Citation Nr: 1620754 Decision Date: 05/23/16 Archive Date: 06/02/16 DOCKET NO. 09-35 864 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for peripheral vascular disease (PVD), to include as secondary to service-connected diabetes mellitus and/or coronary artery disease. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus and/or coronary artery disease. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Carole Kammel, Counsel INTRODUCTION The Veteran had active military service from July 1965 to May 1967. These matters come to the Board of Veterans' Appeals (Board) from a July 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. By that rating action, the RO, in pertinent part, denied service connection for hypertension and peripheral vascular disease, to include as secondary to the service-connected diabetes mellitus. The Veteran appealed this rating action to the Board. Jurisdiction of the appeal currently resides with the St. Petersburg, Florida, RO. Also developed for appellate consideration was the issue of entitlement to service connection for a cardiovascular disorder. By an October 2011 rating action, the RO granted service connection for status post coronary artery bypass graft times three (3) vessel surgery secondary to Agent Orange exposure. An initial 10 percent evaluation was assigned, effective September 8, 2009--the date VA received the Veteran's initial claim for compensation for this disability. A 100 percent evaluation was assigned, effective September 16, 2009, and a 60 percent evaluation was assigned, effective January 1, 2010. This represents a complete grant of the benefit originally sought. Thus, the Board does not have jurisdiction over this issue. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997) (Board cannot possess jurisdiction over an issue where a rating decision constituted a full award of the benefit sought on appeal). In April 2014, the Board remanded the matters on appeal to the RO for additional development; specifically, to obtain VA opinions as to the etiology of the diagnosed PVD and hypertension, to include whether they were secondary to, or had been aggravated by, his service-connected diabetes mellitus and cardiovascular disorder. In June 2014, a VA nurse practitioner provided the requested opinions. These matters have returned to the Board for further appellate consideration. FINDINGS OF FACT 1. The competent and probative evidence of record does not show that the Veteran's PVD had its onset during active military service or is etiologically related thereto, to include the complaints of leg cramps at discharge nor has PVD been shown to have been caused or aggravated by the service-connected diabetes mellitus, type II, and cardiovascular disorder as it was diagnosed prior to both of these disabilities and has been attributed to smoking and other non-service-related factors (e.g., 30 year history of having smoked cigarettes). 2. The competent and probative evidence of record does not show that the Veteran's hypertension had its onset during active military service or was manifested to a compensable degree within one year of discharge in May 1967 nor has it been shown to have been caused or aggravated by the service-connected diabetes mellitus, type II, and/or cardiovascular disorder. CONCLUSIONS OF LAW 1. PVD was not incurred in service and is not causally related to or aggravated by the service-connected diabetes mellitus or cardiovascular disorder. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2015). 2. Hypertension was not incurred in service, may not be presumed to be, and is not causally related to or aggravated by the service-connected diabetes mellitus or cardiovascular disorder. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West. 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay 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); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). These notice requirements apply to all five elements of a service-connection claim (veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via a February 2008 letter of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines disability ratings and effective dates if service connection is awarded. VA also fulfilled its duty to assist the Veteran by obtaining all relevant evidence in support of the service connection claims decided herein, and therefore appellate review may proceed without prejudicing him. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; Bernard v. Brown, 4 Vet. App. 384, 39 (1993). The RO obtained his service treatment records (STRs), VA treatment records and identified private treatment records. The Veteran's Social Security Administration (SSA) records have also been uploaded to the Veteran's Veterans Benefits Management System (VBMS) electronic claims file. In June 2014, a VA NP provided opinions as to the etiology of the Veteran's PVD and hypertension, to include on a secondary basis. (See June 2014 opinions). Copies of these VA examination opinions have been associated with the Veteran's VBMS electronic record. The June 2014 VA NP specifically addressed the Veteran's medical history, to include his in-service complaints of leg cramps and private treatment records reflecting that he had been diagnosed with PVD and hypertension prior to being diagnosed with diabetes mellitus in 2006 and cardiovascular disorder in 2009. She provided a sufficient evidentiary basis for her opinions relative to the claims for service connection for PVD and hypertension, to include on a secondary basis, to be adjudicated, as specifically directed by the Board in its April 2014 remand directives , such that the requested development has been completed. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA opinions concerning the issues of entitlement to service connection for PVD and hypertension, to include on a secondary basis, has been met. In light of the foregoing, the Board concludes that all the available records and medical evidence has been obtained in order to make an adequate determination as to the service connection claims decided herein such that no further notice or assistance is required to fulfill VA's duty to assist in the development of these claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001), VA has complied with the duty-to-assist requirements. 38 U.S.C.A. § 5103A. II. Legal Analysis The Veteran seeks service connection for PVD and hypertension. He contends that his PVD and hypertension are secondary to his service-connected diabetes mellitus and cardiovascular disorder. After a brief discussion of the laws and regulations pertaining to service connection, the Board will analyze each claim separately. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Certain chronic diseases, such as cardiovascular-renal disease, to include hypertension, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of 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(a)(3), 3.309(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza elements is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As hypertension is a chronic disease, the theory of continuity of symptomatology is applicable with respect to the claim for service connection for this disability. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Service connection may also be granted when a claimed disability is found to be proximately due to or the result of a service-connected disability, or when any increase in severity (aggravation) of a nonservice-connected disease or injury is found to be proximately due to or the result of a service-connected disability, not to the natural progress of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Under the current version of 38 C.F.R. § 3.310, VA will not concede such aggravation unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation and by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The RO will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (rating schedule) and determine the extent of aggravation by deducting the baseline level of severity as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(a). In order to prevail on the issue of entitlement to secondary service connection, there must be: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence, generally medical, establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each issue. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102. On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. i) PVD The Veteran currently has PVD status-post left superficial femoral artery stenting and PVD status post right iliac artery to common femoral artery bypass and right femoral to below knee popliteal bypass. (See June 2014 VA Artery and Vein Disability Benefits Questionnaire (DBQ) report)). Thus, the crux of the Veteran's claim hinges on whether his currently diagnosed PVD of both lower extremities has been caused or aggravated by his service-connected diabetes mellitus and/or hypertension, as he has alleged, or is otherwise etiologically related to his period of military service. The Board will discuss the secondary and direct service connection theories separately in the paragraphs below. There is one (1) VA opinion and it is against the secondary service connection component of the claim. In June 2014, a VA NP opined, after a review of the Veteran's medical history and telephone interview of the Veteran, that it was less likely as not that the Veteran's PVD of the lower extremities was due to, or had been permanently aggravated by, his service-connected diabetes mellitus and/or cardiovascular disorder. The VA NP reasoned that the Veteran's PVD was diagnosed prior to his diagnosis of diabetes mellitus in 2006 and coronary artery disease in 2009. The VA NP indicated the Veteran had undergone revascularization of his left leg in 2003 and 2004, and right leg in 2009. She noted that the Veteran's revascularization of his right leg and coronary artery disease (CAD) were simultaneously diagnosed in 2009. Thus, based on the date of occurrence, the Veteran's peripheral vascular disease was not caused by his diabetes mellitus, type 2, or CAD. In addition, the VA NP also concluded that it was less likely as not (less than 50 percent probability) that the Veteran's PVD had been aggravated by either one of the above-cited service connected-disabilities. The VA NP reasoned that there was improvement of the Veteran's claudication after revascularization, that his CAD had remained stable since 2009 and that his diabetes mellitus also remained well-controlled. The Board accords great probative weight to the June 2014 VA NP's opinion since it is based on an accurate factual premise, and offers clear conclusions with supporting data, and reasoned medical explanations addressing the lack of causation and aggravation between the Veteran's PVD and service-connected diabetes mellitus and CAD. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The VA NP's opinion is consistent with the other medical evidence of record, namely reports, prepared by Med-I-Qwik, Inc. and Parkview Medical Group. A report, dated June 24, 2006, from Med-I-Qwik, Inc., reflects that the Veteran's past medical history included PVD, mainly affecting his left lower extremity with stent placed approximately five years earlier, as compared to a November 14, 2006, report from Parkview Medical Group, reflecting an assessment of "Newly diagnosed diabetes mellitus." These findings support the VA NP's conclusion that the Veteran's PVD was not caused by the service-connected diabetes mellitus because it had been diagnosed prior to 2006. The VA NP's June 2014 report is against the claim for service connection for PVD on a secondary basis and it is uncontroverted. The Board turns to consideration of possible entitlement to service connection for the PVD on a direct-incurrence basis, but finds the claim lacking in this respect as well. With respect to Shedden/Caluza element number two (2), evidence of an in-service disease or injury, the Veteran's service treatment records reflect that he was seen for right leg pain that was associated with an acute low back strain in February 1966. A June 1967 service separation examination report reflects that the Veteran's vascular system was evaluated as "normal." On an accompanying Report of Medical History, the Veteran indicated that he had had leg cramps. The Veteran is competent to report that he had leg cramps during military service as it is a symptom that comes to him through his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); and 38 C.F.R. § 3.159(a)(2). Thus, the crux of the Veteran's claim for PVD on a direct incurrence basis hinges on Hickson element number three (3), evidence of a nexus between currently diagnosed PVD of both lower extremities and his period of military service. This exact question was slated to the June 2014 VA NP. After a review of the above-cited STRs and post-service medical history, the VA NP opined that it was less likely than not (less than 50 percent probability) that the Veteran's complaints of leg cramps at discharge represented the onset of his peripheral vascular disease. The VA examiner reasoned that a review of the Veteran's STRs did not show any complaints of, or treatment for, leg cramps during active duty. In addition, there was no evidence of record that the claimed leg cramps were chronic as there was no treatment or diagnosed illness that defined his leg cramps from 1967. In addition, according to the VA NP, the Veteran was initially seen for intermittent claudication in 2003 and underwent revascularization of his left leg in 2003 and 2004 and right leg in 2009. The VA NP maintained that according to medical literature, the Veteran had several significant and positive risk factors for PVD, such as having been a long-term smoker (i.e, the Veteran had a history of having smoked a pack of cigarettes a day for over 30 years) and a family history of cardiovascular disease. The VA NP's conclusion is consistent with an April 2009 report, prepared by Parkview Medical Group, reflecting that the Veteran had a risk factor of smoking and that he had an established diagnosis of PVD. Notably, the VA NP maintained that according to the medical literature from the American College of Cardiology/American Heart Association (ACC/AHA) guidelines on Peripheral Artery Disease (PAD), the following groups were at risk for lower extremity peripheral artery disease: Ages 50 to 69 years with a history of smoking and 70 years old with a history of diabetes, hypertension, and hypercholesterolemia. At the time of the VA examiner's June 2014 opinion, the Veteran was 70 years old. According to the ACC/AHA, each of the above cited risk factors (i.e., history of smoking, diabetes, hypertension and hypercholesterolemia) was significantly and independently noted to have been associated with a higher risk of PAD. Additionally, the risk increased historically in men, especially those with family history of cardiovascular diseases. The VA NP noted that in a partner study, patients ages 50 to 69 with a history of cigarette smoking more than 10 pack-years, such as the Veteran, showed a significant relationship between cigarette dose and a risk for PAD. The VA NP's June 2014 opinion is against the claim for PVD on a direct incurrence basis and it is uncontroverted. ii) Hypertension The Veteran currently has hypertension. (See June 2014 VA Hypertension DBQ report.) Thus, the crux of the Veteran's claim hinges on whether his currently diagnosed hypertension has been caused or aggravated by his service-connected diabetes mellitus and/or CAD, as he has alleged, or is otherwise etiologically related to his period of military service. The Board will discuss the secondary and direct service connection theories separately in the paragraphs below. There is one (1) VA opinion and it is against the claim for secondary service connection for hypertension. In June 2014, a VA NP opined, after a review of the Veteran's medical history and telephone interview of the Veteran, that it was less likely as not that the Veteran's hypertension had been caused or aggravated (permanent worsened) by the service-connected diabetes mellitus and/or cardiovascular disorder. The VA NP reasoned that the Veteran's hypertension was diagnosed in 1999 which was many years prior to his diabetes mellitus diagnosis in 2006 and CAD in 2009. In addition, the VA NP noted that the Veteran had several risk factors for hypertension, such as significant family history of cardiovascular disease; heavy smoking history; obesity (i.e., he weighed 235 pounds), and hyperlipidemia. Regarding aggravation, the VA NP opined that it was less likely than not that hypertension had been aggravated by the service-connected diabetes mellitus and CAD because it had been well-controlled with oral medication and there was no evidence of any hypertensive crisis during the periods when the Veteran was diagnosed with DM and CAD. The VA NP's opinion is consistent with the other medical evidence of record, namely a May 2007 report, prepared by Parkview Medical Group, reflecting that the Veteran's hypertension was noted to have been stable with medication shortly after he was diagnosed with diabetes mellitus in mid-November 2006. The Board accords great probative weight to the VA NP's June 2014 opinion since it was based on an accurate factual premise, and offer clear conclusions with supporting data, and reasoned medical explanations that are consistent with the other evidence of record, namely the May 2007 report, prepared by Parkview Medical Group, in addressing the lack of causation and aggravation between the Veteran's hypertension and diabetes mellitus and CAD. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). These opinions are against the claim and are uncontroverted. The Board turns to consideration of possible entitlement to service connection for hypertension on a direct-incurrence basis, but finds the claim lacking in this respect as well. With respect to Shedden/Caluza element number two (2), evidence of an in-service disease or injury, the Veteran's service treatment records are wholly devoid of any subjective complaints of elevated blood pressure readings or hypertension. The Veteran's service treatment records show that the Veteran was not noted to have high blood pressure or hypertension during service. Hypertension, or high blood pressure, is not shown in the June 1965 separation examination report, and in the associated "report of medical history," the Veteran indicated that he did not have a history of high or low blood pressure. The Board therefore finds that hypertension is not shown during service. See 38 C.F.R. § 3.303(a), (b). There is no evidence to show the existence of hypertension within one year of separation from service, let alone that hypertension was manifest to a compensable degree within one year of separation from service. Therefore, service connection on a presumptive basis is not warranted. See 38 C.F.R. §§ 3.307, 3.309. As to Hickson element number three (3), evidence of a nexus between currently diagnosed hypertension and his period of military service, although the June 2014 VA NP did not expressly opine as to the direct incurrence basis of the claim, she indirectly concluded that it was not incurred during military service. In this regard, the VA NP noted that the Veteran had several other risk factors for hypertension, such a significant family history of cardiovascular disease; heavy smoker, obese (235 pounds), and hyperlipidemia. This opinion is against the claim for service connection for hypertension on a direct incurrence basis and it is uncontroverted. The earliest post-service medical evidence of hypertension, according to the June 2014 VA NP, is 1999, which is over 30 years after the Veteran's separation from service. There is no competent medical evidence to show that he has hypertension that is related to his service, or to his service-connected diabetes mellitus and CAD. The only competent opinions is the June 2014 VA NP opinion that weighs against the claim. In particular, the Board finds that the July 2014 VA opinion is highly probative evidence against the claim. In this opinion, the VA NP concluded that the Veteran's hypertension was not of service origin nor had it been caused or aggravated by his service-connected diabetes mellitus or CAD, but was attributed to non-service-related risk factors. See 38 C.F.R. §§ 3.303, 3.310. The VA NP indicated that the Veteran's medical history had been reviewed, and the opinion is accompanied by a sufficiently detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion); Neives-Rodriguez v. Peake, 22 Vet. App. 295, 30 (2008). The Board further points out that this opinion is consistent with the other medical evidence of record as discussed in the preceding paragraph. Finally, there is no medical evidence to show that hypertension was manifest to a compensable degree within one year of separation from service, and presumptive service connection is not warranted. See 38 C.F.R. §§ 3.307, 3.309. Similarly, there is no evidence of continuity of symptomatology of hypertension from service separation. In summary, the evidence does not show that the Veteran has hypertension that is related to his service, or to a service-connected disability, and the Board finds that the preponderance of the evidence is against the claim, and that the claim must be denied. As a final matter, and as noted in an October 2011 rating action, a November 1966 service treatment record reflects that the Veteran was seen at an aid station in the Republic of Vietnam (RVN). Therefore, duty in the Republic of Vietnam is shown for the purposes of the regulation governing the presumption of service connection for certain diseases due to herbicide exposure. See 38 C.F.R. §§ 3.307, 3.309. However, there is no competent evidence to show that hypertension was caused by such exposure, Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994), and the applicable law does not include hypertension as a condition for which presumptive service connection may be granted on this basis. See 38 U.S.C.A. § 1116 (West 2014); 38 C.F.R. §§ 3.307(a)(6), 3.309(e) (2015). iii) Conclusion With respect to the Veteran's own contentions, they are competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In this case, the STRs and post-service medical records have been discussed. The Board has determined that service connection is not warranted for PVD and hypertension, each to include on a secondary basis. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, whether the Veteran has PVD and hypertension due to his service, or a service-connected disability, this falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The Board has determined that the service and post-service medical evidence outweighs the Veteran's contentions to the effect that he has the claimed conditions that are related to his service, or to a service-connected disability. Accordingly, the Board finds that the preponderance of the evidence is against the claims, and that the claims must be denied. ORDER Service connection for PVD, to include as secondary to the service-connected diabetes mellitus and CAD, is denied. Service connection for hypertension, to include as secondary to the service-connected diabetes mellitus and CAD, is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs