Citation Nr: 1316181	
Decision Date: 05/16/13    Archive Date: 05/29/13

DOCKET NO.  08-20 693	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Houston, Texas


THE ISSUES

1.  Entitlement to service connection for peripheral neuropathy of the upper extremities, claimed as secondary to herbicide exposure.  

2.  Entitlement to service connection for peripheral neuropathy of the lower extremities, claimed as secondary to herbicide exposure.  


REPRESENTATION

Appellant represented by:	Texas Veterans Commission


WITNESS AT HEARING ON APPEAL

Veteran



ATTORNEY FOR THE BOARD

Kristi L. Gunn, Counsel


INTRODUCTION

The Veteran served on active duty from August 1970 to August 1972.  

This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas.  

In July 2010, the Veteran testified at a videoconference hearing before the undersigned Acting Veterans Law Judge.  A copy of the transcript is of record.  

The Board has reviewed the contents of the Veteran's Virtual VA file and found no medical or other evidence pertinent to this appeal that is not in this claims file.  

In September 2010, March 2012, and November 2012, the Board remanded the claims for additional development and adjudicative action. T he case has been returned to the Board for further appellate review.  


FINDINGS OF FACT

1.  The Veteran had military service in Vietnam, and is presumed to have been exposed to herbicides therein. 

2.  Competent evidence has not been presented establishing onset of peripheral neuropathy of the bilateral lower extremities during military service, as the result of a disease or injury incurred therein, or as secondary to herbicide exposure. 

3.  Competent evidence has not been presented establishing onset of peripheral neuropathy of the bilateral upper extremities during military service, as the result of a disease or injury incurred therein, or as secondary to herbicide exposure. 


CONCLUSIONS OF LAW

1.  Peripheral neuropathy of the bilateral lower extremities was not incurred during active military service, and may not be presumed to have been incurred therein, and service connection must thus be denied.  38 U.S.C.A. §§ 1110, 1112, 1116, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012).

2.  Peripheral neuropathy of the bilateral upper extremities was not incurred during active military service, and may not be presumed to have been incurred therein, and service connection must thus be denied.  38 U.S.C.A. §§ 1110, 1112, 1116, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012).  


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

I.  Duty to Notify & Assist

The Veterans Claims Assistance Act of 2000 (VCAA) imposes obligations on VA in terms of its duty to notify and assist claimants.  When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim.  38 U.S.C.A. § 5.103(a) (West Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002).  In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004), the United States Court of Appeals for Veterans Claims (Court) held that VA must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide.  
The Board finds that the VCAA notice requirements have been satisfied by the February 2006 letter sent to the Veteran.  In the letter, VA informed the Veteran that in order to substantiate a claim for service connection, the evidence needed to show he had a current disability, a disease or injury in service, and evidence of a nexus between the post service disability and the disease or injury in service, which was usually shown by medical records and medical opinions. 

As to informing the Veteran of which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf, VA informed him it had to obtain any records held by any federal agency.  The letter also informed him that on his behalf, VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals.  Finally, the RO told the Veteran that he could obtain private records himself and submit them to VA.  

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.  The Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded.  Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).  In the present appeal, a March 2006 letter to the Veteran included the type of evidence necessary to establish a disability rating or effective date for the disability on appeal should the claim be granted. 

VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim.  38 U.S.C.A. § 5103A (West Supp. 2012); 38 C.F.R. § 3.159 (2012).  In connection with the current appeal, VA has obtained the Veteran's service treatment records, VA outpatient treatment records, and private treatment records.  The Veteran was also provided a VA examination in connection with his claim, which is found to be adequate for rating purposes.  The examiner reviewed the Veteran's medical history, recorded pertinent examination findings, and provided conclusions with supportive rationale.  The Board finds that the VA examination report is probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).   

The Veteran testified at a July 2010 Board hearing before the undersigned.  Under 38 C.F.R. § 3.103(c)(2) (2012), it is the responsibility of the hearing officer to explain fully the issues and suggest the submission of evidence which the claimant may have overlooked and which would be of advantage to the claimant's position.  In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that the hearing officer has two distinct duties under section 3.103(c)(2).  First, the hearing officer must explain fully the issues still outstanding that are relevant and material to substantiating the claim by explicitly identifying them for the claimant.  Id. at 496 (finding that a hearing officer's inquiries regarding the existence of a current disability and a nexus to service did not equate to explaining to the claimant that these issues were material to substantiating the claim).  Second, the hearing officer must suggest that a claimant submit evidence on an issue material to substantiating the claim when such evidence is missing from the record or when the testimony at the hearing raises an issue for which there is no evidence in the record.  Id., at 496-97.  

Importantly, the Court also observed that the rule of prejudicial error applies in assessing any deficiency with respect to the hearing officer's duties under section 3.103(c).  See id. at 498.  Citing Sanders, 556 U.S. at 407, 410, the Court noted in this regard that the rule of prejudicial error requires a case-by-case determination as to whether the error in question was harmless.  Id.  Thus, in Bryant, 23 Vet. App. at 498-99, the Court held that although the hearing officer did not explicitly lay out the material issues of medical nexus and current disability, the "clarity and completeness of the hearing record was intact" and the purpose of section 3.103(c)(2) fulfilled because the record reflected that these issues were developed by VA, including the provision of a VA examination, and there was no indication that the appellant had any additional information to submit.  

The outstanding issue with respect to the Veteran's peripheral neuropathy claims is whether there is a nexus or relationship between the current disorders and active service, to include herbicide exposure.  Any deficiencies in the July 2010 Board hearing under section 3.103(c)(2) were not prejudicial.  Specifically, VA has otherwise developed these claims, including making appropriate efforts to obtain records on the Veteran's behalf, and providing VA examinations which directly address the outstanding issue of whether the Veteran's claimed disabilities are related to active service, as discussed above with regard to VA's duty to assist under the VCAA.  Moreover, the Veteran did not raise any new issues pertaining to his claims at the hearing, and there is no indication that he has any outstanding evidence to submit.  See id. at 499.  

Thus, given the development undertaken by VA with respect to these claims, and in light of the Veteran's testimony at the hearing, the "clarity and completeness of the hearing record [is] intact" and the purpose of section 3.103(c)(2) to develop the record has been fulfilled.  Id. at 498-99.  Accordingly, the Veteran's right to a Board hearing has been satisfied and no prejudicial error exists with regard to the hearing officer's duties under section 3.103(c)(2).  See id.; see also Sanders, 556 U.S. at 407, 410.  

For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claim on appeal.  The evidence of record provides sufficient information to adequately evaluate the claim, and the Board is not aware of the existence of any additional relevant evidence which was not obtained.  Therefore, no further assistance to the Veteran with the development of evidence is required.  38 U.S.C.A. § 5103A(a)(2) (West Supp. 2012); 38 C.F.R. § 3.159(d) (2012); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). 

II.  Decision  

The Veteran claims entitlement to service connection for peripheral neuropathy of the bilateral upper and lower extremities, which he argues were caused or aggravated by exposure to herbicides during his active military service during the course of his tour in Vietnam.  

Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty.  38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a).  Service connection may be granted for any disease diagnosed after discharge from service when the evidence, including that pertinent to service, establishes the disease was incurred in service.  38 C.F.R. § 3.303(d).

In interpreting sections 1110 and 1131 of the statute and section 3.303(a) of the VA regulations, the Federal Circuit Court held that a three-element test must be satisfied in order to establish entitlement to service connection.  Walker v. Shinseki, 708 F.3d 1331, 1333 (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))).  Specifically, the evidence must show (1) the existence of a current disability; 
(2) in-service incurrence or aggravation of a relevant disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement).  Id.

However, claims for certain chronic diseases - namely those listed in 38 C.F.R. § 3.309(a) - benefit from a somewhat more relaxed evidentiary standard under 38 C.F.R. § 3.303(b).  See Walker, 708 F.3d at 1339 (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases").  Specifically, when a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to causes unrelated to service ("intercurrent causes").  38 C.F.R. § 3.303(b).  In order to establish the existence of a chronic disease in service, or during a presumptive period per § 3.307, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic."  Id.  Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain in a claim for arthritis or abnormal heart action in a claim for heart disease) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned.  Id.  If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim.  Id.  

The Federal Circuit Court has clarified that the requirement of showing a continuity of symptomatology after service under subsection 3.303(b) is a distinct and lesser evidentiary burden than the nexus element of the three-part test discussed above:  "The primary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the 'nexus' requirement of the three-element test, whereas the former benefits from presumptive service connection . . . or service connection via continuity of symptomatology" (emphasis added).  Walker, 708 F.3d at 1338-1339.  Thus, showing a continuity of symptomatology after service is an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation."  Id. at 1338; see also id. at 1336 (observing that section 3.303(b) provides a "second route by which a Veteran can establish service connection for a chronic disease").  A continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period."  Id., at 1338.

Not all diseases that may be considered "chronic" from a medical standpoint qualify for the more relaxed evidentiary standard under section 3.303(b).  Rather, the Federal Circuit Court held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a).  Id.  Thus, if the claimed disability is not one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and "the 'nexus' requirement of the three-element test" must be satisfied in order to establish entitlement to service connection benefits.  Id.  For example, the Federal Circuit Court held in Walker that the claimant's allegation of a continuity of hearing loss ever since active service was not sufficient to support the claim under subsection 3.303(b), as it found that the claimant's hearing loss was not among the chronic diseases listed in section 3.309(a)).  Id., at 1336-37, 1340.  A particular type of hearing loss, however, namely, sensorineural hearing loss, as a type of organic disease of the nervous system, has been found to constitute a chronic disease of the type contemplated by § 3.309(a).
Certain diseases associated with exposure to certain herbicide agents used in support of military operations in the Republic of Vietnam during the Vietnam era will be presumed to have been incurred in service.  38 U.S.C.A. § 1116(a)(1); 38 C.F.R. § 3.307(a)(6).  The presumption requires exposure to an herbicide agent and manifestation of the disease to a degree of 10 percent or more within the time period specified for each disease.  38 C.F.R. § 3.307(a)(6)(ii).  Furthermore, even if a Veteran does not have a disease listed at 38 C.F.R. § 3.309(e), he or she is presumed to have been exposed to herbicides if he or she served in Vietnam between January 9, 1962, and May 7, 1975, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service.  38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii).  

In general, for service connection to be granted for most of the presumed diseases, they must be manifested to a degree of 10 percent or more at any time after service. Chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy, however, must be manifest to a degree of 10 percent within one year after the last date on which the Veteran performed active military, naval, or air service in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975.  See 38 U.S.C.A. § 1116 (West 2002 & Supp. 2012); 38 C.F.R. § 3.307(a)(6)(ii); Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001).

Previously, the diseases for which service connection may be presumed to be due to an association with herbicide agents included AL amyloidosis, chloracne or other acneform disease consistent with chloracne, type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma).  38 U.S.C.A. § 1116(a)(2); 38 C.F.R. § 3.309(e).  Further, Note 2 under 38 C.F.R. § 3.309(e) states that, for the purposes of that section, "the term acute and subacute peripheral neuropathy means transient peripheral neuropathy that appears within weeks or months of exposure to an herbicide agent and resolves within two years of the date of onset."  

Recently, on August 31, 2010, the Secretary published a final rule in the Federal Register amending 38 C.F.R. § 3.309(e).  See 75 Fed. Reg. 53,202.  The final rule was effective August 31, 2010.  Specifically, VA amended 38 C.F.R. § 3.309(e) to add hairy cell leukemia and other chronic B-cell leukemias, Parkinson's disease, and ischemic heart disease [including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina] to the list of diseases associated with exposure to certain herbicide agents.  A newly added Note 3 at the end of § 3.309 states that: "for purposes of this section, the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of Ischemic heart disease." 

Because the rule was identified as a major rule, implementation of the rule was subject to the provisions of the Congressional Review Act (CRA).  The CRA requires an agency to wait 60 days before implementing a major rule to allow Congress the opportunity to review the regulation.  On October 29, 2010, the Secretary issued a memorandum lifting the stay of appeals affected by the new herbicide-related presumptions.  See Chairman's Memorandum No. 01-10-37, "Lifting of Stay of Appeals Affected by New Herbicide-Related Presumptions."  The memorandum notes that the CRA waiting period for the regulation expired on October 30, 2010, and accordingly, the stay of the adjudication of the affected claims was lifted October 30, 2010. 

Even where the criteria for service connection under the provisions of 38 C.F.R. § 3.309(e) are not met, a Veteran is not precluded from establishing entitlement to service connection by proof of direct causation.  See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994).  

In a March 2012 decision, the Board found that the Veteran's lay assertions and testimony, combined with those of former service members submitted into the record are credible and tend to show that he as likely as not did visit the Republic of Vietnam while in active service.  Additionally, although the Board recognized that the Veteran does not fit exactly into the M21-1MR guidelines regarding exposure to herbicide during service in Thailand, the descriptions of his duties while serving as a weapons mechanic in Thailand support his assertions that he served on the flight line and at the end of the runway at the perimeter of the base, which likely exposed him to herbicides.  Thus, the Board conceded that the probative evidence of record establishes that the Veteran had service at Nakhon Phanom Royal Thai Air Force Base (RTAFB), that he likely had service in the Republic of Vietnam, and that he likely had exposure to herbicides due to service.  Therefore, his in-service exposure to herbicides is conceded.  Thus, the crux of the case is whether the Veteran has peripheral neuropathy of the bilateral upper and lower extremities and whether it is related to service, to include as due to herbicide exposure.  

Service treatment records reflect no complaints, treatment, or diagnosis of peripheral neuropathy of the bilateral upper and lower extremities.  Upon discharge from service, clinical evaluation of the Veteran's upper and lower extremities were both normal, and the Veteran denied having or had previously swollen or painful joints on his May 1972 report of medical history.  Post service treatment records beginning in January 2001 reflect a diagnosis of left axonal peroneal neuropathy, and in September 2002, sensory nerve study and electromyography (EMG) study testing revealed general sensory peripheral neuropathy.  In March 2003, he was diagnosed with sensory peripheral neuropathy.  Based on these facts, the Board is unable to conclude that the Veteran's peripheral neuropathy manifested within a year of his last exposure to herbicides, as is required for the regulatory presumption. 

Although the Veteran is unable to satisfy the requirements discussed above to be entitled to the regulatory presumption of service connection for peripheral neuropathy as a result of exposure to Agent Orange, the Board is required to evaluate the Veteran's claim on a direct basis as well.  The availability of presumptive service connection for a disability based on exposure to herbicides does not preclude a Veteran from establishing service connection with proof of direct causation.  Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994).  

In April 2012, the Veteran was afforded a VA examination to determine the etiology of the Veteran's peripheral neuropathy of the bilateral upper and lower extremities.  After physical examination testing, the VA examiner diagnosed the Veteran with sensory peripheral neuropathy.  The VA examiner concluded that since there is no clear evidence that chronic peripheral neuropathy can result from Agent Orange exposure, the association of the Veteran's current disability to service related exposure to Agent Orange cannot be commented on without resorting to speculation.  In a June 2012 VA addendum after reviewing the claims file, the same VA examiner reiterated the April 2012 VA medical opinion.  

In November 2012, the Board determined that the April 2012 VA examiner's opinion was insufficient since the examiner was unable to provide an etiologic opinion without resorting to speculation.  As such, the Board requested that the April 2012 VA examiner provide clarification with the opinion.  

In December 2012, the same examiner again reviewed the claims file.  The VA examiner noted that the Veteran did not report any symptoms during his military service relating to chronic peripheral neuropathy nor did his exit physical examination in May 1972 reflect symptoms consistent with peripheral neuropathy.  The VA examiner further added that post service, it wasn't until March 2003 that a diagnosis of peripheral neuropathy was given.  It was also noted by the VA examiner that the Veteran had been requested to quit drinking and on VA outpatient treatment records, alcohol abuse was listed as a problem.  The VA examiner opined that the association of the Veteran's peripheral neuropathy to Agent Orange exposure in service cannot be commented on without resorting to speculation because there was no evidence of acute/subacute peripheral neuropathy related to Agent Orange and the Veteran was diagnosed with peripheral neuropathy approximately 30 years after discharge from service.  Additionally, VA outpatient treatment records reflect a history of alcohol abuse, which is also a known cause of peripheral neuropathy.  

The Court has explained that opinions that contain the "mere speculation" language, without more, amount to 'nonevidence' neither for nor against the claim because service connection may not be based on speculation or remote possibility.  See Bloom v. West, 12 Vet. App. 185 (1999) (holding that a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty).  The Court recently held in Jones v. Shinseki, 23 Vet. App. 382 (2010), that, when a medical examiner concludes that he or she is unable to provide a nexus opinion without speculation, this alone does not make the medical opinion inadequate; a medical opinion with such language may be adequate if the examiner sufficiently explains the reasons for this inability.  Id. at 389-90.  See also Obert v. Brown, 5 Vet. App. 30, 33 (1993) (noting that speculative opinion is not legally sufficient to establish service connection).  

Here, the VA examiner's December 2012 opinion followed his speculative opinion with the rationale that the Veteran was first diagnosed with peripheral neuropathy approximately 30 years after discharge from service, and VA outpatient treatment records reflect a history of alcohol abuse, which is also a known cause of peripheral neuropathy.  As such, the Board finds the December 2012 opinion to be adequate and service connection for peripheral neuropathy of the bilateral upper and lower extremities must be denied.  

The Veteran has alleged that his peripheral neuropathy of the bilateral upper and lower extremities is the result of herbicide exposure during military service in Vietnam.  As a layperson, however, the Veteran is not capable of making medical conclusions; thus, his statements regarding causation are not competent evidence.  See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).  Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation.  Id; see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence).  Neurological disorders, however, are complex disorders which require specialized training for a determination as to diagnosis and causation, and they are therefore not susceptible of lay opinions on etiology, and the Veteran's statements therein cannot be accepted as competent medical evidence.  

In conclusion, the preponderance of the evidence is against the Veteran's claims of service connection for peripheral neuropathy of the bilateral upper and lower extremities, to include as secondary to herbicide exposure.  While herbicide exposure is conceded by VA, onset of such a disability was many years after military service, such that a statutory presumption is not warranted, and the competent evidence of record does not suggest a nexus between such exposure, or any other incident of military service, and his current peripheral neuropathy.  Thus, service connection for peripheral neuropathy must be denied.  As a preponderance of the evidence is against the award of service connection, the benefit of the doubt doctrine is not applicable in the instant appeal.  See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991).  


ORDER

Entitlement to service connection for peripheral neuropathy of the upper extremities, claimed as secondary to herbicide exposure is denied.  

Entitlement to service connection for peripheral neuropathy of the lower extremities, claimed as secondary to herbicide exposure is denied.  



____________________________________________
ROBERT E. O'BRIEN
Acting Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs