Citation Nr: 1327909 Decision Date: 08/30/13 Archive Date: 09/05/13 DOCKET NO. 06-34 760 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a right knee disorder. REPRESENTATION Appellant represented by: Jeany Mark, Attorney ATTORNEY FOR THE BOARD J.R. Bryant, Counsel INTRODUCTION The Veteran served on active military duty from December 1971 to August 1973. This appeal to the Board of Veterans' Appeals (Board) comes from a March 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This matter was initially before the Board in June 2008, at which time it was remanded for further evidentiary development. In a March 2009 decision, the Board denied the Veteran's claim. He appealed to the United States Court of Appeals for Veterans Claims (Court). In a February 2010 Order, the Court remanded the appeal for further development consistent with the instructions in a February 2010 Joint Motion for Remand. To comply with the Order, the Board remanded this matter in September 2010. In a May 2011 decision, the Board again denied the Veteran's claim. He again appealed to the Court. In a January 2012 Order, the Court remanded the appeal for further development consistent with the terms of a January 2012 Joint Motion for Remand. Pursuant to the actions requested in that Joint Motion, the issue was remanded yet again to the Board in July 2012 for the issuance of a Supplemental Statement of the Case to the Veteran's current representative. It has now been returned to the Board for further appellate consideration. FINDING OF FACT A chronic disability of the right knee was not shown in service, degenerative joint disease of the right knee was not diagnosed within one year of service discharge, and the preponderance of the evidence fails to establish that the Veteran's current right knee disability is related to any event, injury, or disease during service. CONCLUSION OF LAW A right knee disorder, diagnosed as degenerative joint disease, was not incurred in or aggravated by service and may not be presumed to have been incurred in service. 38 U.S.C.A §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice 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). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letter dated in February 2006 of VA's duty to assist him in substantiating his claim under the VCAA, and the effect of this duty upon his claim. A May 2006 letter later informed him of how disability ratings and effective dates are assigned. See Dingess, 19 Vet. App. at 484. The timing defect of the May 2006 correspondence was cured by the RO's subsequent readjudication of the appeal and issuance of a Statement of the Case (SOC) in September 2006 and Supplemental SOCs dated in April 2008, January 2009, February 2011, and June 2013. No further development is required regarding the duty to notify. The Board also finds VA has satisfied its duty to assist the Veteran in the development of the claims adjudicated herein. His in-service and pertinent post-service treatment reports are of record. He has not indicated that any additional pertinent evidence exists, and there is no indication that any such evidence exists. The Board has reviewed both the Veteran's physical claims file and the file on the Virtual VA electronic file system, to ensure a total review of the available evidence. The Board is also satisfied that the AMC has substantially complied with the September 2010 and July 2012 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion is required). A VA medical opinion was obtained in December 2010 to assist in determining whether the Veteran's current right knee disorder is attributable to his military service. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination/opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The VA examination is more than adequate. It reflects a full review of all medical and other evidence of record, is supported by sufficient detail, and refers to specific documents and medical history as well as the Veteran's service history to support the conclusions reached. The AMC/RO also reissued the Supplemental Statement of the Case to the Veteran's current representative in June 2013. Accordingly, the Board finds that the AMC/RO has substantially complied with the Board's remand directives. See Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is 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 (Fed. Cir. 2002). Thus, the Board finds that VA has satisfied its duty to assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claim under the VCAA. No useful purpose would be served in remanding this matter for yet more development. A remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit to the Veteran. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); & Quartuccio v. Principi, supra. Law and Analysis The Veteran essentially claims that service connection for a right knee disorder, currently diagnosed as osteoarthritis, is warranted. He contends that he suffered repeated injuries to his right knee that resulted in a chronic knee disability. He maintains that he only sought medical attention on one occasion due to his desire to conform with his peers and not appear weak. He argues that a post-service injury he sustained in 1975 was nothing more than a continuation of his ongoing right knee problems. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). "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. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). Service connection for certain specified chronic diseases, such as arthritis, may be established on a presumptive basis by showing that they manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(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). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Id. When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). (holding that the term "chronic disease in 38 C.F.R. § 3.309(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a)). A grant of service connection under 38 C.F.R. § 3.303(b) does not require proof of the nexus element; it is presumed. Id. After considering all information and lay and medical evidence of record in a case with respect to benefits under laws administered by the Secretary, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The benefit of the doubt rule is inapplicable when the evidence preponderates against the claim. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). A review of the Veteran's service treatment records reveal that he received treatment for sharp pain in the right knee in September 1972, when he feared he pulled a ligament as he had prior to service while playing football. There was no diagnosis of a right knee disorder. There are no records of additional follow-up evaluation or clinical findings. At his separation physical in August 1973, almost a year later, there was no reference to of any right knee abnormalities, problems or impairment of any sort and a clinical evaluation of his musculoskeletal system was normal. The service treatment records, as a whole, provide negative evidence against this claim. They show neither complaints nor evidence of a chronic right knee disorder in service. The Veteran was only seen on one occasion for knee pain in service and one year later he was cleared for discharge without there being any mention of a knee problem. Consideration is given to the Veteran's assertion of experiencing continuous right knee symptomatology since service, but his statements in this regard are not supported by the evidence of record. Post-service records show the Veteran was first examined for right knee pain in October 1975, after he slipped and twisted his right knee while playing football. An antrogram revealed a tear of the medial meniscus in the right knee, for which the Veteran underwent surgery. At the time, the Veteran reported that he served in the Marines for two years without any difficulty. He also reported being extremely active physically, playing football, basketball, and tennis without difficulty. There was no mention of previous a right knee injury associated with military service. See private examination report from Winchester Hospital dated in October 1975. The contradictory nature of the Veteran's statements casts doubt on his assertions that he has experienced right knee problems since service as required to support the claim for entitlement to service connection consistent with 38 C.F.R. § 3.303(b). Emphasis is placed on the fact that the Veteran made no reference to an earlier injury to knee when he was seen in 1975. Had he experienced a significant injury in service that resulted in last disability, one would believe that he would have reported the same to the physician in the course of seeking treatment. Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant); see also Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). His statement of doing various physical and strenuous activities in service and post-service up until his injury in 1975 also undermines his current argument that he had lasting knee problems/pain since service. The next relevant medical evidence is in 2006, when the Veteran sought medical attention for right knee pain. Medical history from that time reveals that he felt his right knee problems began in service, but reported that he began to experience intermittent problems with his right knee since undergoing surgery in 1975. Despite problems with his knee, the Veteran was active in sports and maintained an active lifestyle. The diagnosis at that time was right knee internal derangement and right knee osteoarthritis. See treatment records from West Orange Orthopaedics dated in February 2006. Unfortunately this places the presence of right knee osteoarthritis more than 30 years after service separation in 1973, therefore it is impossible to grant service connection on the basis of the manifestation of a chronic disability (e.g., arthritis) within one year after separation from service. 38 C.F.R. §§ 3.307 and 3.309. While not a dispositive factor, the significant lapse in time between service and post-service diagnosis may be considered as part of the analysis of a service connection claim. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000). Notwithstanding the foregoing, several opinions have been obtained to address whether the Veteran's current right knee disability is related to his active service, to include his right knee strain. The Veteran submitted a medical opinion from a private physician, who reported that based on a review of X-rays, examination, and history as given by the Veteran, it was his opinion that military service had a negative impact on his right knee. He concluded that the Veteran's current right knee condition is directly related to his active duty service in the Marine Corps. See February 2006 statement from P.C. Furey, M.D. A similar statement was received from a second treating physician, wherein it was intimated that the Veteran's right problems were related to his in-service injury. At that time the physician stated that the Veteran's right knee arthritis was a result of an injury or accumulation of injuries occurring earlier in life. He indicated that the Veteran reported injuring his right knee during service and requiring surgery shortly following service. See March 2006 statement from W.K. Cox, M.D. In August 2008, the Dr. Cox provided another statement, indicating that the Veteran underwent a total knee replacement recently and that his need for such a procedure at such a young age likely resulted from a knee injury he sustained in 1973. When examined by VA in August 2008, the VA examiner initially provided a favorable nexus opinion regarding the Veteran's right knee disorder and his military service, stating that the Veteran's right knee disorder was at least as likely as not a result of injuries in military service. This opinion was based on the Veteran's reported history of multiple injuries to the right knee, with records of advanced arthritis that resulted in a total right knee arthoplasty, and a discrepancy between the right knee's condition and the left knee, which remained completely normal. However, as the RO subsequently pointed out, and as the Veteran failed to mention to the VA examiner in August 2008, the Veteran sustained only one knee injury during service. He also led a very active lifestyle following service, playing multiple sports and incurring injuries from playing those sports. Although the VA examiner indicated that he had reviewed the Veteran's claims file and medical records, he appeared unaware of the number of injuries the Veteran incurred in service and of the Veteran's post-service intercurrent injuries. See Deferred Rating Decision dated August 2008. In a subsequent addendum in September 2008, after further review of the Veteran's service treatment records and post-service treatment records, the VA examiner revised his nexus opinion to state that the Veteran's right knee degenerative joint disease was less likely as not caused by or a result of military service. In providing this opinion, the VA examiner called attention to the fact that the records reflect a post-service injury to the Veteran's right knee in 1975, for which he underwent an anterior cruciate ligament (ACL) reconstruction and partial medial meniscectomy. The VA examiner concluded that the 1975 surgery was more likely to be responsible for the Veteran's right knee degenerative joint disease and total knee replacement in 2007. See VA examination addendum report dated in September 2008. In February 2009, an additional statement was received from Dr. Cox in which he pointed out inaccuracies in the January 2003 SSOC. He indicated that while the Veteran gave a history of frequent right knee problems during his military service in the 1970s, it was only documented once in 1972. The Veteran believed that he had torn his ACL while in the Marine Corps, but due to extreme peer pressure was unable to seek needed medical attention. The only time he was treated was when he was having severe pain. He further believed that the 1975 report was simply one more episode of right knee pain and since he was out of the Marine Corps at that time he was able to proceed with treatment. In a second addendum, dated in December 2010, a different VA examiner concluded, that "[a] nexus does not exist between the condition resulting in the [V]eteran reporting knee pain during his active military service on [September 19 1972] and the Veteran's right knee osteoarthritis and subsequent right total knee arthroplasty." Rather a nexus clearly exists between his right knee injury diagnosed and treated in 1975 and his right knee osteoarthritis and subsequent right total knee arthroplasty. In providing this opinion, the Veteran's history of a single complaint of right knee pain during service, his post-service right knee traumatic hemarthrosis from a football injury in 1975, his subsequent right knee surgery, and his current right knee problems were summarized. The VA examiner also noted that the body of scientific evidence confirms that progressive knee osteoarthritis results from both complete and even subtotal medial meniscectomies and ACL tears left untreated. He then indicated that in the Veteran's case the surgery in 1975 was unsuccessful. Medical literature was cited in support of the negative conclusion. The remaining evidence consists primarily of a third statement from the Veteran's treating physician that is substantially similar to the ones provided in August 2008 and February 2009. However on this occasion he indicated that while the Veteran has had right knee problems outside of the military, they began as a result of a significant injury during service in September 1972. See October 2010 statement from W.K. Cox, M.D. After a review of the conflicting medical opinions in this case, the Board finds that the September 2008 and December 2010 VA opinions are the most probative and persuasive medical evidence in this case, as they are based upon a complete review of the Veteran's entire claims file, set out the most helpful and complete discussion of the medical questions, and are supported by detailed rationale. The VA examiners considered the Veteran's history of in-service right knee symptomatology and beliefs that his osteoarthritis is the result of this in-service injury. They also considered the Veteran's relevant history as contained in medical records from service onward, the findings from previous clinical evaluations, and discussed the Veteran's symptoms in the context of that history. Thus they both had sufficient facts and data before them. As a result, they were able to address fully the salient question as to the origin of the Veteran's current right knee osteoarthritis and its relationship to military service. This is particularly important, in the Board's judgment, as the VA examiners' references and specificity make for a more persuasive rationale. Careful consideration has also been given to the opinion of the private physicians as to the nature and etiology of the Veteran's right knee disorder. The Board is cognizant that at least one of the physicians had clearly evaluated the Veteran over the years and thus was well aware of his condition and the medical treatment for it. However the opinions, are fairly cursory in that neither physician explained what evidence in the Veteran's treatment records supported their conclusions, and did not reference any clinical data or other evidence as rationale for their opinions. See Bloom v. West, 12 Vet. App. 1985 (1999) (holding that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion."). For example, Dr. Cox states that the Veteran had a "significant" injury in service that led to his knee disability but pointed to no evidence to support that finding. He identified no evidence in the service treatment records. He also failed to address the 1975 reference to the Veteran being able to engage in multiple activities/sports following service and prior to the 1975 injury. The Board observes that such general statements regarding the etiology of the Veteran's right knee disorder do not have enough probative value to suggest a specific link between the currently diagnosed osteoarthritis and service. The private opinions are further weakened as there is no indication that the physicians reviewed any other relevant evidence in the claims file in formulating their opinions. Neither private physician appeared aware of the Veteran's post-service intercurrent injuries from playing sports. Further, they provided conflicting information regarding the number of knee injuries the Veteran sustained during service, which is a strong indication that they were unfamiliar with the Veteran's pertinent service medical history. It is true that a review of the claims folder or lack thereof does not control the probative value of a medical opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). However, had the private physicians in the present case been able to review the claims file, they would have observed that the 1973 service discharge examination was negative for any complaints or findings of a chronic right knee disorder. This review would also have revealed that the Veteran made no mention of his military service during treatment for a post-service knee injury in 1975. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion); Elkins v. Brown, 12 Vet. App. 209 (1999) (rejecting a medical opinion as "immaterial" where there was no indication that the physician reviewed the claimant's service treatment records or another relevant documents which would have enabled him to form an opinion as to service connection on an independent basis). As a result, the private physicians could not adequately address how it was that events that occurred so long ago were manifesting the current symptomatology claimed by the Veteran, particularly in light of the absence of clinical evidence at service discharge. The physicians also made little reference to the Veteran's post-service right knee injury, or explained its impact on his current osteoarthritis. Therefore, after weighing all the evidence, the Board finds greater probative value in the VA opinions, and, in light of the other evidence of record, these negative nexus opinions are sufficient to satisfy the statutory requirements of producing an adequate statement of reasons and bases where the expert has fairly considered material evidence which appears to support the Veteran's position. Wray v. Brown, 7 Vet. App. 488, at 492-93 (1995). The private medical opinions, while not discounted entirely, are entitled to less probative weight in the face of the remaining evidentiary record. The Board has not overlooked the Veteran's contentions or his statements to healthcare providers. His primary assertion is that his claimed right knee disorder had its onset during service. The Board is keenly aware that lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Jones v. Brown, 7 Vet. App. 134, 137 (1994); Layno v. Brown, 6 Vet. App. 465, 469 (1994) Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Davidson v. Shinseki, 581 F.3d 1313, 1316. 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. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Federal Circuit Court also held in Buchanan (and Davidson and Jandreau), however, that the Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. Thus, to ultimately have probative value, the Veteran's assertions also have to be credible and judged in relation to the other evidence in the file - including any medical evidence addressing the determinative issue of causation. See Rucker v. Brown, 10 Vet. App. 67 (1997) and Layno, 6 Vet. App. at 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating and determining causal connections for musculoskeletal disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. Although the Board recognizes the sincerity of the arguments advanced by the Veteran, his contentions as to the etiology/onset of his claimed right knee disorder are not statements merely about symptoms, an observable medical condition, or a contemporaneous medical diagnosis, but rather clearly fall within the realm of requiring medical expertise, which he simply does not have. That is to say, osteoarthritis is a complex disorder that requires specialized training and medical knowledge for a determination as to diagnosis and causation, and it is therefore not susceptible of lay opinions on etiology alone. So while the Veteran is competent to say he has experienced certain symptoms, even symptoms that often may be associated with an eventual diagnosis of osteoarthritis, he is not in turn competent to ascribe these symptoms to disability related to his military service. However more importantly the Board finds that the Veteran's account of experiencing right knee symptoms since service is not entirely credible, even if competent. As has been noted, his credibility is undermined by the fact that the Veteran did not report any right knee difficulties at separation in 1973. It is plausible that the Veteran avoided treatment after his initial injury in an effort to fit in with his fellow service members. However, such an explanation would make very little sense at discharge. Indeed, he has provided no reason as to why he did not report having knee problems at discharge, if such actually existed. Moreover, his reports of multiple in-service right knee injuries during VA examination in August 2008 is unsupported by his service treatment records and directly contradicts his earlier report of having no difficulty during service during his October 1975 right knee treatment. Rucker supra, at 73 (1997). The Board again finds the Veteran's failure to report his in-service right knee injury to his physician, who was treating him for an injury to the same knee in 1975, to be telling and more probative than his assertions that his current right knee disorder stems from such injury. See Curry v. Brown. Regrettably the various contradictions diminish the probative value of the Veteran's contentions. See Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). In this case, the Veteran's opinion, to the extent it is to be accorded some probative value, is far outweighed by the more thoroughly explained and detailed opinions from the VA examiners. Jandreau, supra & Buchanan, supra. Accordingly, the preponderance of the evidence is against the claim and there is no reasonable doubt to be resolved. 38 U.S.C.A. § 5107(b). ORDER Service connection for a right knee disorder is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs