Citation Nr: 1327067 Decision Date: 08/23/13 Archive Date: 08/29/13 DOCKET NO. 07-00 021 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a heart disorder, including as due to exposure to Agent Orange. 2. Entitlement to service connection for diabetes mellitus, type II, including as due to exposure to Agent Orange. 3. Entitlement to service connection for deterioration of eyesight, also claimed as poor vision and diabetic retinopathy. 4. Entitlement to service connection for transmetatarsal amputation of the left foot. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran had active military service in the United States Air Force from January 1966 to January 1996. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In September 2010, the Veteran, sitting at the RO, testified during a hearing conducted via videoconference with the undersigned, sitting at the Board's main office in Washington, D.C. A transcript of the hearing is of record. In February 2011, the Board remanded the Veteran's case to the RO via the Appeals Management Center (AMC) in Washington, D.C., for further evidentiary development. The matters of entitlement to service connection for deterioration of eyesight, also claimed as poor vision and diabetic retinopathy, and service connection for transmetatarsal amputation of the left foot, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC. FINDINGS OF FACT 1. Resolving all doubt in the Veteran's favor, a heart disorder, currently diagnosed as coronary artery disease, congestive heart failure, and status-post heart transplant, had its onset during active military service, including as due to exposure to Agent Orange. 2. Resolving all doubt in the Veteran's favor, diabetes mellitus, type II, had its onset during active military service, including as due to exposure to Agent Orange. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for a heart disorder are met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2011). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for diabetes mellitus, type II, are met. . 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist As the Board's decision to grant service connection for a heart disorder and diabetes mellitus herein constitutes a complete grant of the benefits sought on appeal, no further action is required to comply with the Veterans Claims Assistance Act of 2000 and the implementing regulations. II. Factual Background and Legal Analysis The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although there is an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that 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 Under 38 U.S.C.A. §§ 1110 and 1131; 38 C.F.R. § 3.303, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by active military service. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); but see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (to the effect that the theory of continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a)). Case law has established 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). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the appellant's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). This is a direct service connection theory of entitlement. Certain chronic diseases, including diabetes mellitus, arteriosclerosis and endocarditis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from active service. See 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. This is also a direct service connection theory of entitlement. Where the determinative issue involves medical causation or a medical diagnosis, there must be competent evidence to the effect that the claim is plausible. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the 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. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the Veteran contends, in pertinent part, that he was exposed to Agent Orange in service that caused or contributed to his post service diagnosis of, and treatment for, coronary artery disease, congestive heart failure, and a heart transplant, and diabetes mellitus, type II. Veterans who, during active service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence of non-exposure. 38 U.S.C.A. §§ 1116; 38 C.F.R. § 3.307. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the Vietnam era. "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). The VA General Counsel has determined that the regulatory definition requires that an individual actually have been present on the land mass of the Republic of Vietnam. VAOPGCPREC 27-97; 62 Fed. Reg. 63604 (1997). Specifically, the General Counsel has concluded that in order to establish qualifying service in Vietnam, a veteran must demonstrate actual duty or visitation in the Republic of Vietnam. Id. Service in the Republic of Vietnam is interpreted as requiring service on the landmass of Vietnam. Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008), cert. denied, 77 U.S.L.W. 3267 (Jan. 21, 2009) (No. 08-525). If a veteran was exposed to a herbicide agent (to include Agent Orange) during active military, naval or air service and has contracted an enumerated disease to a degree of 10 percent or more at any time after service (except for chloracne and acute and sub acute peripheral neuropathy which must be manifested within a year of the last exposure to an herbicide agent during service), the veteran is entitled to a presumption of service connection even though there is no record of such disease during service. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.307, 3.309(e). The enumerated diseases include diabetes mellitus, type II. 38 C.F.R. § 3.309(e). Effective August 31, 2010, VA amended 38 C.F.R. § 3.309(e), in part, to add Parkinson's disease and ischemic heart disease to the list of diseases associated with exposure to certain herbicide agents. See 75 Fed. Reg. 53202-16 (Aug. 31, 2010). The pertinent part of that amendment added the following to § 3.309(e): "Ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina)." 75 Fed. Reg. 53202, 53216 (August 31, 2010). This amended rule applies to claims received by VA on or after August 31, 2010 and to claims pending before VA on that date. 75 Fed. Reg. 53202 (August 31, 2010). Id. The appellant's claim was pending before VA on that date. In light of the foregoing, service connection may be presumed for residuals of Agent Orange exposure by showing two elements. First, the Veteran must show that he served in the Republic of Vietnam during the Vietnam era. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6). Second, the Veteran must be diagnosed with one of the specific diseases listed in 38 C.F.R. § 3.309(e), or otherwise establish a nexus to service. See Brock v. Brown, 10 Vet. App. 155, 162 (1997). The first determination to be clarified is whether the Veteran was exposed to Agent Orange. The above-described presumptions apply only to veterans who actually served on the land mass of the Republic of Vietnam. In written and oral statements, the Veteran has asserted that, while stationed at Takhli Air Base in Thailand in 1968, he made several trips to Vietnam. During his September 2010 Board hearing, the Veteran said that he flew to Vietnam from Thailand approximately three times. See Board hearing transcript at page 7. He stated that he flew classified missions on a C 47 "Gooney Bird" and was on the ground for two or three hours each time. Id. The Veteran's service personnel records reflect that he was stationed at Takhli Air Force Base in Thailand, from June 1968 to June 1969. His military occupation during that time was operations administration and administrative specialist in base operations. The records do not show any temporary duty (TDY) to Vietnam. In November 2004, April 2005, January 2006, November 2009, and September and October 2011 written statements, the Veteran indicated that he repeatedly had TDY in Vietnam on classified missions while stationed in Thailand. In April 2005, he said he was there during 1968-1969. The claims file contains an undated Veterans Benefits Administration (VBA) memorandum that notes review of the Project CHECO Southeast Asia Report: Base Defense in Thailand. It was noted that, while the Thailand CHECO Report did not report use of tactical herbicides on allied bases in Thailand, it did indicate sporadic use of non-tactical (commercial) herbicides within fenced perimeters. Therefore, if a Veteran's military occupational specialty (MOS) or unit was one that regularly had contact with the base perimeter, there was a greater likelihood of exposure to commercial pesticides, including herbicides. Security police units were known to have walked the perimeters, especially dog handlers. There were no records to show that the same tactical herbicides used in Vietnam were used in Thailand. As noted, during his February 2010 Board hearing, the Veteran testified that he flew into Vietnam from Thailand approximately three times and was on the ground for two or three hours each time. A February 2010 RO memorandum found a lack of information to corroborate the Veteran's exposure to herbicides in service. It was noted that he served in the United States Air Force from January 1966 to January 1996 and that his Air Force Specialty Code (AFSC) was as a Military Training Instructor and Military Training Manager (noted on his Report of Release or Discharge from Active Duty (DD Form 214)). But the memorandum further noted that the "Veteran's AFSC also does establish exposure during his service while stationed at Ko Kha (6201 Aerospace Support Squadron) and Taklni Royal Air Base (355 Combat Support Squadron) both in Thailand. [His] performance reports show he was responsible for managing billeting and clerical duties." In a September 13, 2011 written statement to a Member of Congress, the Veteran reiterated that he was exposed to Agent Orange when he had TDY in Vietnam on more than one occasion and set foot on the ground. He noted that he was directed to produce a letter from someone who served with him and that he had "no idea as to the whereabout of any of those people." He was an enlisted member who worked primarily with officers. The Veteran said he was also asked to provide the tail number of the aircraft he flew on when in country but had no information about that number or how to retrieve it. In a September 29, 2011 written statement to the RO, the Veteran said he was stationed at Takhli Royal Air Base and flew into Vietnam on a C24 aircraft but did not know the tail number. At that time, he submitted a VA document obtained from the Internet, entitled Agent Orange: Thailand Military Bases. The document is to the effect, in part, that U.S. Air Force veterans who served on Royal Thai Air Force (RTAF) bases including Takhli, near the air base perimeter, anytime between February 28, 1961 and May 7, 1975, may have been exposed to herbicides and qualify for benefits. The Veteran also submitted a copy of his December 1968 service performance evaluation, signed by C.D.H., a top sergeant, that shows that the Veteran performed administrative and clerical duties. In October 2011, the Veteran noted that, while he was stationed at Takhli Air Base, he worked on the flight line and performed "FOD" checks around the perimeter of the base. According to a later-dated October 2011 Report of General Information, the Veteran said he flew into Ton San Nhut Air Base on one trip but did not recall all his trips. He made another trip sometime between October and November and made the trip(s) to provide or obtain intelligence information. He said "10-98s" were cut. The Veteran also submitted an October 2011 notarized statement from C.D.H., reportedly his retired master sergeant, to the effect that they were stationed together in Takhli, Thailand, in 1968, and went on TDY to Vietnam between June and December 1968. C.D.H. provided his Air Force service number, social security number, and current mailing address in his statement. In an October 25, 2011 response to the RO's inquiry, the NPRC reported that it was unable to determine if the Veteran served in the Republic of Vietnam. It provided additional personnel records at that time. A November 2011 RO memorandum found that the Veteran's service in the Republic of Vietnam could not be verified. However, the Veteran is competent to claim that he was in the Republic of Viet Nam during TDY from Thailand; his description of these events is not implausible. More significantly, the Veteran submitted the October 2011 signed statement from C.H., his former sergeant, indicating that they went on TDY to Vietnam between June and December 1968. But, in the February 2012 supplemental statement of the case (SSOC), the RO reported that C.H.'s service records show active duty from October 8, 1969 to June 3, 1975 and the Veteran's records show Thailand service from June 27, 1968 to June 20, 1969, and from November 25, 1975 to May 26, 1976. The RO said that the Veteran was not stationed in Thailand while Mr. H. was an active service member. However, the RO provided no factual explanation for its conclusion that the C.H. who signed the Veteran's December 1968 performance evaluation was not the C.H. who submitted the October 2011 statement. Furthermore, the Veteran's Official Military Personnel File (OMPF) does not support the RO's conclusion. The Veteran's OMPF includes the December 1968 performance evaluation signed by C.D.H. There is nothing in the record to suggest that the C.D.H. who signed Veteran's December 1968 performance evaluation is not the same C.D.H. who submitted the October 2011 written statement. The Veteran's claim that he was in the Republic of Viet Nam is credible. Giving the Veteran the benefit of the doubt, the Board finds that he did serve on the landmass of Vietnam and, thus, did have qualifying service in the Republic of Vietnam during the Vietnam era. Haas v. Peake, 525 F.3d at 1168. The next question to be answered is whether the Veteran is diagnosed with one of the specific diseases listed in 38 C.F.R. § 3.309(e). In a July 2004 signed statement, A.D., D.O., the Veteran's primary care physician at Brooks City-Base Texas reported that the Veteran's diagnoses included coronary artery disease and coronary bypass graft in March 2004, dilated cardiomyopathy, congestive heart failure, and atrial fibrillation. It was noted that the Veteran also had diabetes mellitus, type II, for which he took prescribed medication. Medical records, including a September 2010 signed Ischemic Heart Disease (HD) Disability Benefits Questionnaire and May and October 2010 signed statements from M.K., M.D., also show that, in March 2004, the Veteran had a myocardial infarction and underwent coronary bypass surgery. In April 2004, the Veteran had an implanted cardiac pacemaker and, in May 2005, he underwent a heart transplant. Here the Board has concluded the Veteran was exposed to Agent Orange during active service and the medical evidence demonstrates that he has an ischemic heart disorder and diabetes mellitus, type II. Therefore, resolving all doubt in the Veteran's favor, service connection for a heart disorder, diagnosed as coronary artery disease, congestive heart failure, and status post heart transplant, and diabetes mellitus, type II, can be granted on a presumptive basis. 38 U.S.C.A. § 1116(a)(1); 38 C.F.R. § 3.307(a)(6). ORDER Service connection for a heart disorder, diagnosed as coronary artery disease, congestive heart failure, and status post heart transplant, including as due to exposure to Agent Orange, is granted. Service connection for diabetes mellitus, type II, including as due to exposure to Agent Orange, is granted. REMAND The Veteran seeks service connection for deterioration of his eyesight, also claimed as poor vision and diabetic retinopathy, and transmetatarsal amputation of the left foot. The Board's decision, herein, grants service connection for diabetes mellitus, type II, and a heart disorder, diagnosed as coronary artery disease, congestive heart failure, and status post heart transplant. The Veteran has variously claimed that his left foot disability is due to exposure to Agent Orange. See e.g., November 2006 statement of the case and October 2009 SSOC. Disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310 (2012). The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service- connected disability caused by a service- connected disability. Allen v. Brown, 7 Vet. App. 439 (1995) During his September 2010 Board hearing, the Veteran testified that his eye condition was diagnosed in 2004 by a physician at Methodist Hospital. See Board hearing transcript at page 10. The Veteran stated his belief that his eye problem was also due to his nearly 25 years of administrative work in the military. Id. The Veteran explained that his left foot disorder occurred after his heart attack. Id. at 11. He went into congestive heart failure and his heart was so weak that he was unable to get oxygen to his lower extremities. Id. The Veteran's left toes did not get proper circulation and died, that required amputation just below the heel area of his foot. Id. He said he was told he had peripheral vascular problems and lacked proper blood flow due to his weak heart that was unable to push his blood into his lower extremities. Id. at 11-12. A private hospital discharge summary shows that the Veteran was hospitalized from March to April 2004, for treatment of cardiac arrest, coronary artery disease and bypass graft. While hospitalized, he lost his left dorsalis pedis pulse. A vascular surgeon was consulted and evidence of underlying peripheral vascular disease was found. A popliteal-tibial bypass surgery was performed to try to salvage the Veteran's lowery extremity digits on the left foot. However, a transmetatarsal amputation was required on April 25, 2004. According to a June 2, 2004 signed statement from G.J.M., M.D., the Veteran was under treatment for diabetes mellitus and had numerous complications from this illness. The Veteran had arterial bypass surgery to his leg secondary to severe peripheral vascular disease. He underwent trans-metatarsal amputation of the left foot complicated by a slow healing wound. The Veteran had coronary artery disease resulting in a myocardial infarction that required coronary artery bypass surgery. He had dilated cardiomyopathy resulting in chronic congestive heart failure. The July 2004 medical record from Dr. A.D., the Veteran's primary care physician at Brooks City-Base, Texas, shows that the Veteran had atherosclerotic peripheral vascular disease. It was noted that the Veteran had arterial bypass surgery on his left lower leg secondary to severe disease and underwent trans-metatarsal amputation of his left foot. An April 13, 2005 private medical record from the Lackland Air Force Base medical facility describes the Veteran's medical history that included a myocardial infarction and coronary bypass in March 2004. It was noted that "[v]ascular complications of the surgery led to partial amputation of his [left] foot." The record does not currently show a diagnosis of diabetic retinopathy. However, in his October 2010 written statement, Dr. M.K., the medical director of the Advanced Heart Failure and Transplant Clinic at Methodist Heart Hospital in San Antonio, Texas, noted that the Veteran did well after his heart transplant but had problems that were difficult to control, including "worsened diabetes" secondary to steroids. Again, the Veteran attributes his left foot transmetatarsal amputation and eyesight disorder, in part, to his service-connected diabetes mellitus and heart disabilities. Some of the medical evidence of record, particularly the April 2004 private hospital discharge summary showing treatment for cardiac arrest, coronary artery disease and bypass graft and subsequent left foot transmetatarasal amputation, Dr. G.J.M.'s June 2004 statement indicating that the Veteran had numerous complications of diabetes mellitus, the April 2005 treatment report indicating that vascular complications of the bypass surgery led to partial amputation of the Veteran's left foot and Dr. M.K.'s October 2010 statement regarding worsened diabetes due to steroid medication, appear to suggest that this may be the case. To date, he has not been afforded a VA examination to obtain an opinion on the relationship between the left foot and eye complaints and the service-connected diabetes mellitus and heart disabilities. Such should be provided on remand. 38 U.S.C.A. § 5103A(d) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); see also McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). The Veteran testified that a physician at Methodist (Heart) Hospital diagnosed his claimed eye disorder. Efforts should be made to obtain all medical records regarding the Veteran's treatment for an eye disorder at Methodist Heart Hospital. It also appears that the Veteran receives Social Security Administration (SSA) disability benefits, according to a September 13, 2004 notice of award letter. In this regard, the Board notes that the possibility that SSA records could contain evidence relevant to the remaining claims on appeal cannot be foreclosed absent a review of those records. As such, the administrative decision and records considered by the SSA in its award of disability benefits must be obtained prior to consideration of the Veteran's claims. 38 C.F.R. § 3.159(c)(2) (2012); see also Murincsak v. Derwinski, 2 Vet. App. 363 (1992). Accordingly, the case is REMANDED for the following action: 1. Obtain all medical records regarding the Veteran's treatment for an eye disorder at Methodist Heart Hospital, 4499 Medical Drive, San Antonio, Texas, 7822, and from any additional VA or non-VA medical provider identified by him. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) (West 2002 & Supp. 2012) and 38 C.F.R. § 3.159(e) (2012). 2. Contact the SSA and request a copy of the administrative decision and all records considered in conjunction with its 2004 award of SSA disability benefits to the Veteran and any subsequent disability determinations regarding him. 3. After accomplishing the above development, schedule the Veteran to undergo VA ophthalmologic and vascular examination(s), performed by physicians (preferably an ophthalmologist and a vascular surgeon) with expertise to determine the etiology of any diagnosed eye and left foot disorders found to be present. The claims file should be made available to the examiner prior to examinations. All indicated tests and studies should be performed and all clinical findings reported in detail. a. The examiners should determine if the Veteran has a diagnosed eye or left foot disorder, including diabetic retinopathy and transmetatarsal amputation of the left foot. b. If so, the examiners should indicate whether any diagnosed eye or left foot disorder is likely as not (50 percent probability or greater) related to the Veteran's active service, including exposure to Agent Orange, or the result of service-connected diabetes mellitus and/or heart (coronary artery diease, congestive heart failure, and status post heart transplant) disability. c. If not, is it at least as likely as not aggravated by service-connected diabetes mellitus and/or heart disability? If aggravated, what permanent, measurable increase in current left foot or eye pathology is attributable to the service-connected diabetes mellitus and/or heart disability? d. The examination reports should include the complete rationale for all opinions expressed. 4. Thereafter, readjudicate the Veteran's claims for service connection for deterioration of eyesight, also claimed as poor vision and diabetic retinopathy, and service connection for transmetatarsal amputation of the left foot, in light of any evidence added to the record. If any benefit sought on appeal remains denied, the appellant and her representative should be provided a SSOC. An appropriate period of time should be allowed for response. No action is required of the Veteran until he is notified by the RO; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2012). The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ M.G. MAZZUCCHELLI Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs