteran was afforded VA examinations to assess the nature and etiology of his current right knee and back disabilities and opinions have been obtained concerning the etiology of these disabilities.

The Veteran has not been afforded VA examinations for his claimed right shoulder and cardiac disabilities and opinions as to the etiology of these disabilities have not otherwise been obtained.  However, when a claim is one to reopen a finally decided claim, VA is not obligated to provide a medical examination or obtain a medical opinion until new and material evidence has been received.  See 38 C.F.R. § 3.159(c)(4)(iii).  As new and material evidence has not been received to reopen the claims of service connection for a right shoulder disability and a cardiac disability, there is no duty to provide an examination or obtain an opinion with respect to these claimed disabilities.  See Woehlaert v. Nicholson, 21 Vet. App. 456, 463 (2007).

In its April 2012 remand, the Board instructed the agency of original jurisdiction (AOJ) to, among other things: send the Veteran a VCAA notice letter and provide him with the appropriate information concerning service connection claims, including information in accordance with Kent; afford him VA examinations to assess the nature and etiology of his claimed right knee and back disabilities; and  obtain opinions as to the etiology of these disabilities.  As explained above, the Veteran was sent a VCAA notice letter in June 2012 which provided information pertaining to service connection claims, including information in accordance with Kent.  Also, the Veteran was afforded VA examinations in September 2012 and opinions were obtained concerning the nature and etiology of his claimed right knee and back disabilities in September and October 2012.  

Thus, the AOJ substantially complied with all of the Board's relevant April 2012 remand instructions and VA has no further duty to attempt to obtain any additional records or conduct additional examinations with respect to the claims being decided herein.  See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998).




Analysis

Petitions to Reopen

Generally, an RO decision denying a claim which has become final and a claim denied in a Board decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(d)(3).  The exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim.  38 U.S.C.A. § 5108.

New evidence is defined as existing evidence not previously submitted to VA, and material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim.  New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim.  38 C.F.R. § 3.156(a).

The newly presented evidence is presumed to be credible for purposes of determining whether it is new and material.  Savage v. Gober, 10 Vet. App. 488 (1997).

For the purpose of determining whether new and material evidence has been presented to reopen a claim, the evidence for consideration is that which has been presented or secured since the last time the claim was finally disallowed on any basis.  Evans v. Brown, 9 Vet. App. 273, 285 (1996).

The Board denied the Veteran's claims of service connection for a right shoulder disability and a right knee disability (characterized as other orthopedic disabilities of multiple joints) in May 2003 on the basis that the disabilities did not have their onset in service and were not otherwise related to a disease or injury in service.  Specifically, the Board explained that the weight of the credible evidence indicated that the disabilities began years after service and were not caused by any incident of service.  The other orthopedic conditions (including right shoulder and knee disabilities) were not incurred in or aggravated by service.  The Board's May 2003 decision was final when issued.  38 U.S.C.A. § 7104(b); 38 C.F.R. § 20.1100(a).

The Veteran attempted to reopen his claims of service connection for right shoulder and knee disabilities (to include Osgood Schlatter's disease) and the RO denied his petitions in April 2004 and July 2005 rating decisions as new and material evidence had not been submitted.  Specifically, there was no new and material evidence showing that either of these disabilities had their onset in service or were otherwise related to a disease or injury in service or that the right shoulder disability was etiologically related to the Veteran's service-connected left shoulder disability.

The RO also denied the Veteran's claim of service connection for a cardiac disability in the April 2004 rating decision on the basis that the disability did not have its onset in service, did not have its onset in the year immediately following service, and was not otherwise related to a disease or injury in service.

The Veteran was notified of the RO's April 2004 decision, he did not appeal, and new and material evidence was not received within one year of the decision.  The April 2004 decision, therefore, became final.  See 38 U.S.C.A. § 7105(d)(3); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 20.302, 20.1103.

As for the July 2005 rating decision, the Veteran submitted a timely notice of disagreement with respect to the denial of his petitions to reopen the claims of service connection for a right shoulder disability and a right knee disability in July 2005 and a statement of the case was issued in December 2005.

Appellate review is initiated by a notice of disagreement and completed by a substantive appeal filed after a statement of the case has been furnished to an appellant.  38 U.S.C.A. § 7105(a); 38 C.F.R. § 20.200.  A substantive appeal must be filed within 60 days from the date of mailing of notice of the result of initial review or determination, or within the remainder of the one year period from the date of mailing of the notification of the determination being appealed, whichever period ends later.  Such notice must be in writing.  38 U.S.C.A. § 7105(b)(2); 38 C.F.R. § 20.302(b).

In the absence of a properly perfected appeal, the RO may close the appeal and the decision becomes final.  38 U.S.C.A. § 7105(d)(3); Roy v. Brown, 5 Vet. App. 554, 556 (1993); 38 C.F.R. § 19.32.  The RO did so in this case, as evidenced by the fact that it did not certify the issues of whether new and material evidence had been received to reopen the claims of service connection for a right shoulder disability and a right knee disability following the December 2005 statement of the case.

As the Veteran did not submit any substantive appeal within one year from the date of mailing of the notification of the July 2005 rating decision (i.e. July 19, 2005) or within 60 days after the issuance of the December 2005 statement of the case, the RO closed the appeal.  The RO did not certify those issues to the Board at that time and no further action had been taken by VA to suggest that these issues were on appeal.  Moreover, new and material evidence was not received within one year of the July 2005 decision.  Thus, the July 2005 rating decision also became final.  See 38 U.S.C.A. § 7105(d)(3); Bond, 659 F.3d at 1362; Fenderson v. West, 12 Vet. App. 119, 128-31 (1999) (discussing the necessity of filing a substantive appeal which comports with governing regulations); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 20.302, 20.1103.

Therefore, the Board will review the evidence submitted since the April 2004 rating decision in order to determine whether it is new and material with respect to the claim of service connection for a cardiac disability and will review the evidence submitted since the July 2005 rating decision in order to determine whether it is new and material with respect to the claims of service connection for a right shoulder disability and a right knee disability.

Pertinent new evidence received since the April 2004 and July 2005 denials includes service personnel records, VA and private treatment records, VA examination reports, various statements submitted by the Veteran and wife, and the Veteran's testimony during the November 2011 Board hearing.  Although the newly submitted treatment records include reports of knee and chest pain and diagnoses of various right shoulder, right knee, and cardiac disabilities (e.g. degenerative joint disease of the right knee, degenerative changes of the right shoulder, congestive heart failure, coronary artery disease), none of the evidence received since the last denials of the Veteran's claims of service connection for a right shoulder disability, a right knee disability, and a cardiac disability indicates that these disabilities had their onset in service or in the year immediately following service, are otherwise related to a disease or injury in service, or are etiologically related to a service-connected disability (including service-connected residuals of a rotator cuff tear of the left shoulder with degenerative joint disease and impingement).  Although the Veteran's wife claimed in a March 2007 letter that the Veteran's right shoulder disability was due to his service-connected left shoulder disability, this contention had already been presented and considered as part of the July 2005 decision.

During the November 2011 hearing, the Veteran contended that his current knee problems were related to a knee injury in service.  He also claimed that he was diagnosed as having arthritis in service, but he did identify any particular joint that experienced arthritis in service and did not specifically claim that right shoulder or knee arthritis was diagnosed in service.  Moreover, he reportedly experienced a heart murmur in service and he contended that his cardiac disability was related to the reported murmur in service.  

Nevertheless, as a lay person, the Veteran can only comment as to symptoms and immediately-observable relationships.  He lacks the expertise in this case, not involving such an immediately observable cause-and-effect relationship, to conclude that his current right knee disability, right shoulder disability, and cardiac disability are related to any specific injury or medical problem in service, as opposed to some other cause.  Rather, it would require medical expertise to evaluate the disabilities, consider all the potential causes, and determine that one was a more likely cause than another.  Hence, the Veteran's opinion on this question is not competent evidence and does not constitute material evidence for purposes of reopening the claims of service connection for a right shoulder disability, a right knee disability, and a cardiac disability.  38 C.F.R. § 3.159(a)(1), (2) (2012).

Furthermore, the Veteran was afforded a VA examination in September 2012 to assess the nature and etiology of his claimed right knee disability and the physician who conducted the examination specifically opined that the current right knee disability (identified as degenerative joint disease) was not likely ("less likely as not") caused by or aggravated by service.  He reasoned that there were subjective reports of right knee pain in service, but that X-rays were negative.  Examinations in April 1975 and April 1977 also reflected no pathology and normal right knee findings.  Degenerative joint disease and a medial meniscus tear were noted in 1993, but this was 18 years following the Veteran's discharge from service.  Also, he was 21 years old at the time of his discharge from service, so the chance of his having had any degenerative changes of the right knee at that time were almost non-existent.

The Board acknowledges that service personnel records that were not previously of record at the time of the April 2004 and July 2005 decisions have been added to the claims file.  Thus, these records constitute new evidence.  When VA receives relevant service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will adjudicate the claim without regard to the prior decision.  Such records include: (i) service records that are related to a claimed in-service event, injury or disease; (ii) additional service records forwarded by the Department of Defense or the service department to VA any time after VA's original request for service records; and (iii) declassified records that could not have been obtained because the records were classified when VA decided the claim.  38 C.F.R. § 3.156(c)(1)(i)-(iii) (2012).  

Nevertheless, the additional service personnel records that have been added to the claims file do not contain any evidence of right shoulder, right knee, or cardiac problems in service and they do not relate to the reasons for the previous denial of the claims of service connection for right shoulder, right knee, and cardiac disabilities.  In the absence of any reference to right shoulder, right knee, and cardiac problems, the additional service personnel records are not relevant to the right shoulder, right knee, and cardiac issues on appeal and are not material because they do not show that right shoulder, right knee, or cardiac disabilities had their onset in service or in the year immediately following service, are otherwise related to a disease or injury in service, or are etiologically related to a service-connected disability.  As a result, the Board has adjudicated the right shoulder, right knee, and cardiac claims as new and material evidence claims under 38 C.F.R. § 3.156(a).

The fact remains that there is no new competent medical or lay evidence reflecting that the Veteran's right shoulder, right knee, or cardiac disabilities had their onset in service or in the year immediately following service, are otherwise related to a disease or injury in service, or are etiologically related to a service-connected disability.  Also, the Veteran has not alluded to the existence of any such evidence.  Hence, there is no new and material evidence pertaining to the bases for the prior final denials.  

While VA has an obligation to assist the Veteran in the development of his claim, it is the Veteran's responsibility to present and support a claim of service connection. 38 U.S.C.A. § 5107(a); see also Skoczen v. Shinseki, 564 F.3d 1319, 1323 (Fed. Cir. 2009).  As the Veteran has not identified or presented new evidence that his current right shoulder disability, right knee disability, or cardiac disability may have had their onset in service or in the year immediately following service, are otherwise related to service, or are related to a service-connected disability, and the absence of such evidence was the basis for the prior final denials, new and material evidence has not been received and the appeal must be denied.

Service Connection

Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C.A. § 1110; 38 C.F.R. § 3.303.

Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303.

Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element for certain chronic disabilities listed in 38 C.F.R. § 3.309(a), such as arthritis, is through a demonstration of continuity of symptomatology.  See Clyburn v. West, 12 Vet. App. 296, 302 (1999).  Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology.  See Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.309(a).

In relevant part, 38 U.S.C.A. § 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits.  Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).

The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional."  Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence").

"Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology."  Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)).  Once evidence is determined to be competent, the Board must determine whether such evidence is also credible.  See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")).
Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).  

Additionally, for veterans 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 such manifested to a compensable degree within one year of separation from service.  38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a).

Notwithstanding the foregoing presumption, a claimant is not precluded from establishing service connection with proof of direct causation.  38 U.S.C.A. § 1113(b); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994).

Moreover, every 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 and was not aggravated.  38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b).

In order to rebut the presumption of sound condition under 38 U.S.C.A. § 1111, the government must show by clear and unmistakable evidence both that the disease or injury existed prior to service, and that the disease or injury was not aggravated by service.  Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004).

To satisfy the second requirement for rebutting the presumption of soundness, the government must rebut a statutory presumption of aggravation by showing, by clear and unmistakable evidence, either that (1) there was no increase in disability during service, or (2) any increase in disability was "due to the natural progression" of the condition.  Joyce v. Nicholson, 443 F.3d 845, 847 (Fed. Cir. 2006).

The clear and unmistakable evidentiary standard applies to the burden to rebut the presumption, but this standard does not require the absence of conflicting evidence. Kent v. Principi, 389 F.3d 1380, 1383 (Fed. Cir. 2004).  If the presumption of soundness is not rebutted, the claim is treated as an ordinary claim of service connection, meaning that if service connection is established there is no deduction for any pre-existing portion of the disability.  Wagner, 370 F. 3d at 1089.

A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease.  38 U.S.C.A. §§ 1153, 1137; 38 C.F.R. § 3.306(a).

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 U.S.C.A. § 1153; 38 C.F.R. §§ 3.304, 3.306(b).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant.  38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).

Left Knee Disability

Medical records reveal that the Veteran has been diagnosed as having various left knee disabilities.  For example, the September 2012 VA examination report includes diagnoses of chronic bursitis of the left tibial tubercle and degenerative joint disease.  Thus, a current left knee disability has been demonstrated.

The report of the Veteran's February 1974 entrance examination indicates that there were no left knee abnormalities at the time he was examined, accepted, and enrolled for service.  As the Veteran's entrance examination did not reveal evidence of a left knee disability, he is entitled to the presumption of soundness and the Board must consider whether that presumption is rebutted by clear and unmistakable evidence.  

 A September 1972 examination report from Jackson Bone and Joint Clinic indicates that the Veteran reported that he developed left knee pain in 7th or 8th grade and that he was experiencing pain at the time of the examination.  The pain was aggravated by physical activity and by bumping the knee and was localized to the tibial tubercle.  The knee had also given way on several occasions.  Examination of the left knee revealed mild to moderate swelling around the left tibial tubercle and exquisite tenderness, but no swelling , effusion, or significant retropatellar crepitation.  Left knee flexion was limited to 90 degrees and was associated with pain in the region of the tibial tubercle.  X-rays revealed no abnormalities other than soft tissue swelling over the anterior aspect of the left tibial tubercle.  The Veteran was diagnosed as having chronic bursitis of the left tibial tubercle.

Moreover, the Veteran reported on several occasions during service that he had experienced left knee symptoms (including pain, swelling, and instability) since prior to service.  The Veteran's own account of the pre-service existence of a left knee disability does not, by itself, constitute evidence that such disability in fact pre-existed service.  See Miller v. West, 11 Vet. App. 345 (1999).  However, the September 1972 examination report supports a conclusion that he had a left knee disability prior to service.

Based upon the history provided by the Veteran and the findings in his medical records, the Board concludes that there is clear and unmistakable evidence that the Veteran's left knee disability existed prior to service.  The remaining question with regard to the presumption of soundness is whether his left knee disability was clearly and unmistakably not aggravated by service beyond the normal progression of the disease.  See 38 U.S.C.A. § 1111.  

Service treatment records include a March 1974 report of treatment for a 2 week history of left knee pain.  The Veteran was diagnosed as having probable Osgood-Schlatter's disease.  In April 1974 he was treated for left knee pain which worsened during periods of exercise.  Diagnoses of Osgood-Schlatter's disease and possible shin splints were provided.  The Veteran experienced limitation of left knee extension in May 1974 and was diagnosed as having an inguinal strain.  In August 1974 he was treated for left knee pain, swelling, stiffness, and limited range of motion.  Examination revealed tenderness over the dorsal patellar region, but there was no effusion or swelling.  A diagnosis of possible chronic cartilage inflammation was provided.  In October 1974 he was treated for left knee pain below the patella associated with episodes of "giving out" and swelling.  Such symptoms had been present for 9 years, but were not due to any specific knee injury.  Examination revealed left patella crepitus and tenderness on palpation of the medial side of the knee.  The Veteran was diagnosed as having patella chondromalacia.  Also, in February 1975 he was treated for subpatellar pain of the left knee that increased when walking down stairs.  Examination revealed that there was mild crepitance and pain on patellar percussion, but there was full range of motion of the knee and no ligamentous laxity or effusion.  A diagnosis of chondromalacia patella was provided.

The Veteran reported on a February 1975 report of medical history for purposes of separation from service that he experienced an 8 year history of chondromalacia of the left knee which was occasionally symptomatic.  He had been treated for left knee arthritis and also experienced a "trick" left knee which swelled during bad weather and following exercise.  His February 1975 separation examination reveals that his lower extremities were abnormal in that he experienced mild pain associated with chondromalacia of the left knee.  However, there was no knee effusion or ligamentous laxity.

The Veteran submitted a claim of service connection for a left knee disability (VA Form 21-526e) within days of his discharge from service in March 1975.  He reported knee pain, swelling, and crepitance.

Medical records dated from May 1975 to March 2009, VA examination reports dated in April 1975, May 1994, and September 2012, the Veteran's testimony during hearings dated in September 1993, August 2002, and November 2011, and letters from the Veteran and his wife dated in March 2007 include reports of left knee problems which began when the Veteran was approximately 8 or 9 years old.  Left knee symptoms worsened in service and had continued in the years since service.  The left knee symptoms reported by the Veteran included knee pain, swelling, stiffness, crepitance, tenderness over the tibial tubercle, and occasional instability.  The pain was constant, was aggravated by standing, walking, bending, going up stairs, and prolonged sitting, and was alleviated by rest.  
Examinations revealed that the Veteran walked with a slight limp on the left, that pressure placed on the left knee caused considerable pain, and that there was tenderness, crepitance, occasional effusion, occasional pain associated with knee motion, limited range of knee motion, and evidence of possible soft tissue swelling and arthritis.  X-rays and MRIs of the left knee revealed narrowing of the femorotibial joint space medially, osteophytes, degenerative changes at the medial aspect of the knee and at the patellofemoral articulation, effusion, a popliteal cyst, and abnormalities of the medial meniscus.  Diagnoses of chondromalacia patellae, chronic bursitis of the left tibial tubercle, torn meniscus, internal derangement, a Baker's cyst, and degenerative joint disease/osteoarthritis were provided.

The Veteran is competent to report symptoms of a left knee disability, such as pain, as well as a continuity of symptomatology.  See Jandreau, 492 F.3d at 1376-77; Buchanan, 451 F.3d at 1336.  Also, there is no affirmative evidence to explicitly contradict his reports, these reports are not inconsistent with the evidence of record, the Veteran submitted a claim of service connection for a left knee disability within weeks of his separation from service, and the clinical evidence of record reflects a long history of treatment for left knee symptoms in the years since service.  Thus, the Board finds that the reports of a continuity of left knee symptomatology in the years since service are credible.

There are conflicting medical opinions as to the etiology of the Veteran's current left knee disability.  The Board, therefore, must weigh the credibility and probative value of this evidence, and in so doing, may favor one medical opinion over the other.  See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)).  The Board must account for the evidence it finds persuasive or unpersuasive and provide reasons for rejecting material evidence favorable to the claim.  See Gabrielson v. Brown, 7 Vet. App. 36, 29-40 (1994).

In a March 2001 letter, Jose L. Ferrer, M.D. opined that the Veteran's left knee disability was related to service.  He reasoned that there was a prior history of knee problems in service and that such problems had deteriorated over time.

In an August 2005 letter, Douglas C. Brown, M.D. opined that the Veteran's left knee disability was related to service.  This opinion was based on the fact that the Veteran sustained a left knee injury in service and that his knee had subsequently deteriorated over the course of his lifetime requiring continued treatment.

The physician who conducted the September 2012 VA examination opined that there was no clear and unmistakable evidence that the Veteran's left knee disability was not aggravated by service.  He reasoned that the examination by a private orthopedist in September 1972 revealed chronic bursitis of the left tibial tubercle and that the orthopedist specifically stated that the Veteran would be unable to perform full military duty as a result of his knee problems.  The Veteran was indeed unable to perform his military duties due, in part, to his knee complaints.  Thus, it appeared clear that the knee disability existed prior to service and was exacerbated quite early due to the physical demands of the military.

However, the September 2012 examiner also opined that was not likely ("less likely as not") that the Veteran experienced aggravation (i.e. a permanent worsening) of his left knee disability during his brief period of enlistment.  There was no specific explanation or reasoning provided for this opinion other than a notation that the Veteran experienced severe degenerative joint disease of the left knee at the time of the examination which was due to or aggravated by his morbid obesity.  As a result of his obesity, a huge load was being placed on his weight bearing joints.

The September 2012 opinion that the Veteran did not likely experience a permanent worsening of his left knee disability during service is of minimal probative value because it is not accompanied by any relevant explanation or reasoning.  See Nieves-Rodriguez v. Peake, 22 Vet. App 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed).

The March 2001 and August 2005 opinions and the September 2012 opinion pertaining to whether there was clear and unmistakable evidence that the Veteran's left knee disability was not aggravated by service, however, are all accompanied by specific rationales that were based upon the Veteran's medical records and reported history are not inconsistent with the evidence of record.  Therefore, these opinions are entitled to substantial probative weight.  See Id.  

In sum, based upon the clinical evidence contained in the Veteran's service treatment records, the post-service treatment records, and the September 2012 opinion, the Board finds that the evidence is not clear and unmistakable that there was no aggravation of the Veteran's left knee disability during service.  As such, the presumption of soundness is not rebutted.

Turning to the elements of a service connection claim, the evidence includes a current diagnosis of a left knee disability.  The Veteran's service treatment records reveal in-service left knee problems and his statements and post-service treatment records contain credible evidence of a continuity of left knee symptomatology since service.  Moreover, there are probative medical opinions linking the Veteran's current left knee disability to service.  Given this evidence and resolving reasonable doubt in favor of the Veteran, service connection for the currently diagnosed left knee disability is granted.  38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. § 3.303.

Back Disability

Medical records reveal that the Veteran has been diagnosed as having various back disabilities.  For example, a September 2012 VA examination report includes a diagnosis of multilevel degenerative disc disease and facet arthrosis with spinal stenosis.  Thus, a current back disability has been demonstrated.

The Veteran contends that he injured his back in service and that back symptoms, including pain, have persisted ever since that time.  During the November 2011 hearing he claimed that he was diagnosed as having arthritis in service, however he was not specific as to what joints were affected.  He is competent to report symptoms of a back disability, such as pain, as well as a continuity of symptomatology.  However, his reports must be weighed against the objective evidence and their credibility must be assessed.  See Jandreau, 492 F.3d at 1377; Buchanan, 451 F.3d at 1337.

Service treatment records include a May 1974 report of treatment for back tenderness in the left lumbar region.  X-rays of the lumbosacral spine were normal.  Diagnoses of an inguinal strain and rule out low back pathology were provided.  There is no evidence of any other complaints of or treatment for a back disability or symptoms associated with a back disability in the Veteran's service treatment records and his February 1975 separation examination was normal other than for lower extremity problems.

The objective evidence otherwise indicates that the Veteran's current back disability did not manifest until more than a year after his separation from service.  The first post-service clinical evidence of back problems is an April 1976 examination report from Dr. Rowlett which includes a report of back pain.  There is no clinical evidence of any earlier back symptoms following service.  

Furthermore, the Veteran has provided varying statements as to the history of his back problems.  For example, he has contended on several occasions that back symptoms (including pain) have persisted ever since service.  However, he reported on the February 1975 report of medical history for purposes of separation from service that he was not experiencing nor had he ever experienced "recurrent back pain."  Although he did report a history of "swollen or painful joints," arthritis, and "bone, joint, or other deformity" at the time of separation, he specifically reported that such symptoms pertained to the left knee and shoulder.  He reported during a December 1991 examination with Randy Easterling, M.D. that he experienced a history of back pain since the summer of 1991, at which time he had bent over and began experiencing back pain.  He was involved in a motor vehicle accident 10 days prior to the December 1991 examination and subsequently experienced significant back pain.  During a January 1998 examination with Daniel Mecca, M.D. he reported that he had experienced back pain for 6 years (i.e. since approximately 1992) following a motor vehicle accident.  Also, a July 2006 VA neurodiagnostics consultation note includes a report of a 30 year history of low back pain (i.e. since approximately 1976).

In light of the absence of any objective evidence of complaints of or treatment for back problems during service other than the May 1974 report of treatment for back tenderness, the fact that the Veteran's February 1975 separation examination did not reflect any back abnormalities, and his inconsistent and contradictory statements concerning the history of his back symptoms, the Board concludes that his reports concerning the history of his back symptoms, including those of a continuity of symptomatology since service and possible back arthritis in service, are not credible.  Thus, neither the clinical record nor the lay statements of record establish a continuity of symptomatology in this case, precluding an award of service connection on this basis.

If a chronic disease, such as arthritis, is shown in service and at any time thereafter, service connection will be conceded.  38 C.F.R. § 3.303(b).  There must, however, be sufficient observations in service to identify the disease entity.  Id.  As discussed above, there is no credible evidence showing any diagnosed back arthritis in service.  Hence, service connection cannot be granted on this basis here.

