Citation Nr: 1318345 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 06-32 142 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for residuals of right knee surgery, to include as secondary to service connected disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Nadine W. Benjamin, Counsel INTRODUCTION The Veteran served on active duty from January 1989 to May 1992; he also had service in the Army Reserve and the Army National Guard, to include active duty for training (ACDUTRA) from December 1, 1995 to December 16, 1995 and from January 26, 1996 to January 27, 1996. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran testified before the undersigned sitting at the RO in March 2011, and a transcript of the hearing is on file. In May 2011, September 2012 and again in February 2013, the Board remanded this case for further development. The Board is satisfied that there was substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In this regard an adequate nexus opinion was obtained. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The case has been returned to the Board and is ready for further review. In September 2011, the Veteran requested service connection for a left knee disorder and a disorder of the sternum. This matter is referred to the RO for the appropriate action. FINDING OF FACT A right knee disorder, to include residuals of right knee surgery, did not have its onset in service, is not otherwise the result of a disease or injury in service and has not been caused or aggravated by a service-connected disability. CONCLUSION OF LAW Residuals of right knee surgery were not incurred in active service and are not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The 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). Upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. A proper notice letter was sent to the Veteran in January 2006. The letter addressed all of the notice elements and was sent prior to the initial unfavorable by the RO in April 2006. The duty to assist was also met in this case. The service treatment records are in the claims file. All pertinent VA and private treatment records have been obtained and associated with the file. The Veteran was afforded a hearing before the Board. VA examinations have been performed. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA opinions obtained in this case are adequate, as they are predicated on a full reading of the VA medical records in the Veteran's claims file. They considered all of the pertinent evidence of record and the statements of the appellant, and the examiners provided rationale for the opinions stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c) (4). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. Service connection may also be granted for a 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). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection for certain chronic diseases, such as arthritis, may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year (three years for active tuberculous disease and Hansen's disease; seven years for multiple sclerosis) from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). The term "chronic disease" refers to those diseases listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C.A. § 1101(3); 38 C.F.R. § 3.309(a); Walker v. Shinseki 708 F.3d 1331 (Fed. Cir. 2013) Where a chronic disease under 3.309(a) is "shown as such in service" ("meaning clearly diagnosed beyond legitimate question" Walker v. Shinseki, supra, or in the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In cases where a chronic disease is "shown as such in service", the Veteran is "relieved of the requirement to show a causal relationship between the condition in service and the condition for which service connected disability compensation is sought." Walker v. Shinseki, supra. Instead, service connection may be granted for subsequent manifestations of the same chronic disease without any evidence of link or connection between the chronic disease shown in service and manifestations of the same disease at a later time. In other words, "there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. If evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not "shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned," i.e., "when the fact of chronicity in service is not adequately supported," then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Walker v. Shinseki, supra. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. Under section 3.310 of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to, or aggravated by, service connected disease or injury. Disability which is proximately due to or the result of a service connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service connected disability aggravates a nonservice connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Temporary or intermittent flare ups of symptoms of a condition, alone, do not constitute sufficient evidence aggravation unless the underlying condition worsened. Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The Veteran contends that he has a right knee disorder related to his service-connected back disorder and as well as being directly related to service. Although the Veteran is primarily contending that his right knee disorder was incurred in service, the Board will address his claim on both a direct and secondary basis. Szemraj v. Principi, 357 F.3d 1370, 1371 Fed. Cir. 2004) (finding that all theories of entitlement, both direct and secondary, must be considered when adjudicating service connection claims). With respect to the claim for service connection for a right knee disorder on a direct basis, the Board notes that the service treatment records contain no complaint or diagnosis of, or treatment for, a right knee disorder. At separation in April 1992, no knee complaints were noted. (The abnormal finding for the lower extremities referred to the left ankle). Additionally National Guard records show no complaint or diagnosis of, or treatment for, a right knee disorder. Private records show that in April 2004, the Veteran was seen for painful knees, especially on the right. Date of injury was noted as "years". Also in April 2004, he reported having a hyperextension injury to his knee in the Airborne but did not tell anyone because he wanted to make another jump. He currently complained of pain. The finding was patellofemoral syndrome and medial compartment chondromalacia. In June 2005, an MRI showed intermediate-grade patellofemoral chondromalacia. By way of history, it was noted that the Veteran was noted to have 11/2 years of medial-sided pain and patellofemoral compartment pain also. In July 2005 he underwent right knee surgery. It was noted that he had a history of jumping out of planes in the military with multiple occasions of blunt trauma. In 2008, he underwent right knee surgery. Two statements from service comrades of the Veteran were received in July 2006. They state that they served with the Veteran and observed him complaining about knee problems. They reported that his knees popped and would grind. On VA examination in August 2010, the Veteran stated that he had intermittent right knee pain during service associated with running, marching, carrying heavy back packs and parachute jumping. He denied any treatment during service, and that severe pain began in 2003. The Veteran was examined. Right knee degenerative joint disease, chondromalacia patella status post arthroscopic debridement, osteochondral defect reconstruction using allgraft cartilage, patella realignment, was the impression. The examiner stated that the opinion rendered is based on the examination, the history and review of the file. It was opined that it is less likely as not that the current right knee condition is caused by or the result of service. The rationale was that the service treatment records show in 1992 at separation the Veteran denied any knee pain or disability symptoms and the knee exam was within normal limits. It was noted that the 1997 National Guard record showed that the Veteran denied any chronic knee pain or disability symptoms, and the knee was again within normal limits. The Veteran was examined by VA in May 2011. He reported having one injury to the right knee at Fort Bragg when he hyperextended the knee. He reported being first treated in 2005. The examiner found degenerative joint disease status post multiple surgical procedures. The examiner stated that the claims file was unavailable and that he could not provide an opinion without resorting to speculation. The examiner stated that when the file became available, an opinion would be given. In July 2011 an addendum was prepared. The claims file was reviewed. The examiner noted that there was no data in the service records showing a complaint or treatment for a right knee disorder. It was noted that private records showed treatment in 2005. Further private records were noted to document treatment. The examiner stated that based on the evidence available he could not establish a right knee condition occurring during active duty not proximate to discharge. The examiner stated that based on the available evidence it was his opinion that the Veteran's right knee condition is not due to military service. In December 2012 a VA opinion was obtained. The claims file was reviewed and the examiner stated that the right knee disorder is less likely than not incurred in or aggravated by the claimed in service injury. The examiner reiterated the opinion reached in the July 2011 addendum and stated that the lay statements provided by the Veteran indicate that the Veteran complained of knee pain at Fort Bragg in 1990 and 1991 to 1992. It was noted that the letter had a complaint of soreness in the knees as well as popping when kneeling, which resolved after a few days. It was noted that a second lay statement indicates complaints of ankle and knee pain as well as swelling and complaints in Turkey in 1991. The examiner noted that there were complaints of popping with kneeling. The examiner reported that despite the lay statements, these complaints do not constitute a medical diagnosis or evidence of a chronic condition of the knees. It was noted that popping and grinding within a joint can be a benign condition, that is, benign crepitus. The examiner noted that soreness/pain with or after physical activity can be a normal result of activity. It was reported that this will generally resolve within a short period of time. It was noted that without corroborative medical documentation indicating a chronic knee condition, the opinion of the examiner was the same with the same rationale. In a February 2013 VA addendum opinion, the claims file was reviewed. The examiner stated that the right knee disability is less likely than not proximately due to or the result of the Veteran's service connected condition of the spine. The examiner stated that the file was reviewed and that there was nothing in the currently accepted reviewed, credible and authoritative orthopedic literature that demonstrates that a spine condition including scoliosis will cause intrinsic conditions of the knee or will cause aggravation of a knee condition. It was opined that the right knee condition is not secondary to the spine condition nor is it aggravated by the spine condition. Discussion As to secondary service connection the Veteran contends that his right knee disorder is due to his service-connected back disorder. However, none of the medical evidence of record supports this theory. The Board notes that there is one medical opinion in the file on this contention and it is against his claim. The February 2013 VA examiner reviewed the claims file and found that the right knee disorder was not secondary to the service-connected back disorder by causation or aggravation. The opinion offered reasoning for the finding. This evidence is highly probative and stands uncontradicted in the record. Although the Veteran might believe that his right knee disorder is related to or aggravated by service-connected disability, his lay opinion is outweighed by the medical evidence against the claim. In this regard, the Board has considered the Veteran's assertions. Lay 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 (Fed. Cir. 2007). Concerning this, the Board is mindful that, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (lay testimony is competent to establish the presence of varicose veins). However, in this case, the Veteran is not providing statements related to the diagnosis of a simple disorder or about symptomatology but is instead rendering an opinion as to whether his right knee disorder is caused or aggravated by his service connected back disorder. Thus, the Board concludes that, although the Veteran is competent to report symptoms he experienced, his statements as to the cause and diagnosis of his current disorder do not constitute competent evidence because the cause of his right knee disorder is a medical matter and not capable of lay observation. Accordingly, for the reasons noted above, the Board finds that the preponderance of the evidence is against the claim for service connection for a right knee disorder as secondary to service-connected disability. As to direct service connection, the Veteran alleges that he injured his right knee in service and that he has had continuous right knee problems since service. The disorder is not noted in service and not documented until many years after service. Moreover, there is no medical evidence showing that the current right knee disorder is in any way related to military service. As noted direct service connection, requires evidence of a connection between the inservice events and the current findings. It is noted that there are VA opinions in the file regarding the etiology of the right knee disorder. It is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in doing so, the Board may accept one medical opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998). Factors that may be considered in assessing the probative value of a medical opinion include a physician's access to the claims file or pertinent evidence, the thoroughness and detail of the opinion, the accuracy of the factual premise underlying the opinion, the scope of examination, the rationale for the opinion offered, the degree of certainty provided, and the qualifications and expertise of the examiner. See generally Prejean v. West, 13 Vet. App. 444, 448-89 (2000); Sklar v. Brown, 5 Vet. App. 140 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993); Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The Board finds that the opinion offered by the VA examiner in December 2012 regarding direct service connection is persuasive. The examiner indicated that the right knee disorder was not related to service. Rationale was provided and the claims file was reviewed. The examiner addressed the lay contentions in the file. Further, the opinion stands without contradiction in the record. With regard to the Veteran's own belief and contentions that his right knee disorder is related to service, as previously noted, the Board notes that lay 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) (lay witness capable of diagnosing dislocated shoulder). For reasons similar to those noted above with regard to the secondary service-connection claim, the Board finds that, although the Veteran is competent to report symptoms he experienced, his statements as to the cause of his current right knee disorder do not constitute competent evidence because the cause of his right knee disorder is a medical matter and not capable of lay observation. Barr, 21 Vet. App. at 309 (lay testimony is competent to establish the presence of varicose veins); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). In this regard, unlike the varicose veins in Barr or dislocated shoulder in Jandreau, the right knee disorder in this case is complex, involving X-ray imaging and several diagnoses. Therefore, the Board concludes determining if the disorder may be the result of in-service injury or symptoms, or the result of continuing knee symptoms since service, is the type of complicated medical question that requires medical expertise. Arthritis is not the type of condition capable of lay diagnosis, much less the type of condition that can be causally related to military service without medical expertise. Davidson, 581 F.3d 1313; Buchanan, 451 F.3d 1331; Jandreau, 492 F.3d 1372. Therefore, the Veteran's statements as to the symptoms he experienced in service and since service constitute competent evidence. However, his own contentions that his current disorder is connected or linked to those symptoms do not constitute competent evidence. Having found that lay evidence is not competent with regard to a nexus between the current right knee disorder in this particular case and an injury or symptoms in service, a discussion as to credibility of lay evidence is not necessary. With regard to the medical evidence of nexus in this case, the Board finds it persuasive. Concerning this, the Board notes that, after reviewing the complete claims file, including the Veteran's service treatment records, the VA doctor found that the Veteran's current disability was not related to service. A full rationale was provided for this opinion. Furthermore, the Board acknowledges the Veteran's assertions regarding continuous right knee pain since his discharge from service as well as the lay statements submitted in support of his claim from two of his service comrades. The Board again acknowledges the Veteran is competent to report knee pain from the time of his in-service duties. Layno, 6 Vet. App. at 469. Further the service comrades are competent to report what they observed during service. Nevertheless, once evidence is determined to be competent, the Board must determine whether the evidence also is also credible. The former, the Court has held, is a legal concept, which is useful in determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker, 10 Vet. App. at 74; see also Layno, supra. The Board must account for the evidence which it finds to be persuasive or unpersuasive, analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, and provide the reasons for its rejection of any such evidence. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164, 169 (1991). Credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony." Caluza v. Brown, 7 Vet. App. at 510-511. The Board emphasizes that personal interest may affect the credibility, but not the competency, of the evidence. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). Here, the Veteran's lay assertions regarding the in-service continuity of his right knee pain are inconsistent with the objective findings of the military examiner and the Veteran's own reported history. It was noted in June 2005 that he had knee pain for 1 and 1/2 years. Additionally he repeatedly reported during the course of this appeal having one injury to the knee inservice; however during his hearing before the undersigned, the Veteran reported another injury during his National Guard service. This was not mentioned in any of the service records or by way of history in any medical treatment records. In this regard, as noted above, lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value. In fact, the first medical evidence of treatment for a right knee disorder in the claims folder is from private treatment in 2004, over ten years after the Veteran's discharge from active duty service. The Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence. Buchanan, 451 F.3d at 1336-37. The Board may, however, in the present case consider a lack of contemporaneous medical evidence as one factor in determining the credibility of lay evidence. Id. at 1337. Furthermore, the Veteran's current statements, taken with his statements at the time of his separation from service provide a history of inconsistent statements regarding the history of his right knee pain symptoms, also reducing his credibility. In summary, the Veteran's lay assertions are less credible in light of these factors. Also the statements of his comrades lack credibility when compared with the objective evidence in the file. A VA examiner has considered the observations of the service comrades and noted that the complaints observed do not constitute a medical diagnosis or a chronic condition of the knees. Finally, since there is no objective indication of arthritis of right knee within one year after service, the Veteran is not entitled to application of the relevant presumptive provisions. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The law provides that when, after consideration of all evidence and material of record, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of a Veteran's claim, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). However, in this case, the preponderance of the evidence is against the claim. As such, the Board does not find that the evidence is in equipoise so as to warrant resolution of any doubt in the Veteran's favor. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). In sum, the post-service medical evidence of record does not show that the Veteran's current disability is related to his active service through direct incurrence. Accordingly, the Board must conclude that the preponderance of the evidence is against the claim, and it is therefore denied. 38 U.S.C.A. § 5107(b). ORDER Service connection for residuals of right knee surgery, to include as secondary to service connected disability, is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs