Citation Nr: 1316306	
Decision Date: 05/17/13    Archive Date: 05/29/13

DOCKET NO.  08-28 317	)	DATE
	)
	)

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


THE ISSUES

1.  Entitlement to service connection for bilateral hearing loss.

2.  Entitlement to service connection for tinnitus.


REPRESENTATION

Appellant represented by:	Texas Veterans Commission


WITNESS AT HEARINGS ON APPEAL

The Veteran


ATTORNEY FOR THE BOARD

B. Elwood, Associate Counsel
INTRODUCTION

The Veteran served on active duty from April 1959 to April 1962 and from May 1963 to May 1967.

These matters initially came before the Board of Veterans' Appeals (Board) from a June 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas.  In that decision, the RO denied entitlement to service connection for bilateral hearing loss and tinnitus.

In March 2011 and March 2012, the Veteran testified at hearings before a Decision Review Officer (DRO) and the undersigned, respectively.  Transcripts of these hearings have been associated with his claims file.

In May 2012, the Board remanded these matters for further development.

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.


FINDINGS OF FACT

1.  A hearing loss did not have its clinical onset in service and is not otherwise related to active duty; a sensorineural hearing loss was not exhibited within the first post service year.  

2.  Tinnitus did not have its clinical onset in service and is not otherwise related to active duty.





CONCLUSIONS OF LAW

1.  Bilateral hearing loss was not incurred or aggravated in service, and a sensorineural hearing loss may not be presumed to have been incurred therein.  38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1113(b), 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.304(b), 3.307, 3.309, 3.385 (2012).

2.  Tinnitus was not incurred or aggravated in service.  38 U.S.C.A. §§ 1110, 1111, 1131, 1137, 5107(b); 38 C.F.R. §§ 3.303, 3.304(b).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012) redefined VA's duty to assist the Veteran in the development of a claim.  VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012).

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 a pre-adjudication letter dated in November 2005, the RO notified the Veteran of the evidence needed to substantiate his claims of service connection for bilateral hearing loss and tinnitus.  This letter 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 a March 2006 letter.  

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 March 2011 and March 2012 hearings, the DRO and the undersigned identified the issues on appeal (including entitlement to service connection for bilateral hearing loss and tinnitus).  The undersigned asked the Veteran about the history of his hearing loss and tinnitus and about the treatment received for these claimed disabilities to ensure that all relevant records were obtained, and informed him of the evidence that was required to substantiate a claim of service connection.  Further, the Veteran provided testimony as to the symptoms and history of his claimed disabilities and the treatment received for these disabilities.  Thus, he has demonstrated actual knowledge of the ability to identify and submit additional relevant evidence.  The duties imposed by Bryant were thereby met.

VA obtained the Veteran's service treatment records, pertinent service personnel records, and all of the identified relevant post-service VA treatment records.  The Veteran has not reported, and the evidence does not otherwise reflect, any relevant post-service private medical treatment for hearing loss or tinnitus.  In addition, the Veteran was afforded VA examinations to assess the nature and etiology of his current hearing loss and tinnitus and opinions have been obtained concerning the etiology of these disabilities.

In its May 2012 remand, the Board instructed the agency of original jurisdiction (AOJ) to obtain opinions as to the etiology of the Veteran's claimed hearing loss and tinnitus.  A VA examination was conducted in June 2012 and opinions were obtained concerning the etiology of the Veteran's hearing loss and tinnitus.  Thus, the AOJ substantially complied with the Board's May 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

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, 1131; 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), including organic diseases of the nervous system (e.g. sensorineural hearing loss), 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 organic diseases of the nervous system, 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).

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).

Hearing loss is considered to be a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition thresholds using the Maryland CNC Test are less than 94 percent.  38 C.F.R. § 3.385.

In this case, the June 2012 VA examination report reveals that the Veteran has been diagnosed as having bilateral hearing loss as defined by VA.  See 38 C.F.R. § 3.385.  A diagnosis of bilateral sensorineural hearing loss was provided.  He has also reported tinnitus.  Thus, current hearing loss and tinnitus has been demonstrated.

The Veteran has reported on various occasions, including on an April 1963 report of medical history completed for purposes of entrance into service, that he experienced ear infections as a child.  He also contended during the June 2012 VA examination that tinnitus may have pre-existed service.  
A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated.  38 U.S.C.A. §§ 1111, 1137; 38 C.F.R. § 3.304(b).

Although the Veteran is certainly competent to report a history of ear problems and tinnitus prior to service, a veteran's report of history, even when related by a medical professional, without an independent basis in the record, is insufficient to rebut the presumption of soundness.  Miller v. West, 11 Vet. App. 345 (1998).  There is no other evidence of any pre-existing hearing loss or tinnitus and the Veteran's April 1959 and April 1963 entrance examinations were normal other than for tattoos, acne, varicose veins, and vision problems. Therefore, the evidence is not clear and unmistakable that hearing loss or tinnitus pre-existed service and was not aggravated in service and he is presumed sound at service entrance.  38 U.S.C.A. § 1111. 

The Veteran contends that his current hearing loss and tinnitus is related to exposure to loud noises in service without the use of hearing protection.  Specifically, he has reported that he was exposed to noises associated with tanks, military weaponry, aircraft, trucks, and power tools.  He has also reported occupational noise exposure without the use of hearing protection in the years since service, including noise associated with factories/plants, machine shops, trucks, automobiles, welding, and power tools.  

The Veteran's DD 214s and service personnel records reflect that his military occupational specialties involved auto and truck maintenance and that he received weapons training.  He is competent to report in-service noise exposure.  See Jandreau, 492 F.3d at 1376-77; Buchanan, 451 F.3d at 1336.  Moreover, there is nothing to explicitly contradict his reports and they are generally consistent with the evidence of record and the circumstances of his service.  Therefore, his reports are credible and in-service acoustic trauma is conceded.  38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.303(a) (each disabling condition for which a veteran seeks service connection must be considered on the basis of the places, types, and circumstances of his service, as shown by the evidence).  Thus, there is evidence of current hearing disabilities and in-service noise exposure.

The Veteran has not reported, and the evidence does not otherwise reflect, a continuity of hearing loss symptomatology in the years since service.  However, he has reported that he has used a radio at night to mask the noises associated with tinnitus "since he left the military."  Thus, he has alluded to a continuity of symptomatology with respect to tinnitus.  He is competent to report tinnitus and 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.

There is no evidence of any complaints of or treatment for tinnitus in the Veteran's service treatment records.  In September 1959 he reported hearing loss and occasional right ear pain.  Examination revealed that his tympanic membranes were normal and an audiogram conducted at that time was within normal limits.  He subsequently reported on numerous occasions in service between April 1964 and February 1967 that his left ear felt "plugged," that it ached and secreted a discharge, that he experienced possible left ear hearing loss, and that he had undergone left ear surgical procedures in the past.  However, he specifically reported in August 1966 that he was not experiencing tinnitus.  

Examinations revealed that the left tympanic membrane had a ground glass appearance and appeared sunken and deformed.  There was occasional erythema of the left inner ear canal and a possible small central perforation on the left.  Also, both tympanic membranes were scarred.  A greater than 40 decibel hearing loss in the left ear was noted in September 1966.  Diagnoses of eustachian tube blockage, scarred tympanic membranes, chronic left otitis media, external otitis, a retracted tympanic membrane, and decreased hearing were provided.

The Veteran's March 1962 and March 1967 separation examinations were normal other than for chronic left serous otitis media, tattoos, varicose veins, and dental problems.  Whispered voice and "SV" tests were both normal (15/15) bilaterally during the March 1962 separation examination.  Moreover, audiometry tests conducted at the time of the separation examinations did not reveal any hearing loss as defined by VA.  Specifically, the audiometry tests conducted during the March 1962 and March 1967 separation examinations reveal that the Veteran's pure tone thresholds were as follows, respectively:


Hertz
500
1,000
2,000
3,000
4,000
Right ear
0
0
0
not tested
5
Left ear
0
0
10
not tested
0


Hertz
500
1,000
2,000
3,000
4,000
Right ear
-5
-5
0
0
5
Left ear
0
0
0
5
5

As the above audiometric tests were administered prior to October 31, 1967, they may require conversion from American Standards Association (ASA) units to International Standards Organization (ISO) units.  Such conversion indicates that the pure tone thresholds were as follows, respectively:

Hertz
500
1,000
2,000
3,000
4,000
Right ear
15
10
10
not tested
10
Left ear
15
10
20
not tested
5

Hertz
500
1,000
2,000
3,000
4,000
Right ear
10
5
10
10
10
Left ear
15
10
10
15
10

If a chronic disease, such as an organic disease of the nervous system (e.g. sensorineural hearing loss), 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 evidence showing any diagnosed sensorineural hearing loss in service.  Hence, service connection cannot be granted on this basis here.
The objective evidence otherwise indicates that the Veteran's current hearing loss and tinnitus did not manifest until many years after service.  The first post-service reports of hearing loss and tinnitus are the Veteran's June and November 2005 service connection claims.  The first post-service clinical evidence of hearing loss is a July 1997 VA audiology consultation note which reveals that the Veteran was diagnosed as having mild to severe hearing loss on the right (primarily conductive hearing loss) and moderate to severe hearing loss on the left (mixed hearing loss).  Also, the first post-service clinical evidence of tinnitus is a May 2004 VA primary care treatment note which reflects that the Veteran's active medical problems included tinnitus.

There is no clinical evidence of any earlier hearing loss or tinnitus following service.  The absence of any evidence of hearing loss or tinnitus for over thirty years after the Veteran's separation from service in May 1967 weighs against a finding that his current hearing loss or tinnitus was present in service or in the year or years immediately after either period of service.

The Veteran has provided varying statements as to the history of his tinnitus.  For example, he has contended that he has used a radio at night to mask the noises associated with tinnitus "since he left the military."  However, he reported during the March 2012 hearing that he was unaware of any hearing problems (including tinnitus) in service and that he did not find out about such problems until he underwent a hearing test sometime after his separation from service.

In light of the absence of any objective evidence of complaints of or treatment for tinnitus during service, the fact that the Veteran's March 1962 and March 1967 separation examinations were normal other than for tattoos, varicose veins, dental problems, and otitis media, the absence of any evidence of tinnitus for decades following service, and the Veteran's inconsistent statements concerning the history of his tinnitus, the Board concludes that his reports concerning the history of his tinnitus, including any reports of a continuity of symptomatology since 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.
Moreover, the only medical opinions of record reflect that the Veteran's current hearing loss and tinnitus are not related to service.  The examiner who conducted a January 2007 VA examination opined that the Veteran's hearing loss and tinnitus were not caused by or a result of military noise exposure.  She reasoned that the Veteran had normal hearing from the time of his enlistment in 1959 until his second separation in 1967, that there were no complaints of hearing loss or tinnitus in his "C-file," and that he had experienced significant post-service occupational noise exposure.

The examiner who conducted the June 2012 VA examination opined that the Veteran's hearing loss and tinnitus were not likely (not "at least as likely as not"/50 percent probability or greater) caused by or a result of any in-service event, including noise exposure.  With respect to hearing loss, the examiner reasoned that the testing at the time of the Veteran's enlistment in 1959 showed normal hearing bilaterally via the whispered voice test.  Also, the hearing thresholds measured at the time of his separation from service in 1967 fell well within the normal range in both ears and the "C-file records" contained no complaints of hearing loss.  The Veteran experienced significant post-service occupational noise exposure which was capable of causing the hearing loss measured at the time of the June 2012 examination.  For example, he reported that he had worked for a steel press company and in a steel mill for a total of 10 years.  Thus, military noise exposure did not cause his hearing loss.

As for tinnitus, the examiner explained that although the Veteran reported that he had used a radio at night to mask the noises in his ears since he had left service, it was likely ("more likely than not") that the middle ear disease that he had experienced prior to service as a child caused the onset of his tinnitus.  The presence of normal hearing in both ears at the time of his separation from service pointed to causes other than military noise exposure.

In January 2013, the Board sought to obtain an expert medical opinion through the Veterans Health Administration (VHA opinion) in accordance with the provisions of 38 C.F.R. § 20.901(a) (2012).  In February 2013, a VA physician reviewed the Veteran's claims file and opined that there was no evidence that his hearing loss or tinnitus was the result of a disease or injury in service.  He reasoned that audiometric screenings at the time of the Veteran's April 1959 entrance into service  and March 1962 separation from service demonstrated normal hearing at all frequencies.  Also, repeat audiometric testing at the time of his May 1963 entrance into service was again normal.  During service he experienced several episodes of eustachian tube dysfunction, acute otitis media, and serous otitis media which were appropriately treated.  During that time, he had reported a history of otitis media (i.e. ear infection problems) during childhood, a history of several myringotomy procedures to treat the otitis media (especially around the age of 11), and a history of hay fever/allergic rhinitis.

The Veteran was treated in March 1966 for left serous otitis media after several weeks of finding prolonged middle ear effusion.  Chronic changes to the left tympanic membrane from his childhood were also noted on examination.  There were no complaints of tinnitus or vertigo reported at that time.  He was again seen in September 1966 for left serous otitis media with conductive hearing loss.  This was appropriately treated and politzerization with good result and clearing of the middle ear effusion was reported during a follow up visit.  Middle ear effusions are commonly associated with upper respiratory infections or allergies in susceptible individuals and the conductive hearing loss resolves when the effusion clears.  There would be no permanent sequelae anticipated from such episodic ear infections or middle ear effusions if they were treated appropriately, as they were with respect to the Veteran.

Moreover, the scarring and changes from the Veteran's history of left ear infections and effusions was reported at the time of his March 1967 separation examination.  However, audiometric testing at that time was again entirely normal at all frequencies.  This would indicate that there were no audiometric sequelae from his history of episodic childhood and adulthood ear infections and middle ear effusions.  Furthermore, there was no evidence that any noise exposure in service resulted in any permanent hearing loss, as demonstrated by the normal audiometric testing at the time of the Veteran's separation from service.  Rather, his reported post-service occupational noise exposure and advancing age were the likely etiology of his current hearing loss and tinnitus.
The medical professionals who provided the January 2007 and February 2013 opinions did not explicitly acknowledge and discuss the reports alluding to a continuity of tinnitus symptomatology in the years since service in formulating their opinions.  However, any claim of a continuity of symptomatology is not deemed to be credible and an opinion based on such an inaccurate history would be inadequate.  See Boggs v. West, 11 Vet. App. 334, 345 (1998); Kightly v. Brown, 6 Vet. App. 200, 205-06 (1994); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993).

The February 2013 opinion was otherwise based upon a review of the Veteran's medical records and reported history and is accompanied by a detailed rationale that is not inconsistent with the evidence of record.  Thus, this opinion is adequate and entitled to substantial probative weight.  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).  Although the January 2007 and June 2012 opinions are of somewhat limited probative value because they either did not reflect consideration of the Veteran's documented ear and hearing problems in service or did not consider the fact that he was presumed sound at the time of service entrance,  they nonetheless support a conclusion that his hearing loss and tinnitus are not related to service.

The Veteran has expressed his belief that his current hearing loss and tinnitus are related to noise exposure in service.  However, as a lay person, he 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 hearing loss and tinnitus are related to noise exposure 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.  38 C.F.R. § 3.159(a)(1), (2) (2012).

There is no other evidence of a relationship between the Veteran's current hearing loss and tinnitus 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 with respect to either disability.  Thus, the preponderance of the evidence is against a finding that the Veteran's current hearing loss and tinnitus are related to service, manifested in service, or manifested within a year after his April 1962 or May 1967 separations from service.

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


ORDER

Entitlement to service connection for bilateral hearing loss is denied.

Entitlement to service connection for tinnitus is denied.



____________________________________________
THOMAS J. DANNAHER
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs