Citation Nr: 1333687 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 09-15 840 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for a low back disability. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Bridgid D. Cleary, Counsel INTRODUCTION The Veteran served on active duty from December 1952 to December 1954. This matter came before the Board of Veterans' Appeals (Board) on appeal from a May 2007 rating decision of the Columbia, South Carolina, Department of Veterans Affairs (VA) Regional Office (RO), which declined to reopen a previously denied claim of service connection for a back disability. The Veteran testified at a RO hearing in March 2009, and at a Board hearing before the undersigned Acting Veterans Law Judge in July 2010. Transcripts of the hearings are associated with the claims file. In October 2010, the Board reopened the Veteran's claim and remanded the underlying service connection issue for further development. In a June 2011 decision, the Board denied the Veteran's claim and he appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a July 2012 Memorandum Decision, the Court vacated the June 2011 Board decision, and remanded the case to the Board for further appellate review. This matter was remanded in March 2013. At the beginning of the appeal, the Veteran was represented by the American Legion (AL). In July 2011, he signed a VA Form 21-22a appointing attorney Mark Lippman as his representative. In November 2011, the attorney filed a Motion to Withdraw and provided notice to the Veteran. The Court granted the motion later that month. The Veteran has not appointed another representative. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this case should take into consideration the existence of this electronic record. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The competent and credible evidence does not show that the Veteran's low back disability is related to his military service. CONCLUSION OF LAW The Veteran does not have a back disability that is the result of disease or injury incurred in or aggravated by active military service; nor may it be presumed to have been incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Proper notice from VA must inform the claimant of any information and 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 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim. Accordingly, notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent a letter in March 2007 that provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. The letter also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record, including testimony provided at a July 2010 hearing before the undersigned. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. In compliance with the Board's October 2010 remand, VA provided the Veteran with a medical examination in November 2010. This examiner reviewed the objective evidence of record, documented the Veteran's current complaints, performed a thorough clinical evaluation, and then offered an opinion as to the nature of the claimed disability, accompanied by a rationale. Therefore, this examination is adequate for VA purposes. In compliance with the Board's March 2013 remand, VA sought Social Security Administration (SSA) records related to his reported disability claim. In a July 2013 response, SSA stated that there were no records related to the Veteran as he did not file for SSA disability benefits. Thus VA has complied with the October 2010 and March 2013 remand instructions. Stegall v. West, 11 Vet. App. 268 (1998). The Court has held that that provisions of 38 C.F.R. § 3.103(c)(2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: The duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). At the hearing the undersigned identified the issue, sought information as to treatment to determine whether all relevant records had been obtained, and sought information as to the onset of the disability. The Board thereby met the duties imposed by 38 C.F.R. § 3.103(c)(2) as interpreted in Bryant. Moreover, the Veteran has not asserted that VA failed to comply with these duties; he has not identified any prejudice in the conduct of the Board hearing. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claim. 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); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Criteria & Analysis Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. 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). Additionally, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if manifested to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also 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). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); see also 38 C.F.R. § 3.303(a). The existence of a current disorder is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that VA's and the Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disorder for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). That a condition or injury occurred in service alone is not enough; there must be disability resulting from that condition or injury. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). In the absence of proof of a present disability, there can be no valid claim or the grant of the benefit. Id. Under § 3.303(b), an alternative method of establishing the second and/or third Caluza element is through a demonstration of continuity of symptomatology. See Savage v. Gober, 10 Vet. App. 488 (1997); see also 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 postservice continuity of the same symptomatology; and (3) medical or, in certain circumstances lay evidence of a nexus between the present disability and the postservice symptomatology. Savage, 10 Vet. App. at 495-96; 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 provisions concerning continuity of symptomatology do not relieve the requirement that there be some evidence of a nexus to service. For service connection to be established by continuity of symptomatology there must be competent medical or other evidence that relates a current condition to that symptomatology. See Savage 10 Vet. App. at 495-98 (1997). With regard to the medical opinions of record, where the Board is presented with conflicting medical evidence, it is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Court has held that the Board must determine how much weight is to be attached to each medical opinion of record. See Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one medical professional's opinion over another, depending on factors such as reasoning employed by the medical professionals and whether or not, and the extent to which, they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994); see also Wensch v. Principi, 15 Vet. App. 362, 367 (2001) (it is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons and bases). Adequate reasons and bases, in short, must be presented if the Board adopts one medical opinion over another. In assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other 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. See Prejean v. West, 13 Vet. 444, 448-9 (2000). In some cases, the physician's special qualifications or expertise in the relevant medical specialty or lack thereof may be a factor. In every case, the Board must support its conclusion with an adequate statement of its reasoning of why it found one medical opinion more persuasive than the other. It is the Board's responsibility to evaluate the entire record on appeal. 38 U.S.C.A. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. In this case, the Veteran seeks service connection for a back disability. As previously mentioned, the first and most fundamental element of any service connection claim is the existence of the claimed disorder. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). Here, the Veteran has received several diagnoses concerning his back disorder including complaints of chronic low back pain since September 1983, lumbar myalgia in August 1985, and degenerative arthritis of the thoracolumbar spine in November 2010, according to the VA compensation examiner. Therefore, he clearly meets this first requirement of service connection. A March 1953 service treatment record reflects complaints of pain in the lumbar area for the past 4 months. A July 1954 service treatment record reflects that the Veteran had a right hip fracture in January 1953. He complained of pain and stiffness in his hip. On physical examination, his right hip had normal motion. A back examination was negative. There was pain over the right sacroiliac joint. X-rays of the hip and sacroiliac joints was negative. The impression was "Probably had a low back strain. Negative now." He was discharged to regular duty. An October 1954 service treatment record reflects a low back strain. The Veteran's December 1954 separation examination failed to note any residuals of the prior low back complaints and his spine was clinically evaluated as normal. In a letter dated in April 1984, the Veteran's now-deceased private physician, Dr. W.H.Y., stated that he had treated the Veteran since childhood for various ailments. Dr. W.H.Y. stated that during the Veteran's service he fell from a truck injuring his back and right leg. He has suffered from these conditions off and on since. Dr. W.H.Y. stated that he treated the Veteran in January 1983 for both ailments and in April 1984, at which time he came in using a cane and complaining of a urinary condition. Also of record are the Veteran's VA treatment records, dated March 1983 to March 1996 and April 2006 to June 2010. The first medical documentation of post-service back pain was in September 1983. In October 1983, the VA treating physician again noted complaints of back pain but specifically found no history of trauma to account for the Veteran's pain. However, the Board recognizes the Veteran's continuous treatment for this disorder since March 1983, and from January 1983 with his private physician. Moreover, the Veteran competently testified to experiencing back pain in service at the Board hearing. But while it is conceded that the Veteran experienced back problems during service, the objective medical evidence does not reflect that he sought post-service treatment for his back problems until over 28 years after separation from service. Thus despite problems experienced during service, the post-service evidence lacks a continuity of subjective and objective symptomatology. The lack of continuity of treatment may bear in a merits determination on the credibility of the evidence of continuity of symptoms by lay parties. Savage v. Gober, 10 Vet. App. 488, 496 (1997). In this regard, the Board notes first that the absence of any evidence of a back disability for over 28 years after discharge from service, or of persistent symptoms related to the back between service-discharge until 1983 and thereafter constitutes negative evidence tending to disprove the claim that the Veteran developed this disability as a result of his in-service problems. See Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom. Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (noting that the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact); see also 38 C.F.R. § 3.102 (noting that reasonable doubt exists because of an approximate balance of positive and "negative" evidence). The lack of any evidence of continuing back symptomatology for 28 years between the period of active duty and the evidence showing a back disability is itself evidence which tends to show that his disability was not incurred as a result of service. Moreover, there is no medical evidence showing that his back disability manifested to a degree of 10 percent or more within one year from the date of separation from active service, and therefore service connection for back disability may not be presumed to have had its onset in service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). While acknowledging the statement of Dr. W.H.Y., this statement appears to be based on the Veteran's self-reported and unsubstantiated history. While the Veteran did incur back symptoms during service and may have incurred back injury falling from a truck (although this is not reflected in the service treatment records), the service treatment records reflect a negative examination in July 1954 and no residuals were shown on examination for separation purposes in December 1954. While the Veteran reported suffering from these conditions off and on since service, Dr. W.H.Y. indicated that the Veteran was not examined for his back condition until January 1983, thus over 28 years after separation from service. Thus, such statement cannot provide the bases for a continuity of symptomatology. A March 2009 letter from a VA treating physician, Dr. R.C., stated the Veteran had a very long history of chronic low back pain, slowly worsening over the years, with degenerative changes of the spine, osteoporosis, and a history of an L-4 compression fracture. Dr. R.C. further stated that whether the Veteran's on-going back problem may be attributable to his in-service treatment and more specifically, to his military service, he cannot be certain one way or another but it is a "distinct possibility." However, a statement like this that, for all intents and purposes, is equivocal or inconclusive as to the origin of a disorder generally cannot be employed as suggestive of a linkage between the disorder and the Veteran's military service. See, e.g., Warren v. Brown, 6 Vet. App. 4, 6 (1993); Sklar v. Brown, 5 Vet. App. 104, 145-6 (1993). There are indeed a line of precedent cases discussing the lesser probative value of opinions like this that are equivocal, in various contexts, which essentially state that it is possible that what posited is true. Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Perman v. Brown, 5 Vet. App. 227, 241 (1993); Winsett v. West, 11 Vet. App. 420, 424 (1998); see, too, Bloom v. West, 13 Vet. App. 185, 187 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). But all of that said, an absolutely accurate determination of etiology is not a condition precedent to granting service connection, nor is definite or obvious etiology. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). That is to say, use of cautious language does not always express inconclusiveness in a doctor's opinion. Rather, the opinion should be viewed in its full context and not characterized solely by the medical professional's choice of words. See Lee v. Brown, 10 Vet. App. 336, 338 (1997). A recent precedent case admonished the Board for relying on medical opinions that were unable to establish this required linkage, that is, without resorting to mere speculation, as cause for denying claims. See Jones v. Shinseki, 23 Vet. App. 382 (2010). In Jones, the Court noted it was unclear whether the examiners were unable to provide this requested definitive medical comment on etiology because they actually were unable to since the limits of medical knowledge had been exhausted or, instead, for example, needed further information to assist in making this determination (e.g., additional records and/or diagnostic studies) or other procurable and assembled data. The Court in Jones acknowledged there are instances where a definitive opinion cannot be provided because required information is missing or can no longer be obtained or current medical knowledge yields multiple possible etiologies with none more likely than not the cause of the claimed disability. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (noting the Board need not obtain further medical evidence where the medical evidence "indicates that determining the cause is speculative"). The Court in Jones held, however, that in order to rely upon a statement that an opinion cannot be provided without resort to mere speculation, it must be clear that the procurable and assembled data was fully considered and the basis for the opinion must be provided by the examiner or apparent upon a review of the record. Given the fact that the Veteran has current treatment associated with this disorder, the in-service notations concerning low back pain, and the Veteran's assertions with regard to his in-service and post-service symptoms, the Board, in October 2010 found that a VA examination that included a competent nexus opinion was warranted. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); see McLendon v. Nicholson, 20 Vet. App. 79 (2006). This examination was conducted in November 2010. Upon physical examination, the examiner noted the Veteran requires the use of a cane but seems to have symmetry between his cervical and lumbar spines, without any obvious scoliosis. Further, the Veteran maintained a position of 20 degrees flexion, which was noted as a fixed deformity compatible with compression fractures. The examiner opined that the Veteran's back disorder is less likely as not caused by or the result of the Veteran's active military duty. The examiner indicated that the Veteran's claims file had been reviewed in connection with the examination and report. The Veteran's medical history was noted for the record. These findings, which admittedly, alone, are not dispositive of the opinions probative value according to the holding in Nieves-Rodriguez. But equally significant, this examiner also performed a personal clinical evaluation of the Veteran to assess his physical status, so the Board finds this opinion constitutes compelling evidence against the claim for service connection. See Wray v. Brown, 7 Vet. App. 488, 493 (1995) (holding that the adoption of an expert medical opinion may satisfy the Board's statutory requirement of an adequate statement of reasons and bases if the expert fairly considered the material evidence seemingly supporting the Veteran's position). The Board finds that the opinion of this November 2010 VA examiner is more probative than Dr. R.C.'s because the VA examiner's opinion is in more conclusive language ("more likely than not...without indication of exacerbation"), whereas Dr. R.C.'s opinion is equivocal ("cannot be certain" and "distinct possibility"). See Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches.... As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [Board as] adjudicators. . ."); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence.). Likewise, Dr. R.C.'s opinion was not supported by any clinical evidence or rationale. There also is no indication that Dr. R.C. was privy to the Veteran's claims file for a comprehensive view of the Veteran's clinical history. In assessing the probative value of this opinion, the Board notes that the failure of a physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Tokens v. West, 11 Vet. App. 379, 382 (1998). Other 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. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The Board has considered the Veteran's contention that a relationship exists between his current back disability, and his complaints in service. In adjudicating this claim, the Board must assess the Veteran's competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368- 69 (2005). In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court, citing Layno v. Brown, 6 Vet. App. 465, 467-69 (1994), emphasized that lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge. See also 38 C.F.R. § 3.159(a)(2) (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person). In this capacity, the Board finds the Veteran is competent to attest to his in-service complaints and symptomatology, and find his assertions credible. The Veteran, however, is not competent to provide an opinion that his current back disability is due to his service as he does not have the requisite medical expertise. Although it is conceded that he had in-service back problems during service, the fact remains that his back disability was not shown until over 28 years after separation from service. The VA examiner considered the Veteran's assertions in offering an etiological opinion but determined that it was not likely that his back disability was due to service. The VA examiner was aware of the Veteran's in-service problems based on the Veteran's statements and review of the claims folder, but concluded that his back disability was not due to service. The Veteran's contentions are outweighed by the medical evidence and opinion of the VA medical examiner which reflect that his back disability is not due to service. The negative clinical and documentary evidence post service for decades after service is more probative than the remote assertions of the Veteran. Again, the lack of continuity of treatment may bear in a merits determination on the credibility of the evidence of continuity of symptoms by lay parties. Savage v. Gober, 10 Vet. App. 488, 496 (1997). In sum, the Board is left with no documented complaints or findings of back disability until over 28 years after service, and a medical opinion to the effect that such back disability is not etiologically related to service. The questions involved regarding causation are medical in nature. As discussed above, the medical opinion of the VA medical examiner (based on a review of the claims file and with knowledge of the Veteran's in-service duties and in-service complaints) were negative, and are more probative than the Dr. R.C.'s opinion for the reasoning discussed herein. Under these circumstances, the Board is unable to find that there is a state of equipoise of the positive evidence and negative evidence. The preponderance of the evidence now of record is against the Veteran's claim of service connection for back disability . ORDER Service connection for a low back disability is denied. ____________________________________________ M. W. KREINDLER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs