Citation Nr: 1746971 Decision Date: 10/20/17 Archive Date: 10/31/17 DOCKET NO. 07-37 474 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for right pes planus. 2. Entitlement to service connection for left pes planus. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD S. Schick, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1967 to January 1970 and from June 1971 to June 1974, and his decorations include the Bronze Star Medal with "V" device for heroism. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Togus, Maine. Jurisdiction has subsequently been transferred to the RO in Detroit, Michigan. The Board previously remanded the issue of entitlement to service connection for bilateral pes planus in January 2010, May 2012, February 2013, and December 2014. The case has been returned to the Board for appellate review. FINDINGS OF FACT 1. Preexisting right pes planus was noted upon entrance to active duty; clear and unmistakable evidence does not show that his right pes planus was not aggravated by service. 2. Preexisting left pes planus was noted upon entrance to active duty; clear and unmistakable evidence does not show that his left pes planus was not aggravated by service. CONCLUSIONS OF LAW 1. The Veteran's preexisting right pes planus was aggravated by active service beyond its natural progression. 38 U.S.C.A. §§ 1110, 1111, 1153, 5103, 5103A, 5107 (West 2014); 3.102, 3.303, 3.304, 3.306, 3.309 (2016). 2. The Veteran's preexisting left pes planus was aggravated by active service beyond its natural progression. 38 U.S.C.A. §§ 1110, 1111, 1153, 5103, 5103A, 5107 (West 2014); 3.102, 3.303, 3.304, 3.306, 3.309 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Legal Criteria Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. See 38 U.S.C.A. § 1110. However, that an injury or disease occurred in service is not enough; there must also be a chronic disability resulting from that injury or disease. If there is no showing of the chronic disability during service, then a showing of continuous symptoms after service is required to support a finding of chronicity. See 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. See 38 C.F.R. § 3.303(d). In order to establish service connection for a disability, there must be (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). A Veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. See 38 U.S.C.A. § 1111 (West 2014); 38 C.F.R. § 3.304(b). To satisfy the second requirement for rebutting the presumption of soundness, the government must rebut a statutory presumption of aggravation by showing, by clear and unmistakable evidence, either that (1) there was no increase in disability during service, or (2) any increase in disability was "due to the natural progression" of the condition. Joyce v. Nicholson, 443 F.3d 845, 847 (Fed. Cir. 2006). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. "Clear and unmistakable evidence" is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that the "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than that of "clear and unmistakable evidence"). It is an "onerous" evidentiary standard, requiring that the preexistence of a condition and the no-aggravation result be "undebatable." See Cotant v. West, 17 Vet. App. 116, 131 (2003) citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993). VA's General Counsel has held that to rebut the presumption of sound condition under 38 U.S.C. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. See VAOPGCPREC 3-2003; see also Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004). The burden of proof is on VA to rebut the presumption by producing clear and unmistakable evidence that a disability existed prior to service. See Kinnaman v. Principi, 4 Vet. App. 20, 27 (1993). The determination of whether there is clear and unmistakable evidence that a defect, infirmity, or disorder existed prior to service should be based on "thorough analysis of the evidentiary showing and careful correlation of all material facts, with due regard to accepted medical principles pertaining to the history, manifestations, clinical course, and character of the particular injury or disease or residuals thereof." See 38 C.F.R. § 3.304(b)(1). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. See 38 U.S.C.A. § 1153 (West 2014); 38 C.F.R. §§ 3.304, 3.306(b). Factual Background The Veteran filed a claim for bilateral pes planus and contends that his bilateral pes planus was aggravated in service. See November 2007 VA Form 9 Substantive Appeal. As initial matter, the Board notes that the Veteran had two separate periods of active service. The first period was from April 1967 to January 1970 and the second period was from June 1971 to April 1974. STRs included a March 1967 Report of Examination at enlistment which noted "low plantar arch." His January 1970 Report of Medical Examination at separation indicated normal clinical findings and no further notation of low plantar arch was indicated. Additionally, in his January 1970 Report of Medical History, the Veteran reported being in good health and that he never had nor did he now have foot trouble or bone, joint, or other deformity. STRs also included a June 1971 Report of Medical Examination at enlistment in which clinical evaluation of the Veteran indicated normal findings with no notation describing any abnormalities. Further, the Veteran reported being in good health and that he never had nor did he now have foot trouble or bone, joint, or other deformity. In his April 1974 Report of Medical Examination at separation clinical evaluation of the Veteran indicated normal findings with no notation describing any abnormalities. The Veteran reported being in good health and no further notation of low plantar arch was indicated. Additionally, in his April 1974 Report of Medical History, the Veteran reported being in good health and that he never had nor did he now have foot trouble or bone, joint, or other deformity. The Veteran submitted an October 2006 private podiatrist evaluation report wherein the podiatrist indicated that Veteran had a chronic problem with his "right foot" for decades that had been worsening with time. Radiographic imaging showed severe "degenerative changes and malposition in the right foot" with loss of calcaneal inclination. There was increased talar declination and severe degenerative changes in the talonavicular joint and medial column on the right side compared to the left. The podiatrist opined that when this syndrome is found "unilaterally" as with the Veteran, it was typically caused by injury to the posterior tibial tendon. The podiatrist further opined that the tendon had either been injured acutely which was rather rare or maybe injured due to chronic overload during ambulation which was the more common scenario. The podiatrist opined that any activity which placed increased strain on the tendon over a period of time including lifting, carrying, walking distances, etc., would all have aggravated the Veteran's condition and caused worsening. The podiatrist indicated that the end result was tibialis posterior tendon dysfunction which led to the changes seen radiographically in the Veteran. The podiatrist explained that he was walking with a limp and has had significant problems with his left foot. The podiatrist opined that the Veteran's service in the Armed Services necessarily added aggravation to this foot type and sped along the degenerative changes that were noted today. He indicated that the Veteran had a partial disability due to "this foot" at this time. The Veteran was afforded a March 2010 VA examination and the examination report indicated the Veteran had a current diagnosis of bilateral pes planus. See May 2010 VA Examination Report. The Veteran submitted a January 2012 evaluation report from the same October 2006 private podiatrist wherein the podiatrist echoed the determinations he made in his October 2006 evaluation report. Significantly, the podiatrist indicated that radiographic imaging showed increasing interval changes and malposition of the right foot, to include loss of calcaneal inclination degenerative talonavicular joint, and an abduction deformity progressing on the right foot over time. The podiatrist again opined that the Veteran's condition which was unilateral and only in one foot, was typically caused by a previous injury to the posterior tibial tendon. The podiatrist indicated that upon today's examination he saw this tendon under the skin riding anteriorally to its typical position. He again indicated that any activity in the past which could have caused him strain on his foot (walking, climbing, carrying items) would have aggravated and worsened his condition as well as instigated it. The podiatrist opined that the Veteran had end stage posterior tibial tendon dysfunction with secondary degenerative changes and had service related aggravation to this condition. Associated with the record is a May 2012 VA medical opinion wherein the VA examiner indicated that she reviewed the Veteran's claim file and opined that his pes planus condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that there was no record of a foot injury or treatment in the Veteran's military records and the outside doctor in January 2012 recorded only a right foot condition. The examiner explained that pes planus is structural and a developmental condition. The examiner further opined that the Veteran's pes planus condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner explained that low arch or pes planus are the same condition and it is a structural condition that is not influenced by activity on feet. In an opinion regarding the conflicting medical evidence, the examiner indicated she reviewed the conflicting medical evidence and opined that no degenerative changes were noted on initial x-rays when the Veteran was in service and the current changes were a natural progression. In a December 2012 Statement in Support of Claim, the Veteran contested the May 2012 VA examiner's opinion and argued that he was never contacted to report for an examination and it was his belief that the opinion was falsified since the examiner may have reviewed the claims filed but the evidence alone did not justify an opinion without a consultation and history of events reported by the Veteran. The March 2010 VA examiner prepared an April 2013 VA medical opinion. The examiner indicated that she reviewed the available records using the Acceptable Clinic Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination and such an examination would likely provide no additional relevant evidence. The examiner opined that it was less likely than not that the Veteran's pes planus was incurred during, caused by, or a result of service. The examiner explained that there was a discrepancy between the Veteran's history, available STRs, and private medical records. In accordance with a February 2013 AOJ request for an IMO, a June 2013 IMO has been associated with the claims file. The independent medical professional opined in June 2013 that it was less likely than not that the Veteran's claimed pes planus condition was aggravated by or aggravated beyond its natural and normal aging process because of military service. The medical professional indicated that her conclusions were based on her comprehensive review of the claims files and CAPRI records. She explained that March 1967 enlistment papers stated that the low-arch was non-symptomatic. The Veteran's separation papers, dated January 1970 did not indicate a low plantar arch condition problem related to this structural condition, bilateral. Additional medical examinations dated in June 1971 and April 1974 did not indicate a low plantar arch low plantar arch condition problem related to this structural condition, bilateral. There was no diagnosis, treatment, or event pertaining to his low arch in active duty medical notes or over the presumptive period following separation. It was the independent medical professional's opinion that it was at least as likely as not that the Veteran's current foot conditional, bilateral was due to his normal and natural aging process rather than his time in military service. The Veteran was afforded a May 2015 VA examination. The examiner opined that the Veteran's condition of pes planus was not caused by his military duty. The examiner explained that there was no record of him having pes planus until October 2003. In February 2016, the Board requested a VHA opinion, which was provided in December 2016. The VHA orthopedist stated that a low plantar arch or flatfoot did not necessarily equate with foot problems. Moreover, the pain associated with a flat foot is not from the foot bony alignment but rather putting the posterior tibialis tendon and spring ligament at a mechanical disadvantage and thereby caused these structures to tear which became painful. Once the pain starts, it typically does not go away without treatment (bracing or surgery) and it is difficult to function without treatment. While the Veteran most likely had flatfoot alignment all of his life (certainly before service as documented), it does not mean he had real pathology (tendon or ligament damage). Participating in military service could increase the stress on a flatfoot and cause tendon or ligament damage but so could activities of daily living as well as aging. The VHA orthopedist indicated that he saw no conclusive evidence that the Veteran's service aggravated his foot condition. The VHA orthopedist opined that it was clear and unmistakable that the deformity preexisted service but it was "not" clear and unmistakable that the "disability" preexisted service. He indicated that from the records, there was no disability until 2002/2003. The deformity and disability from the deformity are two entirely different issues and should be treated as such. The VHA orthopedist opined that it was clear and unmistakable that the disability was not aggravated by service beyond the natural process of the disorder as manifested by the late presentation of about 30 years after the end of his service. The VHA orthopedist opined that it was clear and unmistakable that that the current foot disability is not the result of aggravation during service. If it was, there would have been pain and difficulty performing service-related issues and this should have been documented in the records and would have advanced much faster, requiring treatment sooner than 2002/2003. The VHA orthopedist opined that the current bilateral foot disability is not as least as likely as not to have begun in service or from service-related activity. The current disability is likely related to normal wear and tear of life on top of a preexisting foot condition ("fallen arches"). The current disability is consistent with sequelea of flatfoot/low arch/fallen arches. The VHA orthopedist concluded that the flatfoot alignment can put abnormal physiological stress on the soft-tissue restraints around the bones. Normal wear and tear of life can overload these soft-tissues and make the pathology worse. The VHA orthopedist indicated that he could not say that the Veteran's service or his USPS job were any more implicated in his current disability than other factors in life, meaning that most likely he would have the same disability if he performed a different job. If a specific military service incident caused rupture of the posterior tibial tendon or the spring ligament, then the VHA orthopedist stated he could opine that military service aggravated his condition, but without that documentation, the VHA indicated it was his medical opinion that the Veteran's disability was caused by military service. In a June 2017 Correspondence the Veteran related his bilateral pes planus condition to his service in the military and reported that before being inducted into military service in April 1967 he never had foot problems and that his "low arches" noted at entrance was a "surprise" to him. Additionally, he stated that "my pes planus was aggravated by service" and in support of his claim he submitted May 2017 radiographic imaging of his feet and an opinion from his private podiatrist who provided the October 2006 and January 2012 evaluation reports of record. In May 2017 the private podiatrist indicated that MRI studies showed tear on the posterior tibial tendon with additional chronic tendinitis which the Veteran tied to injury during service and worsening from service activities. It was the podiatrist's opinion that the Veteran's disability with his right foot today was related to an injury, disease, or event occurring during the Veteran's military service and was aggravated by that service. The podiatrist indicated the MRI demonstrated evidence of this injury. Analysis A. Right Foot With regard to the Veteran's right foot, prior to the Veteran's entrance into service for the period from March 1967 to January 1970, a Report of Medical Examination from March 1967 clinically noted that the Veteran had "low plantar arch." As such, the evidence showed that a bilateral foot disability was noted on examination when he was accepted and enrolled into service, and the presumption of soundness on induction is not applicable. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304 (b). In order for the presumption of aggravation to arise, the evidence must show that there was an increase in the severity of the Veteran's right pes planus during service beyond a natural progression. The Veteran's STRs include a January 1970 Report of Medical History at discharge wherein the Veteran indicated he was in good health and the Veteran reported that he never had nor did he now have foot trouble or bone, joint, or other deformity. STRs were silent for complaints and evidence of increased disability during service. In support of his claim, the Veteran submitted three opinions from his private podiatrist relating his right foot pes planus to active service. In an October 2006 evaluation report, the podiatrist indicated that Veteran had a chronic problem with his "right foot" for decades and that had been worsening with time. Radiographic imaging showed severe "degenerative changes and malposition in the right foot" with loss of calcaneal inclination. There was increased talar declination and severe degenerative changes in the talonavicular joint and medial column on the right side compared to the left. The podiatrist opined that when this syndrome is found "unilaterally" as with the Veteran, it was typically caused by injury to the posterior tibial tendon. The podiatrist further opined that the tendon had either been injured acutely which was rather rare or maybe injured due to chronic overload during ambulation which was the more common scenario. The podiatrist opined that any activity which placed increased strain on the tendon over a period of time including lifting, carrying, walking distances, etc. would all have aggravated the Veteran's condition and caused worsening. The podiatrist opined that, the Veteran's service in the Armed Services necessarily added aggravation to this foot type and sped along the degenerative changes that were noted today. He indicated that the Veteran had a partial disability due to "this foot" at this time. In a January 2012 evaluation report from the same October 2006 private podiatrist, the podiatrist echoed the determinations he made in his October 2006 evaluation report. Significantly, the podiatrist indicated that radiographic imaging showed increasing interval changes and malposition of the right foot. The podiatrist again opined that the Veteran's condition which was unilateral and only in one foot, which was typically caused by a previous injury to the posterior tibial tendon. He again indicated that any activity in the past which could have caused him strain on his foot (walking, climbing, carrying items) would have aggravated and worsened his condition as well as instigated it. The podiatrist opined that the Veteran had end stage posterior tibial tendon dysfunction with secondary degenerative changes and had service related aggravation to this condition. In May 2017 the same private podiatrist indicated that MRI studies showed a tear on the posterior tibial tendon with additional chronic tendinitis which the Veteran tied to injury during service and worsening from service activities. It was the podiatrist's opinion that the Veteran's disability with his "right foot" was related to an injury, disease, or event occurring during the Veteran's military service and was aggravated by that service. The podiatrist indicated the MRI demonstrated evidence of this injury. The record also contains a May 2012 VA medical opinion that the Veteran's pes planus condition clearly and unmistakably existed prior to service and was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. In support of this opinion, the examiner noted that the Veteran's initial x- rays in service showed no degenerative changes and that the current changes are the result of the natural progression of the disease. The Board does not find any service x-rays of the Veteran's feet on which the examiner could have based the stated opinion and therefore assigns no probative weight. Moreover, a June 2013 IMO has been associated with the claims file. The independent medical professional opined in June 2013 that it was less likely than not that the Veteran's claimed pes planus condition was aggravated by or aggravated beyond its natural and normal aging process because of military service. Lastly, the record contains a December 2016 VHA opinion wherein the orthopedist opined that it was clear and unmistakable that the disability was not aggravated by service beyond the natural process of the disorder as manifested by the late presentation of about 30 years after the end of his service and that it was clear and unmistakable that that the current foot disability is not the result of aggravation during service. The Board affords greater probative weight to the competent and credible opinions of the private podiatrist who determined that the Veteran's disability with his "right foot" was aggravated by his military service because he examined the Veteran on multiple occasions and was more familiar with Veteran's right pes planus condition. In light of the private opinion and the Veteran's contentions showing a worsening, the presumption of aggravation is applicable. As the evidence is not clear and unmistakable as to whether the Veteran's right pes planus was not aggravated beyond its natural progression during his periods of service from, the Board finds service connection for right pes planus is warranted. B. Left Foot A Report of Medical Examination in March 1967 clinically noted that the Veteran had "low plantar arch." As such, the evidence shows that a foot disability was noted on examination when he was accepted and enrolled into service, and the presumption of soundness on induction as to bilateral pes planus is therefore not applicable. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304 (b). In order for the presumption of aggravation to arise, the evidence must show that there was an increase in the severity of the Veteran's left pes planus during service. His January 1970 Report of Medical Examination at separation indicated normal clinical findings and no further notation of low plantar arch was indicated. STRs were silent for complaints and evidence of increased disability during service. Additionally, in his January 1970 Report of Medical History, the Veteran reported being in good health and that he never had nor did he now have foot trouble or bone, joint, or other deformity. In this regard, in a May 2012 VA medical opinion the VA examiner opined that the Veteran's pes planus condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner explained that low arch or pes planus are the same condition and it is a structural condition that is not influenced by activity on feet. In an opinion regarding the conflicting medical evidence, the examiner indicated she reviewed the conflicting medical evidence and opined that no degenerative changes were noted on initial x-rays when the Veteran was in service and the current changes were a natural progression. As the Board does not find any in-service x-rays of the Veteran's feet on which the examiner could have based the stated opinion, no probative weight is afforded. An independent medical professional opined in June 2013 that it was less likely than not that the Veteran's claimed pes planus condition was aggravated by or aggravated beyond its natural and normal aging process because of military service. See June 2013 IMO. She explained that March 1967 enlistment papers stated that the low-arch was non-symptomatic. The Veteran's separation papers dated in January 1970 did not indicate a low plantar arch condition problem related to this structural condition, bilateral. Lastly, in a December 2016 VHA opinion, the VHA orthopedist stated that a low plantar arch or flatfoot did not necessarily equate with foot problems. Moreover, the pain associated with a flat foot is not from the foot bony alignment but rather putting the posterior tibialis tendon and spring ligament at a mechanical disadvantage and thereby caused these structures to tear which became painful. Once the pain starts, it typically does not go away without treatment (bracing or surgery) and it is difficult to function without treatment. While the Veteran most likely had flatfoot alignment all of his life (certainly before service as documented), it does not mean he had real pathology (tendon or ligament damage). Participating in military service could increase the stress on a flatfoot and cause tendon or ligament damage but so could activities of daily living as well as aging. The VHA orthopedist indicated that he saw no conclusive evidence that the Veteran's service aggravated his foot condition. The VHA orthopedist opined that it was clear and unmistakable that the deformity preexisted service but it was "not" clear and unmistakable that the "disability" preexisted service. He indicated that from the records, there was no disability until 2002/2003. The deformity and disability from the deformity are two entirely different issues and should be treated as such. The VHA orthopedist opined that it was clear and unmistakable that the disability was not aggravated by service beyond the natural process of the disorder as manifested by the late presentation of about 30 years after the end of his service. The VHA orthopedist opined that it was clear and unmistakable that that the current foot disability is not the result of aggravation during service. If it was, there would have been pain and difficulty performing service-related issues and this should have been documented in the records and would have advanced much faster, requiring treatment sooner than 2002/2003. The Board has considered the Veteran's arguments that: (1) shortly after beginning his basis training his feet starting hurting; (2) intense physical training and marching up and down mountains left him in great pain and his footwear provide no support; (3) while in Vietnam he wore jungle boots and had duties of going out on patrol and walking for miles per day which increased his foot pain significantly; (4) in his position as s stock clerk he did a lot of heavy lifting and was on his feet a lot which put strain on his feet; (5) his pain has continued since service. See June 2017 Correspondence. The Board has also considered the other lay statements of record from the Veteran, his former co-workers, his former supervisors, and his family members describing the Veteran's symptoms and relating his pes planus to military service. In an April 2007 Buddy/Lay Statement the Veteran's son described seeing the Veteran have foot problems since he was a child. He indicated that the Veteran wore plates in shoes and walked with a limp that worsened over time. The Veteran's mother-in-law indicated in an April 2007 Buddy/Lay Statement that throughout the years she witnessed her son-in-law walk with a limp that the Veteran attributed to his foot pain. In an April 2007 Buddy/Lay Statement, the Veteran's wife described his foot problems as starting out as a limp that has worsened over the years. The Veteran's former co-workers submitted April and May 2007 Buddy/ Lay Statements wherein they indicated the Veteran suffered foot pain and missed work for medical treatment. The Veteran's former supervisor provided a May 2007 Buddy/Lay Statement wherein she described the Veteran as having awkward gait, increased rest breaks, and animated walking to ease his foot pain. The Board finds that the Veteran's contentions and other lay statements of record are of sufficient credibility such that the presumption of aggravation is applicable. Thus, the question is whether there is clear and unmistakable evidence that no aggravation occurred beyond the natural progress of the disorder. While the medical evidence is persuasive, it is not so persuasive as to rise to the level of clear and unmistakable evidence of no aggravation. For this reason, the Board finds service connection for left pes planus is warranted. ORDER Service connection for right pes planus is granted. Service connection for left pes planus is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs