Citation Nr: 1722181 Decision Date: 06/15/17 Archive Date: 06/29/17 DOCKET NO. 13-22 260 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for the causes of the Veteran's death. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Saikh, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1955 to November 1979. He died in September 2009, and the Appellant claims as his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas (Agency of Original Jurisdiction (AOJ)). The case is now under the jurisdiction of the St. Petersburg, Florida RO. In January 2016, the Board remanded this case to schedule the Appellant for a videoconference hearing. In July 2016, the Appellant testified before the undersigned Veterans Law Judge (VLJ) at a Board videoconference hearing In December 2016, the Board requested expert medical opinion from the Veterans Health Administration (VHA). In March 2017, the Board provided the Appellant and her representative a copy of the January 2017 VHA opinion with an additional 60 day period to provide additional evidence and/or argument. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. The Veteran died in September 2009; the certificate of death listed the immediate causes of death as chronic obstructive pulmonary disease (COPD), chronic respiratory failure, atrial fibrillation, and right ventricular failure. Pseudomonas cellulitis of the left leg was listed as a contributing cause of death. 2. At the time of his death, the Veteran was not service-connected for any disabilities. 3. The Veteran's COPD, chronic respiratory failure, atrial fibrillation, right ventricular failure, and pseudomonas cellulitis were not shown to have manifested in service or within one year of service, or to be otherwise related to active service. CONCLUSION OF LAW The criteria for service connection for the cause of the Veteran's death are not met. 38 U.S.C.A. § 1101, 1110, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 3.5, 3.102, 3.159, 3.303, 3.307, 3.309, 3.312 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSION VCAA Notice The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2016). Under the VCAA, VA is required to notify the claimant and her representative 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In the context of a claim for Dependency and Indemnity Compensation (DIC) benefits, which includes a claim of service connection for the cause of the Veteran's death, VCAA notice must include (1) a statement of the conditions, if any, for which a veteran was service-connected at the time of his death; (2) an explanation of the evidence and information required to substantiate a DIC claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate a DIC claim based on a condition not yet service-connected. Hupp v. Nicholson, 21 Vet. App. 342, 352-53 (2007), rev'd on other grounds, Hupp v. Shinseki, 329 Fed. Appx. 277 (Fed. Cir. May 19, 2009) (unpublished). In a July 2010 letter, the AOJ notified the Appellant of the evidence needed to substantiate the claim for entitlement to service connection for the cause of the Veteran's death. The AOJ wrote, that to establish entitlement to the benefit sought, the evidence must show that a disability was incurred or aggravated during service and was the primary or contributory cause of death. The AOJ also notified the Appellant that the Veteran was not service-connected for any disability at the time of death, and described the requirements for a DIC claim based on a disability that was not yet service-connected. Accordingly, the notice requirements of the VCAA have been met in this case. The Board notes that the Veteran's personnel records reflect that he set foot in Vietnam during the Vietnam era and, as such, is presumed to have been exposed to herbicides. 38 C.F.R. § 3.307(a)(6)(i). His diagnosis of prostate cancer is presumed due to service. 38 U.S.C.A. § 1116(a)(2); 38 C.F.R. § 3.309(e). At the hearing, the Appellant and her representative expressed actual knowledge of this fact and have submitted evidence attempting to show that the Veteran's form of prostate cancer contributed to his death. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate any claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his or her claims, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claims. 38 C.F.R. § 3.159(c)(4). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the general duty to assist provision, 38 U.S.C.A. § 5103A(a), rather than the provision specifically addressing when medical examinations are required in compensation claims, 38 U.S.C.A. § 5103A(d), is applicable to claims for service connection for the cause of a veteran's death. Wood v. Peake, 520 F.3d 1345, 1347 (Fed. Cir. 2008); DeLaRosa v. Peake, 515 F.3d 1319, 1322 (Fed. Cir. 2008). While 38 U.S.C.A. § 5103A(a) does not always require VA to assist a claimant in obtaining a medical examination or assistance, such assistance is required whenever a medical opinion is "necessary to substantiate the claim," and VA is excused from providing such assistance only when "no reasonable possibility exists that such assistance would aid in substantiating the claim." Wood, 520 F.3d at 1348. In this case, VA fulfilled its duty to assist by attempting to obtain all identified and available evidence needed to substantiate the claim on appeal. In January 2017, the Board obtained an expert medical opinion specifically addressing the etiology of the Veteran's disabilities, and whether they were the primary or contributory causes of the Veteran's death. During the Board hearing, the undersigned VLJ discussed with the Appellant the issue on appeal, the evidence required to substantiate the claim, and asked questions to elicit information relevant to the claim. This action supplemented VA's compliance with the VCAA. 38 C.F.R. § 3.103. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements with regard to these claims. There is no additional evidence which needs to be obtained. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Appellant. Law and Analysis DIC benefits are payable to the surviving spouse of a Veteran if the Veteran died from a service-connected disability. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.5(a)(1). In order to establish service connection for the cause of the Veteran's death, the evidence must show that a disability incurred in or aggravated by active service was the principal or contributory cause of death. 38 C.F.R. § 3.312(a). In order to constitute the principal cause of death, the service-connected disability must be one of the immediate or underlying causes of death, or be etiologically related to the cause of death. 38 C.F.R. § 3.312(b). A contributory cause of death is inherently not one related to the principal cause. In order to constitute the contributory cause of death, it must be shown that the service-connected disability contributed substantially or materially; that it combined to cause death; or that it aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c)(1). In determining whether the disability that resulted in the death of the Veteran was incurred in service, the laws and regulations generally applicable to compensation for service connected disabilities apply. 38 U.S.C.A. § 1310. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the current disability and an in-service precipitating disease, injury, or event. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for certain chronic diseases, if the disease is manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic as per 38 C.F.R. § 3.309(a)). VA laws and regulations provide that, if a Veteran was exposed to Agent Orange during service, certain listed diseases are presumptively service-connected. 38 U.S.C.A. § 1116(a)(1); 38 C.F.R. § 3.309(e). A Veteran who "served in the Republic of Vietnam" between January 9, 1962 and May 7, 1975, is presumed to have been exposed during such service to Agent Orange. 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). The listed diseases are: AL amyloidosis, chloracne or other acneform disease consistent with chloracne, Type II diabetes mellitus (adult-onset diabetes), Hodgkin's disease, ischemic heart disease, chronic B-cell leukemias, multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx or trachea); and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). In addition, the Secretary of VA has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-46 (1994); Notice, 61 Fed. Reg. 41, 442-49 (1996); Notice, 72 Fed. Reg. 32,395-32,407 (Jun. 12, 2007); Notice, 74 Fed. Reg. 21,258-21,260 (May 7, 2009); Notice, 75 Fed. Reg. 32540 (June 8, 2010). In a DIC claim based on cause of death, the current disability element will always have been met (the current disability being the one that caused the Veteran to die). Carbino v. Gober, 10 Vet. App. 507, 509 (1997), aff'd sub nom. Carbino v. West, 168 F.3d 32 (Fed. Cir. 1999). The Appellant initially contended that the Veteran's ischemic heart disease, which she claims resulted from exposure to herbicides while in service, caused his death. The Appellant later revised her claim to assert that the Veteran's service-connected prostate cancer caused his death. The Veteran's death certificate lists COPD, chronic respiratory failure, atrial fibrillation, and right ventricular failure as immediate causes of death. The certificate also lists pseudomonas cellulitis of the left leg as a contributing cause of death. Service treatment records from October 1965, reveal that the Veteran had a functional heart murmur. A November 1977 electrocardiograph (EKG) report revealed that the Veteran had sinus bradycardia, but that his other results were otherwise within normal limits. His October 1979 separation exam noted no abnormalities in the clinical evaluation section, however there was a notation made regarding his prostate. However, it is unclear what was meant by the notation. In January 2008, the Veteran underwent cardiac catherization which revealed severe to critical aortic stenosis, mild aortic insufficiency with aortic root dilatation, mild non obstructive coronary artery disease, and normal right heart pressures. The Veteran was also diagnosed with COPD and supraventricular tachycardia. Subsequent records from January 2008 show that a valve replacement surgery was recommended for the Veteran, but that he was a poor candidate for surgery due to his pulmonary condition. March 2008 records revealed that the Veteran had mild non obstructive coronary artery disease, and a history of valvular heart disease. Records from April 2008 show that the Veteran underwent aortic valve replacement, but still had difficulties with his COPD. May 2008 private medical records show that the Veteran's stress test was abnormal, showing evidence of reversible ischemia in the inferior wall of his heart. Private medical records from June 2009 show that the Veteran had worsening COPD and possible congestive heart failure, in addition to status post aortic valve replacement. Records from June 2009 also note that the Veteran had an extensive history of smoking. In August 2009, the Veteran was initially admitted to the hospital due to cellulitis in both of his lower extremities. An EKG was ordered which revealed that the Veteran had right heart failure secondary to his pulmonary hypertension. June 2010 records revealed that the Veteran had been diagnosed with prostate cancer in 2004, and treated with Casodex and x-ray therapy. The Veteran stopped receiving treatment in June 2009 due to his severe emphysema. In a November 2010 VA opinion, the examiner concluded that it was less likely as not that the Veteran's cause of death was ischemic cardiovascular disease. The examiner noted that the Veteran was a long time heavy smoker and had a long history of COPD and respiratory failure. The examiner also noted that there was no diagnosis of ischemic heart disease. In order to establish a diagnosis of ischemic heart disease, there needed to have been an autopsy performed at the time of death. The diagnosis of ischemic heart disease was not established anti-mortem, and the examiner noted that the thallium stress test completed a few years prior to the Veteran's death did not reveal ischemic heart disease. The examiner concluded that respiratory failure would appear to be most likely the cause of death. In a subsequent May 2013 VA opinion, the examiner concluded that the Veteran's functional murmur and/or bradycardia noted in service was not the primary cause and/or contributor to the Veteran's death, as per the death certificate. In the July 2013 Form 9, the Appellant indicated that she wanted the claim to be changed to reflect that she was now claiming service connection for cause of death for prostate cancer. In support of her statement, she submitted a letter dated July 2013, from the Veteran's private physician. In the letter, the physician explained that he had treated the Veteran for prostate cancer which was diagnosed in 2004 as a Gleason 5T1c. The physician noted that he was aware that there was some association between Agent Orange and prostate cancer, and that while this seemed to be an aggressive cancer for a Gleason 5, he was unable to say that Agent Orange caused the Veteran's respiratory failure. He was unable to say whether Agent Orange caused the Veteran's respiratory failure, but he did state that the Veteran had prostate cancer which seemed to be a bit more aggressive than the normal Gleason 5. In a July 2013 VA opinion, the examiner concluded that the Veteran's prostate cancer post initial treatment with rising prostate-specific antigen (PSA) levels did not contribute to the Veteran's death. In support of the opinion, the examiner noted that as per the death certificate, the causes of death included COPD with underlying chronic respiratory failure, atrial fibrillation, and right ventricular failure. During the July 2016 hearing, the Appellant testified that the Veteran's physician, who treated him for his prostate cancer, believed that the Veteran's prostate cancer caused his death. The Appellant testified that the Veteran had gone into remission for a time, but that his prostate cancer returned in the years leading up to his death. The Appellant also testified that the Veteran had heart valve replacement surgeries, and was hospitalized many times for difficulties with his heart. In July 2016, the Appellant submitted a letter from the Veteran's physician which was almost identical to the letter submitted in July 2013. The physician continued to state that he was unable to say that Agent Orange caused the Veteran's respiratory failure, but that he did have cancer of the prostate which seemed more aggressive than the normal Gleason 5. In January 2017, a VHA expert in internal medicine opined that it was less likely as not that the Veteran's functional murmur and/or sinus bradycardia noted in service caused or substantially contributed to his death. The physician explained that as noted on the death certificate, the Veteran's cause of death was cardio-respiratory arrest which was consistent with hospital records documenting his admission for severe COPD that was complicated by right heart failure and bilateral lower extremity edema with cellulitis. The physician indicated that there was no evidence that he had a symptomatic valve or bradycardiac heart condition, since records showed that his heart valve seemed to be functioning well after the valve replacement in 2008. The Veteran had no evidence of chronic symptomatic bradycardia, and the bradycardia noted prior to the Veteran's death was at least as likely as not due to his declining respiratory status. The atrial fibrillation that developed while he was hospitalized was at least as likely as not due to active infections and hypoxemia. The physician opined that it was less likely than not that the Veteran's prostate cancer, including complications from treatment, caused or substantially contributed to his death. The physician again explained that as noted on the Veteran's death certificate, his cause of death was cardio-respiratory arrest, which was at least as likely due to his COPD and right heart failure. The physician noted that this was consistent with hospital records which noted the Veteran's deteriorating respiratory status due to his COPD, right heart failure secondary to COPD, and bilateral leg cellulitis. The physician further explained that there was no medical evidence to support a causal association between prostate cancer with COPD, right heart failure, cellulitis, or cardio-respiratory arrest. There was also no evidence that the Veteran's prostate cancer involved his lungs, and the treatments used to treat his cancer do not cause any respiratory or cardiac complications. With regards to whether the Veteran's coronary artery disease caused or substantially contributed to his death, the physician noted that the Veteran was found to have non-obstructive coronary artery disease based upon the angiogram done in January 2008 and it was very unlikely that a significant change had occurred in the degree of stenosis from the time of that angiogram until the time of the Veteran's death. There was also no evidence that the Veteran suffered any acute coronary event during his hospital admission. Finally, with regards to whether herbicide exposure caused or substantially contributed to the Veteran's death, the physician explained that neither COPD with right heart failure or cellulitis is associated with herbicide exposure. Rather, the physician found that the Veteran's COPD was at least as likely as not related to his previous history of heavy smoking. After reviewing the evidence of record, the Board finds that the Veteran's prostate cancer did not cause or contribute to the Veteran' s death. The Board also finds that ischemic heart disease resulting from herbicide exposure did not cause or contribute to the Veteran's death. As a preliminary matter, the Veteran was not service-connected for COPD, chronic respiratory failure, atrial fibrillation, right ventricular failure, or pseudomonas cellulitis. In fact, the Veteran was not service-connected for any disability at the time of his death. These disabilities were listed as the causes of death on the death certificate; however the Appellant may still be entitled to compensation if the disabilities meet the general criteria for service-connection. See 38 U.S.C.A. § 1310 (a); 38 C.F.R. § 3.313. Service treatment records do not show that the Veteran complained of, was treated for, or diagnosed with symptoms related to COPD, chronic respiratory failure, atrial fibrillation, right ventricular failure, or pseudomonas cellulitis, while he was in service, or within the year following his separation from service. Thus, the Veteran's causes of death alone do not the meet the criteria for establishing service-connection for cause of death. Service treatment records show that the Veteran had a functional heart murmur and record of sinus bradycardia in service, but his EKG from service was found to be otherwise within normal limits. Service records also show that there was some record made regarding the Veteran's prostate at the time of separation, but no specific abnormalities were noted. There are no records of any treatment for heart or prostate disabilities in service. It was several years after separation from service that the Veteran was treated for heart related disabilities. Similarly, the Veteran was diagnosed with prostate cancer in 2004, again, several years after separation from service. Most importantly, the weight of the evidence does not show that these disabilities caused or contributed to the causes of death listed on the Veteran's death certificate. In this regard, the January 2017 VHA medical opinion is the most probative opinion in the case. The Board considers evidence to be more probative if it includes clear conclusions and supporting data with a reasoned analysis connecting the data and conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). To that end, the Board finds the January 2017 medical opinion to have significant probative value because it was based on a thorough review of the Veteran's medical history, and supported by reasoned analysis. In the January 2017 opinion, the examiner found that it was less likely than not that the Veteran's heart murmur and sinus bradycardia noted in service caused or contributed to his death, since there was no evidence that the Veteran had a symptomatic valve or bradycardic heart condition at the time of his death. Rather, the bradycardia noted at the time of the Veteran's death was likely due to his declining respiratory status, and the atrial fibrillation that developed was likely due to active infections and hypoxemia. Similarly, in the January 2017 opinion, the examiner found that the Veteran's prostate cancer did not cause or contribute to the Veteran's death since the causes of death were COPD, right heart failure, respiratory failure, and cellulitis, and there was no medical evidence to support a causal association between prostate cancer and COPD, right heart failure, respiratory failure, and cellulitis. Furthermore, the examiner noted that there was no evidence that the Veteran's prostate cancer involved his lungs, nor was there evidence that the treatments used to treat his cancer caused any respiratory or cardiac complications. Thus, the examiners' conclusions that the Veteran's heart murmur and sinus bradycardia noted in service, and his later development of prostate cancer, did not cause or contribute to his COPD, right heart failure, respiratory failure, and cellulitis, are significantly more probative as they are based upon the medical evidence of record as well as established medical principles. In the January 2017 opinion, the examiner also found that the Veteran's coronary artery disease and herbicide exposure neither caused nor substantially contributed to the Veteran's causes of death. The examiner explained that the while the Veteran was found to have non-obstructive coronary artery disease diagnosed from an angiogram done in January 2008, it is unlikely that a significant change occurred in the degree of stenosis from that time to the time of the Veteran's death, and there was no evidence that the Veteran suffered any acute coronary event during his hospital admission. Similarly, the examiner explained that neither COPD with right heart failure or cellulitis, is associated with herbicide exposure. Rather, the examiner found it was likely that the Veteran's COPD was related to his previous history of heavy smoking. In contrast, the July 2016 letter submitted by the Appellant from the Veteran's physician, lacks sufficient probative value. The physician who wrote the letter, treated the Veteran for prostate cancer, however as was previously noted, prostate cancer was not listed as a cause of the Veteran's death, and as the VA examiner noted in the January 2017 opinion, was unrelated to any of the Veteran's causes of death. The letter did not address any of the specific causes of death listed on the Veteran's death certificate. The physician only noted that he was aware that there was a relationship between Agent Orange and prostate cancer. The physician also clearly indicated that he was unable to say that Agent Orange caused the Veteran's respiratory failure, which is one of the causes of death listed on his death certificate. Thus, the July 2016 letter has little, if any, probative value which is greatly outweighed by the January 2017 VHA opinion. To the extent that the Appellant contends that a medical relationship exists between the Veteran's prostate cancer and heart conditions noted in service and his causes of death, the Board acknowledges that the Appellant is competent to testify as to her own observations. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In the instant case however, the Board finds the question as to the etiology of the Veteran's causes of death, a question that requires medical expertise to answer. While the Appellant is competent to describe symptoms of the Veteran she had knowledge of, an opinion regarding the etiology of his cause of death is not within the competence of a layperson. See Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). Thus, the January 2017 opinion is more probative in finding that it is less likely than not that the Veteran's conditions noted in service or diagnosed subsequent to service, either caused or substantially contributed to his causes of death. In sum, the evidence deemed most probative by the Board weighs against a finding that the Veteran's in-service history of heart murmurs or sinus bradycardia, caused or substantially contributed to his COPD, chronic respiratory failure, atrial fibrillation, right ventricular failure, or pseudomonas cellulitis, which were the causes of the Veteran's death. Similarly, the most probative evidence of record weighs against a finding that the Veteran's prostate cancer caused or substantially contributed to the specific causes of death listed above. Furthermore, a review of the Veteran's service treatment records showed no indication that the Veteran ever complained of, was diagnosed with, or was treated for COPD, chronic respiratory failure, atrial fibrillation, right ventricular failure, or pseudomonas cellulitis. The Board acknowledges that the Veteran appears to have had service in the Republic of Vietnam during the Vietnam Era, but the record does not show that any disease or disability presumed due to herbicide exposure caused or contributed to the Veteran's death. See generally 38 U.S.C.A. § 1116. Likewise, the medical evidence of record weighs against a finding that the Veteran's causes of death resulted from or were related to herbicide exposure. Accordingly, after weighing all of the evidence, the Board finds the preponderance of the evidence is against the claim discussed above, and the benefit-of-the-doubt standard of proof does not apply. See 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). ORDER Service connection for the causes of the Veteran's death is denied. ____________________________________________ T. MAINELLI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs