Citation Nr: 1316922 Decision Date: 05/23/13 Archive Date: 05/31/13 DOCKET NO. 11-08 638 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to service connection for a low back disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD K. Neilson, Counsel INTRODUCTION The Veteran had active military service from February 1959 to February 1963. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a January 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. On April 1, 2013, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge, sitting at the RO. A transcript of that hearing is of record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT A low back disability was not manifest to a compensable degree within a year of the Veteran's military service, is not shown to be otherwise related to his military service, and is not shown to be proximately due to, the result of, or made worse by a service-connected disability. CONCLUSION OF LAW The Veteran does not have a low back disability that is the result of disease or injury incurred in or aggravated during active military service, or that is caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.310, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Notice and Assistance The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim. They also require VA to notify the claimant and the claimant's representative of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The VCAA notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the instant case, the Veteran was apprised of VA's duties to both notify and assist through correspondence dated in August 2010 and June 2012. Specifically, the notifications to the Veteran apprised him of what the evidence must show to establish entitlement to service connection on both a direct and a secondary basis, what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. The letters further advised the Veteran on the types of evidence he could submit that would support his claim for service connection, such as the dates of medical treatment during service, evidence of medical treatment since service, employment physical examination reports, insurance examination reports, and statements by persons who knew of the Veteran's disability. The notice also included the criteria for assigning a disability rating and an effective date as required by Dingess, supra. Although the complete notice required by the VCAA was not provided until after the initial adjudication of the Veteran's claim, any timing errors have been cured by the RO's readjudication of the Veteran's claim via a November 2012 supplemental statement of the case. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (a timing error can be effectively "cured" by providing any necessary VCAA notice followed by a readjudication of the claim). The Veteran has not disputed the contents of the VCAA notice in this case. Further, the Board finds that the August 2010 and June 2012 notice letters comply with the requirements of 38 U.S.C.A. § 5103(a) and afforded the Veteran a meaningful opportunity to participate in the development of his service connection claim. Thus, the Board is satisfied that the duty-to-notify requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) were satisfied. Regarding the duty to assist, the Board also finds that VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate his claim. All available relevant evidence pertaining to the Veteran's claims has been obtained. The evidence includes his service treatment records (STRs), service personnel records, VA treatment records, VA examination reports, private medical records, and lay statements in support of his claim, to include his April 2013 hearing testimony. The Board notes that the agency or original jurisdiction (AOJ) attempted to obtain the Veteran's records from the Social Security Administration (SSA), but a response received from SSA stated that records were unavailable as they had been destroyed. Although the Veteran disputes VA's formal finding of unavailability based on his belief that SSA records are available indefinitely, the Veteran has presented no evidence to suggest that SSA's finding was made in error. As such, the Board finds no reason to again seek to obtain the Veteran's SSA records. Similarly, no further attempts to obtain private medical records are necessary. Either the Veteran has supplied the private records or the AOJ has received the requested records or received responses indicating that records had been destroyed. As will be discussed below, the Veteran himself stated that records related to an alleged 1966 surgery were not available. The Veteran has also argued that his service treatment and personnel records are incomplete. Although this does not appear correct based on the records received, the Board notes that even if the Veteran's service records are somehow incomplete, the outcome of this case turns on whether the Veteran's account of an alleged in-service injury is credible, the analysis of which is primarily centered on inconsistencies in the Veteran's story. The Veteran also argues that VA should have obtained ship or deck logs to substantiate his alleged injury. As will be discussed below, the Veteran has testified that the injury occurred while aboard the USS Intrepid, an assertion that is clearly contradicted by official service personnel records. Accordingly, the Board finds that a remand to attempt to obtain additional records is not necessary. The AOJ has also obtained several medical opinions in connection with the Veteran's claim. As will be discussed below, because the Board does not need to reach the issue of whether there is medical nexus evidence on account of its finding that there is no credible evidence of an in-service back injury, to specifically include the alleged incident involving an air compressor, any error with regard to a March 2012 VA examination afforded in connection with his claim on a direct basis would not be determinative. Further, as to the issue of secondary service connection, VA clinicians reviewed the claims folder, to include the private medical records and lay statements contained therein, and provided their opinions regarding the likelihood that the Veteran's knee disability has caused or aggravated his lumbar spine degenerative disc/degenerative joint disease. The Board finds that the opinions obtained in this case are adequate as they were predicated on a reading of the medical records in the Veteran's claims file and current medical literature. The Board notes that while the opinions of record are lacking somewhat in supporting rationale with regard to the issue of secondary service connection, as will be discussed in greater detail below, the Board does not find that the lack of a more detailed rationale renders the opinions inadequate. The Board thus concludes the Veteran was provided with an adequate medical opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). II. Analysis In the instant case, the Veteran is seeking service connection for a disability of the lumbar spine, which he asserts is either directly attributable to military service or related to his service-connected internal derangement of the right knee. Specifically, during his April 2013 hearing, the Veteran testified that prior to reporting to sick call on March 10, 1959, he was approaching the rear of the hangar deck where aircraft tires were being serviced, at which time the air compressor or air tank exploded. The Veteran stated that "the next thing [he] knew, [he] was in sick bay because [he] was out." The Veteran also reported having again later injured his back in service "when [he] was playing football for the Naval Air Station at Millington," as well as having reinjured it after service. He further stated that his surgeon was of the opinion that his service-connected knee disability had contributed to the hastening or worsening of his back disability. The law provides that service connection may be granted for disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1131 (West. 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). In addition, certain chronic diseases, including degenerative joint disease (arthritis), may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). A disability may be found service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); 38 C.F.R. § 3.310 (2012). The Board notes that the evidence of record reveals a diagnosis of lumbar spine degenerative disc/degenerative joint disease. As such, whether the Veteran has a current disability is not at issue in this case. At the outset, the Board finds there to be no indication that the Veteran's lumbar spine degenerative joint disease manifested to a compensable degree within one year of his separation from military service in February 1963. While the Veteran contends that he injured his back in service and underwent his first back surgery in 1966, there is no evidence of record upon which to base a finding that arthritis manifested to compensable degree within a year of discharge. First, the Veteran's STRs are silent for evidence of arthritis of the lumbar spine. Further, by his own admission, the Veteran did not seek treatment related to his back until a year and a half to two years after service. Moreover, records related to the alleged 1966 surgery were apparently destroyed, as the Veteran has asserted that any such records are non-existent on account of the fact that the doctor who performed the surgery passed away. Of note, the Board points out that the evidence raises a question as to the accuracy of the Veteran's account of having undergone surgery in 1966. Indeed, an April 1983 private treatment record indicates a past medical history significant for "multiple low back pain procedures with diskectomies in 1970, 1976, 1978, and 1980," with no mention of a surgery in 1966. Additionally, a July 2010 VA treatment record notes the Veteran's assertions that "he has had 5 previous surgeries[,] the last being in 1990." Lastly, although the Veteran has indicated consistent back pain since his alleged in-service injury, his lay statements are not competent evidence of arthritis either in or within a year of service because arthritis must be established by objective testing. See 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5003 (2012) (noting that degenerative arthritis must be established by x-ray findings). Thus, service connection is not warranted for the Veteran's diagnosed degenerative joint disease on a presumptive basis for chronic diseases. See 38 U.S.C.A §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3); 3.309(a). As to whether service connection is warranted for lumbar spine degenerative disc/degenerative joint disease on a direct basis, there is no question that the Veteran has a current disability. Further, while the Veteran has testified as to the presence of back pain since his alleged in-service injury and S.L., D.O., the Veteran's private doctor submitted a statement dated in March 2011 wherein he opined that the Veteran's "chronic back problems may very well be the result of an injury sustained during his service in the armed forces," the Board finds that the outcome of this case turns on whether there is credible evidence establishing that the Veteran sustained a back injury in service, as he has alleged. See Davidson, supra (establishing service connection requires, among other things, evidence of an in-service incurrence or aggravation of a disease or injury). The Board acknowledges that the Veteran STRs document a complaint of low back pain on March 10, 1959. That same entry notes complaints of a sore throat and contains a diagnosis of pharyngitis. The Veteran's STRs are otherwise silent for complaints or treatment related to his back. As outlined above, during his April 2013 hearing, the Veteran testified that he injured his back in service when an air compressor or air tank exploded, knocking him unconscious. He reported having experienced back pain since that injury. The Veteran specifically stated that this injury occurred prior to reporting to sick call in March 1959 for throat problems. When asked whether he recalled the name of the ship where the alleged accident occurred, the Veteran replied that the incident occurred while working aboard the USS Intrepid. There is no question that the Veteran is competent to report as to the circumstance of his alleged injury in service. However, to be probative, those statements must also be credible. A review of the record shows that in filing a claim of service connection for a right knee disability, the Veteran reported having injured his right knee in late 1961 while aboard the USS Roosevelt. The Veteran alleged that an air compressor exploded and knocked him down, after which he spent several days in sick bay. During a September 2010 VA examination, the Veteran stated his right knee injury occurred in 1962 "when he was near a crew working on an aircraft split rim tire that exploded." He reported being knocked unconscious and awaking in sick bay with a swollen and painful right knee. During a March 2012 VA examination, afforded in connection with the current claim, the Veteran reported having injured his back in service, around 1961, when an air compressor exploded and knocked him over. He stated that he spent one to three days in sick bay after the injury. As noted above, the Veteran's STRs document a complaint of low back pain in March 1959. There is no indication that the Veteran was brought into sick call on account of having been knocked unconscious as a result of an air compressor explosion. Further, while the STRs show that he several times injured his right knee in service, all records related to injury indicate that he injured his knee while playing football. Again, the records do not support the Veteran's contention that he injured his knee when an air compressor exploded and knocked him to the ground. Notably, although the Veteran has asserted that he sustained injury to his back while aboard the USS Intrepid, the March 1959 treatment entry clearly indicated that the Veteran was at the United States Naval Training Center (USNTC), Great Lakes, Illinois. Further, the Veteran's service personnel records show that he was participating in recruit training at the USNTC Great Lakes from February 14, 1959, to April 27, 1959. There is no indication that the Veteran was ordered to duty aboard a ship during his period of recruit training, and the Veteran has proffered no evidence of the USS Intrepid having ever been in Lake Michigan. In this regard, the Board notes that according to the history of the USS Intrepid, as taken from the Dictionary of American Fighting Ships, published by the Naval Historical Center, and provided on the U.S. Navy website, during the time period in question, the USS Intrepid "alternated Mediterranean deployments with operations along the Atlantic coast of the United States and exercises in the Caribbean." http://www.navy.mil/navydata/nav_legacy.asp?id=28. Upon review of the evidence of record, the Board finds that although the Veteran may be competent to report on the existence of an injury in service, in the instant case, the inconsistencies in the Veteran's account regarding the alleged air compressor injury renders his self-reported history not credible. Indeed, the Veteran has reported the injury to have occurred in 1959, 1961, or 1962. However, his STRs are completely devoid of any evidence to substantiate the alleged injury. Although the Veteran claims to have injured his right knee as a result of the alleged air compressor injury, the STRs relate his right knee injury to playing football. Further, the Veteran testified, under oath, that the alleged air compressor injury, to which he relates his current back disability, occurred while aboard the USS Intrepid and happened prior to him being seen in sick call in March 1959, which treatment entry noted a complaint of low back pain. The Veteran's service personnel records clearly contradict the Veteran's assertion in this regard, as the Veteran was stationed at the USNTC Great Lakes from February to April 1959. To the extent that the Veteran is alleging that his STRs are incomplete in that they do not reflect that he was seen in sick call immediately following the alleged injury, the fact remains that the Veteran's allegations are contradicted by official service department records. The Board finds no reason to doubt the veracity of the information contained in the Veteran's service personnel records, which place the Veteran at the USNTC Great Lakes from his time of enlistment until the March 10, 1959, treatment entry. The Board has also considered the Veteran's allegation that he again injured his back subsequent to the air compressor injury while playing football, but similarly finds this statement to be incredible. Although the Veteran's STRs suggest that he injured his right knee playing football, there is no indication of any resulting back injury. The Board is mindful that it "cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence." Buchanan v. Nicholson, 451 F.3d 1331, 1334-37 (Fed.Cir.2006). However, at his March 2012 VA examination, during which he related his back injury to the alleged air compressor accident in 1961, the Veteran reported that "[h]e couldn't play football after this incident because his back hurt too much." Although this statement is seemingly contradicted by the STRs, which arguably indicate that the Veteran was able to football after 1961, the Board finds the inconsistencies in the Veteran's report, along with the lack of any in-service evidence documenting, or even suggesting, a back injury during that time (save for one complaint in 1959, which a VA examiner has attributed to a viral infection), make him an incredible historian as to all assertions of an in-service back injury. See Buchanan, 451 F.3d at 1337 ("[T]he Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc."); Caluza v. Brown, 7 Vet. App. 498, 511 (1995) ("The credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character."), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). In this regard, the Board notes that the Veteran has also alleged that he was an Under-Water Demolition Team (UDT) swimmer and asserted that his current back disability may be related to such duties. The AOJ took steps to confirm the Veteran's duty as a UDT swimmer, as neither the Veteran's service personnel records nor his DD Form 214 contain supporting evidence of such. However, no such verification was returned. Given the absence of any proof that the Veteran was a UDT swimmer, the Board finds no reason to further entertain the Veteran's argument in this regard, especially given the fact that the Board has already found the Veteran to be an incredible historian. In sum, the Board finds there to be no evidence, other than the Veteran's own statement, which the Board has deemed not credible, that the Veteran sustained a back injury in service. Without evidence of in-service incurrence or aggravation of a disease or injury, a finding of service connection cannot be made. See Davidson, supra. The Board has considered the Veteran's various arguments concerning VA's failure to properly assist him in obtaining evidence and regarding the adequacy of the medical examination and opinions obtained in this case. The Board finds, however, that any actual error in this regard would not be determinative, as there is no credible evidence of an in-service back injury. As discussed above, although the Veteran suggests that VA should have sought to obtain certain ships logs, the evidence fails to establish that the Veteran was aboard the USS Intrepid at the time of the alleged injury in 1959. As to the Veteran's later assertion that the injury occurred in 1961, the Board has already determined that the Veteran's account of his alleged in-service injury, regardless of when claimed to have occurred, is not credible, because his statements are highly inconsistent and there is no evidence in service that suggests any injury to the back. Lastly, regarding Dr. S.L.'s opinion that the Veteran's "chronic back problems may very well be the result of an injury sustained during his service in the armed forces," given that the Board has deemed the Veteran's account of an in-service back injury not credible, Dr. S.L.'s opinion lacks probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based upon an inaccurate factual premise has no probative value). In this same vein, the Board finds that to the extent that a VA examiner's notation in a July 2012 opinion report that an acute injury leading to a herniated disc may also begin the degeneration process can be read as evidence favorable to the issue of direct service connection, the Board finds no credible evidence on an in-service fall and thus cannot conclude that the VA examiner's statement is evidence supportive of the Veteran's claim. As noted above, the Veteran has also contended that his degenerative disc/degenerative joint disease of the lumbar spine is related to his service-connected right knee disability, characterized as internal derangement with meniscal cartilage damage and degenerative arthritis. Here, the Veteran was granted service connection for a right knee disability in September 2010. Thus, the question before the Board is whether the Veteran's disease of the lumbar spine is proximately due to or the result of his right knee disability or whether his lumbar disease has been aggravated by his right knee disability. See Allen, supra. Relevant to this issue, the Veteran was afforded a VA examination in March 2012. Thereafter, the examiner who had examined the Veteran at that time was asked to provide an addendum to her examination report that included an opinion on causation and/or aggravation of the Veteran's lumbar spine disability, which opinion was obtained in July 2012. After discussing the fact that medical literature does not provide support for finding that a knee condition or a resulting antalgic gait is a risk factor or cause for disc herniation of degenerative disc disease, the examiner opined that it was less likely than not that the Veteran's lumbar spine disability was proximately due to or a result of his service-connected right knee disability. The examiner explained that degenerative disc disease was a term used to describe normal changes in the spine due to the aging process and stated that such changes were more likely to occur in those who, like the Veteran, smoked cigarettes, were overweight, and engaged in heavy physical work. The examiner also pointed out the evidence documenting post-service injuries. In this regard, the Board notes that the Veteran himself has admitted to several post-service back injuries and a March 1983 treatment entry reveals the onset of low back pain immediately after a lifting injury. The examiner also indicated her opinion that it was not as least as likely as not that the Veteran's low back disability was aggravated beyond its natural progression due to his service-connected right knee disability, as supporting evidence of such was not found in the medical literature. In November 2012, another VA examiner reviewed the claims folder, to include the March 2012 VA examination report and subsequent addendum opinion. Although the examiner checked the box stating that it was at least as likely as not that the Veteran's lumbar spine disability was proximately due to or the result of his service-connected right knee disability, it is clear from the stated rationale that that box was checked in error. Indeed, the examiner noted no evidence of gait disturbance leading to back pain, as well as the lack of evidence supporting a finding of causation or aggravation. The examiner also explicitly stated her opinion that the Veteran's degenerative joint disease was more likely due to interceding, intervening events. Further, the record contains a November 2012 report of general information noting that the VA clinician was contacted regarding the apparent inconsistency in her report. The clinician reviewed her opinion and stated that she should have marked the box indicating that the claimed condition was less likely than not proximately due to or aggravated by the Veteran's service-connected right knee disability. In view of the above findings, which are uncontradicted by the remaining credible evidence of record, the Board finds that service connection for lumbar spine degenerative disc/degenerative joint disease must be denied on a secondary basis as well. In this regard, the Board acknowledges the Veteran's assertion made during his April 2013 hearing that it was his surgeon's opinion that his right knee disability was contributing to the worsening of his back disability. The Veteran provided no further details as to when his surgeon informed him of such or why his surgeon believed this to be so. Further, none of the private medical records submitted or obtained in support of his claim contains, to include those by physicians who had previously performed surgery on the Veteran, any suggestion of aggravation of the Veteran's back disability due to his right knee. Notably, it does not appear that the Veteran has undergone back surgery since 1990 or 1992, which was nearly 20 years prior to the effective date of his award of service connection for a right knee disability and the nature of any right knee disability at that time is not disclosed by the record currently before the Board. Accordingly, the Board finds more probative the VA examiners' findings, as it is clear that their opinions were based upon a review of the record and current medical literature. Further, the Board is aware that the examiners' opinions are lacking somewhat in rationale. However, there is no requirement imposed on a medical examiner to provide detailed reasons for an opinion. See Ardison v. Brown, 6 Vet. App. 405, 407 (1994). Rather, an examiner is required only to consider all of the relevant evidence before forming an opinion and support his or her opinion with an analysis that the Board can consider and weigh against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In the instant case, there is no indication that either clinician failed to consider any piece of relevant evidence before providing their opinions. The Board also finds no reason to discount the medical opinions based on the physicians' expertise and qualifications as medical professionals. Further, given the absence of contrary medical evidence in this case, the Board need not weigh the VA and VA contract examiners' opinions against other evidence. Indeed, there is no evidence, other than the Veteran's own assertions, to suggest that his lumbar spine degenerative disc/degenerative joint disease has been caused or aggravated by his service-connected right knee disability. Although the Veteran believes that his lumbar disease is due to his right knee disability, the etiology of dysfunctions and disorders is generally a medical determination. See Jandreau v. Nicholson, 492 F.3d 1372, 1374-75 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). Here, the Veteran, as a lay person without the appropriate medical training and expertise, is not competent to make such an etiological conclusion, especially in light of the VA examiners' conclusions to the contrary. See Jandreau, supra. As such, the Board finds that the lack of a more detailed rationale does not render either of the opinions obtained in this case inadequate. For the foregoing reasons, the Board finds that the claim of service connection for low back disability must be denied. In reaching this conclusion, the Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The Board is unable to identify a reasonable basis for granting service connection for a lumbar spine disability under any theory advanced by the Veteran. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 C.F.R. § 3.102 (2012). ORDER Service connection for a low back disability is denied. _______________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs