Citation Nr: 1329910 Decision Date: 09/18/13 Archive Date: 09/25/13 DOCKET NO. 08-35 467 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a blood disorder, claimed as irregular platelets, diagnosed as essential thrombocytosis, including as due to an undiagnosed illness. 2. Entitlement to service connection for erectile dysfunction, including as secondary to hypertension. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD F. Yankey, Counsel INTRODUCTION The Veteran served on active duty from April 1973 to July 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the St. Petersburg, Florida Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran later testified before the undersigned at a January 2011 Video Conference hearing. The hearing transcript is of record. The Board additionally notes that in an August 2012 rating decision, the RO granted service connection for sleep apnea. This was a full grant of the benefit sought with regard to that issue. Grantham v. Brown, 114 F .3d 1156 (Fed. Cir. 1997). The issue of entitlement to service connection for erectile dysfunction is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's blood disorder has been diagnosed as essential thrombocytosis. 2. Essential thrombocytosis was not present in service or for years thereafter, and is not etiologically related to service. CONCLUSION OF LAW Essential thrombocytosis was not incurred in or aggravated by active duty, nor may its incurrence or aggravation during such service be presumed. 38 U.S.C.A. §§ 1110, 1131, 1117 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012) defined VA's duty to assist a Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, VA must inform the claimant of any information and 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. Pelegrini v. Principi (Pelegrini), 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In a June 2007 letter, issued prior to the adjudication of the claim, the RO notified the Veteran of the evidence needed to substantiate his claim for service connection. The letter satisfied the second and third elements of the duty to notify by informing the Veteran that VA would try to obtain medical records, employment records, or records held by other Federal agencies, but that he was nevertheless responsible for providing any necessary releases and enough information about the records to enable VA to request them from the person or agency that had them. The Veteran has substantiated his status as a Veteran. He was notified of all elements of Dingess, including the disability-rating and effective-date elements of the claim, in the June 2007 letter. VCAA notice should be provided to a claimant before the initial unfavorable decision on a claim, as was done here. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). The Duty to Assist The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103S; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.1599(c)(4). VA has obtained records of treatment reported by the Veteran, including service treatment records, and VA and private treatment records. The Board's March 2011 remand was to afford the Veteran an adequate VA examination and opinion. The VA examination and opinion was provided in April 2011 and the requested information was obtained. Therefore, the Board is satisfied that there was substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Some discussion of the Veteran's January 2011 hearing before the Board is also necessary. The individual presiding over a hearing must comply with the duties set forth in 38 C.F.R. § 3.103(c)(2). See Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. They were met here. The issues on appeal were identified. Information was elicited from the Veteran concerning his contentions regarding the etiology of his essential thrombocytosis. Notably, the Veteran's testimony triggered the Board's decision to remand the matter to obtain the above referenced VA examination/opinion. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The appeal is thus ready to be considered on the merits. Legal Criteria Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current 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 claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). The theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In relevant part, 38 U.S.C.A. 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has further held that "[l]ay 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); see also Buchanan v. Nicholson, 451 F.3d at 1337 ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (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"). 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, as opposed to merely isolated findings or a diagnosis including the word "chronic." That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without medical evidence of a current disability, medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) (table). For Veterans with service in the Southwest Asia theater of operations during the Persian Gulf War, service connection may also be established under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. Under that section, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than not later than December 31, 2011. 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. 1117(d) warrants a presumption of service-connection. Under the applicable provisions, an undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.117, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. A medically unexplained chronic multi symptom illness is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, and any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multi symptom illness. A "medically unexplained chronic multi symptom illness" means a diagnosed illness without conclusive pathophysiology or etiology, which is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). The Secretary has determined that certain infectious diseases, not at issue here, warrant a presumption of service connection under 38 C.F.R. § 3.317(a)(2)(C). 75 Fed. Reg. 59,970 (Sept. 29, 2010); 75 Fed. Reg. 61,356, Oct. 5, 2010; 75 Fed Reg. 61,997 (Oct. 7, 2010) (to be codified at 38 C.F.R. § 3.317(c)-(d)). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary 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 Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Essential Thrombocytosis The Veteran contends that he is entitled to service connection for essential thrombocytosis (ET). The Veteran contends in particular that, although this disorder was not diagnosed until several years after his service discharge in July 1997, the disorder was present during service, but the diagnosis was missed. ET was not diagnosed until many years after service, and there is no competent evidence to establish that it is due to any event or incident of the Veteran's period of active duty. Service treatment records are negative for any evidence of complaints, treatment or a diagnosis related to ET or any other chronic blood disorder. A February 2001 outpatient treatment note from the military medical facility at which the Veteran was receiving treatment discloses that the Veteran's platelet count had increased x3 over the last year, and that the Veteran was asymptomatic. A March 2001 note from Dr. M.L. indicates that the Veteran's platelet had been 600 (600,000) for the last few months. Treatment records from Baptist Regional Cancer Institute show a diagnosis of moderate thrombocytosis in March 2001. Treatment records from Shands Jacksonville show a history and treatment for thrombocythemia from 2006-2008. Treatment records from the Jacksonville Naval Hospital and private treatment records from M.L., MD show that the Veteran has been diagnosed with essential thrombocytosis. In a February 2010 statement, M.L., MD stated that he had been treating the Veteran since 2001, when he was diagnosed with ET, and that since that time, the Veteran had been treated with medication with good control. He also stated that it is "conceivable" that the Veteran would have had thrombocytosis several months to years before the diagnosis. However, he also noted that the Veteran apparently had not had a complete blood count done before 2001, so he was not sure how long he had the disease. However, he concluded that, considering the natural history of the disease, it is "very possible" that the Veteran had the disease several months to several years before 2001. The Board finds that Dr. M.L.'s opinion that it is "conceivable" and "very possible" that the Veteran's ET was present for several months or years prior to his 2001 diagnosis, is equivocal as to whether the Veteran's ET was present or incurred in service. The equivocal nature of this opinion diminishes its probative value. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, Dr. M.L. did not indicate that he had reviewed the Veteran's claims file prior to rendering his opinion, and for this reason also, the Board finds that the opinion lacks probative value. The Veteran was afforded a VA examination in April 2011, in accordance with the Board's March 2011 remand. The examiner opined that the Veteran's currently asymptomatic thrombocytosis was not caused by any diagnosed condition during his active duty. In rendering his opinion, he noted that there were no documented platelet counts in the Veteran's 1996 and 1997 examinations. However, a February 2001 note states that platelets had increased x3 over the last year, and in a March 2001 statement, Dr. M.L. commented that the Veteran's platelet was 600 (600,000), which meant that the Veteran's platelet count in 2000 was somewhere around 200,000, which is a normal value. The examiner also noted that according to medical literature reviews, the presenting symptoms of Veterans with ET are quite variable. In this regard, many patients (12-67 percent) reach medical attention fortuitously, as a result of the extreme degree of thrombocytosis detected when obtaining a routine blood cell count-76-84 percent of the cases were asymptomatic, and the diagnosis was made incidentally. The examiner also noted that most patients present with symptoms related to small or large vessel thrombosis or minor bleeding, and the most common symptom of the ET is headaches, which in the Veteran's case, was documented in February 2006 when he reported severe headaches from November 2005 to January 2006, which had completely abated. The examiner also noted that it was even conceivable that the Veteran had ET all his life since it is asymptomatic in 76-84 percent of the population until complications manifest. However, he concluded that he could not make a diagnosis of a disease in a vacuum, without some medical evidence, and the earliest documentation related to ET was in 2001, when the Veteran was diagnosed with the disease. There is no probative medical opinion against that of the VA examiner, and that opinion was based on an accurate history and supported by an implicit rationale; it is thus adequate. There is no other medical evidence of record, VA or private, which indicates that the Veteran's ET is related to his active military service. The Veteran is also not entitled to service connection for a blood disorder as a Persian Gulf Veteran suffering from a chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multi-symptom illness. In this regard, the Board notes that the Veteran's blood disorder has been diagnosed as essential thrombocytosis. Furthermore, the Veteran's ET is not a disability for which presumptive service connection is available under the revised 38 C.F.R. § 3.317. The Veteran is competent to report the symptoms of his disability; however, it would require medical expertise to say that the current ET, identified years after service, is the result of a disease or injury in service. The Veteran, as a layperson, is not qualified to render an opinion concerning the medical cause of his ET. 38 C.F.R. § 3.159(a)(1),(2) (2012). For the same reason, his statements are also not sufficient to link his ET to service based on continuity of symptomatology, even if this condition were specifically identified as a chronic condition under 38 C.F.R. § 3.309(a). Based on the foregoing, the Board finds that a preponderance of the evidence is against the Veteran's claims for service connection for ET. Such disorder did not manifest during service or for many years thereafter and has not been shown to be causally or etiologically related to an event, disease, or injury in service. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not applicable. ORDER Service connection for essential thrombocytosis is denied. REMAND After a review of the evidence, the Board is of the opinion that further development is required before the Board decides the issue on appeal. The Veteran contends he has erectile dysfunction (ED), which developed as a result of military service, or as a result of his service-connected hypertension. Service treatment records are negative for any evidence of complaints, treatment or a diagnosis related to erectile dysfunction. Treatment records from the Jacksonville Naval Hospital dated from January 2001 to April 2009 show that the Veteran was diagnosed with sexual dysfunction in August 2005 and with male erectile disorder in January 2006. They also show that the Veteran was treated for hypertension as early as 2001. Treatment records from Shands Jacksonville show a history and treatment for hypertension and thrombocythemia from 2006-2008. They do not show treatment for ED. In an April 2009 statement, the Veteran's private physician, P.P., MD reported that the Veteran had been treated with medications for hypertension and ED since 1985 and 1999 respectively, and opined that it is "certainly possible that the antihypertensive agents [had] contributed to his erectile dysfunction." The Veteran was afforded a VA examination in September 2009, in response to his claim. He reported at that time that he started experiencing problems with obtaining and maintaining an erection in the 1990s, and that he was placed on testosterone injections in 2007, due to low testosterone, and that he was taking Cialis at that time. The examiner noted that ED was present, however, he also noted that through the use of oral medication, vaginal penetration was possible, which was effective in allowing intercourse and normal ejaculation. The examiner diagnosed incomplete ED and opined that it was less likely than not caused by or a result of his service-connected hypertension. His explanation was that the Veteran was diagnosed with low testosterone (well-known also as hypogonadism) in 2007, and that he had been treated with testosterone injections and Cialis since 2007. He also noted that hypertensive medication has known side effects that may contribute to erectile dysfunction, however, to what degree in the Veteran would be mere speculation. In the March 2011 remand, the Board found that the opinion of the September 2009 VA examiner was incomplete because the examiner did not address whether hypogonadism and low testosterone were incurred during or first manifested in service. Accordingly, the Veteran was afforded another VA examination in April 2011. He reported that he was diagnosed with ED during active duty, and placed on medication in 2000. He also reported that the condition had progressively worsened since his diagnosis, and that he was taking Viagra with good results. The examiner diagnosed ED, and concluded that the most likely etiology was endocrine disease. He also opined that the Veteran's ED did not have its onset during his active service, and that it was not caused by the Veteran's service-connected hypertension. In rendering his rationale, he noted that the first diagnosis of ED in the record was in August 2005, and that the Veteran was then noted to have low testosterone level in August 2006, for which he was prescribed depo-testosterone injection treatment every two months. He concluded that this chronological history and treatment of the Veteran's ED indicates that it was caused by his testosterone level rather than hypertension or antihypertensive medication. The April 2011 examiner opined that the Veteran's ED was not directly related to service, or caused by his service-connected hypertension. However, although he was directed to do so in the March 2011 remand, the examiner did not address whether the service-connected hypertension aggravated the ED, pursuant to 38 C.F.R. § 3.310(a) & (b) (2012); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Accordingly, the Board find's that the negative opinion is inadequate for rating purposes. Once VA undertakes to provide an examination it is obligated to insure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). VA regulations provide that where an examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes. 38 C.F.R. § 4.2 (2012). Where the Board makes a decision based on an examination report which does not contain sufficient detail, remand is required "for compliance with the duty to assist by conducting a thorough and contemporaneous medical examination." Goss v. Brown, 9 Vet. App. 109, 114 (1996); Stanton v. Brown, 5 Vet.App. 563, 569 (1993). A remand by the Board confers on an appellant the right to VA compliance with the terms of the remand order and imposes on the Secretary a concomitant duty to ensure compliance with those terms. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In Stegall, the Court held that "where . . . the remand orders of the Board . . . are not complied with, the Board itself errs in failing to insure compliance." Id. As such, the Board has determined that VA has a duty to assist by seeking another medical opinion. See 38 C.F.R. § 4.2 (2012). The appellant is advised that it is his responsibility to report for the examination and to cooperate in the development of the case, and that the consequences of failure to report for a VA examination without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158 and 3.655 (2012). Accordingly, the case is REMANDED for the following action: 1. Ask the examiner who conducted the April 2011 VA examination to provide an opinion as whether it is at least as likely as not (50 percent probability or more) that the Veteran's current (erectile dysfunction) ED was caused by or aggravated by his service-connected hypertension. If ED was not caused or aggravated by the service-connected hypertension, please provide an opinion as to the likely cause of the Veteran's current ED. The examiner should review the claims folder and provided a clear rationale for all opinions and conclusions expressed. The examiner is advised that the Veteran is competent to report injuries and symptoms and that his reports must be considered in formulating the requested opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. If the April 2011 examiner is not available, another qualified medical professional should review the claims file and provide the necessary opinion. If another examination is needed, it should be provided. "Aggravation" means a chronic or permanent worsening of the underlying condition (versus a temporary flare-up of symptoms) beyond its natural progression. 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). ______________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs