Citation Nr: 1342671	
Decision Date: 12/24/13    Archive Date: 12/31/13

DOCKET NO.  10-44 644	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Lincoln, Nebraska


THE ISSUES

1.  Entitlement to a rating in excess of 20 percent for diabetes mellitus, type II, with erectile dysfunction.

2.  Entitlement to service connection for peripheral arterial disease of the lower extremities, to include as secondary to diabetes mellitus, type II, and/or herbicide exposure.

3.  Entitlement to service connection for peripheral neuropathy of the lower extremities, to include as secondary to diabetes mellitus, type II, and/or herbicide exposure.


REPRESENTATION

Appellant represented by:	Veterans of Foreign Wars of the United States



WITNESS AT HEARING ON APPEAL

Appellant


ATTORNEY FOR THE BOARD

E. Joyner, Counsel


INTRODUCTION

The Veteran served on active duty from January 1966 to January 1968, to include service in the Republic of Vietnam.  

This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in May 2010 and March 2011 of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska.  

In March 2013 the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge.  A transcript of that hearing is of record.

The issues of entitlement to service connection for peripheral arterial disease of the lower extremities, to include as secondary to diabetes mellitus, type II, and/or herbicide exposure, and entitlement to service connection for peripheral neuropathy of the lower extremities, to include as secondary to diabetes mellitus, type II, and/or herbicide exposure, 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.





FINDING OF FACT

Throughout the pendency of this appeal, the Veteran's diabetes mellitus, type II, with erectile dysfunction, required oral medication, insulin injections and a restricted diet, but not a regulation of his activities; the Veteran experiences loss of erectile power with no penile deformity.


CONCLUSION OF LAW

The criteria for a disability rating in excess of 20 percent for diabetes mellitus, type II, with erectile dysfunction, have not been met.  38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.119, Diagnostic Codes 7913, 7522 (2013). 


REASONS AND BASES FOR FINDING AND CONCLUSION

The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's 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, and 3.326(a) (2013). 

Duty to Notify

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) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002).  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.  VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim.  Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006).

In March 2006, the United States Court of Appeals for Veterans Claims (Court) issued its decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).  The Court in Dingess/Hartman held that the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim.  As previously defined by the courts, 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.  Upon receipt of an application for "service connection," therefore, VA is required to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application.  This includes notice that a disability rating and/or an effective date will be assigned if service connection is awarded.  Because the Court's decision is premised on the five elements of a service connection claim, it is the consensus opinion within the VA that the analysis employed can be analogously applied to any matter that involves any one of the five elements of a "service connection" claim, to include an increased rating claim. 

In VA correspondence dated in March 2010, the Veteran was informed of what evidence was required to substantiate his increased rating claim, and of his and VA's respective duties for obtaining evidence.  Also, the notice letter informed the Veteran of the criteria for consideration in assigning an effective date and/or disability rating.  

In Pelegrini, the Court held that compliance with 38 U.S.C.A. § 5103 required that VCAA notice be provided prior to an initial unfavorable AOJ decision.  Because VCAA notice in this case was completed prior to the initial AOJ adjudication denying the claim, the timing of the notice complies with the express requirements of the law as found by the Court in Pelegrini.  

In light of the above, the content of the March 2010 notice fully complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), and Dingess/Hartman.  The Veteran has been provided with every opportunity to submit evidence and argument in support of his claim, and to respond to VA notice. 

All the VCAA requires is that the duty to notify is satisfied, and that claimants are given the opportunity to submit information and evidence in support of their claims.  Once this has been accomplished, all due process concerns have been satisfied.  See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996).  The Board finds the VCAA notice requirements have been met in this case.

Duty to assist

With regard to the duty to assist, the claim's file contains the Veteran's service treatment records, VA treatment records, VA examination reports, private treatment records, letters/notes from private health care providers, and the Veteran's statements in support of his claim.  The Board has carefully reviewed the Veteran's statements and concludes that there has been no identification of further available evidence not already of record.  The Board has also reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim for which VA has a further duty to obtain.  
	
With respect to the VA examinations of record, the Veteran was afforded VA examinations with respect to his claim in April 2010, February 2011, and March 2012.  To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate.  Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).  The Board finds that together the April 2010, February 2011, and March 2012 VA examination reports are adequate.  The April 2010 and February 2011 VA examiners reviewed the claims file, all VA examiners conducted an examination, and together, the examination reports provide the medical information addressing the rating criteria in this case.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).  Consequently, the Board finds that the VA examinations are adequate. 

In Bryant v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) recently held that 38 C.F.R. 3.103(c)(2) (2013) requires that the Veterans Law Judge who conducts a hearing fulfill two duties to comply with the above the regulation.  Bryant v. Shinseki, 23 Vet. App. 488 (2010).  These duties consist of (1) the duty to fully explain the issue or issues on appeal and (2) the duty to suggest the submission of evidence that may have been overlooked.  In this case, the Veterans Law Judge explained the issues on appeal, and discussed the submission of outstanding relevant evidence.  The Veterans Law Judge and the Veteran's representative asked the Veteran questions about the symptoms and severity of his diabetes mellitus, type II, currently on appeal.  Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor identified any prejudice in the conduct of the Board hearing.  As such, the Board finds that the Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2), consistent with Bryant, and that any error in notice provided during the Veteran's hearing constitutes harmless error. 

Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist in developing the facts pertinent to the claim.  Essentially, all available evidence that could substantiate the claim has been obtained.

Legal Analysis

Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's 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. Part 4 (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.  After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran.  Id.  § 4.3. 

Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition.  It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history.  Id.  § 4.1.  Nevertheless, the present level of disability is of primary concern.  Francisco v. Brown, 7 Vet. App. 55, 58 (1994).  The Board notes that 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).

In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied.  38 U.S.C.A. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 

The Board has reviewed all the evidence in the appellant's claims file.  Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail.  Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim.  See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000).

Under Diagnostic Code 7913, a 20 percent rating is warranted for diabetes mellitus, type II, which requires insulin and restricted diet, or; oral hypoglycemic agent and restricted diet.  38 C.F.R. § 4.119, Diagnostic Code 7913.  A 40 percent rating is warranted when diabetes mellitus, type II, requires insulin, restricted diet, and regulation of activities.  A 60 percent rating is warranted for diabetes mellitus, type II, which requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately rated.  A 100 percent rating is warranted for diabetes mellitus, type II, which requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately rated.  Compensable complications of diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent rating under Diagnostic Code 7913.  Id. at Note (1).  Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913.  Id. 

The Board finds that the criteria for a higher rating under Diagnostic Code 7913 have not been met at any time during the pendency of the appeal.  The criteria for a higher rating under this diagnostic code are conjunctive not disjunctive, i.e., there must be insulin dependence (or oral hypoglycemia agents) and restricted diet and regulation of activities.  "Regulation of activities" is defined by Diagnostic Code 7913 as the "avoidance of strenuous occupational and recreational activities."  Medical evidence is required to show that occupational and recreational activities have been restricted.  Camacho v. Nicholson, 21 Vet. App. 360 (2007).  The medical evidence of record demonstrates that the Veteran's diabetes mellitus is treated by diet, insulin and oral hypoglycemic agents.  These manifestations meet the criteria for a 20 percent rating.  The Veteran is not shown to have been instructed by a physician to avoid strenuous occupational and recreational activities, as is required for a higher 40 percent rating.  In fact, to the contrary, VA records show that his diabetic regimen included exercise.  In this regard, a January 2009 VA treatment record indicates that the Veteran was instructed on weight loss, diet, and exercise.  An October 2009 VA treatment record indicates that the Veteran had not been exercising due to knee pain.  Additionally, a January 2010 VA treatment record indicates that he had not initiated an exercise program.  As noted in the March 2012 VA examination the Veteran's diabetes mellitus does not impact his ability to work, and it does not require regulation of activities as part of medical management.  The April 2010 VA examination report indicates that the Veteran's activities are naturally restricted relative to his diabetes simply because of the complexity of the multiple injections during the day combined with his need to take oral hypoglycemic medication.  The examination report further notes that this insulin/medication regimen has eliminated spontaneous activities.  However, the record does not indicate that the Veteran has been medically restricted in his activities due to his diabetes.  Further, the Veteran has not actually stated that his physicians have required him to restrict his activities; instead, it seems to be more of a scheduling issue involving him feeling as though he does not have the freedom to participate in spontaneous activities due to his need to take insulin and oral hypoglycemic medications.  As such, there is no medical evidence of restriction of activities and therefore, a higher 40 percent rating is not warranted.

As previously noted, noncompensable complications are considered part of the diabetes.  In this regard, the RO has considered the Veteran's erectile dysfunction as part of the currently assigned 20 percent rating for diabetes mellitus because the erectile dysfunction is not currently compensable.  In order to receive a separate compensable rating for erectile dysfunction, it must be shown that there is loss of erectile power with penile deformity.  38 C.F.R. § 4.115b, Diagnostic Code 7522.  As there is no evidence of penile deformity (and the Veteran does not contend that there is such deformity), a separate compensable rating for erectile deformity is not for application.  38 C.F.R. § 4.115b, Diagnostic Code 7522. 

In sum, there is simply no basis upon which to grant a rating in excess of 20 percent for the Veteran's diabetes mellitus, type II, with erectile dysfunction.  Staged ratings are not warranted, as there appears to be no identifiable period on appeal during which the disability manifested symptoms meriting a higher disability rating.  The preponderance of the evidence therefore is against the Veteran's claim for a higher rating, and the benefit of the doubt rule does not apply.  38 U.S.C.A. § 5107(b).

In making its determination, the Board considered the applicability of the benefit of the doubt rule.  38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990).  However, as a preponderance of the evidence is against the assignment of a higher disability rating, such rule does not apply and the claim must be denied.

In reaching this conclusion, the Board acknowledges the Veteran's belief that his diabetes mellitus, type II, with erectile dysfunction, is more severe than the current disability evaluation reflects.  In this regard, the Board must consider the entire evidence of record when analyzing the criteria set forth in the ratings schedule.  While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, as a lay person without demonstration of requisite training, he is not competent to assess whether the symptomatology meets a specific disability rating under the applicable diagnostic code criteria.  As such, the Board finds that the medical evidence of record is more persuasive regarding whether he is entitled to a higher disability rating in accordance with the schedular criteria.  The VA examiners considered the Veteran's reported symptoms and provided the clinical findings to rate the Veteran's disability with respect to the rating criteria.  Therefore, the Board finds that the medical evidence is more persuasive than the Veteran's own statements regarding his increased diabetes mellitus, type II, with erectile dysfunction, symptomatology.

Other Considerations

Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical.  See Fisher v. Principi, 4 Vet. App. 57, 60 1993).  An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards.  See 38 C.F.R. § 3.321(b)(1) (2013). 

Under Thun v. Peake, 22 Vet App 111 (2008), there is a three- step inquiry for determining whether a Veteran is entitled to an extraschedular rating.  First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate.  Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms."  Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating.  

With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular criteria are inadequate.  The rating criteria reasonably describe the Veteran's disability level and symptomatology due to his service-connected diabetes mellitus, type II, with erectile dysfunction.  As discussed above, there are higher ratings available under the diagnostic codes, but the Veteran's diabetes mellitus, type II, with erectile dysfunction, is not productive of such manifestations.  Therefore, a further analysis under Thun is not warranted.  In any event, there is no evidence of any hospitalization for the Veteran's diabetes mellitus and the evidence does not show marked interference with employment.  Notably, the March 2012 VA examiner indicated that the Veteran's diabetes mellitus, type II, with erectile dysfunction does not impact his ability to work at all.  As such, referral for extraschedular consideration is not warranted.

Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009).  In Rice, the Court held that a claim for a total rating based on unemployability due to service-connected disability, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating.  In this case, during the pendency of the increased rating claim for diabetes mellitus, the Veteran filed a claim for TDIU (in February 2012), indicating that his diabetes renders him unemployable.  However, the RO denied entitlement to a TDIU in a June 2012 rating action.  The Veteran did not appeal this decision and has not raised the issue of unemployability due to his service-connected disability since the June 2012 rating action denying the claim.  Importantly, the Veteran did not provide any testimony at the March 2013 videoconference hearing suggesting that he is unemployable due to his diabetes mellitus or otherwise indicate that he was still pursuing a claim for entitlement to TDIU.  As such, the Board finds that the issue of entitlement to TDIU is not currently before the Board.


ORDER

Entitlement to a rating in excess of 20 percent for diabetes mellitus, type II, with erectile dysfunction, is denied.


REMAND

Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration.  38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159.

If VA undertakes the effort to provide the Veteran with a medical examination, it must ensure that such exam is an adequate one.  See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).  A medical opinion must support its conclusion with an analysis the Board can consider and weigh against other evidence in the record.  Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007).  Furthermore, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.  Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008).

Service connection may be established on a secondary basis for a disability, which is proximately due to, the result of, or chronically aggravated by, service-connected disease or injury.  38 C.F.R. § 3.310(a) and (b).  Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability.  Allen v. Brown, 7 Vet. App. 439, 448 (1995).  

The April 2010 VA examination report reflects that the Veteran was diagnosed with discoloration around both ankles secondary to venous stasis in both lower extremities, not caused by or a result of peripheral arterial disease or the service-connected diabetes mellitus, type II.  The examiner indicated that there was no current objective evidence supporting a diagnosis of clinically significant peripheral arterial disease.  The examiner further stated that the Veteran's asymptomatic peripheral arterial disease is less likely as not a result of his service-connected diabetes mellitus, type II.  

The February 2011 VA examination indicates that the Veteran's bilateral peripheral neuropathy is less likely as not caused by or a result of his type II diabetes.  

Although the April 2012 VA addendum opinion report indicates that the Veteran's diabetes mellitus has not permanently aggravated any disability (specifically, the examiner did not check the box for any possible disability listed, namely cardiac conditions, hypertension, renal disease, peripheral vascular disease, and eye conditions), no rationale was provided regarding why the service-connected diabetes mellitus has not aggravated the Veteran's asymptomatic peripheral arterial disease, his venous stasis, or his peripheral neuropathy.  As such, a remand is required.

There is also no medical opinion regarding whether the Veteran's venous stasis, asymptomatic peripheral arterial disease, and/or his peripheral neuropathy are caused by exposure to Agent Orange.  As the Veteran has confirmed service in Vietnam, and the case is being remanded for a VA opinion as indicted above, such an opinion should also be obtained.  

The record reflects that the Veteran receives medical treatment through VA.  The most recent VA treatment records in the Virtual claims file are dated in May 2012.  The Veteran indicated that the videoconference hearing that he had an upcoming appointment in the next month with his VA physician to discuss his lower extremity symptoms.  As such, VA treatment records dating from May 2012 to the present should also be obtained.  38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim).

Accordingly, the case is REMANDED for the following action:

1.  Obtain copies of the Veteran's VA treatment records dating from May 2012 to the present, and associate them with the claims file.

2.  Return the claims file, to include a copy of this remand, to the VA examiner who conducted the March 2012 VA examination and provided the April 2012 addendum opinion, or suitable substitute.  The examiner must review the claims file, to include any additional records obtained since the March 2012 VA examination.  The examiner is requested to provide an opinion as to the following:

Is it at least as likely as not that the Veteran's peripheral neuropathy of the lower extremities (diagnosed at the February 2011 VA examination) is aggravated by (permanently worsened in severity beyond the natural progression of the disorder) the service-connected diabetes mellitus, type II, with erectile dysfunction.  The examiner is instructed to ignore any lack of a current diagnosis of peripheral neuropathy found at the March 2012 VA examination and focus solely on the prior February 2011 diagnosis of peripheral neuropathy of the lower extremities.

Is it at least as likely as not that the Veteran's venous stasis and asymptomatic peripheral arterial disease of the lower extremities (diagnosed at the April 2010 VA examination) is aggravated by (permanently worsened in severity beyond the natural progression of the disorder) the service-connected diabetes mellitus, type II, with erectile dysfunction.  The examiner is instructed to ignore any lack of a current diagnosis of peripheral arterial disease and focus solely on the prior April 2010 diagnosis of venous stasis and asymptomatic peripheral arterial disease of the lower extremities.

The examiner must also opine as to whether it is at least as likely as not that peripheral neuropathy of the lower extremities, venous stasis of the lower extremities and peripheral arterial disease of the lower extremities is related to active service, to include his conceded exposure to herbicides. 

The rationale for all opinions offered must be provided.

3.  After completing the above actions, and any other development as may be indicated, the claims must be readjudicated.  If any benefit sought remains denied, a supplemental statement of the case must be provided to the Veteran and his representative.  After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review.

The appellant has the right to submit additional evidence and argument on the matter or 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. 2013).



______________________________________________
U. R. POWELL
Veterans Law Judge, Board of Veterans' Appeals


Department of Veterans Affairs