There are conflicting medical opinions as to the etiology of the Veteran's current back disability.  In his March 2001 letter, Dr. Ferrer opined that the Veteran's back disability was related to service.  He reasoned that there was a prior history of back problems in service and that such problems had deteriorated over time.

In his August 2005 letter, Dr. Brown opined that the Veteran's back disability was related to service.  This opinion was based on the fact that the Veteran sustained a back injury in service and that his back had subsequently deteriorated over the course of his lifetime requiring continued treatment.

The physician who conducted the September 2012 VA examination essentially opined that the Veteran's current back disability was not related to service.  He explained that despite the complaint of back pain in 1976 and Dr. Brown's August 2005 opinion, there was no evidence of back problems in service.  The Veteran had disc disease at the time of the September 2012 examination and he was 21 years old at the time he was discharged from service.  The chances of him having experienced disc disease in service were quite remote.

In October 2012, the examiner who had conducted the September 2012 VA examination reviewed the Veteran's claims file and opined that his current back disability was not likely ("less likely than not"/"less than 50 percent probability") proximately due to or the result of service.  He again reasoned that there was no evidence of a back problem in service, that the Veteran was 21 years old at the time of his separation from service, and that he had current disc disease.  His current back findings represented age related changes and were not related to any in-service complaints, incidents, or occurrences.  Also, his opinion and rationale remained unchanged despite the fact that the Veteran experienced back pain as early as 1976 and despite Dr. Brown's August 2005 opinion.

The March 2001 and August 2005 opinions are minimally probative because they are predominantly based on the Veteran's reports of a continuity of back symptomatology in the years since service.  However, as explained above, the Board has determined that such reports are not credible in this case.  Thus, as the March 2001 and August 2005 opinions are based on an inaccurate history they are of little probative value.  Boggs v. West, 11 Vet. App. 334, 345 (1998); Kightly v. Brown, 6 Vet. App. 200, 205-06 (1994) (finding that presumption of credibility of evidence did not arise as to medical opinion that a veteran's disability was incurred in service because it was based on an inaccurate history, one which failed to acknowledge an injury well-documented in the record, and hence holding such evidence not "material"); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (finding that presumption of credibility did not arise because physician's opinion was based upon "an inaccurate factual premise" and thus had "no probative value").

The examiner who provided the September and October 2012 opinions reasoned that there was no evidence of a back problem in service.  However, as explained above, the Veteran was treated for back tenderness in the left lumbar region in May 1974.  Nevertheless, the fact remains that there is no objective evidence of a specific back problem in service because the reported pain in May 1974 was attributed to an inguinal strain, X-rays of the lumbosacral spine did not reveal any abnormalities, and only a diagnosis of "rule out" back pathology was provided.  Also, although the examiner did not explicitly acknowledge and comment on the Veteran's reports of a continuity of symptomatology in formulating his opinions, the Board has determined that such reports are not credible and an opinion based on such an inaccurate history would be inadequate.  See Id.      

The September and October 2012 opinions were otherwise based upon an examination of the Veteran and a review of his medical records and reported history and are accompanied by specific rationales that are not inconsistent with the evidence of record.  Thus, these opinions are adequate and entitled to substantial probative weight.  See Nieves-Rodriguez, 22 Vet. App. at 304.

There is no other evidence of a relationship between the Veteran's current back disability and service, and neither the Veteran nor his representative have alluded to the existence of any such evidence.  Also, as discussed above, the record fails to demonstrate any credible evidence of a continuity of symptomatology.  Thus, the preponderance of the evidence is against a finding that the Veteran's current back disability is related to service, manifested in service, or manifested within a year after his March 1975 separation from service.

For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim.  The benefit-of-the-doubt doctrine is therefore not for application in this case and the claim of service connection for a back disability must be denied.  See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. at 55-57.


ORDER

As new and material evidence has not been received, the claim of service connection for a right shoulder disability is not reopened, and the appeal is denied.

As new and material evidence has not been received, the claim of service connection for a cardiac disability is not reopened, and the appeal is denied.

As new and material evidence has not been received, the claim of service connection for a right knee disability is not reopened, and the appeal is denied.

Entitlement to service connection for a left knee disability is granted.

Entitlement to service connection for a back disability is denied.


REMAND

Once the Secretary undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, he must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided.  Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).

The Veteran was afforded a VA audiological examination in September 2012 to assess the nature and etiology of any current hearing loss.  He was diagnosed as having right ear hearing loss as defined by VA, but left ear hearing loss as defined by VA has not been identified.  See 38 C.F.R. § 3.385 (2012).  

The examiner who conducted the September 2012 VA examination opined that the Veteran's hearing loss was not likely ("less likely than not"/"less than 50 percent probability") caused by or the result of military noise exposure.  This opinion is inadequate, however, because she did not provide any further explanation or reasoning for her opinion other than to note that there was "no nexus."  See Nieves-Rodriguez, 22 Vet. App. at 304.  Thus, a remand is necessary to afford the Veteran a new VA examination to obtain an opinion as to the nature and etiology of his claimed hearing loss.

As for the claim of service connection for a psychiatric disability, the Veteran contends that he began to experience depression in service and that depression has continued since that time.  Nevertheless, there is some evidence to the contrary.  He has also reported several in-service stressors, including witnessing the death of a fellow service member who jumped from an upper floor window with razor blades in his mouth, being stressed while awaiting deployment to Vietnam and Cambodia, and being unable to visit his mother while she was ill.  

In the alternative, the Veteran contends that his current psychiatric disability is related to the pain associated with his service-connected disabilities.  There are several medical opinions of record which attribute his depression to symptoms associated with his various physical disabilities, including service-connected disabilities.

The Veteran was afforded a VA psychiatric examination in August 2012 and was diagnosed as having depressive disorder with psychotic features.  In October 2012, the psychologist who conducted the examination opined that it was not possible to determine whether the Veteran's current psychiatric disability was caused or aggravated by his service-connected left shoulder disability and the pain associated with that disability.  He explained that the Veteran reported a high degree of pain all over his body and that the pain was described as continuous.  It would be mere speculation to attempt to parcel what portion of the pain he felt from his shoulder and whether the pain in that specific area was enough to cause or aggravate his depression.

The examiner also explained that the Veteran reported that he had struggled with depression during and after service.  His physical problems limited his ability to meet military physical standards and he was subsequently discharged after approximately 1 year of service.  The Veteran reported that he had struggled with depression ever since he left service.  However, the examiner was unable to find any evidence of mental health problems (diagnosis or treatment) immediately following the Veteran's discharge from service.  It was possible, however, that he had symptoms of depression and never sought assistance.  In sum, the Veteran's reports of depression during and after service was the only evidence of a depressive disorder around the time period of his separation from service.  Such evidence was not sufficient to render an opinion without resorting to mere speculation.

The October 2012 opinion is adequate to the extent that it is accompanied by a specific rationale addressing why a definitive conclusion as to whether the Veteran's psychiatric disability was caused or aggravated by his service-connected left shoulder disability could not be made.  See Jones v. Shinseki, 23 Vet. App. 382 (2010).  Nevertheless, the examiner stated that an opinion could not be provided without resort to speculation and this statement weighs neither for nor against the claim.  Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009).

Additionally, the Board is granting service connection for a left knee disability.  As the October 2012 opinion does not address this disability, a remand is necessary to obtain a new opinion as to whether the Veteran's current psychiatric disability was caused or aggravated by his service-connected disability.

Furthermore, although the examiner who provided the October 2012 opinion alluded to a conclusion that he was unable to provide an opinion as to whether the Veteran's current psychiatric disability was directly related to service, he did not provide a specific opinion pertaining to direct service connection.  An adequate medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.  See Nieves-Rodriguez, 22 Vet. App. at 304.

Moreover, the VA adjudication manual instructs that requests for stressor verification must include, among other things, a two-month specific date range during which the claimed stressors occurred.  See M21-1MR, Part IV, Subpart ii, Chapter 1, Section D, 15(c) (May 7, 2012) (indicating that information in requests to the U.S. Army and Joint Services Records Research Center (JSRRC) should include month and year during which the stressful event occurred and noting that JSRRC will research records dated 30 days before and 30 days after).

The Veteran has claimed that he witnessed the death of a fellow service member who jumped from an upper floor window with razor blades in his mouth.  This stressor reportedly occurred when the Veteran was stationed at Fort Polk, Louisiana in March 1974.  In light of this stressor information, a remand is also required to contact the JSRRC to attempt to verify the Veteran's claimed stressor.

With respect to the claim of service connection for a bilateral hip disability, a September 2012 VA examination report includes a diagnosis of mild degenerative joint disease of both hips.  Also, service treatment records include reports of treatment for pain and swelling in the left groin area which rendered the Veteran unable to raise his left hip.  There was decreased range of hip flexion, but X-rays of the hip were normal.  Diagnoses of an inguinal strain and rule out hip pathology were provided.

The Veteran contends that his bilateral hip disability is related to his knee disabilities.  The physician who conducted the September 2012 VA examination opined that he was unable to define a nexus between the Veteran's mild degenerative changes of the hips with any event or occurrence in service.  He reasoned that the degenerative changes were age related and that the Veteran was 21 years old at the time of his discharge from service.

The examiner also opined that it was not likely ("less likely than not"/"less than 50 percent probability") that the Veteran's bilateral hip disability was proximately due to or the result of a service-connected disability.  He did not provide any further explanation or reasoning for this opinion other than to note that there was no defineable nexus between any hip findings or complaints and the Veteran's bilateral knee problems.  Also, the examiner noted that the question of whether the bilateral hip disability was caused or aggravated by a knee disability was moot because the Veteran had not been granted service connection for any knee disability.

The opinion pertaining to whether the Veteran's current bilateral hip disability was caused or aggravated by a service-connected disability is inadequate because it is not accompanied by any specific explanation or reasoning.  See Nieves-Rodriguez, 22 Vet. App. at 304.  Furthermore, as the Board is granting service connection for a left knee disability, a new opinion needs to be obtained that takes into consideration this now service-connected disability.

As for the claim for an increased rating for the service-connected left shoulder disability, disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. §§ 4.40, 4.45 (2012), pertaining to functional impairment.  The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare ups.  Such inquiry is not to be limited to muscles or nerves.  These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare ups, or pain.  The examiner should also determine the point, if any, at which such factors cause functional impairment.  Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2012).

The Veteran was afforded a VA examination in September 2012 to determine the severity of his service-connected left shoulder disability.  Ranges of left shoulder motion were reported and it was noted that there was pain at 0 degrees of shoulder flexion and abduction.  However, the Veteran was able to flex and abduct his shoulder to 80 degrees and 70 degrees, respectively.  Also, there was weakened movement associated with the left shoulder. 

Although the examiner noted that there were no changes in the ranges of shoulder motion following repetitive use, he did not note the point, if any, at which pain or weakness caused functional impairment.  Thus, clarification is required.  See Mitchell, 25 Vet. App. at 43-4; 38 C.F.R. §§ 4.40, 4.45, 4.59.

VA regulations provide that where an examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes.  38 C.F.R. § 4.2 (2012); see 38 C.F.R. § 19.9 (2012).  Where the Board makes a decision based on an examination report that does not contain sufficient detail, remand is required "for compliance with the duty to assist by conducting a thorough and contemporaneous medical examination."  Goss v. Brown, 9 Vet. App 109, 114 (1996); Stanton v. Brown, 5 Vet. App. 563, 569 (1993).

With respect to the claim for a TDIU, the Court has held that in the case of a claim for a TDIU, the duty to assist requires that VA obtain an examination that includes an opinion on what effect a veteran's service-connected disability has on his ability to work.  Friscia v. Brown, 7 Vet. App. 294, 297 (1994).  Although there are various opinions of record concerning the impact of the Veteran's disabilities on his employability, there is no specific opinion as to whether his service-connected disabilities, by themselves, are sufficient to prevent him from securing and following employment for which his education and occupational experience would otherwise qualify him.

The Veteran does not currently meet the percentage requirements for a TDIU under 38 C.F.R. § 4.16(a) (2012).  VA policy is to grant a TDIU in all cases where service-connected disabilities preclude gainful employment, regardless of the percentage evaluations.  38 C.F.R. § 4.16(b).  However, the Board is prohibited from assigning a TDIU on the basis of 38 C.F.R. § 4.16(b) without ensuring that the claim is referred to VA's Director of Compensation and Pension (C&P) for consideration of an extraschedular rating under 38 C.F.R. § 4.16(b).  Bowling v. Principi, 15 Vet. App. 1 (2001).

Also, the claim for a TDIU as well as the claims for SMC and a certificate of eligibility for specially adapted housing or a special home adaptation grant are inextricably intertwined with the service connection and increased rating issues currently on appeal that are being remanded.

Moreover, the VCAA requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim.  38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d).  The VCAA's duty to assist includes a duty to help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody.  38 C.F.R. § 3.159(c)(4).

A January 2012 VA mental health consultation note included among the Veteran's paperless records in the Virtual VA system reveals that he was scheduled for a follow up psychiatric evaluation in March 2012.  The most recent VA treatment record in the claims file and among the Veteran's paperless records in the Virtual VA system are from the VA Medical Center in Jackson, Mississippi (VAMC Jackson) and are dated in January 2012. 

Thus, it appears that there are additional VA treatment records that have not yet been obtained.  VA has a duty to obtain any additional relevant records.  38 U.S.C.A. § 5103A(b),(c); Bell v. Derwinski, 2 Vet. App. 611, 612-13 (1992).

Furthermore, in the May 2007 rating decision, the RO denied entitlement to a temporary total rating under 38 C.F.R. § 4.30 based upon convalescence for the service-connected left shoulder disability.  In June 2007, the Veteran submitted a notice of disagreement with that decision.  A statement of the case has not been issued as to the claim for a temporary total rating based upon convalescence for the service-connected left shoulder disability.  38 U.S.C.A. § 7105(a) (West 2002).  The Board is required to remand this claim for issuance of the necessary statement of the case.  Manlincon v. West, 12 Vet. App. 238 (1999).

Accordingly, the case is REMANDED for the following action:

(Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012).  Expedited handling is requested.)

1.  The AOJ shall implement the Board's decision regarding the grant of service connection for a left knee disability and assign an initial disability rating.

2.  The AOJ shall issue a statement of the case as to the issue of entitlement to a temporary total rating under 38 C.F.R. § 4.30 based upon convalescence for the service-connected left shoulder disability.  This issue shall not be certified to the Board unless a sufficient substantive appeal is submitted.

3.  Obtain and associate with the claims file all records of the Veteran's treatment for hearing loss, a psychiatric disability, a bilateral hip disability, a left shoulder disability, and a left knee disability from VAMC Jackson dated from January 2012 through the present, and from any other sufficiently identified VA facility.

All efforts to obtain these records must be documented in the claims file.  Such efforts shall continue until the records are obtained or it is reasonably certain that they do not exist or that further efforts to obtain them would be futile.

4.  Prepare a summary of the claimed in-service stressor for which there is sufficient information to make an inquiry, to include dates and assigned units.  The in-service stressor reported by the Veteran involves witnessing the death of a fellow service member who jumped from an upper floor window with razor blades in his mouth.  This stressor reportedly occurred when the Veteran was stationed at Fort Polk, Louisiana in March 1974.

This summary, along with a copy of the Veteran's DD Form 214 and any pertinent service personnel records shall be sent to the JSRRC or other appropriate service department entity.  All efforts to obtain stressor verification must be documented in the claims file.

5.  After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for a VA audiological examination to determine the nature and etiology of any current hearing loss.  All indicates tests and studies shall be conducted.

The claims folder, including this remand and any relevant records contained in the Virtual VA system, along with any records obtained pursuant to this remand, must be sent to the examiner for review; consideration of such shall be reflected in the completed examination report or in an addendum.  

The Veteran shall be afforded audiology testing, including a puretone audiometry test and a speech recognition test (Maryland CNC), and all results of such tests shall be recorded in the examination report.  The examiner must also fully describe the functional effects of the Veteran's hearing disability.  

With respect to any hearing loss diagnosed since June 2008, the examiner shall answer the following questions:

(a)  Is it at least as likely as not (50 percent probability or more) that the current hearing loss had its onset in service, had its onset in the year immediately following service, is related to noise exposure in service, or is otherwise the result of a disease or injury in service?

(b)  Is the current hearing loss sensorineural hearing loss?

In formulating the above opinions, the examiner must acknowledge and comment on any hearing loss diagnosed since June 2008 and any reports of noise exposure in service.  

The examiner must provide reasons for each opinion given.  

The examiner is advised that the Veteran is competent to report his symptoms and history, and such statements by the Veteran must be specifically acknowledged and considered in formulating any opinions.  If the examiner rejects the Veteran's reports regarding symptoms, the examiner must provide a reason for doing so.  The absence of evidence of treatment for hearing loss in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion.  

If the examiner determines that he or she cannot provide an opinion without resorting to speculation, the examiner shall explain the inability to provide an opinion, identifying precisely what facts could not be determined.  In particular, he or she shall comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion.  Jones v. Shinseki, 23 Vet. App. 382, 389 (2010).  (The AOJ shall ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained.)

6.  After all efforts have been exhausted to verify the Veteran's reported stressors and to obtain and associate with the claims file any additional treatment records, schedule him for a VA psychiatric examination with an examiner who has not yet examined him to determine the nature and etiology of his current psychiatric disability, including PTSD.  All indicated tests and studies shall be conducted.

The claims folder, including this remand and any relevant records contained in the Virtual VA system, along with any records obtained pursuant to this remand, must be sent to the examiner for review; consideration of such shall be reflected in the completed examination report or in an addendum.  
For each current psychiatric disability identified (i.e. any psychiatric disability diagnosed since June 2008), the examiner shall answer all of the following questions:

(a)  Is it at least as likely as not (50 percent probability or more) that the current psychiatric disability had its onset in service, had its onset in the year immediately following service (with respect to any current psychosis), is related to the Veteran's reported stressors in service, or is otherwise the result of a disease or injury in service?

(b)  Is it at least as likely as not (50 percent probability or more) that the current psychiatric disability was caused (in whole or in part) by the Veteran's service-connected residuals of a rotator cuff tear of the left shoulder with degenerative joint disease and impingement and/or left knee disability (to include pain associated with these disabilities)?

(c)  Is it at least as likely as not (50 percent probability or more) that the current psychiatric disability was aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by the Veteran's service-connected residuals of a rotator cuff tear of the left shoulder with degenerative joint disease and impingement and/or left knee disability (to include pain associated with these disabilities)?

If any current psychiatric disability was aggravated by a service-connected disability, the examiner shall also indicate the extent of such aggravation by identifying the baseline level of disability.  This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his symptoms over time.

(d)  If the Veteran meets the criteria for a diagnosis of PTSD, what are the stressors that support the diagnosis?

In formulating the above opinions, the examiner shall specifically acknowledge and comment on all psychiatric disabilities diagnosed since June 2008 and the Veteran's reported stressors in service (including witnessing the death of a fellow service member who jumped from an upper floor window with razor blades in his mouth, being stressed while awaiting deployment to Vietnam and Cambodia, and being unable to visit his mother while she was ill).  

The examiner must provide reasons for each opinion given.  

The examiner is advised that the Veteran is competent to report stressors in service, his symptoms, and history, and such statements by the Veteran must be specifically acknowledged and considered in formulating any opinions.  If the examiner rejects the Veteran's reports regarding symptoms, the examiner must provide a reason for doing so.  The absence of evidence of a particular stressor or of treatment for psychiatric problems in the Veteran's service records cannot, standing alone, serve as the basis for a negative opinion.

If the examiner determines that he or she cannot provide an opinion without resorting to speculation, the examiner shall explain the inability to provide an opinion, identifying precisely what facts could not be determined.  In particular, he or she shall comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion.  Jones, 23 Vet. App. at 389.  (The AOJ shall ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained.)

7.  After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for a VA examination to determine the etiology of his current bilateral hip disability.  All indicates tests and studies shall be conducted.

The claims folder, including this remand and any relevant records contained in the Virtual VA system, along with any records obtained pursuant to this remand, must be sent to the examiner for review; consideration of such shall be reflected in the completed examination report or in an addendum.  

For each current bilateral hip disability identified (i.e. any hip disability diagnosed since June 2008), the examiner shall answer all of the following questions:
(a)  Is it at least as likely as not (50 percent probability or more) that the current hip disability had its onset in service, had its onset in the year immediately following service, is related to the hip symptoms in service in May 1974, or is otherwise the result of a disease or injury in service?

(b)  Is it at least as likely as not (50 percent probability or more) that the current hip disability was caused (in whole or in part) by the Veteran's now service-connected left knee disability?
 
(c)  Is it at least as likely as not (50 percent probability or more) that the current hip disability was aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by the Veteran's now service-connected left knee disability?

If any current hip disability was aggravated by a service-connected disability, the examiner shall also indicate the extent of such aggravation by identifying the baseline level of disability.  This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his symptoms over time.

In formulating the above opinions, the examiner must acknowledge and comment on any hip disability diagnosed since June 2008 and the reports of treatment for hip symptoms in service in May 1974.  
The examiner must provide reasons for each opinion given.  

The examiner is advised that the Veteran is competent to report his symptoms and history, and such statements by the Veteran must be specifically acknowledged and considered in formulating any opinions.  If the examiner rejects the Veteran's reports regarding symptoms, the examiner must provide a reason for doing so.  The absence of evidence of treatment for particular hip problems in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion.  

If the examiner determines that he or she cannot provide an opinion without resorting to speculation, the examiner shall explain the inability to provide an opinion, identifying precisely what facts could not be determined.  In particular, he or she shall comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion.  Jones, 23 Vet. App. at 389.  (The AOJ shall ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained.)

8.  After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for a VA examination to evaluate the current severity of the service-connected left shoulder disability.  All indicated tests and studies shall be conducted.
The claims folder, including this remand and any relevant records contained in the Virtual VA system, along with any records obtained pursuant to this remand, must be sent to the examiner for review; consideration of such shall be reflected in the completed examination report or in an addendum.  

The ranges of left shoulder motion shall be reported in degrees.  The examiner shall also specifically answer the following question with respect to all appropriate ranges of shoulder motion: 

What is the degree of any additional range-of-motion loss (in degrees) of left shoulder ranges of motion due to weakened movement, excess fatigability, incoordination, pain, or flare ups?

The examiner shall also report the nature and severity of any ankylosis of the scapulohumeral articulation and any impairment of the humerus, clavicle, and scapula.

The examiner must provide reasons for any opinion given.  

The examiner is advised that the Veteran is competent to report his symptoms and history, and such statements by the Veteran must be specifically acknowledged and considered in formulating any opinions.  If the examiner rejects the Veteran's reports regarding symptoms, the examiner must provide a reason for doing so.  

If the examiner determines that he or she cannot provide an opinion without resorting to speculation, the examiner shall explain the inability to provide an opinion, identifying precisely what facts could not be determined.  In particular, he or she shall comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion.  Jones, 23 Vet. App. at 389.  (The AOJ shall ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained.)

9.  After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for a VA examination with a physician with appropriate expertise to determine whether his service-connected disabilities prevent him from securing and following substantially gainful employment for which his education and occupational experience would otherwise qualify him.  All indicated tests and studies shall be conducted.

The examiner shall answer all of the following questions:

(a)  Is it at least as likely as not (50 percent probability or more) that the Veteran's service-connected disabilities (residuals of a rotator cuff tear of the left shoulder with degenerative joint disease and impingement; and a left knee disability) would, in combination and without regard to any non service-connected disabilities, prevent him from securing and following substantially gainful employment for which his education and occupational experience would otherwise qualify him?

(b)  Would the above opinion change if hearing loss, a psychiatric disability, and/or a hip disability were considered service-connected disabilities?

The examiner must provide reasons for each opinion given.  

The examiner is advised that the Veteran is competent to report his symptoms and history, and such statements by the Veteran must be specifically acknowledged and considered in formulating any opinions.  If the examiner rejects the Veteran's reports regarding symptoms, the examiner must provide a reason for doing so.  

If the examiner determines that he or she cannot provide an opinion without resorting to speculation, the examiner shall explain the inability to provide an opinion, identifying precisely what facts could not be determined.  In particular, he or she shall comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion.  Jones, 23 Vet. App. at 389.  (The AOJ shall ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained.)

10.  The AOJ shall review the examination reports to ensure that they contain the information and opinions requested in this remand and are otherwise complete.

11.  If, after completion of instructions 1 through 10 above, there is any period since March 2007 that the Veteran was unemployed and did not meet the schedular requirements for a TDIU under 38 C.F.R. § 4.16(a), the AOJ shall refer the case to VA's Director of C&P for consideration of entitlement to a TDIU under the provisions of 38 C.F.R. § 4.16(b) during those periods.

12.  If any benefit sought on appeal remains denied, the AOJ shall issue a supplemental statement of the case. After the Veteran is given opportunity to respond, the case shall be returned to the Board.

The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded.  Kutscherousky v. West, 12 Vet. App. 369 (1999).

This claim must be afforded expeditious treatment.  The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner.  See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012).




______________________________________________
J. A. MARKEY
Veterans Law Judge, Board of Veterans' Appeals


Department of Veterans Affairs