Citation Nr: 1628280 Decision Date: 07/15/16 Archive Date: 07/28/16 DOCKET NO. 11-00 675 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Whether the discontinuance of a separate 30 percent evaluation for residuals of laparoscopic cholecystectomy was proper. 2. Entitlement to an initial compensable rating for scars, residuals of abdominal surgeries. 3. Entitlement to an initial compensable rating for hemorrhoids. 4. Entitlement to an increased rating for residuals of caesarian section, to include claim for scar tissue with lysis of adhesions, loss of stomach muscle, abdominal pain, cholecystectomy, and irritable bowel syndrome. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran served on active duty from October 1992 to July 2001. These matters come to the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in July 2010, May 2013, and May 2014. The Veteran presented testimony at a personal hearing before the undersigned Veterans Law Judge (VLJ) in February 2016. A transcript is of record. The Board recognizes that the Veteran has attempted to raise the issue of service connection for gastroesophageal reflux disease during her hearing, and service connection incontinence, hypertension, a cervical spine disorder, sinusitis, bronchitis, allergic rhinitis, as well as a claim for increased rating involving the service-connected chronic urinary tract infections in statements submitted with medical evidence In April 2016. The Veteran is advised that a claim for benefits must be submitted on the application form prescribed by the Secretary. 38 C.F.R. §§ 3.1(p), 3.155, 3.160 (2015). The issues of entitlement to an increased rating for abdominal scars and residuals of caesarian section, to include claim for scar tissue with lysis of adhesions, loss of stomach muscle, abdominal pain, cholecystectomy, and irritable bowel syndrome, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The award of a separate 30 percent evaluation for residuals of laparoscopic cholecystectomy violated the rule against pyramiding and was clearly and unmistakably erroneous. 2. In June 2012, the Veteran had thrombotic external hemorrhoids prior to their excision on June 6, 2012, but there is no evidence dated between June 22, 2011 and June 5, 2012, that the thrombotic external hemorrhoids were irreducible with excessive redundant tissue and frequent recurrences; or that the reported persistent bleeding was accompanied by secondary anemia or fissures. 3. There is no evidence that the Veteran has had hemorrhoids since their removal. CONCLUSIONS OF LAW 1. The discontinuance of the award of a separate 30 percent evaluation for residuals of laparoscopic cholecystectomy was proper. 38 U.S.C.A. §§ 1155, 5112 (West 2014); 38 C.F.R. §§ 3.105, 4.14, 4.114 (2015). 2. The criteria for an initial compensable rating for hemorrhoids have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.114, Diagnostic Code 7336 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the appellant or obtained on her 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) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Discontinuance of a separate 30 percent evaluation for residuals of laparoscopic cholecystectomy The Veteran filed a claim for service connection for residuals of a caesarian section and residuals of gallbladder removal in June 2001. An October 2001 rating decision granted service connection for residuals of cholecystectomy and assigned a noncompensable (zero percent) evaluation pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7318, effective July 24, 2001. Service connection for residuals of a caesarian section was denied. The Veteran attempted to reopen this claim on several occasions but the prior denial was continued. See rating decisions dated May 2003, July 2003, May 2006 and December 2006. In an April 2007 rating decision, the service-connected residuals of cholecystectomy was recharacterized as residuals of cesarean section (to include claim for scar tissue with lysis of adhesions, loss of stomach muscle, abdominal pain and cholecystectomy) and the rating was increased to 10 percent pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7318-7310, effective March 9, 2006. See 38 C.F.R. § 4.27 (Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned). Diagnostic Code 7318 evaluates gall bladder removal and Diagnostic Code 7310 evaluates residuals of stomach injury, with direction to evaluate the condition as peritoneal adhesions (Diagnostic Code 7301). See 38 C.F.R. § 4.114. The Veteran filed a claim seeking service connection for removal of her gallbladder in February 2008. In July 2008, the RO awarded a separate 30 percent rating for residuals from laparoscopic cholecystectomy pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7318, effective February 28, 2008. The Veteran filed a claim for increased rating in June 2009. A May 2010 rating decision continued the rating assigned for residuals from laparoscopic cholecystectomy and deferred a decision on the residuals of cesarean section. The rating for evaluation of residuals of cesarean section (to include claim for scar tissue with lysis of adhesions, loss of stomach muscle, abdominal pain and cholecystectomy) was continued at 10 percent in the July 2010 rating decision. This appeal ensued. In May 2013, the RO notified the Veteran that it planned to discontinue the separate evaluation granted for residuals from laparoscopic cholecystectomy. The RO determined that the July 2008 rating decision was clearly and unmistakably erroneous for granting a separate evaluation for residuals from laparoscopic cholecystectomy under Diagnostic Code 7318 when service connection was already established and compensated for residuals of cesarean section (to include claim for scar tissue with lysis of adhesions, loss of stomach muscle, abdominal pain and cholecystectomy) under Diagnostic Code 7310. It was proposed that the separate evaluation be discontinued and residuals of laparoscopic cholecystectomy be evaluated with the residuals of cesarean section. A May 2014 rating decision discontinued the separate 30 percent evaluation for residuals from laparoscopic cholecystectomy effective August 1, 2014, but increased the rating for residuals of cesarean section (to include claim for scar tissue with lysis of adhesions, loss of stomach muscle, abdominal pain, cholecystectomy, and irritable bowel syndrome) to 30 percent effective August 1, 2014, under Diagnostic Code 7310-7318. As an initial matter, the Board notes that discontinuance of the separate rating did not result in a reduction of the Veteran's combined rating. More specifically, the Veteran's combined rating was 90 percent effective March 10, 2011, and continued at 90 percent thereafter, except when temporary 100 percent ratings were in effect. Given the foregoing, the notice requirements found at 38 C.F.R. § 3.105(e) do not apply. Irrespective of the foregoing, the RO notified the Veteran of the proposal to discontinue the separate rating in a May 2013 rating decision and in a letter dated June 7, 2013. These documents provided the Veteran with detailed reasons for the proposed discontinuance; the June 2013 letter informed the Veteran of the type of information or evidence she could submit in response and her rights to a personal hearing and to representation. The letter also informed the Veteran that unless additional evidence was received within 60 days, benefits would be discontinued. The separate 30 percent evaluation for residuals of laparoscopic cholecystectomy was subsequently discontinued in May 2014 effective August 1, 2014. The Board finds that the Veteran was provided due process and the matter is ready for adjudication. The Board would also like to point out the unique facts of this case. The RO did not sever or discontinue service connection in this case. Rather, it discontinued a separate rating because service connection and a compensable rating had already been established for that disability. In other words, the Veteran was service-connected and compensated for the same disability twice. Although the separate rating for residuals of laparoscopic cholecystectomy was discontinued effective August 1, 2014, the Board wants to make clear that the Veteran is still service-connected for the disability, characterized as residuals of cesarean section (to include claim for scar tissue with lysis of adhesions, loss of stomach muscle, abdominal pain, cholecystectomy, and irritable bowel syndrome). Previous determinations which are final and binding, including decisions of service connection and degree of disability, will be accepted as correct in the absence of clear and unmistakable error. Where evidence establishes such error, the prior decision will be reversed or amended. See 38 C.F.R. § 3.105(a). Clear and unmistakable error is the kind of error in fact or law that, when called to the attention of later reviewers, compels the conclusion, to which reasonable minds could not differ, that the result would manifestly have been different but for the error. Generally, the correct facts, as they were known at the time, were not before the RO, or the statutory and regulatory provisions extant at the time were incorrectly applied. Even when the premise of error is accepted, if it is not absolutely clear that a different result would have ensued, the error complained of cannot be ipso facto clear and unmistakable. Fugo v. Brown, 6 Vet. App. 40, 43-44 (1993) (citing Russell v. Principi, 3 Vet. App. 310, 313 (1992)). The error must be undebatable and of the sort that, had it not been made, would have manifestly changed the outcome at the time it was made. See Damrel v. Brown, 6 Vet. App. 242, 245 (1994). The reviewable evidence in a severance or reduction claim is not limited to that which was before the RO in making its initial service connection award. Daniels v. Gober, 10 Vet. App. 474, 480 (1997). Upon review of the record, the Board finds that the discontinuance of the 30 percent rating for residuals of laparoscopic cholecystectomy was proper. The procedural history involving the service-connected residuals of laparoscopic cholecystectomy and the service-connected residuals of cesarean section (to include claim for scar tissue with lysis of adhesions, loss of stomach muscle, abdominal pain, cholecystectomy, and irritable bowel syndrome) has been detailed above. As discussed previously, the grant of a separate rating for residuals of laparoscopic cholecystectomy in the July 2008 rating decision was, quite simply, the grant of service connection and compensation for an already service-connected disability. It appears this action was undertaken as a result of the RO's recharacterization of the original disability (residuals of cholecystectomy under Diagnostic Code 7318 in the October 2011 rating decision) to residuals of cesarean section (to include claim for scar tissue with lysis of adhesions, loss of stomach muscle, abdominal pain and cholecystectomy) under Diagnostic Codes 7318-7310 in the April 2007 rating decision. The action undertaken in the July 2008 rating decision in granting a separate rating for residuals of laparoscopic cholecystectomy clearly violated the rule against pyramiding, which specifically states that evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14. It further violates the dictates of 38 C.F.R. § 4.114, indicating that ratings under Diagnostic Codes 7301 through 7329, 7331, 7342, and 7345 through 7348 will not be combined with each other. In this case, the residuals of cholecystectomy was initially service connected in an October 2001 rating decision and later combined with residuals of cesarean section (to include claim for scar tissue with lysis of adhesions, loss of stomach muscle, abdominal pain and cholecystectomy) in an April 2007 rating decision. The grant of a separate rating for residuals of laparoscopic cholecystectomy in the July 2008 rating decision was pyramiding. Given the foregoing, the Board finds the July 2008 rating decision was clearly and unmistakably erroneous in granting a separate 30 percent evaluation for residuals of laparoscopic cholecystectomy and discontinuance was proper. Increased Rating Under the Veterans Claims Assistance Act of 2000 (VCAA) VA has a duty to notify and assist a claimant in the development of a claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2015). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2015). In this case, the Veteran's increased rating claim for hemorrhoids arises from her disagreement with the initial evaluation that was assigned following the grant of service connection. Once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007) ((section 5103(a) notice is no longer required after service-connection is awarded). In addition, the Board finds that the duty to assist a claimant has been satisfied. The Veteran's service treatment records are on file, as are various post-service medical records. VA examinations have been conducted and opinions obtained. The Veteran was also afforded a hearing before the Board and a copy of the transcript has been placed in the record. Neither the Veteran nor her representative has alleged any deficiency in the hearing. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The May 2013 rating decision that is the subject of this appeal granted service connection for hemorrhoids pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7336. A noncompensable rating was assigned effective June 22, 2011; an evaluation of 100 percent was assigned effective June 5, 2012, based on surgical or other treatment necessitating convalescence; and the noncompensable evaluation was reassigned from August 1, 2012. Given the foregoing, the Board will determine whether the Veteran is entitled to a compensable rating between June 22, 2011 and June 5, 2012, and as of August 1, 2012. Diagnostic Code 7336 provides the rating criteria for external or internal hemorrhoids. Hemorrhoids that are mild or moderate are assigned a noncompensable (zero percent) rating. Hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences, are assigned a 10 percent rating. Hemorrhoids with persistent bleeding and with secondary anemia, or with fissures, are assigned a 20 percent rating. In an August 2011 VA Form 21-4138, the Veteran reported hemorrhoids as a result of chronic constipation, pregnancies, and her service-connected disabilities. In a November 2011 VA Form 21-4138, the Veteran reported that her hemorrhoids are always there and bleed due to constant straining. In a November 2012 VA Form 21-4138, the Veteran reported that she continued to have problems after hemorrhoid surgery, indicating that she bled every time she had a bowel movement. During her hearing in February 2016, the Veteran candidly acknowledged that she does not have hemorrhoids as they were surgically removed, but that she has constant bleeding as a result of pressure wiping and that area is irritated. The situation had been continuous since her hemorrhoid surgery in August 2012 and she needed to wear something absorbent. In addition to the Veteran's statements in support of her claim, the evidence of record includes private treatment records and several VA examination reports. The Veteran was found to have a thrombosed external hemorrhoid on June 5, 2012, which was surgically removed on June 6, 2012. See records from Doctors Care and Tuomey Healthcare System. The operative report contains a preoperative diagnosis of thrombosed external hemorrhoid and the procedure was excision of multiple thrombosed external hemorrhoids. Indications for the procedure included a two day history of excruciating perianal pain. It was noted that the Veteran had an incomplete incision and drainage at the emergency room, which necessitated the scheduling of surgery for full excision and treatment. There were no internal hemorrhoids. The postoperative diagnosis was multiple thrombosed external hemorrhoids. The Veteran underwent a VA examination in April 2013, during which it was noted that she experienced a thrombosed hemorrhoid in June 2012 with subsequent excision and continued treatment with stool softener and other methods to help alleviate constipation. The Veteran underwent a VA hemorrhoids Disability Benefits Questionnaire (DBQ) examination in May 2013. The diagnosis was internal or external hemorrhoids. It was noted that in June 2012, the Veteran experienced a thrombosed hemorrhoid with subsequent excision, and continued treatment with stool softener and other treatments to help alleviate constipation. The Veteran still reported bright red blood per rectum with bowel movements; however, this very well could be from her constipation instead of hemorrhoids. The Veteran did not have any findings, signs or symptoms attributable to the diagnosed internal or external hemorrhoids. Examination was normal, with no external hemorrhoids, anal fissures, or other abnormalities. The condition did not impact her ability to work. In the remarks section, the examiner noted that the Veteran reported bright red blood per rectum with bowel movements but that she did not have any hemorrhoids on examination and that it was likely that the blood may just be from passing hard stools. The preponderance of the evidence of record is against the assignment of an initial compensable rating for the service-connected hemorrhoids at any time during the appellate period. The Board acknowledges that the Veteran had thrombotic external hemorrhoids prior to their excision on June 6, 2012, but there is no evidence dated between June 22, 2011 and June 5, 2012, that the thrombotic external hemorrhoids were irreducible with excessive redundant tissue and frequent recurrences so as to support the next highest (10 percent) rating under Diagnostic Code 7336. The only reference to hemorrhoids dated prior to the removal surgery on June 6, 2012, is the operative report, which documented that indications for the procedure included a two day history of excruciating perianal pain. The Board acknowledges the Veteran's November 2011 report that her hemorrhoids are always there and bleed due to constant straining, see VA Form 21-4138, but there is no medical evidence to support a finding that persistent bleeding was accompanied by secondary anemia or fissures so as to support a 20 percent rating under Diagnostic Code 7336 between June 22, 2011 and June 5, 2012. In regards to the assignment of a compensable rating as of August 1, 2012, there is no evidence the Veteran has had hemorrhoids since their removal and it appears the reported bleeding is due to constipation/ passing hard stools. See May 2013 rectum and anus conditions (including hemorrhoids) DBQ; February 2016 hearing transcript. The Veteran is separately rated for irritable bowel syndrome, which contemplates constipation. At most, the Veteran's rectal symptoms would be analogous to mild or moderate hemorrhoids, in the absence of actual hemorrhoids, anal fissures, or anemia. In sum, the preponderance of the evidence dated between June 22, 2011 and June 5, 2012, and since August 1, 2012, supports the currently-assigned noncompensable rating for the service-connected hemorrhoids. The Board has considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extraschedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2015); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor is whether the disability picture presented in the record is adequately contemplated by the rating schedule. Thun v. Peake, 22 Vet. App. 111, 118 (2008). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology and provide for additional or more severe symptoms than currently shown by the evidence. Indeed, the rating criteria for hemorrhoids contemplate bleeding. Additionally, she is separately rated for irritable bowel syndrome which contemplates constipation. As her disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate. Id. at 115. In any event, the Veteran does not contend and the evidence does not suggest her hemorrhoids have resulted in frequent periods of hospitalization or marked interference with employment. Accordingly, referral for extraschedular consideration for the disability is not warranted. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2014); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Discontinuance of a separate 30 percent evaluation for residuals of laparoscopic cholecystectomy was proper, and the appeal is denied. An initial compensable rating for hemorrhoids is denied. REMAND Additional development is needed before the Board adjudicates the claim for increased ratings for abdominal scars and residuals of caesarian section, to include claim for scar tissue with lysis of adhesions, loss of stomach muscle, abdominal pain, cholecystectomy, and irritable bowel syndrome. With respect to the scar claim, VA examinations in 2010 and 2011 revealed nontender, nonadherent, and stable abdominal surgical scars. The Veteran has reported that the scars are adherent and painful. It is unclear whether her reported symptoms are actually associated with her internal adhesions or are related to the surgical scars themselves. Accordingly, an additional examination is warranted. Additionally, the Board finds that a VA muscle injuries examination should be scheduled to determine the extent, if any, of impairment of stomach muscle, which the RO has included as part of this service-connected disability; and a contemporaneous VA peritoneal adhesions examination should be scheduled to determine the current severity of her adhesions. The scheduling of these examinations is necessary because, as explained during the February 2016 Board hearing, 38 C.F.R. § 4.114 provides that ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other and that a single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. The Veteran is hereby notified that it is her responsibility to report for any scheduled examination and to cooperate in the development of the case, and that the consequences of failing to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158 and 3.655 (2015). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA muscle injuries examination to address any abdominal muscle impairment associated with her surgeries. The claims file must be reviewed in conjunction with the examination. All indicated tests and studies should be performed and all clinical findings reported in detail. Following examination of the Veteran and review of the claims file, the examiner should determine the extent of any impairment of stomach muscle attributed to her caesarian section, cholecystectomy and lysis of adhesions. The examiner should explain the reasons for all conclusions reached. 2. Schedule the Veteran for a VA peritoneal adhesions examination. The claims file must be reviewed in conjunction with the examination. All indicated tests should be performed and all symptomatology and clinical findings reported in detail. 3. Schedule the Veteran for a VA scar examination to determine the nature of her surgical abdominal scars. The claims file must be reviewed in conjunction with the examination. All indicated tests should be performed and all symptomatology and clinical findings reported in detail. Following examination of the Veteran and review of the claims file, the examiner is asked to indicate whether any of the Veteran's abdominal surgical scars are adherent to underlying tissue and whether the scars are tender. In addition, the examiner is asked to indicate whether the described pulling pain the Veteran has reported during the claim is associated with the surgical scars, or is associated with the internal adhesions from surgery. A rationale for the opinions expressed should be provided. 4. After undertaking the development above and any additional development deemed necessary, the Veteran's claim should be readjudicated. On readjudication, the AOJ is reminded of the rule against pyramiding in 38 C.F.R. § 4.14 and the specific rule against assigning separate ratings for certain digestive conditions under 38 C.F.R. § 4.114. If the benefit sought on appeal remains denied, the appellant and her representative should be furnished a supplemental statement of the case and be given an appropriate period to respond thereto before the case is returned to the Board, if in order. The appellant has the right to submit additional evidence and argument on the matter 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 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 2014). ______________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs