Citation Nr: 1321390 Decision Date: 07/03/13 Archive Date: 07/12/13 DOCKET NO. 10-35 850 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of service connection for left ear hearing loss. 2. Entitlement to service connection for left ear hearing loss. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from July 1969 to March 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which essentially reopened the Veteran's previously denied claim of service connection for left ear hearing loss and denied this claim on the merits. A Travel Board hearing was held at the RO in January 2012 before the undersigned and a copy of the hearing transcript has been added to the record. The Board observes that, in a January 2007 rating decision, the RO denied the Veteran's claim of service connection for bilateral hearing loss. The Veteran disagreed with this decision in January 2008. In a June 2009 rating decision, the RO granted service connection for right ear hearing loss, assigning a zero percent rating effective September 29, 2006. The RO also promulgated a Statement of the Case (SOC) on the issue of entitlement to service connection for left ear hearing loss later in June 2009. The Veteran did not perfect a timely appeal on this claim; thus, the January 2007 rating decision became final with respect to the issue of entitlement to service connection for left ear hearing loss. See 38 U.S.C.A. § 7104 (West 2002). There also is no subsequent correspondence from the Veteran expressing disagreement with the rating or effective date assigned for his service-connected right ear hearing loss in the June 2009 rating decision. Accordingly, an issue relating to right ear hearing loss is no longer in appellate status. See Grantham v. Brown, 114 F .3d 1156 (1997). The Board does not have jurisdiction to consider a claim that has been adjudicated previously unless new and material evidence is presented. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Therefore, the issue of whether new and material evidence has been received to reopen a claim of service connection for left ear hearing loss is as stated on the title page of this decision. Regardless of the RO's actions, the Board must make its own determination as to whether new and material evidence has been received to reopen this claim. That is, the Board has a jurisdictional responsibility to consider whether a claim should be reopened. See Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). FINDINGS OF FACT 1. In January 2007, the RO denied, in pertinent part, the claim of service connection for left ear hearing loss and the Veteran did not perfect a timely appeal. 2. The record evidence submitted since January 2007 relates to an unestablished fact necessary to substantiate the claim of service connection for left ear hearing loss because it suggests that the Veteran was exposed to significant in-service acoustic trauma which caused his current left ear hearing loss. 3. The record evidence indicates that the Veteran was exposed to significant in-service acoustic trauma during active service. 4. The record evidence is in relative equipoise as to whether the Veteran's current left ear hearing loss is related to active service. CONCLUSIONS OF LAW 1. The January 2007 rating decision, which denied, in pertinent part, the Veteran's claim of service connection for left ear hearing loss, is final. 38 U.S.C.A. § 7105(c) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2012). 2. Evidence submitted since the January 2007 RO decision in support of the claim of service connection for left ear hearing loss is new and material; accordingly, this claim is reopened. 38 U.S.C.A. § 5108 (West 2002 & Supp. 2012); 38 C.F.R. § 3.156 (2012). 3. Left ear hearing loss was incurred during active service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. Given the favorable disposition of the action here with respect to the Veteran's application to reopen a previously denied service connection claim for left ear hearing loss, which is not prejudicial to him, the Board need not assess VA's compliance with the VCAA with respect to this claim. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92, 57 Fed. Reg. 49,747 (1992). New & Material Evidence Claim In January 2007, the RO denied, in pertinent part, the Veteran's claim of service connection for bilateral hearing loss. A finally adjudicated claim is an application which has been allowed or disallowed by the agency of original jurisdiction, the action having become final by the expiration of one year after the date of notice of an award or disallowance, or by denial on appellate review, whichever is the earlier. 38 U.S.C.A. §§ 7104, 7105 (West 2002); 38 C.F.R. §§ 3.160(d), 20.302, 20.1103 (2012). As noted in the Introduction, although the Veteran timely disagreed with the January 2007 rating decision in January 2008, he did not perfect a timely appeal on this claim; thus, the January 2007 rating decision became final. The claim of service connection for left ear hearing loss may be reopened if new and material evidence is received. Manio v. Derwinski, 1 Vet. App. 140 (1991). The Veteran filed an application to reopen his previously denied service connection claim for left ear hearing loss in a letter from his service representative which was date stamped as received by the RO on September 1, 2009. New and material evidence is defined by regulation. See 38 C.F.R. § 3.156(a) (2012). As relevant to this appeal, new evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with the previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. Id. In determining whether evidence is new and material, the credibility of the new evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). With respect to the Veteran's application to reopen a claim of service connection for left ear hearing loss, the evidence before VA at the time of the prior final RO decision in January 2007 consisted of the Veteran's service treatment records, his service personnel records, and his post-service VA and private outpatient treatment records. The RO found that, although a January 2007 private audiology consult demonstrated the presence of moderate to severe sensorineural hearing loss in the left ear, and although the Veteran contended that he was exposed to significant in-service acoustic trauma as a result of rifle and machine gun fire, there was no evidence corroborating the Veteran's reported in-service noise exposure. The RO concluded that the Veteran's left ear hearing loss was unrelated to service because it first was shown approximately 34 years after service separation. Thus, the claim was denied. The newly received evidence includes additional post-service VA and private outpatient treatment records, including VA examination reports, a copy of the Veteran's DD Form 215, and the Veteran's lay statements and his April 2009 RO hearing testimony and January 2012 Board hearing testimony. This evidence shows that the Veteran experiences left ear hearing loss that may be related to active service, to include as due to significant in-service acoustic trauma. The Veteran's DD Form 215, date-stamped as received by the RO in April 2009, shows that his DD Form 214 was corrected to show that he received the Republic of Vietnam Campaign Medal w/Device, the Republic of Vietnam Gallantry Cross w/Palm Unit Citation Badge, and the Expert Qualification Badge w/Rifle, Machine, Grenade Bar. Attached to this form was a copy of the Veteran's U.S. Army orders dated in January 1972 showing that he had been appointed a Sergeant and Unit Training Officer in the 1st Signal Brigade. This appointment was for an indefinite period and its purpose was "[t]o supervise training within" this unit "for all personnel." Also attached to this form was a statement from the Veteran in which he asserted that, although his MOS was in the clerical field, his in-service duties, in fact, included training Reserve Officer Training Corps (ROTC) personnel in operating machine guns by firing blank ammunition during training exercises. He also asserted that, while on active service in Vietnam, his duties included training his unit "by conducting weapons classes and range firing for rifle, machine gun, and M-79 grenade launcher. I was exposed to severe noise on many occasions." In an August 2009 letter, S.E.P., M.D., stated that the Veteran "has has sensorineural hearing loss for many years after his history of gun exposure in the military in Vietnam. He has had extensive exposure without hearing protection shooting rifles and machine guns in the military. He is right-handed, so certainly his left ear would have gotten the most exposure." Dr. S.E.P. also opined that the Veteran's hearing loss "is consistent with that type of noise exposure hearing loss and I certainly do think that this is military related to his gun exposure." With respect to the Veteran's service connection claim for left ear hearing loss, the Board notes that the evidence which was of record in January 2007 did not indicate that this disability could be attributed to active service, to include as due to in-service noise exposure. The RO found it especially persuasive in January 2007 that there was no record evidence corroborating the Veteran's reported in-service noise exposure. The newly submitted evidence suggests the presence of left ear hearing loss which could be attributable to active service, to include as due to in-service noise exposure (which was confirmed by the submission of new evidence - in this case, the Veteran's DD Form 215 -since January 2007). The Board observes in this regard that, in Shade v. Shinseki, 24 Vet. App 110 (2010), the Court held that the phrase "raises a reasonable possibility of substantiating the claim" found in the post-VCAA version of 38 C.F.R. § 3.156(a) must be viewed as "enabling" reopening of a previously denied claim rather than "precluding" it. All of the newly submitted evidence is presumed credible for the limited purpose of reopening the previously denied claims. See Justus, 3 Vet. App. at 513. Thus, the Board finds that the evidence submitted since January 2007 is new, in that it has not been submitted previously to agency adjudicators, and is material, in that it relates to an unestablished fact necessary to substantiate the claim of service connection for left ear hearing loss and raises a reasonable possibility of substantiating it. Because new and material evidence has been received, the Board finds that the previously denied claim of service connection for left ear hearing loss is reopened. Having reopened the Veteran's previously denied claim of service connection for left ear hearing loss, the Board will proceed to adjudicate this claim on the merits. Service Connection for Left Ear Hearing Loss The Veteran contends that he incurred left ear hearing loss during active service. He specifically contends that in-service noise exposure to rifle and machine gun fire and grenades, including while on active service in Vietnam, caused or contributed to his current left ear hearing loss. He also contends that his left ear hearing loss arose from the same etiology (in-service noise exposure) as his service-connected right ear hearing loss and bilateral tinnitus. Law and Regulations Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including sensorineural hearing loss (as an organic disease of the nervous system), are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Establishing service connection generally requires (1) medical evidence of a presently existing disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claim in-service disease or injury and the present disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)); Hickson v. West, 12 Vet. App. 247, 253 (1999). Clinically, the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For compensation purposes, however, impaired hearing is considered a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels (dB) or greater or where the auditory thresholds for at least three of these frequencies are 26 dB or greater or when speech recognition scores are less than 94 percent. 38 C.F.R. § 3.385. If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b). In Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), the Federal Circuit recently overruled Savage v. Gober, 10 Vet. App. 488 (1997) and limited the applicability of the theory of continuity of symptomatology in service connection claims to those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also 38 C.F.R. § 3.309(a). Because sensorineural hearing loss (as an organic disease of the nervous system) is considered a "chronic" disability under 38 C.F.R. § 3.309(a), the theory of continuity of symptomatology remains valid in adjudicating the Veteran's claim. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. Factual Background In addition to the evidence outlined above, the Veteran's service treatment records show that, at his enlistment physical examination in June 1969, clinical evaluation of his ears was normal. The Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 -5 -5 0 0 LEFT -5 -5 -5 -5 5 The Veteran denied all relevant pre-service medical history. At his separation physical examination in March 1972, clinical evaluation of the Veteran's ears was normal. His pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 X X X X LEFT 30 10 10 15 5 The Veteran stated that he was in good health. A review of the Veteran's DA Form 20 shows that his military occupational specialty (MOS) included light weapons infantryman. He received 8 weeks of training as a light weapons infantryman. He was qualified as an expert on the grenade launcher, M-16, M-60, and M-1911A1. He participated in the Fifteenth Unnamed Campaign in Vietnam. He served in Vietnam from December 1971 to June 1972. A review of the Veteran's DD Form 214 shows that his MOS was personnel management specialist. The post-service evidence shows that, following private audiology testing in September 2006, the Veteran's speech discrimination score was 92 percent in the left ear. The Veteran's pure tone thresholds were not interpreted. In a December 2006 statement, the Veteran asserted that his current hearing loss "is the result of rifle + machine gun fire to which I was continuously exposed for over 2 years of service." On VA outpatient treatment in January 2007, the Veteran complained of gradual onset bilateral hearing loss which began "while in the military ('69-72) when he was chronically exposed to high levels of noise as the result of his military duty as a machine-gunner." A history of military and occupational and "possible" recreational noise exposure was noted. Audiometric testing showed moderate to severe high frequency sensorineural hearing loss in the left ear. On VA examination in January 2009, the Veteran's complaints included hearing loss. He reported that his hearing loss began during active service "during Vietnam" when he "was exposed to the firing of guns and explosions." His situations of greatest difficulty hearing were "hearing his children and hearing the TV at a normal volume." A history of in-service noise exposure "from gunfire and explosions with occasional use of hearing protection" was noted. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. This examiner noted that the Veteran's hearing was within normal limits at his enlistment physical examination and at his separation physical examination. There was a 30 decibel (dB) threshold at 500 Hertz (Hz) at separation as well. A history of bilateral high frequency sensorineural hearing loss in January 2007 also was noted. The Veteran stated that, following his service separation, "he worked for General Motors for 32 years" although hearing protection was not mandatory there until the 1980s. He also reported occasional recreational noise exposure with the use of hearing protection. The Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 30 65 LEFT 10 15 25 70 75 Speech audiometry revealed speech recognition ability of 98 percent in each ear. The VA examiner opined that, based on a review of the claims file and the Veteran's "extensive noise exposure post military," it was less likely than not that the Veteran's hearing loss was related to active service. The diagnoses included bilateral high frequency sensorineural hearing loss. In an opinion provided in February 2009, a different VA clinical audiologist stated that, based on a review of the Veteran's January 2009 examination, the Veteran's hearing loss "stems from...noise exposure. The observation of hearing within normal limits at the time of discharge from the military does not rule out the likelihood that the present hearing loss was caused by noise exposure." This examiner also noted the Veteran's "significant occupational noise exposure." The Veteran testified at his April 2009 RO hearing that his in-service duties while in Vietnam included training his unit on firing pistols, grenade launchers, and machine guns. He stated, " I spent most of my time there [in Vietnam] as a weapons instructor." See RO hearing transcript dated April 15, 2009, at pp. 3. He also testified that his post-service occupational noise exposure was minimal. Id., at pp. 6-7. On VA examination in June 2009, the Veteran's complaints included bilateral hearing loss "that he noticed shortly after separation from the military." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records, and noted the Veteran's normal bilateral hearing at his enlistment physical examination and "normal hearing on the left side at separation." The Veteran reported that his situation of greatest hearing difficulty was "difficulty communicating in the presence of background noise and hearing the television." He also reported serving in combat in Vietnam and having an MOS as an infantryman. An in-service history of exposure to gunfire, explosions, and artillery with only intermittent use of hearing protection was reported. The Veteran denied any occupational noise exposure. He also reported a history of recreational noise exposure "due to hunting" with intermittent use of hearing protection. The Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 30 65 LEFT 10 15 25 70 75 Speech audiometry revealed speech recognition ability of 94 percent in the right ear and of 96 percent in the left ear. The VA examiner opined that, based on a review of the Veteran's claims file "and the fact that no hearing loss was present at separation," his left ear hearing loss was not caused by or a result of in-service noise exposure. The diagnoses included normal hearing in the left ear from 250 to 2000 Hz with severe sensorineural hearing loss from 3000 to 8000 Hz. In a November 2009 statement, the Veteran questioned the validity of the hearing test results reported on his separation physical examination. Following VA outpatient treatment in December 2011, the diagnoses included normal hearing through 1000 Hz decreasing to mild to severe sensorineural hearing loss in the left ear. The Veteran testified at his January 2012 Board hearing that his in-service duties included work as an infantryman. See Board hearing transcript dated January 31, 2012, at pp. 4-5. The Veteran also testified about his in-service exposure to rifle and machine gun fire. Id., at pp. 5-6. He testified further that his in-service duties in Vietnam included training other soldiers on a variety of weapons, including machine guns, pistols, and grenade launchers. Id., at pp. 8-9. Analysis The Board finds that the evidence is in relative equipoise on the issue of whether the Veteran's current left ear hearing loss is related to active service. The Veteran has asserted consistently that exposure to significant in-service acoustic trauma caused or contributed to his current left ear hearing loss and to his service-connected right ear hearing loss and bilateral tinnitus. The Board acknowledges that service connection is in effect for right ear hearing loss and for bilateral tinnitus. The Board notes that the Veteran's consistent lay statements and credible hearing testimony concerning significant in-service acoustic trauma due to noise exposure from rifle and machine gun fire and grenades is supported by his expert qualifications on all of these weapons as shown by his DD Form 215. The Veteran's lay statements and hearing testimony concerning his significant in-service acoustic trauma also seem consistent with his MOS and training as a light weapons infantryman listed on his DA Form 20. The Veteran's statements and testimony concerning his significant in-service acoustic trauma are supported further by the official U.S. Army orders which he submitted in support of this claim. These orders show that the Veteran was responsible for training all of the soldiers in his unit for approximately 6 months (between January and June 1972) while on active service in Vietnam. Given the Veteran's expert qualifications in using multiple weapons (as shown on his DA Form 20), his appointment as unit training officer in January 1972 (as shown by the official orders he submitted), and his service in Vietnam through June 1972 (as shown on his DA Form 20), it seems reasonable to conclude that he would have been responsible for training others in his unit on using weapons rather than on clerical duties (as reflected in the MOS of Personnel Management Specialist listed on his DD Form 214). There is medical evidence which supports and weighs against the Veteran's service connection claim for left ear hearing loss. The Veteran's service treatment records show no complaints of or treatment for left ear hearing loss at any time during service. It is not clear why the audiometric testing conducted at the Veteran's separation physical examination did not include all of the relevant threshold levels in both ears. As noted above, it appears that the Veteran's hearing in the left ear was tested at multiple auditory thresholds while his hearing in the right ear only was tested at 500 Hz at his separation physical examination. The Veteran has contended strenuously throughout the pendency of this appeal that he did not receive a hearing test when he separated from active service. Although the Veteran's audiometric testing results at separation appear incomplete, they were recorded on his separation physical examination. The Board notes in this regard that the existence of audiometric testing results demonstrating either the presence or absence of left ear hearing loss at service separation is not a bar to granting service connection for this disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). The Board also notes in this regard that, following VA examination in June 2009, the VA examiner opined that, based on a review of the claims file "and the fact that no hearing loss was present at separation," the Veteran's left ear hearing loss was not related to active service. It appears that the June 2009 VA examiner found the lack of complaints of or treatment for left ear hearing loss during the Veteran's active service, including the audiometric testing results reported at his separation physical examination, to be persuasive support for her negative nexus opinion concerning the contended causal relationship between left ear hearing loss and active service. The Board, however, must be mindful that even when hearing loss is not shown at separation, service connection may be otherwise warranted if current hearing loss is shown to be etiologically related to service. See Hensley v. Brown, 5 Vet. App. 155 (1993). The remaining evidence shows that, following VA examination in January 2009, the VA examiner opined that, based on a review of the claims file and the Veteran's "extensive" post-service occupational noise exposure, it was less likely than not that his hearing loss was related to active service. The Board notes in this regard that the Court has held that claims file review is not indicative of the probative value of a medical opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). By contrast, following an evaluation of the Veteran in August 2009, Dr. S.E.P. opined that, because the Veteran's left ear hearing loss was consistent with his reported in-service history of noise exposure from "shooting rifles and machine guns," this disability likely was related to active service. It is not clear from a review of Dr. S.E.P.'s August 2009 opinion whether the Veteran reported his post-service occupational noise exposure to this clinician. Having reviewed the record evidence, the Board finds that there is an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim of service connection for left ear hearing loss. See 38 C.F.R. § 3.102. The Board already has found the Veteran's lay statements and hearing testimony concerning his in-service duties training other soldiers on using multiple weapons, exposing him to significant in-service acoustic trauma, including while on active service in Vietnam, to be consistent, credible, and persuasive evidence of his exposure to such trauma during active service. The Veteran's statements and hearing testimony concerning in-service acoustic trauma from rifle and machine gun fire and grenades also are supported by a review of his available service personnel records which show his expert qualifications in multiple weapons and in-service duties as a training officer for other soldiers in his unit in Vietnam. The Board finds it especially significant that the Veteran has asserted consistently that his bilateral hearing loss arose from in-service noise exposure and service connection already is in effect for right ear hearing loss based on such exposure. In summary, after resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection for left ear hearing loss is warranted. Id. ORDER As new and material evidence has been received, the previously denied claim of service connection for left ear hearing loss is reopened. Entitlement to service connection for left ear hearing loss is granted. ____________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs