Citation Nr: 1643043 Decision Date: 11/09/16 Archive Date: 12/01/16 DOCKET NO. 09-38 590 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for a respiratory disability, to include as secondary to service connected gastroesophageal reflux disease (GERD). 2. Entitlement to an initial evaluation in excess of 20 percent for service-connected multilevel degenerative disc disease of the lumbar spine prior to May 4, 2012. 3. Entitlement to an evaluation in excess of 40 percent for service-connected multilevel degenerative disc disease (DDD) of the lumbar spine from May 4, 2012. REPRESENTATION Appellant represented by: John S. Berry, Attorney ATTORNEY FOR THE BOARD M. Prem, Counsel INTRODUCTION The Veteran served on active duty from August 1965 to August 1967. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). The issue of entitlement to service connection for a respiratory disability was remanded in March 2016 for further development. In November 2014, the Board issued a decision denying entitlement to increased ratings for multilevel degenerative disc disease (DDD) of the lumbar spine. In May 2016, the United States Court of Appeals for Veterans Claims (Court) vacated the Board's decision. The issue of entitlement to service connection for a respiratory disability, to include as secondary to service connected gastroesophageal reflux disease (GERD) is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. Prior to October 2, 2009, the service-connected multilevel DDD of the lumbar spine is shown to have been productive of a disability picture manifested by a functional loss due to pain that approximated that of forward flexion of the lumbar spine restricted to 40 degrees; forward flexion of the thoracolumbar spine restricted to 30 degrees or less, favorable ankylosis of the entire thoracolumbar spine, or incapacitating episodes due to intervertebral disc syndrome is not demonstrated. 2. Effective October 2, 2009, the service-connected multilevel DDD of the lumbar spine is shown to have been productive of a disability picture manifested by a functional loss due to pain that approximated that of forward flexion of the thoracolumbar spine restricted to 30 degrees or less; neither unfavorable ankylosis of the entire thoracolumbar spine, nor incapacitating episodes due to intervertebral disc syndrome is demonstrated. CONCLUSIONS OF LAW 1. The criteria for the assignment of a rating in excess of 20 percent for the service-connected multilevel DDD of the lumbar spine prior to October 2, 2009, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.40, 4.45, 4.71a including Diagnostic Code (DC) 5243 (2015). 2. Effective October 2, 2009, the criteria for the assignment of a rating of 40 percent, but no greater, for the service-connected multilevel DDD of the lumbar spine are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.40, 4.45, 4.71a including Diagnostic Code (DC) 5243 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) In January 2009 and April 2009 letters, 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). 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 he was expected to provide. The Veteran was informed of the process by which initial disability ratings and effective dates are assigned, as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The "duty to assist" contemplates that VA will help a claimant obtain records relevant to the claim, whether or not the records are in Federal custody, and that VA will provide a medical examination when necessary to make a decision on the claim. 38 C.F.R. § 3.159 (2015). VA has done everything reasonably possible to assist the Veteran with respect to the claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2014) and 38 C.F.R. § 3.159(c) (2015). Relevant service treatment and other medical records have been associated with the claims file. The Veteran was given VA examinations in April 2009, September 2012, and December 2013, which are fully adequate. The duties to notify and to assist have been met. Increased Ratings Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet.App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The current General Rating Formula for Diseases and Injuries holds that for diagnostic codes 5235 to 5243 (unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome based on incapacitating episode) a 100 percent rating is warranted when there is unfavorable ankylosis of the entire spine. A 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. A 40 percent rating is warranted when there is unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 30 percent rating is warranted when there is forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 20 percent rating is warranted when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The criteria also include the following provisions: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 5235 Vertebral fracture or dislocation 5236 Sacroiliac injury and weakness 5237 Lumbosacral or cervical strain 5238 Spinal stenosis 5239 Spondylolisthesis or segmental instability 5240 Ankylosing spondylitis 5241 Spinal fusion 5242 Degenerative arthritis of the spine (see also diagnostic code 5003) 5243 Intervertebral disc syndrome Additionally, a 60 percent disability rating is warranted when there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. A 40 percent rating is warranted when there are incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past 12 months. A 20 percent rating is warranted when there are incapacitating episodes having a total duration of at least two weeks, but less than four weeks during the past 12 months. A 10 percent rating is warranted when there are incapacitating episodes having a total duration of at least one week, but less than two weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that required bed rest prescribed by a physician and treatment by a physician. An evaluation can be had either on the total duration of incapacitating episodes over the past 12 months or by combining separate evaluations of the chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities under 38 C.F.R. § 4.25, whichever method resulted in the higher evaluation. In the present case, it should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. The Board notes the recent decision Correia v. McDonald, 28 Vet. App. 158 (2016), in which the Court stated that the final sentence in 38 C.F.R. § 4.59 ("[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weightbearing and, if possible, with the range of the opposite undamaged joint") creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The Board notes that the spine examinations of record did not fully test the spine in accord with all of the notations in § 4.59 (as noted below). However, the Board finds that this is a moot point because in order to obtain a higher rating for the spine the evidence would need to a form of ankylosis, which by definition in Note (5) above, is when the spine is fixed in flexion or extension. The Board also finds no prejudice in this case because the Veteran has consistently complained of knee pain with prolonged use (standing, walking, etc.) but has never complained of pain with weightbearing versus nonweightbearing activities, and there is no evidence of record which suggests that passive motion of the right knee would be worse than active, or that with weight-bearing, The Veteran's claim for service connection for his lumbar spine disability was received in January 2009. In the appealed May 2009 rating decision, the RO assigned a 20 percent rating effective January 2, 2009. In a November 2012 rating decision, the RO increased the rating to 40 percent, effective on May 4, 2012. This increase during the appeal did not constitute a full grant of the benefit sought. Therefore, the Veteran's claim for an increased rating for the lumbar spine disability remains on appeal. See AB v. Brown, 6 Vet. App. 35, 39 (1993). The April 2009 VA examination reflects the Veteran's complaint of progressively worsening symptomatology associated with his lumbar spine disability. He reported that he had daily, severe flare-ups of spinal disability that lasted hours in duration. Rest, medication and massage provided some relief. During flare-ups of pain, he had to stop all usual activities until the pain subsided. He also reported radiating pain into both buttocks with shooting down the entire right leg. He did not experience any incapacitating episodes of spine disease. Objectively, he had no abnormal spinal curvatures; there was no lumbar spine ankylosis. He did have spasm, guarding, pain with motion and tenderness. However they did not result in abnormal gait or abnormal spinal contour. The range of motion for the lumbar spine was noted to be as follows: forward flexion to 60 degrees, extension to 15 degrees, right rotation to 10 degrees, left rotation to 10 degrees and lateral flexion to 15 degrees, bilaterally. The Veteran had pain with repetitive use and demonstrated additional loss of motion following repetitive use as follows: forward flexion to 40 degrees, extension to 10 degrees, right rotation to 5 degrees, left rotation to 5 degrees and lateral flexion to 10 degrees, bilaterally. Outpatient records treatment dated October 2009 to February 2010 reflect complaints of increased back pain (VBMS, 7/23/10, pgs. 84, 108). The records also reflect that he was prescribed morphine on October 2, 2009 (VBMS, 7/23/10, p. 122). Based on this apparent increase in severity, the Board remanded the claim in May 2012, so that the Veteran could undergo a new VA examination. A September 2012 VA examination report reflects the Veteran's complaints of pain, stiffness and achiness into the midline, low lumbar as well as the right low paralumbar region. He also described radiculopathy symptoms radiating into the lower extremities bilaterally. He sought chiropractic treatment for his lumbar spine disability approximately every 10 days. Medication, rest, activity limitation and icing helped alleviate his lumbar spine symptoms. He used a cane for ambulation. Prolonged driving and sitting aggravated his lumbar spine symptoms. On examination, the range of motion of the lumbar spine was noted to be as follows: forward flexion to 15 degrees (with objective evidence of painful motion beginning at 5 degrees), extension to 10 degrees (with objective evidence of painful motion beginning at 0 degrees), right rotation to 15 degrees (with objective evidence of painful motion beginning at 5 degrees), left rotation to 15 degrees (with objective evidence of painful motion beginning at 5 degrees) and lateral flexion to 15 degrees, bilaterally (with objective evidence of painful motion beginning at 5 degrees, bilaterally). The Veteran had pain with repetitive use and demonstrated additional loss of motion following repetitive use as follows: forward flexion to 10 degrees, extension to 10 degrees, right rotation to 10 degrees, left rotation to 10 degrees and lateral flexion to 15 degrees, bilaterally. Though the Veteran had intervertebral disc syndrome (IVDS) of the lumbar spine, he did not experience any incapacitating episodes of such over the past year. The December 2013 VA examination documents the Veteran's report of worsening symptoms associated with his lumbar spine disability. On examination, the range of motion of the lumbar spine was noted to be as follows: forward flexion to 40 degrees (with objective evidence of painful motion beginning at 20 degrees), extension to 15 degrees (with objective evidence of painful motion beginning at 5 degrees), right rotation to 15 degrees (with objective evidence of painful motion beginning at 10 degrees), left rotation to 15 degrees (with objective evidence of painful motion beginning at 10 degrees) and lateral flexion to 15 degrees, bilaterally (with objective evidence of painful motion beginning at 10 degrees, bilaterally). The Veteran had pain with repetitive use and demonstrated additional loss of motion following repetitive use as follows: forward flexion to 25 degrees, extension to 10 degrees, right rotation to 10 degrees, left rotation to 10 degrees and lateral flexion to 15 degrees, bilaterally. While he had localized tenderness or pain to palpation demonstrated by midline lumbar tenderness; paralumbar tenderness, he did not have muscle spasm or guarding that resulted in abnormal spinal. He did not have ankylosis. He had not experienced any incapacitating episodes of his IVDS of the lumbar spine in the past year. On this record, the Board finds that a rating in excess of 20 percent for the service-connected multilevel DDD of the lumbar spine prior to October 2, 2009 is not warranted. The VA examination in April 2009 showed that his forward flexion of the lumbar spine was restricted to 60 degrees. The Board is aware that he demonstrated additional loss of motion following repetitive use evidenced by forward flexion of the lumbar spine restricted to 40 degrees. However, even with this additional limitation of motion following repetitive use, his range of motion findings are contemplated by the 20 percent rating which considers forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees. As findings of forward flexion of the thoracolumbar spine limited to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine are not demonstrated. A higher rating is not assignable on this basis. Additionally, absent the showing of any incapacitating episodes due to intervertebral disc syndrome, a higher rating also is not assignable in accordance with these rating criteria. The Board's November 2014 decision on this issue was vacated because the RO granted a 40 percent rating effective May 4, 2012; and the Board failed to explain why the effective date of the increase was May 4, 2012. There are indications that the Veteran's low back disability became more severe on October 2, 2009. It was on that date that the Veteran was prescribed morphine for increased pain. The increased severity of the disability would be confirmed by way of a September 2012 VA examination. Consequently, the Board finds that a 40 percent rating is warranted October 2, 2009 as this is when it became factually ascertainable based on the evidence of record that this is when his low back disability increased in severity. 38 C.F.R. § 3.400(o)(2). Beginning October 2, 2009, the assigned 40 percent rating for the lumbar spine disability contemplates the Veteran's manifestations, including forward flexion of the lumbar spine limited to 15 degrees (with objective evidence of painful motion beginning at 5 degrees), with additional loss of motion following repetitive use demonstrated by forward flexion of the lumbar spine limited to 10 degrees (September 2012 VA examination) and forward flexion of the lumbar spine limited to 40 degrees (with objective evidence of painful motion beginning at 20 degrees), with additional loss of motion following repetitive use demonstrated by forward flexion of the lumbar spine limited to 25 degrees (December 2013 VA examination). The Board recognizes that at his April 2009 VA examination, it was recorded that the Veteran would stop all usual activities until the pain returned to baseline during flare-ups He also reported radiating pain into both buttocks with shooting down the entire right leg. He did not experience any incapacitating episodes of spine disease. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011); the Court found examination findings to be inadequate where the examiner did not explicitly report whether and at what point during the range of motion the appellant experienced any limitation of motion that was specifically attributable to pain. In addition, the Court noted that, when discussing functional loss due to flare-ups, the examiner should provide the detail. In this case, the April 2009 VA examination preceded Mitchell. Consequently, the April 2009 VA examiner did not render a medical opinion regarding additional limitation of motion during flare-ups. To grant an increased rating effective April 2009 (or January 2009, when the claim was filed) would require the Board to render speculation on a medical issue or require a remand to allow a VA clinician to look at the April 2009 examination report (now over 7 years old) and supply the information required by a Court case decided years later. The Board finds that given the length of time that has passed since the 2009 examination this would be an exercise in futility and only delay the award of benefit as adjudicated herein. . See Scott v. McDonald, 789 F.3d 1375,1381 (Fed. Cir. 2015) (noting that "[a] veteran's interest may be better served by prompt resolution of his claims rather than by further remands to cure procedural errors that, at the end of the day, may be irrelevant to final resolution and may indeed merely delay resolution"). For this reason, the date of the increase to 40 percent is October 2, 2009 (the date it became factually ascertainable that an increase in severity had occurred) as ordered below. As findings of unfavorable ankylosis of the entire thoracolumbar spine are not demonstrated at any time during the appeal, a higher rating is not assignable on this basis. Additionally, absent the showing of any incapacitating episodes due to intervertebral disc syndrome, a higher rating also is not assignable in accordance with these rating criteria. The Board notes that the 40 percent evaluation is the maximum evaluation for limitation of motion. Therefore, further DeLuca analysis is not required. Johnston v. Brown, 10 Vet. App. 80 (1997). Extraschedular Ratings Pursuant to 38 C.F.R. § 3.321(b)(1) (2015), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "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." The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242, 244 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Initially, there must be a comparison between the level of severity and symptomatology of a claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors are marked interference with employment and frequent periods of hospitalization). The rating criteria fully contemplate the Veteran's disability as noted above, his symptomatology has consisted of pain and limitation of motion. These symptoms are contemplated in the rating criteria. The rating criteria are therefore adequate to evaluate the Veteran's disability and referral for consideration of extraschedular rating is, therefore, not warranted. 38 C.F.R. § 3.321(b)(1). ORDER Prior October 2, 2009, a rating in excess of 20 percent for the service-connected multilevel DDD of the lumbar spine is denied. Effective October 2, 2009, a rating of 40 percent, but no greater, for the service-connected multilevel DDD of the lumbar spine is granted. REMAND Respiratory disability The Board remanded this issue in March 2016 with instructions for the RO to schedule the Veteran for a VA examination for the purpose of determining the etiology of the Veteran's respiratory disability. Specifically, the examiner was to render an opinion regarding whether the Veteran's respiratory disability was caused or aggravated by service connected GERD. The examiner opined that the Veteran did not have a respiratory disability caused or aggravated by GERD (VBMS, 6/28/16, p. 12; VBMS, 7/2/16). In its May 2009 rating decision, the RO found that the Veteran's upper respiratory infections preexisted service. The Veteran has contended that exposure to mercury caused or aggravated his respiratory disability. He submitted a correspondence that includes an internet article listing numerous disabilities that can be caused by exposure to mercury (VBMS, 4/11/16). The RO recognized that an addendum was needed (VBMS, 6/28/16) because although the examiner noted "military exposures" it was not clear if the examiner was referring to mercury exposure. The RO requested an addendum "to clarify whether or not the Veteran's current [chronic obstructive pulmonary disease] is due to or aggravated by the exposure to mercury as a dental assistant during military service?" The RO noted that "If aggravation is found, can a base line be established?" The examiner submitted an addendum opinion. However, the addendum opinion only addressed aggravation as it related to whether the Veteran's respiratory disability was secondary to GERD. It did not clarify the opinion as it related to mercury exposure. Accordingly, the case is REMANDED for the following actions: 1. Obtain an addendum from the June 2016 VA examiner. He should render an opinion in which he acknowledges the article from mercurytalk.com submitted by the Veteran (VBMS, 4/11/16). He should then opine whether it is at least as likely as not (a 50 percent or greater probability) that any respiratory disability was proximately due to, or aggravated by, his exposure to mercury as a dental assistant during military service. 2. After completion of the above, review the relevant evidence of record and determine if the benefit sought can be granted. If the claim remains denied, then furnish the Veteran and his representative with a supplemental statement of the case, and afford a reasonable opportunity for response before returning the record to the Board for further review. 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 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 2014). ______________________________________________ Paul Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs