Citation Nr: 1327074 Decision Date: 08/23/13 Archive Date: 08/29/13 DOCKET NO. 08-05 308 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York THE ISSUE Entitlement to an evaluation for post traumatic stress disorder (PTSD) with major depressive disorder in excess of 30 percent prior to, and in excess of 70 percent from January 2, 2013. REPRESENTATION Appellant represented by: Jaya Shurtliff, Attorney ATTORNEY FOR THE BOARD Christopher Maynard, Counsel INTRODUCTION The Veteran had active service from March 1987 to April 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2007 decision by the RO which denied an increase in the 30 percent evaluation then assigned for PTSD with major depressive disorder. In December 2011, the Board denied the Veteran's claim for increase, and he appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a May 2012 unilateral motion for vacatur and remand by the Secretary of Veterans Affairs, the Court vacated the Board's December 2011 decision and remanded the appeal to the Board for further action. In November 2012, the Board remanded the appeal for additional development. By rating action in January 2013, the RO assigned an increased rating to 70 percent; effective from January 2, 2013, the date of VA examination. 38 C.F.R. § 3.400(o)(2). FINDINGS OF FACT 1. Prior to January 2, 2013, the Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity due to various symptoms. 2. From January 2, 2013, the Veteran's symptoms are not shown to be productive of total occupational and social impairment due to such symptoms as, gross impairment in thought processes or communication, danger of hurting self or others, or disorientation. CONCLUSIONS OF LAW 1. The criteria for an increased evaluation to 50 percent, and no higher, for PTSD with major depressive disorder prior to January 2, 2013 have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.126, 4.130, Part 4, Diagnostic Code 9411 (2012). 2. The criteria for an evaluation in excess of 70 percent for PTSD with major depressive disorder from January 2, 2013, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.126, 4.130, Part 4, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before addressing the merits of the Veteran's claim, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). The notification obligation in this case was accomplished by way of a letter from the RO to the Veteran dated in November 2006. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b)(1); see also, Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). Furthermore, based on the communications sent to the Veteran and his representatives over the course of this appeal, he has shown actual knowledge of the evidence that he is required to submit in this case. Based on the Veteran's contentions as well as the communications provided to him by VA, it is reasonable to expect that he understands what is needed to prevail on his claim. As to VA's duty to assist, the Board finds that all necessary development has been accomplished and that appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran's service treatment records (STRs) and all VA medical records have been obtained and associated with the claims file. The Veteran was examined by VA at least three times during the pendency of this appeal and was offered an opportunity for a personal hearing, but declined. The Board has also reviewed the Veteran's Virtual VA records. Further, neither the Veteran nor his representative have made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide the issue on appeal, and have not argued that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced him in the adjudication of his appeal. See Shinseki v. Sanders, 129 S.Ct.1696 (2009). Finally, the claim was remanded by the Board in November 2012 for additional development of the record. The remand directives included obtaining a current VA psychiatric examination and all VA treatment records since November 2008. The Veteran's VA treatment records were associated with Virtual VA records system, and the Veteran was examined by VA in January 2013. The Board finds the VA examination was comprehensive and adequate upon which to base a decision concerning the claim for increase, and there is no competent or credible evidence indicating that there has been a material change in the severity of the Veteran's PTSD with major depressive disorder since that examination. The examiner personally interviewed and examined the Veteran, elicited a medical and occupational history, and provided a rational explanation for her conclusions. In light of the foregoing, the Board finds that the AMC has substantially complied with the November 2012 remand orders, and that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 106 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Based on a review of the claims file, the Board concludes that there is no indication in the record that any additional evidence relevant to the issue to be decided herein is available and not part of the claims file. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. Increased Ratings - In General In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. The percentage ratings in VA's Schedule for Rating Disabilities (Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Under Diagnostic Code (DC) 9411, a 30 percent rating is assigned when there is 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, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is for assignment when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereo-typed 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. A 70 percent disability evaluation is contemplated for 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted when there is evidence of 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. The use of the term "such as" in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as" followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Id. 38 C.F.R. § 4.130, DC 9411. Historically, it should be noted that the Veteran was initially awarded service connection for PTSD with major depressive disorder by rating action in May 2006, and was assigned a 30 percent evaluation effective from December 14, 2005, the date of receipt of claim, based primarily on the findings from a May 2006 VA examination. 38 C.F.R. § 3.400(b)(2)(i). The Veteran and his representative were notified of this decision and did not express dissatisfaction with the award or indicate a desire to appeal that rating decision. See 38 C.F.R. §§ 20.201, 20.302. In a letter received in October 2006, the Veteran stated that, "my [PTSD] has become progressively worse" and requested to be scheduled for a VA examination. Thereafter, the Veteran was afforded a VA (QTC) examination and his VA treatment records were associated with the claims file. By rating action in January 2007, the RO denied his claim for an increased rating. A notice of disagreement was received in November 2007, and the Veteran subsequently perfected on appeal in February 2008. Although the Board denied the Veteran's claim for increase in December 2011, that decision was vacated by the Court in May 2012. Therefore, the Board must review the Veteran's current appeal on a de novo basis. Given the Veteran's clear expression that his disability had worsened since the last rating decision, the complete absence of any suggestion that he disagreed with the May 2006 rating decision or the 30 percent evaluation assigned, and the failure to submit a notice of disagreement within one year of notification of the May 2006 rating decision, the Board finds that the May 2006 rating decision was final, and that current appeal arises from the January 2007 rating action. As noted above, the Veteran's 30 percent rating for his service-connected psychiatric disorder was increased to 70 percent by rating action in January 2013; effective from January 2, 2013, based primarily on the findings on a January 2013 VA examination. Thus, the question before the Board is whether the Veteran is entitled to an evaluation in excess of 30 percent prior to January 2, 2013, and to an evaluation in excess of 70 percent from that date. The evidentiary record includes numerous VA medical records showing treatment for various maladies, including PTSD with major depressive disorder from May 2006 to the present. The Veteran was also examined by VA three times during the pendency of this appeal, including in December 2006, 2007, and January 2013. The Veteran's complaints and the clinical findings on all of the reports were not materially different and showed that he suffers from mood swings, depression, irritability, angry outbursts, intrusive thoughts, panic attacks a couple of times a month, anxiety, hypervigilance, exaggerated startle response, sleep disturbance and nightmares. The Global Functioning Scale (GAF) scores on all of the outpatient notes, including records in the Virtual VA system, ranged from 55 to 68. When examined by VA in December 2006, the Veteran reported that he was diagnosed with sleep apnea and wears a CPAP at night, but that he continued to thrash about in his sleep, kicks and shouts in his dreams, and was short tempered with family members. He reported that his medications have helped to some extent, but that he continued to have sleep disturbance and a short fuse with his family members. He said that his wife sleeps in a different room and that his symptoms have affected his marriage. The report indicated that the Veteran was married for 13 years and had two children. On mental status examination, the Veteran appeared somewhat cunning, guarded, hyper alert and hyper vigilant. He was attentive throughout the interview and sat on his chair quite rigidly and remained guarded all the time. The Veteran showed no signs of speech impediment, angry outburst, mental blocking, loosening of associations or mental blocking. He reported some flashbacks which generated some apprehension, and that he sometimes feels a little uneasy which dampens his spirits. Otherwise, he did not demonstrate any signs of delusions, thought disorder or hallucinations. His affect was mildly depressed and his mood was low. The Veteran becomes easily excitable and agitated with a short fuse, and his impulse control was somewhat compromised, but he denied any suicidal or homicidal ideations. The Veteran's cognitive functioning was clearly intact, he was well oriented, and his memory was fairly intact with a short attention span. His ability to abstract and generalize was fair, he had an adequate fund of information and his intelligence was estimated to be about average. The Veteran had some insight to his problem and his judgment was fair. The diagnosis was PTSD and the GAF score was 60 for current and 65 for past year. In a letter received in November 2007, his wife reported that the Veteran had become increasingly more irritable and isolative in his behavior, and rarely attended family gatherings or other special occasions unless guilted into it. She also reported that his mood fluctuated from irrational outburst of anger when, for example, the children leave their toys lying around, while at other times, not seeming to care about the same situation. She can't count on the Veteran helping out around the house because of his mood swings, and feels like a single parent. He used to take his oldest son hunting, fishing and golfing, but doesn't engage in any of those activities anymore and wants to be left alone. The Veteran's complaints and the clinical findings were essentially the same when examined by the same QTC examiner in December 2007. Additionally, the Veteran reported that he was preoccupied with all the flashbacks of his experiences in Desert Storm and was not able to focus or concentrate. On several occasions he was cited for attendance problems at work and got upset each time, and was currently on attendance watch, which required that he get prior approval for any absence. He reported being easily moody and snappy, mostly at family members. On mental status examination, the Veteran was restless, nervous and tense. He had a hard time sitting still and relaxing during the interview and kept shifting back and forth. His attitude was guarded and cynical and he doesn't trust anyone. He was very safety conscious, checking the doors and window regularly, and said that family members make fun of it. Otherwise, the Veteran was attentive, serious and somewhat subdued and sad. He showed increased psychomotor activity and easily fidgety and agitated. His speech was pressured and did not seem able to elaborate. His social interactions were constricted and he preferred to stay at home to avoid engaging in conversations with others which generates a lot of apprehension and friction. There was no evidence of delusions, hallucinations, confabulations, confusion or any thought disorder, and his content of thought was logically connected and without mental blocking. The Veteran's affect was somewhat depressed, his mood was low, and he reported explosive outbursts. His cognitive functioning was clearly intact, he was hypervigilant all the time. He was well oriented, and there was no evidence of memory deficit. The diagnosis was PTSD with bouts of depression, and the GAF score was 50 for current and 60 for the past year. When examined by VA in January 2013, the examiner indicated that the claims file was reviewed and included a detailed description of the Veteran's complaints, medical and occupational history, and the clinical findings on examination. The Veteran reported that he doesn't like crowds and will stand off by himself when attending his son's hockey games rather than sit in the bleachers. He has anxiety when going out to dinner with his wife and other couples, and doesn't let people get close to him emotionally. He reported panic attacks a couple of times a month and said that his wife tells him he has nightmares every night, but that he does not know if he has nightmares. His wife sleeps in another room because of his sleep apnea and his thrashing about at night. The Veteran's symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, circumstantial, circumlocutory or stereotyped speech, irritability, difficulty concentrating, exaggerated startle response, hypervigilance, disturbance of motivation and mood, difficulty adapting to stressful circumstances and obsessional rituals which interfere with routine activities. The diagnoses included chronic, moderate PTSD, depressive disorder by history and panic disorder without agoraphobia. The GAF score was 63. The examiner commented that while it was possible to differentiate the symptoms for each diagnosis, it was not possible to differentiate how each disorder impacted the Veteran's social and occupational impairment. The Veteran's PTSD was manifested by hyperarousal, panic attacks, nightmares and emotional numbing. His depressive disorder was manifested by depressed mood, anxiety, decreased interest in activities and affective liability, and his panic disorder was manifested by unexpected panic attacks and worry about recurrences, but was not associated with a specific trigger. The examiner indicated that the Veteran's level of impairment from all of the diagnoses was best described as causing occupational and social impairment with reduced reliability and productivity. As noted above, the GAF scores on the VA outpatient notes during the pendency of this appeal ranged from 55 to 68, with the median score of around 60. The GAF scores on the VA (QTC) examinations were 60 in December 2006, 50 in December 2007, and 63 in January 2013. A GAF score is an indicator of the examiner's assessment of the individual's overall functioning. A GAF score between 41 and 50 contemplates a level of impairment of 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). A GAF score between 51 and 60 contemplates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score between 61 and 70 contemplates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational or school functioning (e.g., occasional truancy, or theft with the household), but generally functioning pretty well, has some meaningful interpersonal relationships. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (4th. ed., 1994) (DSM-IV). While the Board has considered the degree of functioning as evidenced by the reported scale scores, they are but one factor for consideration in assigning a rating in this case. In this regard, the Board notes that the Veteran's complaints and the findings reported on the outpatient notes and VA examinations prior to January 2, 2013, do not show any of the symptoms given as examples for a GAF score between 41 and 50. On the other hand, the Veteran's complaints and the findings on all of the medical reports were consistent with the criteria for moderate impairment and more accurately reflect the Veteran's actual social functioning. Further, the evidence shows that the Veteran has been employed as a corrections officer for some 20 years, and reported that he has a good relationship with his co-workers. While the Veteran reported that he uses all of his authorized sick time, he also reported that his job allows him flexibility of sick time when he is too stressed out to be on the job. Parenthetically, the evidence indicated that the Veteran has been out on recurring workman's comp since 2007 due to an on-the-job injury. (See December 2007 and January 2013 VA examination reports). The Veteran did not report any difficulties in the performance of his employment duties or in his relationships with his co-workers or supervisors due to his psychiatric problems. While he reported having a poor relationship with his father, who he described as an "angry and violent man," and doesn't talk to his brother because of the way he treated his son, he reported that he had a close relationship with his mother. Overall, the evidence of record does not show that the Veteran's symptoms prior to January 2, 2013, caused more than moderate impairment on his daily activities. While the evidence suggests that the Veteran has been able to control his symptoms with medication over the years, the Board does not discount the effect that his sleep disturbance, irritability, mood swings and depression have on his daily life. The Veteran isolates himself to some extent, and has periods of irritability and mood disturbance which affect his social capacity. The fact that he has been able to control his symptoms with medication does not diminish the degree of his psychiatric impairment. The material question is whether the Veteran has sufficient occupational and social impairment to disrupt his performance of occupational tasks to the extent set forth in the rating criteria described above for a higher evaluation of 50 percent or greater prior to January 2, 2013. 38 C.F.R. § 4.130 (2012). After reviewing the evidence of record, the Board concludes that the Veteran's psychiatric disability picture prior to January 2, 2013, more closely approximated the criteria for a 50 percent schedular rating, and no higher. While the evidence shows reduced reliability and some problems with interpersonal relationships, it does not suggest that his psychiatric symptoms prior to January 2, 2013, were of such severity to warrant a rating of 70 percent or higher. The evidence did not reflect any impairment of thought process or communication, inappropriate behavior, actual danger of hurting himself or others, or an inability to perform the routine activities of daily living. The Veteran has never displayed any evidence of disorientation or any psychotic symptoms. He is well-oriented and his thought processes were logical, coherent and goal directed. Prior to January 2, 2013, the Veteran did not demonstrate occupational and social impairment due to symptoms related to PTSD with major depressive disorder, such as, obsessional rituals which interfere with routine activities; intermittent, illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, or an inability to establish and maintain effective relationships. On the contrary, the medical reports showed that he was always neatly dressed and maintained good hygiene. His speech was always logical, coherent and goal directed, and his thinking was well organized and relevant. Prior to January 2, 2013, he never described any obsessional rituals and consistently denied any active suicidal ideations. Concerning the issue of an evaluation in excess of 70 percent from January 2, 2013, the Board notes that the none of the medical reports from 2006 to the present, including the three VA examinations demonstrated total occupational and social impairment with symptoms such as, gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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; or memory loss of names of close relatives, own occupation or own name. While the Veteran has demonstrated increased symptoms of depression and isolative behavior, the evidence does not reflect any material change in his judgment, thinking, or mood beyond that contemplated for a 70 percent evaluation. The medical reports throughout the appeal indicated that while the Veteran has irrational outbursts of anger directed primarily at family members, neither his wife nor the various psychiatric examiners have ever described him as being a danger to himself or others. The Veteran did not describe nor do the medical reports show any symptoms, such as, gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; intermittent inability to perform activities of daily living; disorientation to time place; memory loss for names of close relatives, own occupation or own name. Thus, the Board finds that the evidence of record does not suggest the degree of severity of symptoms of the Veteran's PTSD with major depressive disorder contemplated for total social and occupational impairment. Therefore, an evaluation in excess of 70 percent is not warranted from January 2, 2013. The Board has considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extraschedular consideration under 38 C.F.R. § 3.321(b)(1) (2012). In this case, the Board finds that the manifestations of the Veteran's PTSD with major depressive disorder is consistent with the schedular criteria, and there is no persuasive evidence that any manifestations related to the service-connected disability is unusual or exceptional. In view of this, referral of this case for extraschedular consideration is not in order. See Thun v. Peake, 22 Vet. App. 111 (2008); Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996); see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Finally, the Board notes that, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. In this case, the Board finds that a claim for a TDIU was not expressly raised by the Veteran or reasonably raised by the record. The Veteran has been employed as a guard at a correctional facility for nearly 20 years and has not required any hospitalization for his service-connected psychiatric disorder. Accordingly, the Board finds that consideration of a TDIU is not warranted. In this case, the Veteran has been assigned a 50 percent evaluation for his PTSD based on the clinical and diagnostic findings demonstrated on examinations and evaluations prior to January 2, 2013. The evidence does not show, however, that his disability was more or less disabling than reflected in the 50 percent evaluation assigned prior January 2, 2013, including the one year period prior to receipt of his claim for increase in October 2006, or in excess of 70 percent from January 2, 2013. Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). ORDER An increased evaluation to 50 percent for PTSD with major depressive disorder prior to January 2, 2013, is granted, subject to VA laws and regulations pertaining to the payment of monetary benefits. An evaluation in excess of 70 percent for PTSD with major depressive disorder from January 2, 2013, is denied. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs