Citation Nr: 1332844 Decision Date: 10/21/13 Archive Date: 10/24/13 DOCKET NO. 03-10 769 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for bone spurs in both feet. 2. Entitlement to an initial rating in excess of 20 percent for lumbar spine disability prior to February 4, 2003. 3. Entitlement to an initial rating in excess of 40 percent for lumbar spine disability for the period from February 4, 2003 to June 10, 2003. 4. Entitlement to an initial rating in excess of 20 percent for lumbar spine disability after June 10, 2003. 5. Entitlement to an initial rating in excess of 10 percent for cervical spine disability prior to March 10, 2007. 6. Entitlement to an initial rating in excess of 20 percent for cervical spine disability after March 10, 2007. 7. Entitlement to an effective date prior to July 23, 2009, for the award of a total disability rating based on individual unemployment (TDIU). WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Laura E. Collins, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1970 to January 1972 and from August 1972 to May 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In March 2004, the Veteran testified at a hearing at the RO before a Decision Review Officer (DRO). In correspondence received in November 2011, prior to the certification of the appeal, the Veteran's private attorney indicated that he was withdrawing power of attorney on behalf of the Veteran. The Veteran has not identified another representative. Accordingly, he proceeds unrepresented. In December 2012, the Board remanded the case for additional development. As discussed further herein, the Board finds that the agency of original jurisdiction (AOJ) substantially complied with the remand orders and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (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). FINDINGS OF FACT 1. On March 11, 2004, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran that he requested withdrawal of the appeal of entitlement to service connection for bone spurs in both feet. 2. For the entire appeal period, the Veteran's lumbar spine disability was productive of pronounced intervertebral disc syndrome (IVDS), with persistent symptoms compatible with sciatic neuropathy with characteristic pain and little intermittent relief. 3. For the entire appeal period, the Veteran's lumbar spine disability has been productive of neurological impairment of the left lower extremity that results in disability analogous to moderate incomplete paralysis of the sciatic nerve. 4. For the entire appeal period, the Veteran's lumbar spine disability has been productive of neurological impairment of the right lower extremity that results in disability analogous to mild incomplete paralysis of the sciatic nerve. 5. The Veteran's lumbar spine disability is not manifested by unfavorable ankylosis of the entire thoracolumbar spine. 6. The Veteran's lumbar spine disability is not manifested by a vertebral fracture, cord involvement, or unfavorable ankylosis of the whole spine. 7. The Veteran's lumbar spine disability is not productive of bowel or bladder impairment. 8. For the entire appeal period, the Veteran's cervical spine disability was productive of severe limitation of motion. 9. The Veteran's cervical spine disability is not manifested by unfavorable ankylosis of the entire cervical spine. 10. The Veteran's cervical spine disability is not manifested by a vertebral fracture, cord involvement, or unfavorable ankylosis of the whole spine. 11. The Veteran's cervical spine disability is not productive of any neurological impairment. 12. Since November 29, 2002, the Veteran has been unable to secure or follow a substantially gainful occupation due to his service-connected lumbar spine disability. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal of entitlement to service connection for bone spurs in both feet by the Veteran have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2013). 2. Effective April 29, 2002, with resolution of all reasonable doubt in the Veteran's favor, the criteria for a 60 percent evaluation for a lumbar spine disability have been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a; Diagnostic Codes 5235-5243, 5285, 5286, 5292, 5293, 5295 (2002, 2003, 2013). 3. Effective April 29, 2002, with resolution of all reasonable doubt in the Veteran's favor, the criteria for a 30 percent evaluation for a cervical spine disability have been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a; Diagnostic Codes 5235-5243, 5285, 5286, 5287, 5290, 5293 (2002, 2003, 2013). 4. Effective November 29, 2002, the criteria for a TDIU have been met. 38 U.S.C.A. §§ 1154(a), 5107(b), 5110, 5111 (West 2002); 38 C.F.R. §§ 3.31, 3.102, 3.400, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Bone spur claim The Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2012). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2013). Withdrawal may be made by the Veteran or by his or her authorized representative. 38 C.F.R. § 20.204. In a signed March 11, 2004, statement, the Veteran withdrew his appeal seeking service connection for bone spurs in both feet and, hence, there remain no allegations of errors of fact or law for appellate consideration. As such, the Board does not have jurisdiction to review the appeal and it is dismissed. II. VA's Duty to Notify and Assist The Veteran's higher rating claims arise from his disagreement with the initial evaluation following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). As to his bone spurs claim, in light of his withdrawal of his appeal, no discussion of VA's duty to notify and assist is necessary. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records, pertinent treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's VA treatment records and identified private treatment records have been obtained. The Veteran identified private physician Dr. R as having treated his back pain. VA attempted to obtain these records, but Dr. R's office responded that his last treatment was in 1991 and the practice only keeps medical records for seven years. Therefore, his records had been destroyed and further attempts to obtain them would be futile. Federal employee disability benefits records have also been obtained. Pursuant to the December 2012 Board remand, VA treatment records dated after March 2010 were associated with the claims file and the Veteran was given an opportunity to identify any additional providers. The Veteran has not identified any additional outstanding records that VA should seek to obtain on his behalf. During the appeal period, the Veteran was provided with VA spine examinations in March 2007, May 2007, and February 2013 as well as a VA general medical examination in June 2008. He has not alleged that such are legally inadequate for adjudication purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected spine disabilities as they include physical examinations of the Veteran and review of the claims file. The Veteran has not reported, nor does the record show, that his service-connected disabilities have worsened in severity since the most recent examinations in 2013. As such, a new examination is not required. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). The February 2013 examination was completed pursuant to the December 2012 Board remand. Pursuant to the remand directives, the examiner addressed not only spine disabilities, but also provided a medical opinion regarding the impact of the Veteran's service-connected disabilities on his ability to secure or follow a substantially gainful occupation. As such, the Board finds that the AOJ has substantially complied with the previous remand directives such that no further action is necessary in this regard. D'Aries. The Board finds that all relevant facts have been properly developed, and all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claims, and no further assistance to develop evidence is required. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. III. Higher Ratings Claims Disability evaluations are determined by the application of a schedule of ratings that is based on the average impairment of earning capacity. Separate diagnostic codes (DCs) identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Veteran's entire history is reviewed when making disability evaluations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1995). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different DCs is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. Notwithstanding the above, VA is required to provide separate evaluations for separate manifestations of the same disability that are not duplicative or overlapping. See Esteban v. Brown, 6 Vet. App. 259, 261 (1994). The Board notes that because the service-connected back and neck disabilities specifically include disc pathology, the Board is required to consider adjudicating them under the criteria for intervertebral disc syndrome (IVDS). See Baughman v. Derwinski, 1 Vet. App. 563, 566 (1991). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular DC is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One DC may be more appropriate than another based on such factors as the Veteran's relevant medical history, his current diagnosis, and demonstrated symptomatology. Any change in DC by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit, citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). When evaluating joint disabilities rated on the basis of limitation of motion (LOM), VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, LOM due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath, 1 Vet. App. at 592. Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59 relating to painful motion are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Effective September 23, 2002, VA revised the criteria for evaluating spinal disorders under Diagnostic Code 5293, IVDS. 67 Fed. Reg. 54,345-54,349 (2002). VA again revised the criteria for evaluating spine disorders, effective September 26, 2003. See 68 Fed. Reg. 51,454-51,458 (2003). VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the Veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C.A. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. VA thus must consider the claim for a higher rating pursuant to the former and revised regulations. See VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Because the Veteran's claim was filed on March 29, 2002, it precedes the effective dates of the revised regulations (September 26, 2002, and September 23, 2003), and the Board will consider this claim under both the old and new regulations. Id. at 467; cf. VAOPGCPREC 3-2000 (which contemplates an appellate period that both precedes and succeeds the effective date of the regulatory change). Under former DC 5293, a 20 percent evaluation required moderate IVDS, with recurring attacks. A 40 percent evaluation contemplated severe IVDS, characterized by recurrent attacks with intermittent relief. Finally, a maximum evaluation of 60 percent evaluation required pronounced IVDS, with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of the diseased disc, and little intermittent relief. Under an amendment to the rating schedule effective on September 23, 2002, the rating formula for evaluating IVDS was changed. Under DC 5293, as amended, IVDS is evaluated either on the total duration of incapacitating episodes over the past twelve months, or by combining under 38 C.F.R. § 4.25 separate evaluations of its chronic orthopedic and neurologic manifestations along with evaluation of all other disabilities, whichever method results in the higher evaluation. The revised criteria provide that a 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks per year. A 40 percent rating requires that the disability be productive of incapacitating episodes having a total duration of at least four but less than six weeks per year. Finally, a maximum 60 percent rating is available when the condition is manifested by incapacitating episodes having a total duration of at least six weeks, during the past 12 months. For purposes of evaluations under revised Diagnostic Code 5293 (now 5243, see below), an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. In a precedent opinion dated December 12, 1997, the Acting General Counsel of the VA held that the criteria under DC 5293, which pertains to IVDS, "involves loss of range of motion because the nerve defects and resulting pain associated with injury to the sciatic nerve may cause LOM of the cervical, thoracic, or lumbar vertebrae." The Acting General Counsel clarified that a veteran cannot be evaluated under both DC 5293 for IVDS based in part upon LOM and DC 5292 (LOM of the lumbar spine) due to the provisions of 38 C.F.R. § 4.14 prohibiting the evaluation of "an identical manifestation under two different diagnoses." VAOPGPREC 36-97 (Dec. 12, 1997). Effective September 26, 2003, VA again revised the criteria for rating spinal disorders. These revisions consist of a new rating formula encompassing such disabling symptoms as pain, ankylosis, LOM, muscle spasm, and tenderness. These changes are listed under DCs 5235-5243, with DC 5243 now embodying the recently revised provisions of the former DC 5293 (for IVDS). Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under the appropriate DCs. 38 C.F.R. § 4.71a, DCs 5235 to 5243 and Note (1) A. Lumbar spine disability In its October 2007 rating decision granting service connection for lumbar spine stenosis, the RO assigned staged ratings under former DC 5293: 20 percent effective March 29, 2002; 40 percent effective February 4, 2003; and 20 percent effective June 10, 2003. Secondary to the lumbar spine disability, separate ratings of 20 percent and 10 percent have been assigned for radiculitis of the left lower extremity and right lower extremity, respectively. The Veteran contends that his disability is more severe than the currently assigned ratings and that he is entitled to a higher initial rating. Prior to the revisions, DCs 5289, 5292, 5293 (discussed above), and 5295 provided ratings for lumbar disability. Former DC 5289 provided ratings of 40 percent for favorable ankylosis of the lumbar spine and 50 percent for unfavorable ankylosis. Former DC 5292 provided that a 20 percent rating was warranted for moderate LOM of the lumbar spine and a maximum rating of 40 percent required severe LOM. Former DC 5295 provided that a 20 percent evaluation required muscle spasm on extreme forward bending and loss of lateral spine motion; a maximum rating of 40 percent was warranted when the disability was productive of severe disability manifested by listing of the whole spine to the opposite side, a positive Goldthwaite's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of joint space or some of the above with abnormal mobility on forced motion. Effective September 26, 2003, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 20 percent evaluation is warranted when forward flexion of the thoracolumbar spine is greater than 30 degrees, but not greater than 60 degrees; or, combined range of motion (ROM) of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted when forward flexion of the thoracolumbar spine is limited to 30 degrees or less, or where there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent evaluation is warranted when there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5242. The Court has noted that when rating spine disabilities, the Board must discuss any additional limitation of motion that a Veteran has due to pain, weakness, or fatigue. See Cullen v. Shinseki, 24 Vet. App. 74, 85 (2010). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. 38 C.F.R. § 4.71a, DCs 5235 to 5243, Note (2). In addition, as to the Veteran's bilateral low back sciatic radiculopathy, under Diagnostic Code 8520, a 10 percent evaluation is warranted for mild incomplete paralysis of the sciatic nerve; a 20 percent evaluation requires moderate incomplete paralysis of the sciatic nerve; a 40 percent evaluation requires moderately severe incomplete paralysis; a 60 percent evaluation requires severe incomplete paralysis with marked muscular atrophy; an 80 percent evaluation requires complete paralysis of the sciatic nerve. When there is complete paralysis, the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. Lumbar spine evidence VA treatment records show complaints of worsening low back pain in September 2000. The pain was so severe that the Veteran had difficulty sleeping. Examination showed some difficulty bending over but no spasm, positive straight leg raising test on the left, and no motor or sensory deficits in either lower extremity. In October 2000 he could forward flex to touch three inches below the knee. In May 2001 he had slightly decreased ROM of the low back and a steady gait. In November 2001 he had slight decrease of ROM with forward bending. In February 2002 his back pain was more severe but he had a fair ROM, slight decrease with flexion and extension. In May 2002 his spine was midline but he had a slight limp to the left. In June 2002 an MRI showed generalized disk bulging with L4-L5 disk protrusion and mild to moderate lumbar spondylosis. He had decreased lumbar ROM and limped slightly to the left. A PT note in the same month showed that low back pain was hindering the Veteran's daily activities, but he was independent with all functional mobilities and ambulated without assistive devices. In August 2002 the Veteran was continuing to work six days a week, eight hours per day as a post office supervisor. He reported that a TENS unit had not helped but he had no difficulty ambulating. On examination, he had decreased lumbar ROM but it was within normal limits. He was observed to rise slowly from a sitting position and ambulate gingerly, but his gait was within normal limits. Vicodin was maxed out, and Lorcet was added to Tylenol. Steroid facet joint injections in October 2002 and December 2002 relieved pain for 24 hours but he returned to baseline after two to three days. In November 2002 his spinal ROM was intact, but he ambulated in a stooping position due to back pain. A Certification of Medical Provider for leave under the Family and Medical Leave Act (FMLA), dated November 29, 2002 stated that due to "chronic degenerative disk disease (DDD) of the lumbar spine [the Veteran] requires bed rest and time off his feet one to two times a week due to exacerbation of back pain." The physician stated that this condition commenced approximately in 1995 and was likely to continue for the rest of his life. It would be necessary for him to work only intermittently or on a less than full schedule as a result of the condition, for life. The condition resulted in incapacitation one to two times per week, and would necessitate monthly epidural injection treatments. Moreover, when he was absent from work for treatment, he would be unable to perform work of any kind. In January 2003 his pain was at an 8/10 and 9/10. In February 2003 the Veteran reported that he could not walk for any length of time or lift anything, and he was planning to apply for disability retirement from the post office. On examination he had pain on flexion and extension. The record includes two restrictions from VA physicians, both dated in March 2003. Together they state that the Veteran was restricted to full bed rest from February 4, 2003 to June 9, 2003 due to chronic back pain. In a March 2003 lay statement he reported that he was unable to work at all due to his back pain. He had been off of work since February 4, 2003 on restrictions from his primary care physician. He had made a recent trip to the emergency room with 10/10 pain. Another March 2003 VA treatment record noted he was ambulating slowly. In his March 2003 application for federal employee disability benefits, he stated that he had severe pain in his lower back and down his legs. Steroid shots and facet blocks had not helped, and he could only stand or sit upright for 15 to 20 minutes before the pain required him to lie down. His current daily medication included 105mL of morphine and six Neurontin pills. His supervisor confirmed on that application that due to 1) the November 2002 Certification of Medical Provider and 2) the extensive restrictions given by his physicians beginning February 4, 2003, they had been unable to provide him with work. In May 2003 he reported that an epidural injection the prior month had no effect. In June 2003 there was decreased ROM of the lumbar spine but in August 2003 his ROM and gait were within normal limits. The Veteran reported in an October 2003 a lay statement that he had been prescribed a back brace and that his pain required him to constantly shift from sitting to standing to lying down all day and sometimes at night. At his March 2004 DRO hearing, the Veteran testified that without medication, his current pain could reach a 9/10 or 10/10, and it kept him awake at night. With medication it was reduced to a 3/10 or 4/10. He reported that he stopped working on November 25, 2002 because his back pain had become so disabling. He wore a back brace to the hearing and stated that he could not bend forward and touch below his knees without pain. He wore the brace when he was going to be out of the house for more than an hour, and when he was at home he spent more of his time in an adjustable recliner. He could not bend or squat. He could walk his dogs for six blocks every two or three days. The pain limited his driving because he could not sit in one place for more than 30 or 45 minutes. A private treatment record dated August 2004 showed the Veteran spent most of his day in his recliner and pain interfered significantly with his daily activities, including walking ability, daily housework, and sleep. He was taking hydrocodone, morphine, gabapentin, and felodipine, among other drugs, daily. On examination, his gait was normal, though he limped when ambulating on toes. ROM of the spine revealed flexion of 30 degrees, mildly decreased extension, and bilateral lateral flexion and lateral rotation were all "midway." The physician diagnosed chronic low back pain secondary to degenerative joint disease of the spine and left sacroiliac dysfunction. The Veteran underwent a VA spine examination in March 2007. He reported incapacitating low back pain with repetitive movement of his low back requiring him to modify his daily activities. He could not walk for more than 30 minutes, and had to rest the legs in a flexed posture. He was taking Neurontin, Vicodin, morphine, and diazepam. On examination, his low back was nontender along the midline, but tender along the SI joint on the left. He had a positive straight leg raise on the left. His ROM was forward flexion of 50 degrees, 10 degrees extension, and 15 degrees lateral bend. In March 2007 a lay statement, the Veteran's daughter stated that he could only remain active for one to two hours before having to lie down and rest due to excruciating back pain. His mobility had declined since 2001. A second VA examination was provided in May 2007. The examiner noted that the Veteran had been treated for chronic pain management through a VA pain clinic since 2002. The Veteran reported 100 to 120 exacerbations during the last 12 months. Each flare-up raised his back pain from a typical 3/10 (night) to 6/10 (daytime) up to 7/10 or 8/10. They lasted from several hours up to three days and during a flare-up he has to get off his feet and apply heat to the area. Back braces, TENS unit, and epidural injections offered little relief. His typical functional limitations were standing 15 to 20 minutes, walking one hour, driving 90 minutes, and sleep interruptions four times a week. These limitations had existed for two years. He could only lift 6 or 7 pounds. On physical examination, he had normal gait with no limp. Flexion was 60 degrees (with pain on repetition), extension was 20 degrees, lateral bending was 30 degrees bilaterally, and lateral rotation was 30 degrees bilaterally (pain at 20 degrees). His combined ROM was 200 (180 with pain). At a June 2008 VA general medical examination, the Veteran complained of increased cervical and lumbosacral spine pain that flared up with bending, lifting, or repetitive motion. On examination, there was pain to palpation at L4-5 and L5-S1. He had painful and limited ROM, with forward flexion limited to 65 degrees (60 on repetition), extension to 10 degrees (5 on repetition), bilateral flexion to 25 degrees, and bilateral rotation to 30 degrees. On repetition there was increased pain, easy fatigability and lack of endurance. His combined ROM was 185 (175 with pain). There was no spasm. X-ray and MRI showed multilevel DDD with disc bulging. The VA examiner diagnosed lumbosacral spine strain with multilevel DDD and spinal canal stenosis. He described the Veteran's spinal condition as "severe" and stated he had limited ability for any gainful job. Lay statements dated in May 2008 from the Veteran's daughters stated that he had to lie down every two to three hours and could not sit or stand for more than 10 to 15 minutes without being in extreme pain. He could not walk for extended periods of time, and would stumble even walking in the house. His pain impacted his driving, lifting, and walking, and he had to lie down most of the time. VA treatment records dated in March 2010 and April 2011 note that his back pain was stable. The February 2013 VA examiner diagnosed DDD of the lumbar spine, osteoarthritis of the lumbar spine, and lumbar spinal stenosis, based on physical examination and review of the claims file. The Veteran reported that flare-ups impacted the function of the thoracolumbar spine in that increased activity caused increased pain. ROM was limited to 60 degrees of forward flexion (pain beginning at 40 degrees), 20 degrees of extension (pain at 0 degrees), 25 degrees right lateral flexion (pain at 0 degrees), 20 degrees left lateral flexion (pain at 0 degrees), and 20 degrees bilateral rotation (pain at 20 degrees on the right and 15 degrees on the left). On repetition, flexion ended at 40 degrees, extension at 10 degrees, bilateral flexion at 20 degrees, and bilateral rotation at 20 degrees. Thus, his combined lumbar ROM was 165 degrees and 130 degrees on repetition. After repetition, the VA examiner found additional limitation of ROM and functional loss, namely: less movement than normal, excess fatigability, pain on movement, disturbance of locomotion, and interference with sitting, standing, and/or weightbearing. On physical examination, there was also tenderness of L4-5 with lumbar paravertebral tenderness and spasm. There was guarding or muscle spasm of the lumbar spine that was severe enough to result in abnormal gait. The Veteran used a wheelchair occasionally and a cane constantly. The VA examiner concluded that the Veteran "is no longer able to sit, stand, or walk for any period of time," which impacted his ability to work. Neurological impairment evidence A VA treatment record dated September 2000 showed an assessment of backache with sciatica on the left side. In August 2002 the Veteran reported radiation of pain to both legs and numbness in both heels. In November 2002 he continued to complain of pain from the left hip to left toes. A March 2003 VA treatment record noted he had bilateral sciatica with his low back pain. At his March 2004 hearing he testified his left foot was numb from the arch to the back of the heel. There was tingling only at the middle of the arch, but the rest was just numb. The pain went from his left buttock down the outside of the leg to the heel. In an August 2004 private treatment record he reported some pain in the right buttock and right anterior and posterior thigh, and that the left heel was constantly numb. The physician diagnosed possible chronic L5-S1 radiculopathy based on physical examination and reported symptoms, and prescribed Lexapro. A February 2006 VA treatment record showed a prescription of morphine for lumbago with radiculopathy. At the March 2007 VA examination, he reported pain shooting through his posterior and lateral left leg and posterior calf into the bottom of his foot. He could not walk for more than 30 minutes, and had to rest the legs in a flexed posture. Numbness and tingling were fairly constant in the bottom of the left foot. He had notably decreased hip flexor strength bilaterally, and decreased sensation over his left posterior calf, popliteal space, and plantar surface of the left foot. Otherwise his sensation was intact, including his entire right lower extremity. The VA examiner found "obvious radiculopathy on the left side with associated numbness and tingling in the pattern of an L4-5 nerve compression." At the June 2008 VA general medical examination, physical examination showed antalgic gait and he was limping on the left leg with use of a cane. The limp was due to radiating low back pain to the left lower extremity and left knee chronic pain. The examiner diagnosed radiculitis in the left leg. In a lay statement received in February 2009, the Veteran stated, "I was able to walk and exercise some before April 2008 but since then my left leg hurts all the time." (Emphasis in original.) He reported that he had to sit or lie down 98 percent of the time and could get no exercise. If he walked for 400 feet, he had to use a cane. However, an October 2008 VA treatment note states that he is able to walk three miles per day. At an October 2009 VA psychiatric examination, he used a cane at the appointment and stated that he had to lie down 8-10 hours a day. His pain was at a 7/10 on a daily basis. In a November 2009 VA treatment record, the Veteran was concerned that his left leg would collapse while he was walking because for the last month it had intermittently just been "go[ing] dead." There was no pain associated with these incidents. The physician noted worsening leg weakness. The February 2013 VA examiner diagnosed lumbar radiculopathy based on physical examination and review of the claims file. The date of diagnosis was unknown, but the Veteran reported low back pain regularly radiating to the left leg in the 1990s. On sensory examination, sensation to light touch was absent bilaterally in the lower leg/ankle (L4/L5/S1) and foot/toes (L5). Straight leg raising test was positive bilaterally. The VA examiner found intermittent pain in the left leg (moderate) and right leg (mild), paresthesias and/or dysesthesias in the left leg (moderate) and right leg (mild), and numbness in the left leg (moderate) and right leg (mild). There was no constant pain in the right leg, but the left leg had moderate constant pain. The VA examiner found that the sciatic nerve was involved, resulting in mild radiculopathy in the right leg, and moderate radiculopathy in the left leg. Analysis Based on the foregoing evidence and resolving all doubt in favor of the Veteran, the Board finds that he is entitled to a rating of 60 percent disability for lumbar spine disability throughout the entire appeal period. A 60 percent rating under old DC 5293 is warranted for pronounced IVDS, with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of the diseased disc, and little intermittent relief. In this case, the Veteran showed persistent symptoms compatible with sciatic neuropathy as early as September 2000, and consistently thereafter. There is evidence of pronounced IVDS with characteristic pain and little intermittent relief on November 29, 2002, when the Certification of Medical Provider stated that the Veteran was having incapacitating episodes one to two days a week that necessitated bed rest. The Veteran never worked after November 2002 because his back pain had become so disabling. From February 4, 2003 to June 9, 2003, he was restricted from work for bed rest. After February 4, 2003, he never returned to work and his treatment records show that his pain consistently kept him from sitting, standing, or walking for more than a short period of time. The evidence does not suggest that his pain or functional limitations have improved since November 2002. Rather, his pain is constant, with regular flare-ups to a severe level of pain, and he cannot stay in one position for very long before he has to shift. Epidural injections and a TENS unit provide little to no relief. His pain has been managed with varying success via medication since 2002. The 2008 VA examiner described his condition as severe, and treatment records in 2010 and 2011 show that it has remained stable at that level. By February 2013, the Veteran was using a cane all the time, and a wheelchair occasionally. The 2013 VA examiner concluded that the Veteran "is no longer able to sit, stand, or walk for any period of time." Lay statements from the Veteran and his family members consistently show that he has to spend most of his time in a recliner due to pain and has difficulty ambulating. The Board finds that this evidence shows a pronounced lumbar spine disability with little intermittent relief. In reaching this determination, the Board observes that in Jones v. Shinseki, 26 Vet. App. 56 (2012), the Court recently held that VA committed legal error when it considered the ameliorative effects of medication on the Veteran's disability where those effects were not explicitly contemplated by the rating criteria. Thus, the Court held that where, as here, a Diagnostic Code is silent as to the effects of medication, VA may not deny entitlement to a higher disability rating based on the relief provided by medication. Id. The record shows that the Veteran's lumbar disability has been treated with significant regimen of medication, including at various points: a TENS unit, Tylenol, Vicodin, Lorcet, facet blocks, steroid injections, morphine, Neurontin, hydrocodone, gabapentin, felodipine, and diazepam. In light of Jones, because the Veteran receives treatment for his lumbar spine disability, the Board, resolving all reasonable doubt in his favor, concludes that without such treatment his disability would most closely approximate pronounced IVDS with little intermittent relief. Moreover, from February 2003 to June 2003, for roughly 18 weeks, the Veteran was on bed rest prescribed by his physician. He therefore also qualifies for a 60 percent disability rating for this period under revised DC 5423. The physician who completed the November 2002 Certification of Medical Provider stated that the Veteran's low back condition would cause incapacitating episodes one to two days a week for the rest of his life. The Veteran currently has separate ratings for his bilateral radiculopathy. Because he is now being evaluated under the DC for IVDS, which contemplates sciatic symptoms, separate ratings can no longer be assigned for his bilateral radiculopathy. 38 C.F.R. § 4.14. If the Board were to assign ratings separately for lumbar spine disability and bilateral radiculopathy, the outcome would not be beneficial to the Veteran. Removing the sciatic symptoms from consideration, the highest rating available to the Veteran for his lumbar spine disability would be 40 percent, even when pain and the DeLuca factors are considered. The evidence shows moderate paralysis of the sciatic nerve in the left lower extremity, and mild paralysis of the sciatic nerve in the right lower extremity, which would warrant 20 and 10 percent ratings, respectively. The Veteran would not be entitled to higher ratings under DC 8520 for either lower extremity because the schedule of ratings states that "when the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree." The evidence shows only sensory involvement, and therefore a rating in excess of the moderate degree is not appropriate for either leg. The application of the bilateral factor contained in 38 C.F.R. § 4.26 and the combined ratings table in 38 C.F.R. § 4.25 would yield a 31 percent for his bilateral radiculopathy, which when rated with the 40 percent for lumbar spine disability, would result in a 58 percent combined rating, which is less than a single 60 percent evaluation. Thus, rating the Veteran's lumbar spine disability under the former criteria is most beneficial to him. Additionally, there is no evidence of bowel, bladder, or other objective neurologic abnormalities associated with the spinal disability that would warrant separate evaluations. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). The Veteran specifically denied bowel or bladder functional loss in November 2002 and March 2009 VA treatment notes, and the 2013 VA examiner found no bowel or bladder problems. The Board has also considered whether evaluation of the Veteran's disability under any other former or revised DC could result in an evaluation higher than 60 percent. Pursuant to the former criteria, because the evidence is negative for any cord involvement or evidence of a fractured vertebra or ankylosis of the whole spine, there is no basis for a higher evaluation. Similarly, because a 60 percent rating is the maximum evaluation available under Diagnostic Code 5243, and since the veteran does not have unfavorable ankylosis of the whole spine, an evaluation in excess of 60 percent is not warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (2009). B. Cervical spine disability In its October 2007 rating decision granting service connection for cervical spine spondylosis, the RO assigned staged ratings under current DC 5242: 10 percent effective March 29, 2002, and 20 percent March 10, 2007. The Veteran contends that his disability is more severe than the currently assigned ratings and that he is entitled to a higher initial rating. Prior to the revisions, DCs 5287, 5290, and 5293 (discussed above) provided ratings for cervical spine disability. Former DC 5287 provided ratings of 30 percent for favorable ankylosis of the cervical spine and 40 percent for unfavorable ankylosis. Former DC 5290 provided that a 10 percent rating was warranted for slight LOM of the cervical spine, a 20 percent rating was warranted for moderate LOM, and a maximum rating of 30 percent required severe LOM. Effective September 26, 2003, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 10 percent evaluation is warranted when forward flexion of the cervical spine is greater than 30 degrees but not greater than 40 degrees; or combined ROM of the cervical spine is greater than 170 degrees but not greater than 335 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted when forward flexion of the cervical spine is greater than 15 degrees, but not greater than 30 degrees; or, combined ROM of the cervical spine is not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent evaluation is warranted when forward flexion of the cervical spine is limited to 150 degrees or less, or where there is favorable ankylosis of the entire cervical spine. A 100 percent rating is warranted when there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5242. VA treatment records show that in February 2002 the Veteran reported his neck burning, especially on the left side. His cervical ROM was good with slight decrease of extension. He had pain with lateral movement, and x-rays showed some osteoarthritis. He was diagnosed with cervicalgia. In March 2002 at a physical therapy (PT) appointment he had burning, stinging pain the neck. His flexion was described as "3 fingers pain" and his extension "30% pain stinging." Right rotation was "50% pulling on left" and left rotation was "50% pulling stinging on left." After a PT session, this improved to "1 finger no pain" on flexion, "50% slight pull" on extension, 90% right rotation and 80% left rotation. At his March 2004 hearing, he testified that he had arthritis in his neck and it was a burning sensation like fire. He stated he could not turn his neck very far. At the March 2007 VA examination, he reported burning pain in the neck, and decreased motion with pain at the extreme of the motion, especially side-to-side. It was relatively non-incapacitating compared to his low back. On examination, he was tender to palpation at C6-7, with a ROM of 30 degrees forward flexion, 18 degrees extension, 18 degrees left lateral bend (13 on repetition), 20 degrees right lateral bend (15 on repetition), and 45 degrees bilateral rotation (40 on repetition). Thus his combined cervical spine ROM was 176 degrees (156 on repetition). The VA examiner found he had quite a bit of pain with cervical motion, but there was no obvious neural dysfunction at that level. He felt there was cervical spondylosis. The Veteran reported to the May 2007 VA examiner that he had 35 cervical pain flare-ups in the last 12 months. They were characterized by pain at a 9/10 to 10/10. At the June 2008 VA general medical examination, the Veteran complained of increased cervical spine pain that flared up with repetitive motion. On examination, there was pain on palpation at C5-6 with painful and mild limitation of ROM. Forward flexion was 40 degrees, extension was 35 degrees, bilateral flexion was 45 degrees, and bilateral rotation was 80 degrees. On repetition, there was increased pain, easy fatigability, and lack of endurance but no change of ROM. There was no spasm of the paravertebral muscles. X-ray showed spondylosis and DDD. Lay statements dated in May 2008 from the Veteran's daughters stated that he frequently complained of burning pain in the neck. The 2013 VA examiner diagnosed DDD of the cervical spine and osteoarthritis of the cervical spine based on physical examination and review of the claims file. The Veteran reported that flare-ups impacted the function of his cervical spine in that symptoms increased with changes in the weather. ROM was limited to 40 degrees of forward flexion, 40 degrees of extension, 20 degrees right lateral flexion, 10 degrees left lateral flexion, 50 degrees right lateral rotation, and 15 degrees left lateral rotation. Pain began at 0 degrees in every measurement. On repetition, ROM remained the same, with the exception of the lateral rotation, which decreased to 30 degrees on the right and 10 degrees on the left. Thus, his combined cervical spine ROM was 175 degrees and 150 degrees on repetition with pain beginning at 0 degrees. After repetition, the VA examiner found additional limitation of ROM and functional loss, namely: less movement than normal, weakened movement, excess fatigability, and pain on movement. On physical examination, there was localized tenderness of the joints/soft tissue of the cervical spine, but no guarding or muscle spasm. There was no radicular pain or other signs or symptoms due to radiculopathy of the upper extremities. Based on the foregoing evidence and resolving all doubt in favor of the Veteran, the Board finds that he is entitled to a 30 percent disability evaluation for cervical spine disability. A 30 percent rating under former DC 5290 is warranted for severe LOM of the cervical spine. In March 2007, the Veteran's ROM was limited, at most, to 30 degrees forward flexion, 18 degrees extension, 13 degrees left lateral flexion, 15 degrees right lateral flexion, and 40 degrees bilateral rotation. Considering DeLuca factors, he consistently reported burning pain in his neck, and by February 2013 he had pain at 0 degrees with every ROM measurement. Repetition resulted in additional functional loss and limitation of ROM, including less movement than normal, weakened movement, excess fatigability, and pain on movement. VA treatment records dated prior to March 2007 do not contain any numeric measurements of ROM. However, resolving all doubt in favor of the Veteran, the Board finds that he is entitled to a 30 percent disability evaluation for the entire appeal period. The Board has also considered whether evaluation of the Veteran's disability under any other former or revised DC could result in an evaluation higher than 30 percent. Pursuant to the former criteria, because the evidence is negative for pronounced IVDS with persistent symptoms compatible with neurological findings, any cord involvement, evidence of a fractured vertebra, or ankylosis of the whole spine, there is no basis for a higher evaluation. Similarly, because a 30 percent rating is the maximum evaluation available under Diagnostic Code 5242, and since the Veteran does not have unfavorable ankylosis of the entire cervical spine or entire spine, an evaluation in excess of 30 percent is not warranted under the revised criteria. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert. Finally, there is no evidence of objective or subjective neurologic abnormalities associated with the cervical spine disability that would warrant separate evaluations. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). The March 2007 VA examiner found no obvious neural dysfunction, and the 2013 VA examiner found no radicular pain or other signs or symptoms due to radiculopathy of the upper extremities. C. Other considerations The Board has considered whether staged ratings are appropriate for the Veteran's service-connected disabilities. However, the Board finds that the Veteran's overall symptomatology has been stable throughout the appeal period. Thus, staged ratings are not warranted. Fenderson; Hart. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria contemplate the Veteran's disabilities. The Veteran's lumbar spine disability is characterized by pronounced IVDS, with persistent symptoms compatible with sciatic neuropathy with characteristic pain and little intermittent relief. However, there is no vertebral fracture, cord involvement, ankylosis, or bowel or bladder impairment. His cervical spine disability is characterized by severe LOM. These manifestations are contemplated in the applicable rating criteria. Further, the additional functional effects of painful motion of the lumbar and cervical spine are contemplated in his current 60 percent and 30 percent evaluations under DeLuca. In sum, the Board finds that the Veteran has not described other functional effects that are "exceptional" or not otherwise contemplated by the assigned evaluation. Rather, his descriptions of lumbar and cervical spine symptoms are consistent with the degrees of disability addressed by such evaluations. The rating criteria are therefore adequate to evaluate the Veteran's disabilities and referral for consideration of extraschedular ratings is not warranted. The RO awarded a TDIU in a March 2010 rating decision, effective July 23, 2009. After the Board remanded the case for further development, in a July 2013 rating decision the RO assigned a May 13, 2003, effective date for the TDIU. However, as TDIU is an aspect of a claim for a higher rating, a claim for a TDIU has been pending since the Veteran appealed the initial ratings assigned for his service-connected lumbar and cervical spine disabilities. Rice v. Shinseki, 22 Vet. App. 447 (2009). The evidence shows that the Veteran's last day of work was either November 25, 2002 (see the Veteran's hearing testimony) or November 29, 2002 (see the May 2003 application for a TDIU), and that he stopped working because of his back disability. The "Certification of Medical Provider for leave under the FMLA" is also dated November 29, 2002. The 2013 VA examiners opined that the Veteran was unable to work due to his service-connected lumbar spine disability. Thus, the Board finds that the evidence shows he was unable to secure or follow a substantially gainful occupation due to his lumbar spine disability beginning on November 29, 2002. Payment of monetary benefits based, as here, on an award of compensation, may not be made for any period prior to the first day of the calendar month following the month in which the award became effective, i.e., December 1, 2002. See 38 U.S.C.A. § 5111(a) (West 2002); 38 C.F.R. § 3.31 (2013). Thus, whether the final day the Veteran worked was November 25 or November 29 is not critical, as both dates result in an initial payment date of December 1, 2002. The Board finds that the Veteran is entitled to a TDIU effective November 29, 2002. ORDER The claim of entitlement to service connection for bone spurs in both feet is dismissed. Subject to the law and regulations governing payment of monetary benefits, effective April 29, 2002, a 60 percent rating for lumbar spine disability is granted. Subject to the law and regulations governing payment of monetary benefits, effective April 29, 2002, a 30 percent rating for cervical spine disability is granted. Subject to the law and regulations governing payment of monetary benefits, an effective date of November 29, 2002, for the award of a TDIU is granted. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs