Citation Nr: 1334142 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 10-03 094 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUE Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1968 to January 1970. This appeal to the Board of Veterans' Appeals (Board) arises from a rating decision of the New York, New York Regional Office (RO) of the Department of Veterans' Affairs (VA). In August 2011 a Board hearing was held at the RO before a Veteran's Law Judge (VLJ) who is no longer with the Board; a transcript of the hearing is of record. In November 2012, this issue was remanded in order to afford the Veteran an opportunity to provide testimony before the undersigned VLJ. In May 2013, he was afforded a Travel Board hearing and a transcript has been associated with the Virtual VA electronic claims file. Subsequent to the issuance of the September 2012 statement of the case, the Veteran submitted additional evidence in May 2013, for which a waiver of initial RO consideration was provided. FINDINGS OF FACT 1. For the entire rating period, PTSD has been manifested by depressed mood, anxiety, and chronic sleep impairment characterized by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. For the entire rating period, PTSD has not resulted in occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for an initial rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). However, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3. While a veteran's entire history is reviewed when assigning a disability evaluation, where service connection has already been established and an increase in the rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). In determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. At the outset, the Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Board must review the entire record, but does not have to discuss each piece of evidence. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate. The Veteran is in receipt of a 30 percent rating for PTSD under DC 9411. A 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, or for the veteran's own occupation or name. In applying the above criteria, the Board notes that, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See 38 C.F.R. § 3.102 (2013); Mittleider v. West, 11 Vet. App. 181 (1998) (citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so, but may not disregard such evidence of differentiation in the record)). In determining the level of impairment under 38 C.F.R. § 4.130, a rating specialist is not restricted to the symptoms provided under the diagnostic code, and should consider all symptoms which affect occupational and social impairment, including those identified in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed. 1994) (hereinafter DSM- IV). See Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that a claimant suffers symptoms or effects that cause an occupational or social impairment equivalent to those listed in that diagnostic code, the appropriate, equivalent rating is assigned. Id. Within the DSM-IV, Global Assessment Functioning (GAF) scale scores ranging from 1 to 100, reflect "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family arguments); resulting in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind school work). GAF scores from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech which is at times illogical, obscure, or irrelevant) or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood (e.g. a depressed patient who avoids friends, neglects family, and is unable to do work). In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). After a review of all the evidence, lay and medical, the Board finds that for the entire rating period, the Veteran's psychiatric symptoms result in occupational and social impairment occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks with reduced reliability and productivity as indicated for a 30 percent rating under DC 9411. In a February 2001 VA examination, the Veteran reported symptoms of irritability, startled response, avoidance of violent movies, and intrusive memories relating to combat in Vietnam. Upon mental status examination, mood was depressed with congruent affect. Suicidal and homicidal ideations were denied. Thinking was noted as logical an goal-oriented without evidence of underlying thought disorder. He denied hallucination and delusion. Although some periods of anxiety were reported, panic attacks were denied. The examiner found that the Veteran did not meet the DSM-IV criteria for PTSD, but diagnosed depressive disorder. A GAF score of 68 was assigned, reflecting some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. See DSM-IV at 46-47 VA treatment records reflect that in July 2007 the Veteran reported flashbacks from his time in Vietnam. During the July 2007 evaluation, he was alert and oriented, with coherent and normal speech. He became tearful when discussing the killing of innocent people in Vietnam. He stated that his family noticed a change in him when he returned from Vietnam. He reported increased startled response and irritability. He also reported working full-time, having a good relationship with his wife, children and grandchildren. The evidence of record also includes various letters and a March 2008 report from S.R., a certified trauma therapist and PTSD expert from the Institute for Crime and Trauma Survivors. In a March 2008 report, S.R. noted that the Veteran's PTSD was severe and provided various reports of testing in support of that claim. S.R. also provided an article from Dr. M.F. on the subject of diagnosing and assessing the severity of PTSD. The article by Dr. M.F. listed several diagnostic tools, including the Davidson Self-Rating PTSD scale. S.R. reported that the Veteran's PTSD showed severe symptoms based on the Davidson Scale and on two other tests administered in the March 2008 report, including the Trauma Symptom Inventory and the Impact of Event Scale. Based on these test results, S.R. opined that the Veteran had severe symptoms of PTSD. Letters from S.R., to include the most recent April 2013 correspondence, do not reflect a discussion or assessment of the Veteran's PTSD, but address the procedural history of the case and argument in support of an increased PTSD rating. In a following May 2008 VA examination, the Veteran stated that he lived with his wife and adult child. It was noted that he had some issues with showing emotions and warmth; however, he continued to work full-time and did not report any problems with his occupation. Mental status examination revealed that his mood was neutral and affect was constricted. He denied suicidal or homicidal ideation. Speech and thought process was unimpaired, memory was grossly intact, and judgment and insight were present. The VA examiner noted symptoms of heightened emotionality at funerals, infrequent re-experiencing, sleep disturbance, and irritability. A GAF score of 64 was assigned, indicative of some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. During the most recent VA examination in January 2012, the Veteran reported a stable relationship with his wife, adult children, grandchildren, and stated that he sometimes plays golf with a friend. He also reported heightened emotionality at funerals and while watching television. It was noted that he continued to work full-time as a fire safety officer at a museum and denied being absent from work or any impairment with his occupation as a result of PTSD symptoms. Upon mental status examination, the Veteran was alert and oriented in all spheres, mood was mildly dysphoric, affect was constricted, but congruent. He denied suicidal or homicidal ideation. Speech and thought process were unimpaired and he denied hallucinations, panic attacks, and delusions. Memory was intact and attention and concentration were adequate. He reported sleep impairment, depressed mood, and some anxiety. The VA examiner assigned a GAF score of 60, reflecting moderate symptoms or moderate difficulty in social, occupational, or school functioning. The Board has also reviewed and considered the Veteran's statements, to include his testimony at the August 2011 and May 2013 Board hearings. At these hearings, he denied receiving mental health treatment or medication for his symptoms. He reported increased startled response, irritability, and difficulty sleeping. It was also stated that he had a good relationship with his family and continued to work full-time as a fire safety officer. Upon review of the evidence of record, the Board finds that the February 2001, May 2008, and January 2013 VA examiners, who conducted a mental status examination in accordance with DSM-IV criteria, reviewed the claims file, interviewed the Veteran in person, and provided an assessment consistent with the examination of the Veteran, are the most probative evidence of record with regard to the severity of his PTSD, to include the March 2008 report from S.R. See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when VA gives an adequate statement of reasons and bases). In support of this finding, the Board notes that although S.R. opined that the Veteran has severe PTSD symptoms, he did not report which specific symptoms were used in the assessment. Also, it does not appear that S.R. reviewed the claims file prior to rendering the March 2008 opinion. Despite the Veteran's contention that he spoke to S.R. on the telephone on several occasions, the March 2008 report from S.R. does not reference or discuss any symptoms or complaints by the Veteran in regard to his PTSD. Moreover, S.R. did not render an opinion as to how or what to extent PTSD symptoms manifest deficiencies in the Veteran's occupational and social areas. For these reasons, the Board has accorded more probative weight to the findings from the February 2001, May 2008, and January 2013 VA examinations. See Guerrieri v. Brown, 4 Vet. App. 467, 470 (1993) (the credibility and weight to be attached to these opinions is within the province of the Board). To support a rating in excess of 30 percent, symptoms would be consistent with occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The Board recognizes that the Court in Mauerhan v. Principi, 16 Vet. App. 436 (2002), stated that the symptoms listed in VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating; however, the Court further indicated that without those examples, differentiating between rating evaluations would be extremely ambiguous. Id. at 442. With this in mind, the weight of the lay and medical evidence shows that the Veteran's overall PTSD picture is already adequately contemplated by the existing 30 percent rating. Specifically, he experiences sleep problems, but this is specifically listed under the criteria for a 30 percent rating. Next, although he manifests symptoms of depression and has been diagnosed with major depressive disorder as noted in the February 2001 VA examination, this symptom is specifically contemplated by a 30 percent PTSD rating. Other symptoms reported by the Veteran, including anxiety and suspiciousness (startled response), are considered in the 30 percent PTSD rating criteria. Further, he has continuously denied suicidal and homicidal ideations. The VA examiners also found that his speech, attention, and concentration were all within normal limits. Thought process and content were coherent and normal. Judgment and insight were good and memory was intact. The Veteran has also not shown difficulty in establishing and maintaining effective work and social relationships as he has consistently reported a good and stable relationship with family members, friends, and has maintained full-time employment without incident. The majority of the GAF scores of record also indicative mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. The Board has also considered the Veteran's statements that his disability is worse. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's PTSD has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which this disability is evaluated. Moreover, as the examiners have the requisite medical expertise to render a medical opinion regarding the degree of impairment caused by the disability and had sufficient facts and data on which to base the conclusion, the Board affords the medical opinions great probative value. Based on all of the evidence discussed above, lay and medical, the Board finds that the Veteran's PTSD has been manifested by depressed mood, anxiety, and chronic sleep impairment characterized by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Board finds that such symptoms are consistent with the criteria for a 30 percent rating under DC 9411, but no more. Therefore, a higher rating for PTSD is not warranted and the appeal is denied. Next, the Board has considered whether referral for an extraschedular evaluation is warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2013). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b) (1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's psychiatric disorder is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. Specifically, the schedular rating criteria, DC 9411, provide for ratings based on a combination of clinical psychiatric symptoms and findings. In this case, considering the lay and medical evidence, the Veteran's psychiatric disorder, diagnosed as PTSD is manifested by symptoms of anxiety, depression, sleep impairment, startled response, and some irritability. These symptoms are part of or similar to symptoms listed under the schedular rating criteria. The schedular rating criteria specifically include occupational and social impairment occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due the Veteran's psychiatric symptoms. The schedular rating criteria also include analogous symptoms that are "like or similar to" listed schedular rating criteria. Mauerhan, 16 Vet. App at 442; see also 38 C.F.R. § 4.21 (2013). Additionally, the Board has considered probative GAF scores, which are incorporated through the DSM-IV as part of the schedular rating criteria, as reflective of the degree of severity of psychiatric symptoms or overall functional impairment caused by PTSD. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1 (2013). In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above. In the absence of exceptional factors associated with PTSD, the Board finds that the criteria for referral for consideration of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b) (1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Finally, 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, 3.326(a) (2013). 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This 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). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. In this case, the Veteran's psychiatric claim arises from his disagreement with the initial evaluation following the grant of service connection. Courts have held that 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). Therefore, no further notice is needed under VCAA. Next, VA has a duty to assist a veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Service treatment records, VA and private treatment records, VA examination reports, hearing transcripts, and various lay statements have been associated with the claims file. In addition, the Veteran was afforded VA examinations in February 2001, May 2008, and January 2013. These examinations are adequate as they contains a description of the history of the disability at issue, document and consider the reported complaints and symptoms, address the relevant rating criteria, contain mental status examinations, and note functional effects of the disability on daily activities. Accordingly, the VA examinations are both adequate and probative and VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. VA has provided the Veteran with every opportunity to submit evidence and arguments in support of his claim, and to respond to VA notices. Therefore, the available records and medical evidence have been obtained in order to make an adequate determination as to this claim. Significantly, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance is required to fulfill VA's duty to assist 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). Finally, a claim for a total rating based on individual unemployability due to service-connected disabilities (TDIU) is part of an increased rating issue when such claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran has indicated that he is currently employed full-time as a fire security officer. As such, the issue of TDIU is not raised in this case. ORDER An initial rating in excess of 30 percent for PTSD is denied. ____________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs