Citation Nr: 1320948 Decision Date: 06/28/13 Archive Date: 07/05/13 DOCKET NO. 12-28 973 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to an initial evaluation in excess of 30 percent disabling for posttraumatic stress disorder (PTSD). 2. Entitlement to a compensable initial evaluation for bilateral hearing loss. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Juliano, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1943 to June 1948. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2011 rating decision of the Department of Veterans Affairs (VA) regional office (RO) located in Boston, Massachusetts that granted service connection for PTSD and bilateral hearing loss and assigned 30 percent and noncompensable ratings, respectively, effective September 20, 2010. Please note 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). FINDINGS OF FACT 1. The Veteran's PTSD is manifested by no more than occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks as a result of symptoms of irritability, nightmares, hyperreactivity to loud noises, and mild memory loss (such as forgetting names). 2. On VA examination in May 2011, the Veteran's hearing impairment based on pure tone threshold averages and speech discrimination scores corresponded to no worse than Level III hearing in the right ear and Level II hearing in the left ear. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 30 percent disabling for PTSD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130 (Diagnostic Code 9411) (2012). 2. The criteria for a compensable evaluation for bilateral hearing loss have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.85 (Diagnostic Code 6100), 4.86 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) With regard to the Veteran's claims for higher evaluations for his PTSD and hearing loss, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5102, 5103(a), 5103A, 5106 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is generally required to "notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided . . . that is necessary to substantiate the claim." 38 U.S.C.A. § 5103(a)(1) (West Supp. 2012). As part of that notice, VA must "indicate which portion of that information and evidence, if any, is to be provided by the claimant and which portion, if any, the Secretary . . will attempt to obtain on behalf of the claimant." 38 U.S.C.A. § 5103(a)(1) (West Supp. 2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Where service connection has been granted and the initial rating has been assigned, the claim of service connection has been more than substantiated, as it has been proven. As such, 38 U.S.C.A. § 5103(a) notice is no longer required since the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. Therefore, any defect as to 38 U.S.C.A. § 5103(a) notice is nonprejudicial. See Dingess v. Nicholson, 19 Vet. App. 473, 490-491 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008) (where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). The Board also concludes that VA's duty to assist has been satisfied. The Board notes that the Veteran has only identified private treatment records from Massachusetts General Hospital, but none of these relate to his claims herein. At no time has the Veteran referenced any relevant treatment records relating to his claim, despite being asked by the RO to submit Forms 21-4142 regarding any treatment he may have received so that any outstanding treatment records could be obtained. VA's duty to assist includes the duty to conduct a thorough and contemporaneous examination of the Veteran. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Where the evidence of record does not reflect the current state of a veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991); 38 C.F.R. § 3.327(a) (2012). The Veteran was provided with VA examinations in February 2011 relating to his PTSD, and in May 2011 relating to his hearing loss. There is no evidence indicating that there has been a change in the severity of the Veteran's PTSD or bilateral hearing loss since the time of the VA examinations, including no assertion of such made by the Veteran. See 38 C.F.R. § 3.327(a) (2012). While the Board acknowledges that the Veteran's representative, in his May 2013 brief, requested that the Veteran be provided with new VA examinations if his claims were not granted due to the passage of time since 2011, the Board notes that the duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. VAOPGCPREC 11-95. The Board finds the February 2011 and May 2011 VA examinations to be thorough and adequate upon which to base a decision with regard to the Veteran's claims. The VA examiners personally interviewed and examined the Veteran and provided the information necessary to evaluate the Veteran's disabilities under the applicable rating criteria. While the Board acknowledges that the February 2011 VA examiner (PTSD) noted that the claims file was not available for review, the Board finds this VA examination report to nevertheless be adequate in that the examiner noted (as reported by the Veteran himself) that he had never received any counseling or other treatment for his PTSD, and as noted by the examiner, he was a good historian and credible reporter. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Analysis The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports a claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of a veteran. 38 C.F.R. § 4.3 (2012). A veteran's entire history is reviewed when making a disability determination. 38 C.F.R. § 4.1 (2012). When a veteran timely appeals an initial rating for a service-connected disability within one year of the rating decision, VA must consider whether the veteran is entitled to "staged" ratings to compensate him for periods of time since the filing of his claim when his disability may have been more severe than others. Fenderson v. West, 12 Vet. App. 119 (1999). A. PTSD The Veteran's PTSD is currently assigned a 30 percent disability rating under Diagnostic Code 9411, effective September 20, 2010. See 38 C.F.R. § 4.130. The Veteran seeks a higher initial rating. The Veteran's service-connected PTSD is evaluated under Diagnostic Code 9411. The regulations establish a general rating formula for mental disabilities. 38 C.F.R. § 4.130 (2012). Ratings are assigned according to the manifestation of particular symptoms. Notably, the term "such as" in 38 C.F.R. § 4.130 precedes lists of symptoms that are not exhaustive, but rather serve as examples of the type and degree of symptoms and their effects that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F. R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). Diagnostic Code 9411 provides rating criteria for 30, 50, 70, and 100 percent ratings as follows: 30 Percent - Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 50 Percent - Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 70 Percent - Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. 100 Percent - Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Within the DSM-IV, Global Assessment Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF score is, of course, just one part of the medical evidence to be considered and is not dispositive. The same is true of any physician's statement as to the severity of a disability. It remains the Board's responsibility to evaluate the probative value of any doctor's opinion in light of all the evidence of record. GAF scores ranging from 61 to 70 represent some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, but generally functioning pretty well and having some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 represent moderate symptoms, such as flat affect, circumstantial speech, and occasional panic attacks, or moderate difficulty in social, occupational, or school functioning (such as few friends or conflicts with peers or coworkers). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior that is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. See 38 C.F.R. § 4.130 (2012) (incorporating by reference VA's adoption of the DSM-IV for rating purposes). The February 2011 VA examination report reflects the examiner noted the Veteran's history of service in Europe during World War II, including the Veteran's account of a firing upon German soldiers near the Rur or Ruhr River for a period of three weeks and seeing many dead bodies. The Veteran reported that after service, he worked for a meat packing company for 38 years until he retired at the age of 62, after which he worked in security until 2007 when he reported he had to stop working due to a heart surgery. He reported that he was married for 64 years, had three children, and that in his leisure time his activities include going shopping, attending a gym, and doing certain recreational activities in the senior residential care center where he and his wife have resided for five years. The examiner noted that the Veteran's main complaint was recurring nightmares, and that he also reported some hyperreactivity to loud noises and a history of irritability (but no unprovoked violence was noted). Mental status examination revealed that the Veteran was neatly dressed, he denied delusions, hallucinations, or suicidal or homicidal ideation, he was able to maintain all of his activities of daily living, he was oriented in all spheres, memory was noted as reasonably good except that the Veteran reported sometimes forgetting names or word finding, speech was normal, and he denied panic attacks or depression. A diagnosis of PTSD, chronic and mild-to-moderate, and a GAF score of 50 were recorded. In light of the above, the Board finds that the Veteran's PTSD disability picture more nearly approximates the currently assigned 30 percent rating criteria, and that the preponderance of the evidence is against assigning a higher rating. As shown above, the Veteran reports that he has been married for over 64 years, had a 38 year career with a meat packer and retired at 62, he engages in recreational activities with his wife, and his complaints are nightmares, thinking of his war experiences, hyperreactivity to loud noises, and a history of irritability. The Board finds that these types of symptoms are already contemplated by the currently assigned 30 percent rating criteria, which criteria contemplate symptoms such as chronic sleep impairment and mild memory loss, and which criteria contemplate generally functioning satisfactorily as is the Veteran. The symptoms shown do not more nearly approximate the criteria for the next higher, 50 percent rating, which, as noted above, contemplate occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect, circumstantial, circumlocutory or stereotyped speech, panic attacks, difficulty in understanding complex commands, short and long-term memory impairment, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. As noted above, the Veteran denied panic attacks or depression, and he has maintained a 64-year marriage and a 38 year career in meat packing. He and his wife did report that he could get angry over nothing which affected his relationships with family members; he also had nightmares and was nervous and defensive. No deficits with respect to affect, speech, judgment, thinking or difficulty in understanding complex commands were reported or noted. In addition, the Veteran reported that he did engage in activities thereby showing there is not disturbance of motivation. Moreover, other symptoms similar to and representative of occupational and social impairment with reduced reliability and productivity are not reported by the Veteran nor were they found on psychiatric examination. Instead, his symptoms which include anxiety, chronic sleep impairment, anger, nightmares, and defensiveness more nearly approximate occupational and social impairment with an occasional decrease in work efficiency and intermittent inability to perform occupational tasks. The Board acknowledges that the Veteran's GAF score was noted as 50 by the May 2011 VA examiner. This is generally consistent with serious symptoms, however, the Board ultimately places more weight on the more detailed account of the Veteran's specific symptomatology described by the Veteran and the VA examiner, and the assessment of the disorder as mild to moderate, which is consistent with the symptoms and the severity thereof, as opposed to the mere numerical score. The Board acknowledges two lay statements submitted by the Veteran's wife, in which she reported that the Veteran has experienced symptoms including nightmares, anger, or irritability, and nervousness. The Board finds, however, that these symptoms are already contemplated by the currently assigned 30 percent rating, which contemplates symptoms such as chronic sleep impairment and anxiety. The Board also notes that the above symptoms, including reports of irritability are not of the severity contemplated by the 70 percent rating criteria, which criteria contemplate a more severe form of irritability, such as with periods of unprovoked violence. In addition, the Board finds that this one symptom of irritability, by itself, is not enough such that the Veteran's disability picture as a whole due to his PTSD would more nearly approximate the higher rating criteria. Moreover, the evidence does not show total occupational and social impairment as the Veteran maintains a relationship with his wife and other family members. In summary, the Board finds that the preponderance of the evidence is against assigning a rating in excess of 30 percent disabling for the Veteran's PTSD for the entire period on appeal. There is not an approximate balance of evidence. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has considered whether referral for an extraschedular rating is appropriate. "The determination of whether a claimant is entitled to an extraschedular rating under 38 C.F.R. § 3.321(b) is a three-step inquiry. . . The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. . ." Thun v. Peake, 22 Vet App 111, 115 (2008) (citing Fisher v. Principi, 4 Vet.App. 57, 60 (1993), and Floyd v. Brown, 9 Vet.App. 88, 95 (1996)). "Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. . .[I]f the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun at 115. "[I]n the second step of the inquiry, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as 'governing norms.' 38 C.F.R. § 3.321(b)(1) (related factors include 'marked interference with employment' and 'frequent periods of hospitalization')." Thun at 115-116. "When an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating." Thun at 116. With respect to the first prong of Thun, the Board finds that the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology as discussed above. As such, an extraschedular rating is not appropriate. The Board has also considered whether staged ratings are necessary during the appeal period. However, based on the facts found, the current 30 percent rating is appropriate for the entire period. See Fenderson v. West, supra. In sum, the preponderance of the evidence is against the Veteran's claim for an initial rating in excess of 30 percent disabling for his PTSD; the benefit of the doubt rule is not for application. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. B. Hearing Loss The Veteran's bilateral hearing loss is currently assigned a noncompensable rating under Diagnostic Code 6100, effective September 20, 2010. See 38 C.F.R. § 4.85. The Veteran seeks a higher initial rating. Evaluations of defective hearing range from noncompensable to 100 percent. This is based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests, together with the average hearing threshold level as measured by pure tone audiometric tests in the frequencies of 1000, 2000, 3000, and 4000 Hertz. To evaluate the degree of disability from service-connected hearing loss, the rating schedule establishes eleven auditory acuity levels ranging from numeric level I for essentially normal acuity, through numeric level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII, Diagnostic Code 6100 (2012). The ratings for disability compensation for hearing loss are generally determined by the mechanical application of the criteria in Table VI and Table VII (except, for example, to the extent of extraschedular consideration). See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). When the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, Table VI or Table VIa is to be used, whichever results in the higher numeral, to determine the Roman numeral designation for hearing impairment. 38 C.F.R. § 4.86(a) (2012). Additionally, when the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, Table VI or Table VIa is to be used, whichever results in the higher numeral. Thereafter, that numeral will be elevated to the next higher numeral. 38 C.F.R. § 4.86(b) (2012). The May 2011 VA audiological examination report reflects pure tone thresholds were as follows: Hertz (decibels) 500 1000 2000 3000 4000 Avg. RIGHT n/a 35 50 90 105+ 70 LEFT n/a 30 50 85 105+ 67.5 Speech recognition ability (using Maryland CNC word lists) was measured as 90 for the right ear and 94 for the left ear. Using Table VI of 38 C.F.R. § 4.85, these audiological testing results correlate to level III hearing in the right ear and level II hearing in the left ear. Using Table VII (Diagnostic Code 6100) of 38 C.F.R. § 4.85, the combination of level III and level II hearing corresponds to a noncompensable rating. The examiner recorded a diagnosis of sensorineural hearing loss, normal to profound. The examiner noted in a June 2011 addendum (addressing service connection) that there was no record of treatment for the Veteran's hearing loss. There is no exceptional pattern of hearing impairment pursuant to 38 C.F.R. § 4.86. In light of the above, the Board finds that there is no objective evidence of record to indicate that the Veteran is entitled to a compensable evaluation for his bilateral hearing loss based on the schedular rating criteria. The Board notes, again, that the disability ratings for hearing loss are generally determined by the mechanical application of the criteria in Table VI and Table VII of 38 C.F.R. § 4.85 (except, for example, to the extent that extraschedular rating is required, which is addressed below). See Lendenmann, supra. The Board acknowledges a September 2010 lay statement from the Veteran's wife in which she reports that the Veteran had hearing problems since his discharge from service and that it had worsened through the years. While the Board acknowledges her lay account of his hearing difficulties, unfortunately, the Board reiterates that a mechanical application of the rating criteria do not allow for a higher rating. The Board has also considered whether a higher rating would be warranted on an extraschedular basis. The Board finds, however, that the schedular rating criteria adequately contemplate the Veteran's symptomatology, and that the requirements for an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1) have not been met. See Thun v. Peake, 22 Vet. App. 111 (2008); Fisher v. Principi, 4 Vet. App. 57, 60 (1993); 38 C.F.R. § 3.321(b)(1) (2012). The VA examiner noted that the disability's impact on occupational activities was difficulty hearing and that it had no effects on usual daily activities. The Board notes that difficulty hearing is specifically contemplated by the rating criteria for hearing loss. Accordingly, the Board finds that the rating criteria adequately contemplate the Veteran's symptomatology, and that a remand to the RO for referral of this issue to the VA Central Office for consideration of an extraschedular evaluation is not warranted. The Board has also considered whether staged ratings are necessary during the appeal period. However, based on the facts found, the current noncompensable rating is appropriate for the entire period. See Fenderson v. West, supra. In sum, the preponderance of the evidence is against the Veteran's claim for a compensable evaluation for bilateral hearing loss for the entire period on appeal; the benefit of the doubt rule is not for application. ORDER Entitlement to an initial evaluation in excess of 30 percent disabling for PTSD is denied. Entitlement to a compensable initial evaluation for bilateral hearing loss is denied. ______________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs