Citation Nr: 1335577 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 09-49 286 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent disabling for stress fracture supracondylar femur of the left knee with arthritis, including an evaluation greater than 20 percent for limited flexion from April 20, 2012. 2. Entitlement to an evaluation in excess of 10 percent disabling for stress fracture supracondylar femur of the right knee. 3. Entitlement to a compensable initial evaluation for right knee limitation of flexion. 4. Entitlement to a total disability rating for compensation purposes based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Marenna, Associate Counsel INTRODUCTION The appellant had active service from September 1970 to April 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2009 and November 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. In December 2012, the appellant testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of this hearing is associated with the claims file. This case was previously before the Board in April 2012 and remanded for additional development. For the reasons discussed below, the Board finds that there has been substantial compliance with the mandates of the April 2012 remand. See Stegall v. West, 11 Vet. App. 268 (1998). As discussed below, the Board finds that the issues of entitlement to a compensable initial evaluation for right knee limitation of flexion and entitlement to a TDIU have also been raised by the record. The issue of entitlement to a compensable initial evaluation for right knee limitation of flexion and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The appellant's stress fracture supracondylor femur of the left knee with arthritis is manifested by pain and flexion limited to no less than 45 degrees, prior to April 20, 2012, and extension limited to no less than 5 degrees. 2. From April 20, 2012, the appellant's left knee was manifested by painful motion beginning at 30 degrees flexion; a separate evaluation of 20 percent for left knee limitation of flexion has been assigned from April 20, 2012. 3. The appellant's stress fracture supracondylor femur of the right knee with arthritis is manifested by pain and flexion limited to no less than 45 degrees and extension limited to no less than 5 degrees. 4. The appellant's left knee had X-ray evidence of patellar subluxation and symptoms of slight instability due to pain during the period on appeal. 5. The appellant's right knee had X-ray evidence of patellar subluxation and symptoms of slight instability due to pain during the period on appeal. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for stress fracture supracondylor femur of the left knee with arthritis have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. § 3.159, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5060-5261. 2. From April 20, 2012, the criteria for an evaluation in excess of 20 percent for the stress fracture supracondylor femur of the left knee with arthritis based upon limitation of flexion of the left knee have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. § 3.159, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5060-5261. 3. The criteria for an evaluation in excess of 10 percent for stress fracture supracondylor femur of the right knee with arthritis have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. § 3.159, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5060-5261. 4. The criteria for a separate evaluation of 10 percent for slight recurrent subluxation or lateral instability of the left knee have been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. § 3.159, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5057. 5. The criteria for a separate evaluation of 10 percent for slight recurrent subluxation or lateral instability of the right knee have been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. § 3.159, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5057. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the appellant's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Notice and Assistance VA has duties 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). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). More specific notice is required in claims for increased compensation. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VA has met all statutory and regulatory notice and duty to assist provisions as to the appellant's increased rating claims. Appropriate notice was provided in a January 2009 letter. The claim was subsequently adjudicated. Mayfield, 444 F.3d at 1333; See Prickett v. Nicholson, 20 Vet. App. 370 (2006). VA's duty to assist has been satisfied. The appellant's service treatment records and VA medical records are in the file, including the VA treatment records requested in the April 2012 Board remand. See Stegall v. West, 11 Vet. App. 268 (1998). Private medical records identified by the appellant have been obtained, to the extent possible, including records from Santian Physical Therapy, which were requested by the appellant following the April 2012 Board remand. The appellant has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The RO provided the Veteran appropriate VA examinations in April 2009 and April 2012. The examinations are adequate because they are based on thorough examinations, a description of the appellant's pertinent medical history, a review of the claims file and appropriate diagnostic tests, including x-rays. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). The appellant has not reported receiving any recent treatment specifically for this condition and there are no records suggesting an increase in disability has occurred as compared to the prior VA examination findings. There is no objective evidence indicating that there has been a material change in the severity of the appellant's service-connected disorders since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. The VA examination reports are thorough and provided findings pertinent to the rating criteria. The examinations in this case are adequate upon which to base a decision. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). I. Legal Criteria Disability evaluations are determined by comparing a veteran's present symptomatology with the criteria set forth in the Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. 4.1 (2013). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the appellant. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. 38 C.F.R. § 4.1. Nevertheless, where, as here, the appellant is appealing the rating for an already established service-connected condition, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The appellant's right and left knee disabilities are rated under Diagnostic Codes 5260-5261. Diagnostic Code 5260 provides that limitation of flexion of the leg with flexion limited to 645 degrees warrants a 10 percent rating. Flexion limited to 30 degrees warrants a 20 percent rating. Flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, extension limited to 5 degrees warrants a noncompensable rating, to 10 degrees warrants a 10 percent rating, to 15 degrees warrants a 20 percent rating, to 20 degrees warrants a 30 percent rating, to 30 degrees warrants a 40 percent rating, and to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Diagnostic Code 5010 provides that traumatic arthritis, due to trauma and substantiated by x-ray findings, is to be evaluated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by the limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is assigned when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is assigned when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For the purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45 (2013). Slight recurrent subluxation or lateral instability warrants a 10 percent evaluation; moderate recurrent subluxation or lateral instability warrants a 20 percent evaluation; and severe recurrent subluxation or lateral instability warrants a 30 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The words "slight," "moderate" and "severe" as used in various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2013). Instability of the knee and limitation of motion of the knee are two separate disabilities. As such, it is permissible to award separate ratings under both a range of motion code and an instability code, without violating the prohibition on pyramiding under 38 C.F.R. § 4.14. See VAOPGCPREC 23-97. III. Analysis The evidence of record does not demonstrate that the appellant had flexion limited to 30 degrees or less in the right knee, or the left knee prior to April 20, 2012, or extension limited to 20 degrees in either knee. An April 2009 VA examination report reflects that the appellant's range of motion was zero to 138 degrees actively and passively. The range of motion was pain free with three repetitions. An October 2010 VA treatment record indicates the appellant had knee braces and reported falls. He reported that he thought he fell due to his knees and that he used a cane for long distances or on oven ground. He reported the knees ached bilaterally constantly without red or effusion. The knees were without instability on examination. A December 2010 VA treatment record indicates that the appellant had a range of motion with extension limited to 5 degrees on the left-flexion WFL (within functional limit). No laxity was noted. A January 2011 VA treatment record reflects that X-rays showed the appellant's knees had mild bilateral degenerative changes with slight progression of the left. There was bilateral subluxation of the patellae. A February 2011 private treatment record indicates that the appellant had right knee flexion of 5 to 115 degrees and left knee flexion of 5 to 120 degrees. A March 2011 private treatment record reflects that the right knee had active range of motion of 5 to 115 degrees. The left knee had active range of motion of 5 to 120 degrees. The appellant had pain at the end range of passive flexion and extension. The appellant's VA treatment records reflect that the appellant had pain in his knees. A June 2011 VA treatment record reflects that the appellant's knees were tender over the medial joint line with full range of motion with some crepitations bilaterally. No instability, redness, effusion or warmth was noted. An April 2012 VA examination report reflects that the appellant's left knee had flexion of 90 degrees with evidence of painful motion beginning at 30 degrees. The right knee had flexion of 90 degrees with objective evidence of painful motion beginning at 60 degrees. The appellant was able to perform repetitive-use testing with extension and flexion of 0 to 90 degrees in both knees following three repetitions. The VA examiner noted that the appellant had less movement than normal, pain on movement and disturbance of locomotion in both knees. The appellant had tenderness or pain to palpation for the joint line or soft tissues of both knees. Muscle strength was normal. The April 20, 2012 VA examination report indicates that the appellant had left knee flexion ending at 90 degrees with objective evidence of painful motion beginning at 30 degrees. In Deluca v. Brown, 8 Vet. App. 202 (1995), the Court held that VA's review of a service-connected musculoskeletal disability must include an assessment of the functional impairment caused by that disability. See 38 C.F.R. §§ 4.40, 4.45 and 4.59 (2013). As the appellant's left knee flexion had painful motion at 30 degrees, with consideration of DeLuca, a higher rating of 20 percent is warranted for flexion limited to 30 degrees from April 20, 2012. However, in a November 2012 rating decision, the RO granted service connection for left knee limitation of flexion with an evaluation of 20 percent, effective April 20, 2012. As the appellant's limitation of flexion of the left knee is separately evaluated effective April 20, 2012, granting a higher rating for stress fracture supracondylar femur of the left knee with arthritis based on the criteria for limitation of flexion under Diagnostic Code 5261 would violate the prohibition against pyramiding. See 38 C.F.R. § 4.14 (2013). The evaluation of the same disability under various diagnoses is to be avoided. Thus, a higher rating may not be granted based on limitation of flexion for the service-connected stress fracture supracondylor femur of the left knee with arthritis, from April 20, 2012. The evidence of record reflects that the appellant did not have flexion of the left knee limited to 30 degrees, including with consideration of the appellant's symptoms of pain, prior to the April 20, 2012, VA examination. The evidence also does not demonstrate that the appellant's right knee had flexion limited to 30 degrees or extension limited to 20 degrees in either knee. The Board has considered the criteria of DeLuca. However, the evidence does not demonstrate that the appellant had functional impairment of the knees warranting a higher evaluation for limitation of motion. The April 2009 VA examination report reflects that the appellant's range of motion of the knees was pain free with three repetitions. At the April 2012 VA examination, the appellant had pain beginning at 60 degrees in the right knee. The April 2012 VA examiner noted that the appellant had less movement than normal, pain on movement and disturbance of locomotion in both knees. However, following three repetitions, the appellant had post-test extension and flexion of 0 to 90 degrees in both knees. Thus, he had no additional limitation in range of motion following repetitive-use testing. The Board finds that the appellant's pain on motion of the knees has already been contemplated by the 10 percent ratings in both knees for limitation of flexion. The evidence does not demonstrate functional impairment warranting a rating in excess of 10 percent for limited motion. As noted above, it is permissible to award separate ratings for the knees under both a range of motion code and an instability code, without violating the prohibition on pyramiding under 38 C.F.R. § 4.14. See VAOPGCPREC 23-97. The Board finds that a separate rating is warranted for bilateral instability of the knees. A January 2011 VA treatment record notes that X-rays showed that there was bilateral subluxation of the patellae. The appellant has complained of falling due to his knee disabilities during the period on appeal. The April 2012 VA examination report reflects that there was no ligamentous instability and there was normal alignment of the patella without evidence of subluxation of the patella. However, the VA examiner also noted that there was X-ray evidence of bilateral patellar subluxation. The appellant used a cane for all walking. The April 2012 VA examiner noted that, "[d]espite his subjective complaints, he has only mild degenerative changes on x-rays of his knees which is fairly typical for his age. He has no true ligamentous or lateral instability of his knees on exam. His "instability" symptoms are due to giving way from pain and not instability." Although the April 2012 VA examination report indicates that the appellant does not have true ligamentous or lateral instability, the report indicates that he did have symptoms of instability due to pain. With consideration of functional impairment due to pain and the January 2011 X-ray showing bilateral subluxation of the patellae, the Board finds that a 10 percent rating is warranted under Diagnostic Code 5257 for slight recurrent subluxation or lateral instability of the knees. A rating in excess of 10 percent is not warranted as the symptoms of subluxation and instability described are only slight and not moderate, particularly as the April 2012 VA examiner found the appellant did not have true ligamentous or lateral instability. The Board finds that a higher rating is not warranted under any other Diagnostic Code. There is no evidence of ankylosis of the knee, dislocated semilunar cartilage, or impairment of the tibia and fibula. Thus, higher ratings are not warranted under Diagnostic Codes 5256, 5258, or 5262. The Board has considered whether extraschedular consideration is warranted based on the evidence of functional, including occupational, impairment secondary to the left knee disability. See Barringer v. Peake, 22 Vet. App. 242 (2008). The discussion above reflects that the symptoms of the appellant's bilateral knee disabilities are contemplated by the applicable rating criteria. The competent medical evidence of record shows that the bilateral knee disabilities are primarily manifested by limitation of motion due to pain and instability. Many of the applicable diagnostic codes used to rate the appellant's disabilities provide for ratings based on limitation of motion and instability, and the effects of pain and functional impairment have been taken into account and are considered in applying the relevant criteria in the rating schedule. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. The effects of the appellant's disabilities have been fully considered and are contemplated in the rating schedule. Consideration of whether the appellant's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). As discussed below, the Board finds that the issue of entitlement to a TDIU has been raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). In sum, the Board finds that evaluations in excess of 10 percent are not warranted for stress fractures of the supracondylor femur of the right and left knees. The Board finds that separate ratings of 10 percent for subluxation and instability of the bilateral knees are warranted. ORDER Entitlement to an evaluation in excess of 10 percent disabling for stress fracture supracondylar femur of the left knee with arthritis, including an evaluation greater than 20 percent for limited flexion from April 20, 2012, is denied. Entitlement to an evaluation in excess of 10 percent disabling for stress fracture supracondylar femur of the right knee is denied. Entitlement to a separate evaluation of 10 percent for left knee instability is granted. Entitlement to a separate evaluation of 10 percent for right knee instability is granted. REMAND In regard to the appellant's claim for a compensable initial evaluation for right knee limitation of flexion, the Board finds this issue needs to be remanded for issuance of a statement of the case (SOC). In a November 2012 rating decision, the VA Appeals Management Center (AMC) granted entitlement to service connection for right knee limitation of flexion with a noncompensable evaluation effective April 20, 2012. The appellant filed a timely notice of disagreement with the decision, which was received in March 2013. The record does not reflect that a SOC has been issued in response to the appellant's notice of disagreement pursuant to 38 C.F.R. § 19.26 regarding the claim for a compensable initial evaluation for limitation of flexion of the right knee. In this situation, the Court has indicated that the proper action is to remand the issue to the RO for appropriate action. See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999) ("Thus, the next step was for the RO to issue an SOC on the denial of the . . . claim, and the Board should have remanded that issue to the RO, not referred it there, for issuance of that SOC."). As such, the Board finds that this issue should be remanded for the issuance of a SOC by the RO. Entitlement to TDIU is an element of all claims for a higher initial rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). A claim for TDIU is raised where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); see Jackson v. Shinseki, 587 F.3d 1106 (2009) (holding that an inferred claim for a TDIU is raised as part of an increased rating claim only when the Roberson requirements are met). In this case, the issue of entitlement to a TDIU has been raised by the record. The April 2012 VA examination report indicates the appellant had not worked in 3 to 4 years. He was working as a long truck driver and stopped working because he "tore his elbow in two." He reported that his knees made him miserable while he was working and if he tried to work now he would have to have a job that allowed him to sit as tolerated. The VA examiner found that the appellant's bilateral knee disabilities impacted his ability to work. The Board therefore finds that a claim for TDIU has been raised by the record and is part of the increased rating claims currently before the Board. The RO has not explicitly adjudicated the claim for entitlement to TDIU. The appellant would therefore be prejudiced if the Board were to decide this claim without prior adjudication by the RO. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the Veteran has been prejudiced thereby). On remand, the RO should send the appellant a letter that complies with 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013), regarding his claim for entitlement to a TDIU. The claim should then be adjudicated. Accordingly, the case is REMANDED for the following action: 1. Send the appellant appropriate notice regarding the claim for TDIU. Also request that he submit a properly completed VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. 2. Adjudicate the issue of entitlement to TDIU. If the Veteran does not meet the schedular criteria for a grant of TDIU, determine whether the case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 4.16(b). 3. Provide the appellant with a statement of the case as to the issue of entitlement to a compensable initial evaluation for right knee limitation of flexion. The appellant should be informed that he must file a timely and adequate substantive appeal in order to perfect an appeal of these issues to the Board. See 38 C.F.R. §§ 20.200, 20.202, and 20.302(b). If a timely substantive appeal is not filed, the claims should not be certified to the Board. 4. Thereafter, readjudicate the issue on appeal of entitlement to a TDIU. If the benefit sought is not granted, issue a supplemental statement of the case and afford the appellant an appropriate opportunity to respond. The case should then be returned to the Board, as warranted. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs