Citation Nr: 1337342 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 07-39 253 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for chronic residuals of a right knee injury, to include as secondary to the service connected degenerative joint disease of the lumbar spine, status post right L4-5 microdiscectomy. 2. Entitlement to service connection for degenerative arthritis of the left knee, to include as secondary to the service connected degenerative joint disease of the lumbar spine, status post right L4-5 microdiscectomy. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The Veteran served on active duty in the military from April 1974 to May 1982 and from February 2003 to September 2003. He also served in the Army National Guard. This appeal to the Board of Veterans' Appeals (Board) is from a February 2007 rating decision of the Jackson, Mississippi, regional office (RO) of the Department of Veterans Affairs (VA) that in relevant part denied the Veteran's claims of service connection for left and right knee disorders. The February 2007 rating also granted service connection for degenerative joint disease of the lumbar spine, status post right L4-5 microdiscectomy, evaluated as 20 percent disabling; service connection for varicose veins left and right, each separately evaluated as 10 percent disabling; and, service connection for hypertension, evaluated as 0 percent or noncompensably disabling. The Veteran initially disagreed with the initial evaluations assigned to these disabilities, but in July 2007 he withdrew those issues from appeal. In his substantive appeal, received in December 2007, the Veteran requested a Travel Board hearing by a Veterans' Law Judge, but in a September 2007 statement he withdrew his request for a Travel Board hearing. The Veteran testified before the RO's Hearing Officer in May 2008. It must be mentioned that in a February 2012 written statement, prior to certification of the appeal to the Board, the Mississippi State Veterans Affairs Board withdrew as the Veteran's accredited representative. These appeals were previously before the Board in April 2012, when they were remanded for further development. The development has been completed, and the appeals have been returned to the Board for further review. The Board has reviewed the Veteran's electronic record (Virtual VA) prior to rendering a decision in this case. It does not contain any evidence not already in the claims folder or considered by the RO. FINDINGS OF FACT 1. The Veteran is entitled to the presumption of soundness for his period of active duty dating from April 1974 to May 1982. 2. The service treatment records for the period from April 1974 to May 1982 show that the Veteran was seen for a skinned right knee in May 1974; the remainder of the service treatment records are negative for complaints or diagnoses regarding the knees. 3. Arthritis of the knees is not shown to have been manifested during service or to a compensable degree within the first year after discharge from service. 4. The Veteran's knee disabilities clearly and unmistakably existed prior to his period of service from February 2003 to September 2003 and were clearly and unmistakably not aggravated during this period. 5. The competent medical evidence shows that that the Veteran's claimed knee disorders are not due to or aggravated by his service-connected back. CONCLUSIONS OF LAW 1. The criteria for service connection for chronic residuals of a right knee injury, to include as secondary to the service connected degenerative joint disease of the lumbar spine, status post right L4-5 microdiscectomy, have not been met. 38 U.S.C.A. §§ 101(24), 1101, 1110, 1111, 1112, 1113, 1151, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303(a), 3.307, 3.306(a), 3.309, 3.310(a) (2013). 2. The criteria for service connection for degenerative arthritis of the left knee, to include as secondary to the service connected degenerative joint disease of the lumbar spine, status post right L4-5 microdiscectomy, have not been met. 38 U.S.C.A. §§ 101(24), 1101, 1110, 1111, 1112, 1113, 1151, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303(a), 3.307, 3.306(a), 3.309, 3.310(a) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper VCAA notice 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 U.S.C.A. § 5103(a) (West 2002); C.F.R. § 3.159(b)(1) (2013). Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Pelegrini, the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. The Court has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In this case, the Veteran was provided with a letter in November 2006 that contained all of the notification required by 38 C.F.R. § 3.159, as defined by Dingess and Pelegrini. This letter was provided to the Veteran prior to the initial adjudication of his claims. The Board concludes that the duty to notify has been met. The Board further concludes that the duty to assist has also been met. The Veteran's service treatment records have been obtained. Private medical records and VA treatment records have been obtained. The Veteran has offered testimony at a hearing before a hearing officer at the RO, and a transcript of this hearing is in the record. He was afforded appropriate VA examinations, and relevant opinions have been obtained from the examiners after a review of the claims folder. These opinions were clarified following the April 2012 remand. The development requested by the April 2012 remand has also been completed. An attempt was to be made to verify all of the Veteran's dates of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) during his service in the National Guard. The record shows the State Adjutant General was contacted in order to obtain these dates. Although additional personnel and medical records were obtained through this request, the exact dates of ACDUTRA and INACDUTRA were not. The Defense Personnel Records Information Retrieval System (DPRIS) was then utilized at the suggestion of the Adjutant General's Office, and while additional records were obtained the exact dates of ACDUTRA and INACDUTRA were not. It appears that the National Personnel Records Center (NPRC) has previously been contacted and provided all available records. The Board concludes that the exact dates of ACDUTRA and INACDUTRA are not available. However, the Board also finds that no there is no harm to the Veteran's claim to proceed with adjudication without further attempts to verify these dates. The Veteran does not contend that he sustained any additional knee injuries while on ACDUTRA or INACDUTRA. Furthermore, the service treatment records for the Veteran's service with the National Guard appear to be complete. The Board can proceed with adjudication of the Veteran's appeal without fear of prejudice to his claims. Bernard v. Brown, 4 Vet. App. 384, 394 (1993). As there is no indication that there is any relevant evidence outstanding in these claims, the Board will proceed with consideration of the Veteran's appeal. Service Connection The Veteran contends that he has developed bilateral knee disabilities due to active service. He states that he banged his knees up during basic training, and argues that they have periodically become painful and swollen ever since that time. In the alternative, the Veteran contends that his bilateral knee disabilities have developed as a result of his service connected back disability. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for disability resulting from disease or injury incurred in or aggravated while performing active duty for training or injury incurred or aggravated while performing inactive duty training. 38 U.S.C.A. § 101(24). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. However, this method may be used only for the chronic disabilities noted in 38 C.F.R. § 3.309. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Arthritis has been demonstrated in each knee, and therefore continuity of symptomatology must be considered. If arthritis becomes manifest to a degree of 10 percent within one year of separation from active service, then it is presumed to have been incurred during active service, even though there is no evidence of arthritis during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997) Furthermore, a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service connected disability. In this instance, the veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). In a claim for secondary service connection for a diagnosis clearly separate from the service-connected disorder, the veteran must present evidence of a medical nature to support the alleged causal relationship between the service-connected disorder and the disorder for which secondary service connection is sought. See Jones v. Brown, 7 Vet. App. 134 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). The evidence demonstrates that the Veteran has current diagnoses of both a right knee and left knee disability. The current medical evidence shows degenerative changes of the right knee, and the Veteran underwent a total left knee replacement during the course of his claim in August 2009. The Veteran has met the first requirement for service connection. However, the Board finds that service connection for both the right knee and left knee disabilities is not warranted under any theory of entitlement. The evidence does not establish a relationship between the Veteran's current disabilities and active service, nor can such a relationship be presumed. There is also no competent evidence of a relationship between the Veteran's service connected back disability and either of his knee disabilities. The Veteran's service medical records for his first period of active duty show that his lower extremities were normal on the April 1974 entrance examination. The Veteran denied a history of knee and joint problems on a Report of Medical History he completed at that time. A May 1974 entry states that the Veteran injured his right knee that morning. The examiner said that he had skinned his knee, and it hurt when bending. The injury was cleaned and dressed with an ace bandage. There is no mention of any follow-up treatment for this injury, and the remainder of the service treatment records for this period of service is negative for any further mention of the right knee. These records are completely negative for left knee injuries or complaints. The Veteran answered "no" when asked if he had a history of a trick or locked knee on a March 1982 Report of Medical History obtained shortly before his discharge. The lower extremities were normal on a medical examination completed at that time. The records following the Veteran's discharge from his first period of active service are negative for a knee disability during the first year following discharge from service, and continued to be negative until many years after discharge. The service treatment records from the Veteran's Army National Guard service show that he underwent periodic medical examinations. Examinations conducted in May 1990, April 1995 and June 1999 were negative for a disability of either knee. The Veteran denied having a bone, joint or other deformity; or a trick or locked knee in Report of Medical History forms that he self-completed in April 1990, April 1995, and June 1999. Upon entering active service in February 2003, the Veteran completed another Report of Medical History. On this occasion he answered "yes" to a history of "knee trouble". The comments section further noted that the Veteran had knee problems but that he denied a history of surgery. A physical evaluation board convened in April 2003 and May 2003 determined that the Veteran was unable to perform his duties due to a back disability. An April 2003 examination conducted as part of this board found the Veteran to be medically unfit for the Army. The only disability noted was the back disability. The Veteran completed another Report of Medical History in May 2003, and he again answered "yes" to a history of knee trouble. A medical examination conducted at this time found that the lower extremities were abnormal. However, the examiner stated that the abnormality was varicose veins. In spite of the extensive medical examinations and testing conducted during this period of service, there was no note of a disability of either knee. There is no evidence of complaints or treatment regarding the knees for the remainder of this period of service. The initial post service evidence of knee disabilities is found in private medical records dating from March 2005. These include a September 2005 record of complaints of pain in both knees, and an October 2005 X-ray study that revealed patellofemoral osteoarthritic changes of the left knee, with no evidence of an acute injury. An April 2006 VA magnetic resonance imaging (MRI) study of the knees revealed a tear of the posterior horn of the medial meniscus of the left knee, and linear tear of the posterior and mid part of the medial meniscus of the right knee with minimal degenerative arthritic changes. An October 2006 VA orthopedic consultation shows that the Veteran was seen for complaints of bilateral knee pain. The pain had been progressive over time. There was no history of previous knee injuries or surgeries. The diagnoses were medial compartment arthrosis, both knees, and degenerative meniscus tears. July 2007 VA treatment records include a history of bilateral knee pain secondary to moderately advanced arthrosis. A May 2009 VA X-ray study showed marked narrowing of the medial joint compartment of both knees with degenerative changes more prominent on the left. The Veteran was afforded a VA examination of his joints in January 2010. The claims folder was reviewed by the examiner. The recent left knee replacement was noted, and the Veteran said that he also needed a replacement on the right side. The impressions were status post left knee arthroplasty, and degenerative joint disease of the right knee. The examiner noted that the only entry in the service treatment records pertaining to his knees was the May 1974 entry when the Veteran skinned his knee. There was no other evidence of knee problems during service, and the 1982 discharge examination was noted to be normal. The examiner opined he was unable to provide a nexus between the current knee condition and any incident or occurrence in the military. The examiner added that in the absence of any sort of medical documentation, to conclude otherwise would be resorting to mere speculation. In regards to the claim that the knees were secondary to the Veteran's service connected low back disability, the examiner said that low back disorders do not cause, predispose, or accelerate joint disease of the knees. The Veteran underwent an additional VA examination of his knees in April 2012. The claims folder was reviewed by the examiner, and a complete physical examination of the knees was conducted. His current diagnoses were a left total knee replacement, degenerative arthritis of the right knee, and a linear tear of the posterior medical meniscus of the right knee. The examiner opined that it was less likely than not that the Veteran's disabilities were incurred or caused by the claimed in-service injury, event, or illness. The examiner's rationale was that there was no finding of a knee disability on entry or exit from the Veteran's first period of service. The only entry regarding the knee was the May 1974 report of the skinned right knee. The examiner opined that she was again unable to provide a nexus between the current knee condition and any incident or occurrence in the military. The examiner added that in the absence of any sort of medical documentation, to conclude otherwise would be resorting to mere speculation. She referred to an October 2006 VA orthopedic consultation noting the Veteran had no history of previous knee injuries or surgery in further support of the opinion. The April 2012 report was returned to the examiner for further comment in December 2012. In particular, she was asked to comment on whether it was clear and unmistakable that the Veteran had a knee disability when he entered service in February 2003 and, if so, if it was clear and unmistakable that it was not made chronically worse beyond the natural progression during this period of service. She was also to comment on the possibility of a relationship between the service connected back disability and the knee disabilities. In reply, the examiner opined that a review of the medical literature revealed no accepted medical studies that support that a knee disability could be secondary to a back disability. It was less likely than not that his bilateral knee condition was the direct or proximate result of the back disability, or that it was aggravated by the back disability. Furthermore, the examiner checked a box that says "The claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness." The rationale was that there was no medical documentation to support that the Veteran complained of, sustained any injury, was diagnosed or treated for a knee condition during the period from February 2003 to September 2003. Her rationale as to why a pre-existing knee disability was not aggravated during the Veteran's first period of service was similar, in that the only treatment recorded was for the skinned right knee in May 1974. Entitlement to service connection is not established on a direct basis for either knee for either period of active service. Before analyzing the two periods of active service in order to determine if the Veteran developed a knee disability in either one, the Board notes that the possibility of a pre-existing knee disability has been raised by the February 2003 Report of Medical History. The Veteran answered "yes" to a history of knee trouble on this examination, and the explanation, while not entirely legible, includes an abbreviation with the possible interpretation that he had knee problems in high school. The Veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered s noted. 38 C.F.R. § 3.304(b). Once it is established that a veteran is entitled to the presumption of soundness, it must be determined whether or not there is sufficient evidence to rebut this presumption. Pursuant to 38 U.S.C.A. § 1111, there is a two-pronged test for consideration in determining whether the presumption of soundness has been rebutted. First, VA must show by clear and unmistakable evidence that the disease or injury existed prior to service. Second, VA must show by clear and unmistakable evidence that the pre-existing disease or injury was not aggravated by service. See VAOPGCPREC 3-2003. A preexisting injury or disease will be considered to have been aggravated by active service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1151; 38 C.F.R. § 3.306(a). One interpretation of the December 2012 addendum, while also not entirely clear due to the limited choices in the pre-printed form, is that the Veteran's knee disabilities clearly and unmistakably existed prior to entering service. It is unclear as to whether this is a reference to both periods of active service or just the second period of service. The Board notes that the same result is reached in this appeal whether or not the Veteran's disabilities existed prior to service. For the first period of service, the Veteran's knees were found to be normal on the examination conducted upon entry into service in April 1974. Therefore, he is entitled to the presumption of soundness. Furthermore, the Board does not find that there is clear and unmistakable evidence to overcome this presumption. The only possible reference to a pre-existing knee disability is found in the February 2003 Report of Medical History, and this reference may or may not refer to knee pain in high school. Even if it is to be interpreted as such, it must be remembered that the Veteran denied a history of knee problems on his April 1974 Report of Medical History, as well as on four other histories obtained between 1974 and 2003. Finally, there is no diagnosis of either a right or left chronic knee disability prior to 2003. The Board finds that the 2003 reference does not constitute clear and unmistakable evidence of a pre-existing disability of either knee. The Veteran is entitled to the presumption of soundness for this period of service. To continue the analysis on this basis, the preponderance of the evidence is against a finding that the Veteran developed a chronic knee disability during this period of service. He was treated for having skinned his right knee in May 1974, without any mention of an internal knee injury. The record is completely negative for a reference to the left knee. Competent medical opinions obtained in January 2010 and April 2012 both state that a nexus between service and a current knee disability could not be established, and both of these examiners agreed that given the lack of evidence of knee disabilities in service it would be complete speculation to find such a nexus. Entitlement to service connection for either knee disability also cannot be presumed based on the first period of active service. There is no diagnosis of a chronic knee disability either during service or until many years following discharge from active service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Finally, continuity of symptomatology is not demonstrated between the first period of active service and the Veteran's current knee disabilities. There is no evidence of treatment for a knee disability between the 1982 discharge and the 2003 entry into service. The Veteran testified at the May 2008 hearing that he hurt his knees during basic training, and that continued to experience pain and swelling every six to eight months for many years after this initial injury. The Veteran has submitted lay statements from his brother and sister that state they had knowledge of the Veteran's complaints of pain and swelling in the knees and legs during his first period of service and thereafter. However, while the Veteran and his siblings are credible, and while they are competent to report pain and swelling, they are not competent to report the etiology of the pain and swelling. Contemporaneous records show that the Veteran received ongoing treatment for pain and swelling in his legs due to varicose veins, which is a disability for which service connection has already been established. These records are negative for knee treatment subsequent to the May 1974 skinned knee, and neither the Veteran nor his siblings are competent to state that the Veteran's pain and swelling were due to bilateral knee disabilities instead of the service connected varicose veins. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The preponderance of the evidence is against a finding of continuity of symptomatology. Finally, even if the Board was to interpret the December 2012 medical addendum as finding that clear and unmistakable evidence shows knee disabilities existed prior to entering service in April 1974, this still would not provide a basis for service connection. The December 2012 addendum also opined that there was clear and unmistakable evidence that the Veteran's disabilities were not aggravated during service. This was based on the finding that the only treatment or complaint during this period was for the skinned right knee in May 1974. The Board also notes that the Veteran denied having knee disabilities when he left service in 1982, and again in 1990, 1995, and 1999. As there is no contemporaneous evidence whatsoever that any pre-existing disability increased in severity, service connection on the basis of aggravation would not be shown. 38 U.S.C.A. §§ 1111, 1151; 38 C.F.R. § 3.306(a). The Board further finds that there is no basis for service connection for either knee disability based on the Veteran's ACDUTRA or INACTDUTRA in the National Guard. As previously noted, the exact dates of all periods of ACDUTRA or INACTDUTRA have not been obtained. However, the Veteran has not offered any specific contentions about sustaining a knee injury during any period of ACDUTRA or INACTDUTRA. In fact, the Veteran denied having a knee disability on the three reports of medical history he completed during this period, and the medical records from his Guard unit are negative for a knee injury or related complaints. Entitlement to service connection based on service in the National Guard is not demonstrated. 38 U.S.C.A. § 101(24). In regards to the Veteran's period of active service from February 2003 to September 2003, the Board finds that service connection for a knee disability is not demonstrated for many of the same reasons articulated in regards to the first period of active service. Although the Veteran reported knee problems on the February 2003 Report of Medical History when he was entering service, he remains entitled to the presumption of soundness for this period. Only disabilities shown on the entrance examination are considered to have been noted, and there is no record of an examination at this time. However, in this case it appears the December 2012 examiner found that there is clear and unmistakable evidence that the knee disabilities existed prior to service, and the presumption of soundness is rebutted. The Board must now determine whether or not there is clear and unmistakable evidence that the knee disabilities were not aggravated. In this case, the December 2012 examiner also determined that there is clear and unmistakable evidence that the Veteran's pre-existing knee disabilities were not aggravated during service. She cited to the complete lack of evidence of complaints or treatment for either knee disability during service to support her rationale. The Board agrees, and notes that much of the Veteran's 2003 period of active duty was spent undergoing medical evaluations to determine whether or not he was fit for duty. Because of this testing he was never deployed. The testing was mainly in regards to his back disability. However, in spite of additional testing to determine the strength of the lower extremities, knee disabilities were not discovered on any of these evaluations, nor did the Veteran make any complaints regarding the knees. In fact, the record is completely devoid of any evidence that his knees were symptomatic, much less aggravated. The first post service evidence of a knee disability is dated 2005, nearly two years after the Veteran's discharge. The Board agrees with the December 2012 examiner that this is clear and unmistakable evidence that the knee disabilities were not aggravated during this period of service. Finally, in regards to the Veteran's contentions that his knee disabilities are secondary to his service connected back disability, both the January 2010 and the December 2012 examiners found that there was no relationship between the back and the knees. The December 2012 examiner also opined that the back did not aggravate the knees. The Board recognizes the Veteran's sincere belief to the contrary, but the etiology of a knee disorder is a complex medical question that is not within the competence of a layperson. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, service connection on a secondary basis is not established. In arriving at its determinations above the Board has considered the benefit-of-the-doubt rule. Because the preponderance of the evidence is against the claims the rule does not apply. Gilbert v. Derwinski, 1 Vet. App. 49, 54-55 (1990). ORDER Entitlement to service connection for chronic residuals of a right knee injury, to include as secondary to the service connected degenerative joint disease of the lumbar spine, status post right L4-5 microdiscectomy, is denied. Entitlement to service connection for degenerative arthritis of the left knee, to include as secondary to the service connected degenerative joint disease of the lumbar spine, status post right L4-5 microdiscectomy, is denied. ____________________________________________ JOHN H. NILON Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs