Citation Nr: 1603429 Decision Date: 02/02/16 Archive Date: 02/11/16 DOCKET NO. 09-27 939A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to an initial rating higher than 30 percent for the service-connected sinusitis with associated headaches. 2. Entitlement to pseudogout of the left foot. 3. Entitlement to service connection for a deviated septum. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Sara Kravitz, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1978 to July 1996 and from November 2004 to June 2008. He also served in the Army Reserve. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision of the RO. The Board notes that the September 2008 rating decision granted service connection for sinusitis with associated headaches and assigned a noncompensable rating, effective on July 1, 2008, the day after the Veteran was separated from service. During the current appeal period, in a rating decision in April 2010, the RO increased the rating to 30 percent effective on July 1, 2008 and thus the issue on appeal is characterized as entitlement to an initial rating higher than 30 percent for sinusitis associated with headaches. Regardless of the RO's actions, the issue remains before the Board because the increased rating was not a complete grant of the maximum benefits available. See AB v. Brown, 6 Vet. App. 3 (1993). In March 2013, the Veteran withdrew his earlier request for a videoconference hearing with the Board. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this case should take into consideration the existence of this electronic record. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's sinusitis has been manifested by constant sinusitis with pain, tenderness and purulent discharge, but only two incapacitating episodes per year and no surgeries for his sinusitis, and no chronic osteomyelitis. 2. The Veteran's deviated septum is not related to a disease, injury, or incident in service. 3. A diagnosis of pseudogout is not shown by the competent evidence of record at any time during the appeal. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for sinusitis are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.97, Diagnostic Code 6513 (2015). 2. A deviated septum was not incurred in active service. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.303 (2015). 3. Pseudogout of the left foot was not incurred in active service. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.303 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Stegall Considerations The Board remanded this matter in May 2013, and specifically instructed the RO/Appeals Management Center (AMC) to afford the Veteran VA examinations. Subsequently, the Veteran was afforded the examinations in August 2013 and thus there is substantial compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits pursuant to 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). Regarding the service connection claims, in correspondence dated in March 2008, prior to the September 2008 rating decision, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2014) and 38 C.F.R. § 3.159(b) (2015). Specifically, the RO notified the Veteran of: information and evidence necessary to substantiate the claim; information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. Regarding sinusitis, in March 2008, the agency of original jurisdiction (AOJ) sent a letter to the Veteran providing the notice required for the initial claim of service connection. Service connection was subsequently granted in September 2008, and the Veteran appealed the initial rating assigned. In cases such as this, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490 (2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Veteran bears the burden of demonstrating any prejudice from defective (or nonexistent) notice with respect to the downstream elements. Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). That burden has not been met in this case with regard to the increased rating claim for sinusitis. Neither the Veteran nor his representative alleges such prejudice in this case. Therefore, no further notice is needed. VA has done everything reasonably possible to assist the Veteran with respect to his claims for benefits in accordance with 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c). Service treatment records and private treatment records have been associated with the claims file. The Veteran was medically evaluated in conjunction with his claims in May 2008, April 2010, and also in August 2013 in accordance with the May 2013 Board Remand. See Stegall, supra. The VA examiners recorded the Veteran's current complaints, conducted appropriate evaluations of the Veteran, and provided sufficient information and opinions to allow the Board to render an informed decision on the Veteran's disabilities. The Board finds the examinations when taken together to be thorough and complete with respect to the Veteran's claimed disabilities. The clinicians reviewed the history and provided an opinion supported by a rationale; therefore, the opinions are adequate. See 38 CF.R. § 4.2 (2015); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2015); Barr, 21 Vet. App. at 312. Also, the Board observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2015). The Veteran requested a hearing, however, he later canceled. Therefore the duties to notify and assist have been met. Analysis - Increased Rating for Sinusitis Disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. Each disability must be viewed in relation to its history, with an emphasis on the limitation of activity imposed by the disabling condition. Medical reports must be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. See 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.7 (2015). While the Veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Therefore, the Board will determine whether staged evaluations are warranted. Diagnostic Code 6510 relates to sinusitis, parasinusitis, chronic. The criteria addressing sinusitis under Diagnostic Codes 6510 are as follows: A 30 percent disability rating is awarded for sinusitis manifested by three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or by more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent disability rating is awarded for sinusitis following radical surgery with chronic osteomyelitis, or manifested by near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. See 38 C.F.R. § 4.97 (2015). An incapacitating episode of sinusitis is one requiring bed rest and treatment by a physician. Id. The criteria for compensable ratings of sinus conditions are stated in the conjunctive, which means that all conditions must be met (near constant sinusitis...and purulent discharge or crusting after repeated surgeries) to warrant a rating of 50 percent or greater. See Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007) (finding that the use of the conjunctive "and" in the criteria for a 40 percent rating for diabetes - "insulin, restricted diet, and regulation of activities" - meant that entitlement to that rating required all three criteria to be met.) In May 2008, the Veteran was afforded a general medical VA examination for compensation purposes. The examiner noted tenderness of the maxillary glands. In April 2010, the Veteran was afforded a VA examination. The examiner noted that the Veteran's present symptoms included headaches on the right side of his face, rhinorrhea, post nasal drainage with yellowish phlegm and some dried blood daily. He was last treated with antibiotics in 2007 but had no acute sinus infection since then. He had no sinus or nasal surgery. He had two incapacitating episodes in the past year. In August 2013, the Veteran was afforded a VA sinus examination. He stated he had green discharge 1-2 times per year, mainly in fall and winter months and mainly experienced congestion in his bilateral maxillary sinuses and pressure in the ears. He had a runny nose and post nasal drainage. He also had soreness to the touch on his maxillary sinuses when he had discharge. He stated he was never told that he had any chronic osteomyelitis or anything resembling a chronic infection of the bones. He also had headaches where he experienced a pain on the side of his face, and would get headaches if he did not clear his sinuses daily. He stated he currently had headaches once every three months and that they were not incapacitating and he could go to work. He had not required antibiotics in the past year. The examiner noted that the Veteran had near constant sinusitis, headaches, pain, and purulent discharge or crusting, and that he had two incapacitating episodes in the past year. The examiner noted the Veteran had never had sinus surgery. In a separate headaches examination, the examiner noted the Veteran did not have characteristic prostrating attaches of migraine headache pain. Throughout the appeal period, the Veterans' sinusitis has been manifested by constant sinusitis with pain, tenderness and purulent discharge, but only two incapacitating episodes per year and no surgeries for his sinusitis, and no chronic osteomyelitis. As the Veteran has not had required surgery for his condition, and has not shown any osteomyelitis, a 50 percent rating is not warranted. See 38 C.F.R. § 4.97; Camancho, supra. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In this case, a separate or higher rating is not available under a different Diagnostic Code. The Board notes that the Veteran has headaches, and has considered whether a higher rating could be applied under 38 C.F.R. § 4.124a, DC 8100. However, the evidence does not indicate that the Veteran experiences prostrating attacks, or that the headaches constitute a distinct and separate symptomology from his sinusitis, for which he has a current disability rating which already contemplates headaches. As such, a higher rating under DC 8100 is not warranted. In this case, the Board finds that a rating in excess of 30 percent is not warranted for the Veteran's sinusitis at any point during the appeal. Furthermore, the Board concludes that assignment of staged ratings is not for application. Fenderson, supra. Extraschedular Consideration of Sinusitis The Board has also considered whether the Veteran's claim should be referred for an extraschedular rating. See 38 C.F.R. § 3.321(b) (2015); Thun v. Peake, 22 Vet. App. 111, 114 (2008). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Id. However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2015). The Board finds that referral for extraschedular consideration is not warranted. The Veteran's service-connected sinusitis is contemplated and reasonably described by the rating criteria under Diagnostic Code 6513. See 38 C.F.R. § 4.97. In this regard, the Veteran's sinusitis is manifested by constant sinusitis with pain, tenderness and purulent discharge, but only two incapacitating episodes per year and no surgeries for his sinusitis, and no chronic osteomyelitis. This type of disability picture is specifically addressed in the rating criteria set forth in Diagnostic Code 6513. In sum, the Board finds that a comparison of the Veteran's sinusitis with the schedular criteria for the disability does not show that it presents "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b) (2015). Consequently, the Board finds that the available schedular evaluations are adequate to rate this disability. As such, in the absence of this threshold finding, there is no need to consider whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). Next, the Board notes that a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Johnson v. McDonald, 2013-7104, 2014 WL 3562218 (Fed. Cir. Aug. 6, 2014). In this case, the Veteran has been granted service connection for apnea, shoulder disabilities, spine disabilities, a bilateral hip disability, bursitis, tinnitus, GERD, bruxism, a bilateral elbow disability, and multiple other disabilities. The medical and treatment records do not reflect that the Veteran's service-connected sinusitis results in further disability when looked at in combination with the above. Therefore, the Board finds that the schedular criteria adequately describe the Veteran's sinusitis 38 C.F.R. § 4.97, Diagnostic Code 6513. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. 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 (TDIU), 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, the Veteran has not argued and the record does not otherwise reflect that his service-connected sinusitis renders him totally unemployable. Accordingly, the Board concludes that a claim for TDIU has not been raised. Service Connection In general, service connection may be granted for a disability or injury incurred in or aggravated by active military service. See 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2015). In order to establish service connection for the claimed disorder, there must be (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) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Deviated Septum In this case, the Veteran currently has a diagnosis of a deviated septum. See e.g. August 2013 VA examination. Therefore, Hickson element (1) is met. With respect to Hickson element (2), in-service disease or injury, review of the service treatment records shows the Veteran had notations of "little to no deviated septum" after being seen in service for nasal obstruction in December 2006, which the examiner attributed to his maxillary surgery residuals. While the notations in the record note the Veteran's deviated septum to be mild at best, affording the benefit of the doubt, Hickson element (2) is at least arguably met. With respect to crucial Hickson element (3), that of nexus, the question is whether there is a relationship between the Veteran's current deviated septum and his military service; this is essentially medical in nature. The Board is prohibited from exercising its own independent judgment to resolve medical questions. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). In May 2008, the Veteran was afforded a general medical VA examination for compensation purposes. The examiner noted that the Veteran stated that he had a deviated septum due to previous injury and problems breathing through the nose, and that he was due for corrective surgery. In April 2010, the Veteran was afforded a VA examination for his sinusitis and imaging for his nose. He stated he was diagnosed with a deviated septum in 2007. Imaging showed very mild septal deviation and swelling of his turbinates leading to obstruction. In August 2013, the Veteran was afforded a VA examination. The VA examiner noted that the Veteran had a very mild deviated septum at best, and that it was not likely a factor in his nasal congestion and sinus condition. The examiner further noted that there was no trauma in the record to suggest a traumatic nasal septal deviation acquired at any time and that it was more than likely congenital. He further that there was no evidence of aggravation of deviated septum in service as there were no symptoms attributed to the deviated septum until 2013. This was because the Veteran's symptoms of sinus congestion and chronic sinusitis were due to his maxillary surgery and not his deviated septum. When assessing the probative value of a medical opinion, the access to the claims file and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves- Rodriguez v. Peake, 22 Vet App 295, 304 (2008). In this case, as to the issue of the etiology of the Veteran's condition, the Board finds that the August 2013 VA examination report is the most probative evidence of record, and the Board gives credence and weight to the VA examiner's opinions as they were rendered after an evaluation of the Veteran, review of the Veteran's history, and consideration of medical principles by a licensed medical professional. This opinion outweighs the Veteran's lay contentions that his deviated septum is due to service. The examiner specifically noted that any symptoms of sinusitis or congestion in service were due the Veteran's maxillary post-surgery residuals, as opposed to aggravation of his very mildly deviated septum and that there was no trauma in service that caused his deviated septum. Accordingly, the Board concludes that the VA opinion carries significant weight. No other competent opinion providing a positive nexus between service and the Veteran's deviated septum has been presented. The Board acknowledges that the Veteran is competent to testify as to his events in service. However, there is nothing in the record to suggest that the Veteran has the appropriate training, experience, or expertise to render a medical opinion regarding the etiology of his deviated septum, and whether it was caused by service. See 38 C.F.R. § 3.159 (a)(1) (2015) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). While the Veteran is competent to report what he has experienced, he is not competent to ascertain the etiology of any current condition, as the causative factors for such are not readily subject to lay observation. It is noted that while the examiner in May 2008 noted that the Veteran had an injury to his nose and trouble breathing, this was based off of the Veteran's history, and nowhere else in the record has the Veteran stated he injured his nose, making these notations not probative. See LaShore v. Brown, 8 Vet App 406 (1995) (holding that a lay history is not transformed into competent evidence merely because it was transcribed by a medical professional). Therefore, the Veteran's claims that his current condition was etiologically related to service are outweighed by the competent and probative medical opinion which states that the Veteran's current condition is not related to service. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); Layno v. Brown, 6 Vet. App. 465 (1994). Therefore, a nexus between service and the Veteran's deviated septum and service cannot be established, and the claims fail on Hickson element (3). In reaching this determination, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran's claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b) (West 2014). Pseudogout of the left foot In a March 2008 report of medical assessment in service, a nurse listed gout in the left foot. Other treatment records from service from around that time period include this finding on the problem list, but there is no explanation of the diagnosis of the gout of the left foot. In May 2008, just prior to the Veteran's separation, he was afforded a general medical VA examination for compensation purposes. The Veteran stated that he had an attack of gout on his left large toe and was told it was pseudogout. He stated he had the attack in 2006 and that his gout responded well to Lodine. He stated he had five attacks from 2006 until 2008. The examiner noted in the final assessment that the Veteran was in complete remission without any evidence of any deformities. In August 2013, the Veteran was afforded a VA examination. The examiner noted that while pseudogout was listed on problem lists between 2006 and 2008, the medical records including service treatment records did not show any incident leading to this listing and that there was no episode that actually correlated with a diagnosis in service, nor any event with a final assessment of pseudogout. The examiner instead diagnosed the Veteran with right first metatarsophalangeal (MTP) strain due to overuse syndrome while in service. The examiner opined that based on the records, there was insufficient evidence to diagnose pseudogout, as the description of the Veteran's toes at the time did not support the type of inflammatory reaction classically seen due to pseudogout. While the examiner acknowledged the Veteran's statement that his symptoms improved after he stopped consuming red meat, the Veteran's medical history still was not supportive of a diagnosis of gout and the examiner noted the cortisone injections would have relieved pain from any form of inflammation including overuse. Overall, the examiner noted that the history of relief due to cortisone, as well as the overall medical history was nonspecific and insufficient to diagnose pseudogout. While the record contains notations of pseudogout in the Veteran's service treatment records problem lists, as well as the March 2008 report of medical assessment, there are no records of a formal diagnosis of pseudogout based on observed symptoms or testing in service or after. It is noted that while the examiner in May 2008 reported that the Veteran had a history of pseudogout, this was told to the examiner by the Veteran, making these notations not probative. See LaShore v. Brown, 8 Vet App 406 (1995) (holding that a lay history is not transformed into competent evidence merely because it was transcribed by a medical professional). Furthermore, the examiner noted the Veteran was currently in remission and showed no signs of gout. The Board points out that a key element in establishing service connection is to show that the Veteran currently has a diagnosis or symptoms of the disability for which service connection is sought. See 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. 3.303 (2015). In this case, there is no clinical evidence in the claims file diagnosing pseudogout of the left foot in accordance with applicable law, other than repeated notations in the problem list that have not been substantiated by a formal diagnosis or treatment related specifically to gout. Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. "In the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As the competent medical evidence of record does not indicate the presence of a diagnosed disability at any time during the appeal period Hickson element (1) has not been met and the claim fails. Cf. McClain v. Nicholson, 21 Vet. App. 319 (2007). The Board would also point out that as a diagnosis of pseudogout is not clinically demonstrated, there is no need to discuss whether this disability was incurred in service. In making this decision, the Board must fully consider the lay assertions of record. In this regard, a layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (noting that a Veteran is competent to report on that of which he or she has personal knowledge). However, while the Veteran has stated he was told he was diagnosed with pseudogout in service, the August 2013 VA examiner has specifically opined that the Veteran did not have pseudogout, but more likely had MPT strain due to overuse. This opinion is afforded great probative value based on the examiner's thorough examination of the Veteran and his reported medical history. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (noting that factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). The Board notes that this MPT disability has already been service-connected in a separate rating decision which is not currently before the board. In reaching this determination, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran's claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b) (West 2014). (CONTINUED ON NEXT PAGE) ORDER Entitlement to an initial rating higher than 30 percent for the service-connected sinusitis with associated headaches is denied. Entitlement to service connection for a deviated septum is denied. Entitlement to pseudogout of the left foot is denied. ____________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs