Citation Nr: 1334978 Decision Date: 10/31/13 Archive Date: 11/06/13 DOCKET NO. 06-24 104 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a joint disorder, to include as secondary to service-connected diabetes mellitus, type II. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for a sleep disorder. 4. Entitlement to service connection for a disability manifested by fatigue. 5. Entitlement to service connection for denture loss. ATTORNEY FOR THE BOARD Amanda Christensen, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1968 to August 1969. He also served in the Army National Guard. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2005 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. In April 2012, the Board remanded the Veteran's claim for additional development. The claim has since been returned to the Board for further appellate action. The Board is satisfied there was substantial compliance with its remand orders. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). Also, in an August 2013 rating decision, the AMC granted service connection for depressive disorder and assigned a 30 percent rating. The award contemplates the Veteran's current psychiatric impairment and is considered a full grant of the benefits sought by the Veteran for his claim for service connection for post-traumatic stress disorder (PTSD) and nervous condition. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that when a claimant makes a psychiatric disorder claim, he or she is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). Therefore, this issue is no longer before the Board. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. The Veteran's joint condition, including osteoarthritis, degenerative joint disease, and shoulder impingement syndrome, is not causally or etiologically related to service; did not manifest to a compensable degree within one year of his discharge; and was not caused or aggravated by his service-connected diabetes mellitus, type II. 2. The Veteran does not have tinnitus that is causally or etiologically related to service. 3. The Veteran does not have a sleep disorder that is a separate disability that is causally or etiologically related to service. 4. The Veteran does not have a disability manifested by fatigue that is causally or etiologically related to service 5. The Veteran had missing teeth at his time of discharge from service, but not as a result of loss of substance of the body of the maxilla or mandible. CONCLUSIONS OF LAW 1. The criteria for service connection for a joint condition have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309 (2013). 2. The criteria for service connection for tinnitus have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2013). 3. The criteria for service connection for a sleep disorder have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2013). 4. The criteria for service connection for a disability manifested by fatigue have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2013). 5. The criteria for service connection for denture loss have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.381 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Additionally, service connection may be granted, on a secondary basis, for a disability which is proximately due to or the result of an established service-connected disorder. 38 C.F.R. § 3.310. Service connection may also be established for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). This has been interpreted as a three-element test based on nexus: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may also be established under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, and subsequent manifestations of the same chronic disease or injury at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Service connection may also be established where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Arthritis is listed as a "chronic disease" under 38 C.F.R. § 3.309(a). For certain chronic diseases, including arthritis, service connection may also be granted if the disease becomes manifest to a compensable degree within one year following separation from service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is 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 facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Joint Disorder The Veteran contends he is entitled to service connection for a joint disorder as secondary to his service-connected diabetes mellitus, type II. On his August 1969 discharge examination the examiner found the Veteran's upper and lower extremities to be normal and the Veteran reported no arthritis or rheumatism. On National Guard examinations in October 1982 and December 1986 the Veteran's upper and lower extremities were again found normal and the Veteran reported no arthritis, rheumatism, or bursitis. August 2005 x-rays showed acromiclavicular degenerative changes of osteoarthritis in the Veteran's right shoulder and degenerative changes of osteoarthritis in both hands. The Veteran was awarded Social Security disability in November 2005 with a primary diagnosis of osteoarthrosis and allied disorders and a secondary diagnosis of affective disorders. In November 2010 the Veteran was afforded a VA examination. He reported pain in his shoulders and knees bilaterally since 2008 with no specific trauma. X-rays showed minimal degenerative and enthesopathic changes of the knees, osteopenia and degenerative changes of the shoulders, and mild osteopenia and degenerative changes of the hands. The examiner diagnosed bilateral shoulder impingement syndrome, bilateral shoulder degenerative changes by x-ray, and degenerative changes of the knees. The examiner opined that the conditions are less likely than not related to the Veteran's service-connected diabetes mellitus, type II. The examiner explained that the medical evidence does not support that diabetes mellitus could cause bilateral shoulder impingement syndrome and degenerative changes at the knees and shoulders. The examiner stated that the degenerative changes are most likely related to the normal aging process. The Veteran underwent another VA examination in August 2012. The examiner opined that the Veteran's left shoulder and bilateral knee conditions were less likely than not incurred in or caused by service. The examiner explained that the conditions are related to the normal process of aging and noted that the Veteran's records contain no evidence of a shoulder or knee condition during service or within one year after separation from service. The Veteran underwent another VA examination in June 2013. The Veteran reported his pain, stiffness, and limited motion of his shoulders and knees had started 20 years ago and worsened since then. The examiner opined that it is less likely than not that the Veteran's current joint disability, to include knee and shoulder disorders, osteoarthritis, and degenerative joint disease, were incurred in or caused by service. The examiner also stated that the Veteran's arthritis was not manifest within one year after separation from service. The examiner stated that the Veteran's current conditions, including age-related arthritis, are degenerative. All three VA medical opinions obtained in this case state that the Veteran's joint condition, namely arthritis, are a result of the normal aging process. The Veteran has specifically contended that his joint condition is a result of his service-connected diabetes mellitus. However, the Board finds that while the Veteran is competent to state what symptoms he feels, such as joint pain, the Veteran does not have the education, training and experience to offer a medical diagnosis or an opinion as to the onset or etiology of this condition. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011); see also Jandreau, 492 F.3d at 1376-77 (holding that "[l]ay evidence can be competent and sufficient to establish a diagnosis when ... a lay person is competent to identify the medical condition" and providing, as an example, that a layperson would be competent to identify a condition such as a broken leg, but would not be competent to identify a form of cancer); Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). Accordingly, the Veteran's lay statements in this regard are not competent or probative evidence supporting his claim. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau, 492 F.3d at 1376-77. The competent opinion addressing secondary service connection in this case, that of the November 2010 VA examiner, is that the Veteran's joint condition is not secondary to his diabetes mellitus. The examiner explained that the medical evidence does not support that diabetes mellitus could cause bilateral shoulder impingement syndrome and degenerative changes at the knees and shoulders. Moreover, the weight of the competent and probative evidence is against a finding that diabetes mellitus aggravates any joint disability. With regard to direct service connection, both the August 2013 and June 2013VA examiners have offered competent opinions that the Veteran's joint disability, to include diagnosed left shoulder and bilateral knee conditions, was less likely than not incurred in or caused by service. Both examiners explained that his condition is age-related. In addition, the medical evidence does not show that the Veteran's arthritis began in service or manifest to a compensable degree within one year of his discharge. His service treatment records contain no joint complaints or diagnosis of arthritis or another joint condition. Further, no medical evidence is of record from after the Veteran's active service showing arthritis until 2005, more than 30 years after the Veteran's discharge from service. Based on the forgoing, the Board finds the Veteran is not entitled to service-connection for a joint disorder, to include as secondary to service-connected diabetes mellitus, type II. As the preponderance of the evidence is against this claim, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. Tinnitus The Veteran contends he is entitled to service connection for a condition he described as "noise inside my ears." The Veteran did not report any ear trouble on his August 1969 report of medical history on discharge from service. He further did not note ear trouble on medical history reports in October 1982 and December 1986. Service treatment records contain no complaints of tinnitus. The Veteran's VA treatment records also contain numerous notations where tinnitus is among the symptoms denied by the Veteran. In addition, an August 2012 VA examination reflects that the Veteran did not report having recurrent tinnitus. However, at a June 2013 VA examination the Veteran reported he has had bilateral, recurrent tinnitus (described as buzzing) since 1968 while deployed to Vietnam in service. He reported continuous artillery noise during that year without the use of hearing protection. The examiner opined that it was less likely than not that the Veteran's tinnitus was caused by military noise exposure. However, noting the Veteran's reported noise exposure in service, the examiner also stated that it is possible that there might be cochlear damage due to acoustic trauma that is causing the Veteran's tinnitus. The Veteran is competent to report he has tinnitus. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) (noting that ringing in the ears is capable of lay observation). However, in this case the Board notes that the Veteran's reports of tinnitus have been inconsistent. Although he reported to the VA examiner in June 2013 that he has had tinnitus since 1968, at a VA examination approximately a year prior the Veteran denied tinnitus. Further, VA treatment records indicate he has regularly failed to report having tinnitus on regular reviews of his symptoms. Service treatment records also contain no notations of tinnitus, including on his discharge examination and report of medical history. Thus, the record, including the Veteran's own prior statements, does not support the Veteran's more recent contention that he has had tinnitus since service. While the June 2013 VA examiner allowed for the possibility that acoustic trauma in service could have caused the Veteran's tinnitus, the examiner opined that it was less likely than not that the tinnitus was caused by noise exposure in service. The Board finds that the examiner's statement with regard to the possible nexus to service is too speculative to give any significant probative weight. See Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992). See also, Tirpak v. Derwinski, 2 Vet. App. 609 (1992) (indicating that a doctor's opinion was too speculative when stating a disability "may be" related to service because this also was tantamount to saying the disability "may not be" related to service). Further, the examiner's opinion is based on the Veteran's self-reported history of recurrent tinnitus since service, a contention that the Board finds is not credible. See Reonal v. Brown, 5 Vet. App. 458 (1993) (An opinion based upon an inaccurate factual premise had no probative value.). Based on the forgoing, the Board finds that the evidence does not support that the Veteran has tinnitus that either began in service or was caused by service. As the preponderance of the evidence is against this claim, the benefit of the doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. Sleep Disorder / Fatigue The Veteran contends he is entitled to service connection for a sleep disorder and fatigue. In August 2012 the Veteran underwent a sleep apnea VA examination. The Veteran reported a history of insomnia and difficulty sleeping due to anxiety and war-related nightmares that wake him up with a sensation of fear, agitation, and fatigue. He reported he has been experiencing sleep difficulties for the past 10 to 15 years. The examiner stated that there is no evidence the Veteran has sleep apnea. The Veteran also underwent a mental health examination in August 2012. He attributed his sleep interruptions, which occur about three times per night, to his diabetes, specifically to his intake of diuretic medication, leg cramps, and leg pain. VA treatment records reflect that the Veteran has reported difficulty falling asleep and waking up tired, irritable, and anxious. He has been prescribed medication for sleep. The Board finds that the evidence reflects that the Veteran's insomnia is not a separate disorder but rather a symptom of his psychiatric disorder or a result of his diabetic symptoms. He has been specifically found not to have sleep apnea and has not been diagnosed with any other independent sleep disorder. In his own statements to VA examiners the Veteran has attributed his sleep difficulties to war-related nightmares and diabetic medication side-effects and symptoms. Thus, the evidence, including the Veteran's own statements, do not support that the Veteran's insomnia is a separate disorder that could be service-connected. Further, the Veteran has not been diagnosed with a separate disability that manifests with fatigue. While the Veteran is competent to report that he experiences fatigue, fatigue as a symptom and not a separate disability cannot be service-connected. To the extent that the Veteran has opined that he has a separate disability that manifests as fatigue, the Board finds such a diagnosis is a complex medical question, not something capable of lay observation, and therefore the Veteran's opinion is not competent. Based on the forgoing, the Board finds a preponderance of the evidence is against service connection for either insomnia or a disability manifest with fatigue, as the evidence shows both complaints are symptoms rather than separate disabilities. Therefore, the benefit of the doubt doctrine does not apply and the Veteran's claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. Denture Loss Disability compensation and VA outpatient dental treatment may be provided for certain specified types of service-connected dental disorders. For other types of service-connected dental disorders, the claimant may receive treatment only and not compensation. 38 U.S.C.A. § 1712; 38 C.F.R. §§ 3.381, 4.150, 17.161 (2011). Dental disabilities that may be awarded compensable disability ratings are set forth under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, loss of the maxilla, nonunion or malunion of the maxilla, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150, Diagnostic Codes 9900-16 The regulations governing dental claims make a fundamental distinction between "replaceable missing teeth", see 38 C.F.R. § 3.381(a), and teeth lost as a result of loss of substance of body of maxilla or mandible due to trauma or disease such as osteomyelitis, and not loss of the alveolar process as a result of periodontal disease. 38 C.F.R. § 4.150; Simington v. West, 11 Vet. App. 41, 44 (1998). Absent a demonstration of dental trauma, service connection may be considered solely for the purpose of determining entitlement to dental examinations or outpatient dental treatment. See also Woodson v. Brown, 8 Vet. App. 352, 354 (1995). Under 38 C.F.R. § 3.381, treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are to be considered service-connected solely for the purpose of establishing eligibility for outpatient dental treatment as provided in 38 C.F.R. § 17.161. Under 38 U.S.C.A. § 1712, outpatient dental services and treatment, and related dental supplies, may be furnished for a dental condition or disability when certain enumerated conditions are met. As to each noncompensable service-connected dental condition, a determination will be made as to whether it was due to combat wounds or other service trauma. 38 C.F.R. § 3.381(b). The significance of finding that a dental condition is due to service trauma ("Class II(a) eligibility") is that those having a service-connected noncompensable dental condition or disability adjudicated as resulting from said trauma may be authorized any treatment indicated as reasonably necessary for its correction, that is, the Veteran will be eligible for VA outpatient dental treatment without being subject to the usual restrictions of a timely application after service and one-time treatment. 38 C.F.R. § 17.161(c). The Veteran is not noted to have any missing teeth on his October 1967 pre-induction examination, but is noted to have three missing teeth (32, 30, 17) on his August 1969 discharge examination. During service, the Veteran was seen at the dental clinic in May 1968. He was noted to have four missing teeth (32, 31, 30, 17), but any treatment provided is not indicated. On an October 1982 National Guard examination the Veteran is noted to have two missing teeth (30, 19) and three restorable teeth (31, 20, 18); in December 1986 he is noted to have two missing teeth (30, 19) and one restorable tooth (20). The Veteran underwent a VA dental examination in August 2012. He was found to have 18 missing teeth (1, 2, 10, 14, 15, 16, 17, 18, 19, 21, 22, 23, 24, 25, 26, 30, 31, 32). The examiner found that the loss of teeth was not due to the loss of substance of the body of the maxilla or mandible without loss of continuity or due to trauma or disease. The Veteran was found to not have loss of the mandible; nonunion or malunion of the mandible; loss of the maxilla; nonunion or malunion of the maxilla; limited temporomandibular motion; anatomical loss or injury of the mouth, lips, or tongue; osteomyelitis, osteoradionecrosis, or bisphosphonate-related osteonecrosis of the jaw; oral neoplasm; or periodontal disease. The Veteran has made no statement as to the cause of his missing teeth or when during service he lost them, and service records do not indicate if the teeth were extracted or lost due to trauma or disease or when they were lost. Thus, although the record indicates the Veteran lost teeth during service, the evidence does not show the Veteran is entitled to service-connection for the missing teeth. Further, as the Veteran phrased his claim as service connection for "denture loss," the Board notes that loss of dentures is not a disability that can be service connected. As the preponderance of the evidence is against this claim, the benefit of the doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. 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 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). While the required notice should be furnished prior to the issuance of the appealed rating decision, any initial errors of notice will not be prejudicial if: 1) corrective actions (e.g., issuance of a post-adjudication notice letter containing the required information) are taken, and 2) the appeal is readjudicated (e.g., in a Supplemental Statement of the Case). See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Here, the VCAA duty to notify was satisfied by way of letters sent to the Veteran in April 2005 and March 2009. In the letters, the RO informed the Veteran of what evidence was required to substantiate the claims for service connection and of the Veteran's and VA's respective duties for obtaining evidence. In the March 2009 letter the RO also provided notice with regard to how VA assigns disability ratings and effective dates in the event that service connection is established. Thus, the duty to notify has been satisfied. VA also has a duty to assist the Veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The Board finds that all necessary development has been accomplished. The RO has obtained the Veteran's service treatment records, VA treatment records, and private treatment records identified by the Veteran. Neither the Veteran nor his representative has 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. The Veteran was afforded VA medical examinations in November 2010, August 2012, and June 2013. The examiners, medical professionals, obtained an accurate history, listened to the Veteran's assertions, and performed the necessary tests. The examiners provided sufficient information and opinions on the nature and etiology of the Veteran's joint, tinnitus, sleep/fatigue, and dental conditions. Therefore, the Board finds that the examinations are adequate and contain sufficient information to decide the issues on appeal. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Hence, no further notice or assistance to the Veteran 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, 16 Vet. App. 183. ORDER Service connection for a joint disorder, to include as secondary to service-connected diabetes mellitus, type II, is denied. Service connection for tinnitus is denied. Service connection for a sleep disorder is denied. Service connection for a disability manifested by fatigue is denied. Service connection for denture loss is denied. ______________________________________________ M. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs