Citation Nr: 1735147 Decision Date: 08/24/17 Archive Date: 09/06/17 DOCKET NO. 08-36 488 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUE Entitlement to an increased evaluation for residuals of small intestine resection with scarred duodenal bulb, rated 20 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jonnese S. Crandol, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1973 to January 1975 and from January 1977 to February 1979. This appeal comes before the Board of Veterans' Appeals (Board) from a May 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In May 2012, the Veteran testified before the undersigned Veterans Law Judge at a Central Office hearing conducted in Washington, D.C. A transcript of this hearing has been associated with the claims file. This matter was remanded for further consideration by the Board in August 2013, December 2015, and in July 2016. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. There is also a paperless, electronic record in the Virtual VA system. FINDINGS OF FACT 1. The Veteran's residuals of small intestine resection with scarred duodenal bulb has been no more than moderate and has not been manifested by anemia and weight loss; recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year; pain only partially relieved by standard ulcer therapy; periodic vomiting; recurrent hematemesis or melena; partial obstruction manifested by delayed motility of barium meal or partial obstruction manifested by frequent and prolonged episodes of severe colic distension, nausea or vomiting, following severe peritonitis, ruptured appendix, perforated ulcer, or operation with drainage. 2. Resolving all reasonable doubt in favor of the Veteran, since May 19, 2014, the Veteran has one painful scar associated with residuals of small intestine resection with scarred duodenal bulb. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for residuals of small intestine resection with scarred duodenal bulb have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.114, Diagnostic Codes 7301 - 7305 (2016). 2. Since May 19, 2014, the criteria for a separate 10 percent rating, but no higher, for painful scar associated with residuals of small intestine resection with scarred duodenal bulb have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.118, Diagnostic Code 7804 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the claims file, and has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104 (West 2014); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each piece of evidence. Id. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. It should not be assumed that the Board has overlooked pieces of evidence that are not explicitly discussed herein. Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. Id. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Equal weight is not accorded to each piece of evidence contained in the record, and every item of evidence does not have the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Id. I. VA's Duty to Notify and Assist VA's duty to notify was satisfied by a letter dated July 2005. See 38 U.S.C.A. § § 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2016); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The VA also has a duty to assist the Veteran in obtaining potentially relevant records, and providing an examination or medical opinion when necessary to make a decision on the claim. Here, the Veteran's available service records, VA records, and identified private treatment records have been obtained and associated with the claims file. The record also indicates that the Veteran has been in receipt of disability payments from the Social Security Administration (SSA). VA also secured these records and associated them with the Veteran's claims file. As part of its duty to assist claimants, VA may also be required to schedule a claimant with a VA medical examination. However, whenever VA has undertaken the effort to afford a claimant an examination, whether or not such an examination is required, VA must provide an adequate examination "or, at a minimum, notify the claimant why one will not or cannot be provided." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion is adequate when it is based upon consideration of the veteran's prior medical history and describes the disability in sufficient detail so that the Board's evaluation of the claimed disability will be fully informed. D'Aries v. Peake, 22 Vet. App. 97, 104 (2008). If an examination report is inadequate or fails to contain sufficient detail, the Board is required to return the report. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001). The issue on appeal was remanded by the Board in August 2013, December 2015, and July 2016. The Board finds that as of the July 2016 remand, the AOJ substantially complied with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial compliance would be required, not strict compliance). In a July 2017 written brief, the Veteran's representative contended that the September 2016 and November 2016 examination and opinions were conclusory and inadequate for VA purposes. The Veteran's representative also contended that "the examiner is not shown to have any particular expertise, experience, training, or competence in commenting on [g]astrointestinal disorders." See July 2017 Appellate Brief. The examination reports and medical opinions of record are accurate and fully descriptive. The Board finds that the Veteran has been afforded adequate examinations and the medical opinions provided are also adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Additionally, as it relates to the Veteran's representative's contention that the VA examiner lacked the necessary expertise required to render an opinion on the Veteran's gastrointestinal condition, the Board finds that the prior remand directives did not require the examiner to have any specialized expertise regarding gastrointestinal disorders, only that the examiner be an appropriate medical professional. The Board also finds that the Veteran's condition is not one so medically complex and unique that it requires an examination from a medical doctor who specializes in gastrointestinal disorders. The Board also finds that the Veteran's September 2016, November 2016, and July 2017 VA examinations were adequate. The examinations were performed by medical professionals based on review of the Veteran's electronic medical records, a solicitation of history and symptomatology from the Veteran, and an in-person examination of the Veteran. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The VA examinations also complied with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 , 271 (1998). For the foregoing reasons, the Board is convinced the VA has satisfied its duties to notify the Veteran and assist him in the development of his claim for an increased rating for his residuals of small intestine resection with scarred duodenal bulb. II. Increased Rating- Relevant Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2016). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2016). Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board must also consider staged ratings, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct periods during the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Veteran's residuals of small intestine resection with scarred duodenal bulb is currently evaluated under 38 C.F.R. § 4.114, Diagnostic Code 7301-7305 and has been evaluated as 20 percent disabling. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2016). Diagnostic Code 7301 refers to adhesions of the peritoneum. Diagnostic Code 7305 pertains to duodenal ulcer. The Board finds that the rating criteria applied by the RO are appropriate. Pernorio v. Derwinski, 2 Vet. App. 625 (1992); 38 C.F.R. §§ 4.20, 4.21 (2016). The Board can identify no more appropriate diagnostic codes and the Veteran has not identified any. Butts v. Brown, 5 Vet. App. 532 (1993). Accordingly, the Board will proceed with an analysis of the Veteran's disability under Diagnostic Codes 7301 and 7305. Words such as "mild," "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule or in the regulations. Consequently, the Board must evaluate all of the evidence to ensure that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2016). Notably, when considering ratings related to the digestive system, ratings under DCs 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single rating will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Under Diagnostic Code 7305, a 10 percent evaluation is warranted for a mild duodenal ulcer, with recurring symptoms once or twice per year. A 20 percent evaluation is in order for a moderate ulcer with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration; or with continuous moderate manifestations. A 40 percent evaluation contemplates a moderately severe ulcer, less than severe but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. A rating of 60 percent is assigned to severe ulcers with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7305. Under Diagnostic Code 7301, mild adhesions of the peritoneum warrant a non-compensable disability rating. A 10 percent disability rating is warranted for moderate peritoneal adhesions resulting in pulling pain on attempting work or aggravated by movements of the body, or occasional episodes of colic pain, nausea, constipation (perhaps alternating with diarrhea) or abdominal distension. A 30 percent disability rating is warranted for moderately severe peritoneal adhesions resulting in partial obstruction manifested by delayed motility of barium meal and less frequent and less prolonged episodes of pain. A maximum schedular 50 percent disability rating is warranted for severe peritoneal adhesions resulting in definite partial obstruction shown by X-ray, with frequent and prolonged episodes of severe gastrointestinal symptoms following severe peritonitis, ruptures appendix, perforated ulcer, or operation with drainage. Additionally, a note to Diagnostic Code 7301 states that ratings for peritoneal adhesions will be considered when there is a history of operative or other traumatic or infectious (intraabdominal) process, and at least two of the following: disturbance of motility, actual partial obstruction, reflex disturbances, presence of pain. 38 C.F.R. § 4.114, Diagnostic Code 7301. III. Analysis The Veteran has contended throughout the appellate period that his residuals of small intestine resection with scarred duodenal bulb are entitled to an evaluation in excess of 20 percent. During the Veteran's May 2012 Board hearing, the Veteran reported that after his January 2004 pancreatitis surgery, his ulcer symptoms "kind of" dissipated. The Veteran also reported that he was experiencing minimal ulcer symptoms during the time of the hearing. In January 2004, the Veteran was admitted to the hospital for acute pancreatitis and later underwent a tracheostomy. An August 2004 ultrasound indicated that the Veteran had no cystic masses, and his kidneys, spleen, and abdominal aorta were within normal limits. In a May 2012 VA treatment note, the examiner indicated that the Veteran had a history of gastric ulcers but that during that examination, he was asymptomatic for gastrointestinal symptoms. In a May 2014 VA examination for diabetes mellitus, the examiner indicated that the Veteran had documentation of surgical treatment for duodenitis, appendicitis, and Meckel's Diverticulum during active duty service in June 1973. As a result of these procedures, the examiner opined that the Veteran developed peritoneal adhesions and pancreatitis. The examiner noted that the Veteran has had severe, life threatening bouts of pancreatitis. On VA examination in May 2014 for stomach and duodenal conditions, the Veteran was noted to take medication for his condition. He was found to have recurring episodes of symptoms that were not severe 3 times a year, and each episode lasted less than 1 day. He also had monthly periodic abdominal pain that was noted to be unrelieved by standard ulcer therapy. The Veteran was not found to have incapacitating episodes due to signs or symptoms of any stomach or duodenum condition. The examiner found that the Veteran's stomach or duodenum conditions did not impact his ability to work. The Veteran was found to have an exploratory laparotomy scar to the midline of the lower abdomen that was painful with pulling, tearing pain on palpation. The scar was 8.6 cm long. In a May 2014 VA examination for gallbladder and pancreas, the examiner noted that continuous medication was not required for control of the Veteran's pancreas condition. The Veteran had abdominal pain confirmed as resulting from pancreatitis by appropriate laboratory and clinical studies, and it was found to be moderately severe with 0 attacks in the past 12 months. The Veteran's pancreas condition was not found to impact his ability to work. In a May 2014 VA examination for intestinal conditions, the Veteran was found to not require continuous medication for control of his condition. He had intermittent episodes of abdominal distension and bloating. He was also noted to have frequent episodes of bowel disturbance with abdominal distress. The Veteran did not have weight loss or malnutrition attributable to his intestinal condition. His intestinal condition was not found to impact his ability to work. In a May 2014 VA examination for intestinal surgery, the Veteran was found to not require continuous medication for control of his condition. He was found to have intermittent abdominal pain, abdominal distension, and bloating. He did not have weight loss or inability to gain weight attributable to intestinal surgery, nor did he have interference with absorption and nutrition attributable to resection of the small intestine. The Veteran also did not have persistent intestinal fistula attributable to a surgical intestinal condition. His intestinal condition was not found to impact his ability to work. In a January 2016 VA treatment note, the examiner noted that the Veteran was negative for pressure ulcer risk. At the time of that examination, the Veteran reported that he did not have any current pressure ulcers. In September 2016, the Veteran underwent a VA examination for gallbladder and pancreas conditions. The Veteran did not show any signs and symptoms attributable to any pancreas conditions or residuals of treatment for pancreas conditions. The Veteran also did not exhibit any pertinent physical findings or complications related to his pancreas condition. Additionally, the examiner opined that the Veteran's pancreas condition did not impact his ability to work. In response to the July 2016 remand directives, the examiner indicated that the Veteran's chronic recurrent pancreatitis is less likely caused by the residuals of small intestinal resection with scarred duodenal bulb disability. The pancreatitis is separate and distinct from the residuals of small intestinal resection with scarred duodenal bulb disability. The examiner reasoned that the Veteran has a history of high triglycerides and alcohol abuse which are both known risk factors for developing chronic pancreatitis. Again, in September 2016, the Veteran underwent another VA examination, but on this occasion it was for his stomach and duodenal conditions. The Veteran noted that he currently takes stool softeners and Omeprazole BID for his condition. The Veteran also did not display any signs or symptoms, nor did the Veteran mention experiencing any incapacitating episodes related to any stomach or duodenum condition. The Veteran's stomach and duodenal-related scar was not painful or unstable, and did not have a total area equal to or greater than 39 square cm. The scar is located on the Veteran's lower abdomen, and it was linear and nontender. Diagnostic testing was not performed during this examination. However, the VA examiner opined the Veteran's stomach or duodenum conditions did not impact his ability to work. In support of this opinion, the VA examiner reasoned that the current level of severity of the Veteran's service-connected residuals of previous small intestinal resection with scarred duodenal bulb is stable without any current symptoms. In a November 2016 VA addendum opinion, the examiner provided a medical opinion regarding whether the Veteran's pancreatitis was aggravated beyond its natural progression by his service-connected residuals of small intestine resection with scarred duodenal bulb. The VA examiner could not establish a baseline because the Veteran's pancreas condition was not aggravated by his service-connected condition, and his pancreas condition was stable with no current symptoms. The VA examiner opined that the Veteran's pancreatitis was not at least as likely as not aggravated beyond its natural progression by his residuals of small intestine resection with scarred duodenal bulb. In support of this opinion, the VA examiner reasoned that the Veteran's current lack of pancreatitis symptoms suggests that his pancreatitis is stable and is not aggravated beyond its natural progression due to his residuals of small intestine resection with scarred duodenal bulb. The Veteran underwent another VA intestinal conditions examination in July 2017. The Veteran was noted to take Omeprazole for his GERD symptoms. The Veteran was noted to not have any signs or symptoms of any non-surgical, non-infectious intestinal condition, any episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of his intestinal condition. The Veteran reported not having any weight loss attributable to his intestinal condition. The examiner noted the Veteran's lower abdominal scar was stable and was not equal to or greater than 39 square centimeters. The examiner did not perform any laboratory or diagnostic testing during this examination. However, this examiner opined that the Veteran's intestinal condition does impact his ability to work due to his abdominal pain. Again in July 2017, the Veteran underwent a VA intestinal surgery examination. During this examination, the Veteran reported that he does not require continuous medication to control his intestinal conditions. The Veteran did not have any signs or symptoms attributable to his prior intestinal surgery, and the Veteran did not have weight loss or experience an inability to gain weight as a result of his prior intestinal surgery. The examiner noted that the Veteran has never had a persistent intestinal fistula attributable to his prior surgical intestinal condition. His surgical scar was noted to be stable. The examiner did not perform any laboratory or diagnostic testing during this examination. However, again, this examiner opined that the Veteran's intestinal condition impacts his ability to work due to his abdominal pain. The Board notes that the examiner who performed this examination is the same one who performed his VA intestinal conditions examination. After a careful review of the medical and lay evidence of record, the Board finds that the currently assigned 20 percent disability rating for the Veteran's residuals of small intestine resection with scarred duodenal bulb disability appropriately approximates the Veteran's degree of disability. To warrant a 40 percent rating under Diagnostic Code 7305, the Veteran's condition would need to be a moderately severe ulcer, that is less than severe but has an impairment of health manifested by anemia and weight loss, or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. Here, the Veteran's treatment records and VA medical examinations show that the Veteran has not experienced any weight loss or anemia attributable to his intestinal and ulcer conditions. Additionally, during the appeal period, the Veteran did not experience recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. In his July 2017 VA examination, the examiner noted that the Veteran's abdominal pain has negatively affected him for no more than one week within the last 12 months. Additionally, during his May 2012 hearing, the Veteran claimed that he was experiencing minimal ulcer-related symptoms. During a May 2012 VA treatment note, the Veteran also reported that he was not experiencing any ulcer related symptoms and did not report experiencing any incapacitating episodes. Furthermore, the Veteran did not report having any incapacitating episodes averaging 10 days or more related to his intestinal or ulcer conditions during either one of his VA examinations during the appeal period. The Board acknowledges that a May 2014 VA examination of the gallbladder and pancreas found moderately severe abdominal pain. However, this abdominal pain was confirmed to be from pancreatitis, which was found to be separate and distinct from the residuals of small intestinal resection with scarred duodenal bulb disability in September 2016. To warrant a 60 percent rating under Diagnostic Code 7305, the Veteran's condition would need to be severe and manifest anemia and weight loss productive of definite impairment of health. Here, again, anemia has never been shown, and the Veteran did not report nor did the medical evidence show him experiencing any weight loss attributable to his intestinal and ulcer conditions. A 60 percent rating would also require pain only partially relieved by standard ulcer therapy, periodic vomiting, and recurrent hematemesis or melena. The evidence does not show that the Veteran has experienced periodic vomiting, recurrent hematemesis, or melena. Furthermore, the Veteran's condition is not severe because the available medical evidence of record does not indicate any frequent complaints of pain or any hospitalizations for his intestinal or ulcer related service-connected conditions during the appeal period. Despite the July 2017 examiner's opinion that the Veteran's abdominal pain may impact his work, the examiner noted that the Veteran's abdominal pain has only negatively affected him for no more than one week within the last 12 months. The Board acknowledges that a May 2014 VA examination for stomach and duodenal conditions indicated that the Veteran's abdominal pain was unrelieved by standard ulcer therapy. However, the examination also found that the Veteran had recurring episodes of symptoms that were not severe 3 times a year, and abdominal pain that was monthly and periodic in frequency. The Veteran was also not found to have incapacitating episodes due to signs or symptoms of any stomach or duodenum condition. The Board recognizes that the Veteran experiences abdominal pain. However, the overall medical evidence of record indicates that this pain may occasionally occur, and it unfortunately does not rise to the level of severity needed to meet the criteria of a 40 or 60 percent rating under Diagnostic Code 7305. To warrant a 30 percent rating under Diagnostic Code 7301, the Veteran's condition would have to be moderately severe and manifest in partial obstruction shown by delayed motility of barium meal and less frequent and less prolonged episodes of pain. The evidence does not show that the Veteran has partial obstruction or delayed motility of barium meal. Indeed, a May 2014 VA intestinal examination shows that the Veteran experienced only intermittent abdominal pain, abdominal distension, and bloating. Similarly, a 50 percent rating under Diagnostic Code 7301 is not warranted, as the evidence does not show that the Veteran's condition is severe with definite partial obstruction shown by x-ray, with frequent and prolonged episodes of severe colic distension, nausea or vomiting, following severe peritonitis, ruptured appendix, perforated ulcer, or operation with drainage. Regarding the May 2014 VA intestinal examination finding of frequent episodes of bowel disturbance with abdominal distress, the Board has also considered whether a higher rating would be warranted for this symptoms under Diagnostic Code 7319, which contemplates irritable colon syndrome. However, frequent episodes of bowel disturbance with abdominal distress would be considered moderate and would only warrant a 10 percent rating under that Diagnostic Code. See 38 C.F.R. § 4.114, Diagnostic Code 7319 (2016). The Board has considered whether a separate rating is warranted for the residual laparotomy scar associated with the Veteran's disability. Under 38 C.F.R. § 4.118, Diagnostic Code 7804 (2016), a 10 percent rating is warranted for one or two scars that are unstable or painful. While the Veteran's lower abdominal scar has been stable for the entire period, at his May 2014 VA examination, the Veteran's exploratory laparotomy scar to the midline of the lower abdomen was found to be painful with pulling, tearing pain on palpation. While subsequent VA examinations found that the Veteran's lower abdomen scar was not painful, resolving all reasonable doubt in favor of the Veteran, the Board finds that a separate 10 percent rating, but no higher, is warranted for the laparotomy scar on the lower abdomen, effective May 19, 2014, the date of the VA examination. The Board has also considered the Veteran's assertions regarding his gastrointestinal symptoms, and acknowledges that he is competent to report his own observations with regard to the severity of his symptomatology. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds his statements to be credible and consistent with the rating now assigned. To the extent he argues his symptomatology is more severe, his statements must be weighed against the other evidence of record. Here, the specific examination findings of trained health care professionals and the documented medical treatment records are of greater probative weight than the Veteran's more general lay assertions that a rating higher than 20 percent is warranted. In sum, the Board finds that the Veteran's residuals of small intestine resection with scarred duodenal bulb is appropriately rated as 20 percent disabling pursuant to DCs 7301 and 7305 throughout the appeal period. However, a separate 10 percent rating for a painful scar associated with the residuals of small intestine resection with scarred duodenal bulb is warranted since May 19, 2014. ORDER A disability rating in excess of 20 percent for residuals of small intestine resection with scarred duodenal bulb is denied. Since May 19, 2014, a separate 10 percent rating, but no higher, for painful scar associated with residuals of small intestine resection with scarred duodenal bulb, is granted. ____________________________________________ JENNIFER HWA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs