Citation Nr: 1754558 Decision Date: 11/29/17 Archive Date: 12/07/17 DOCKET NO. 16-07 839 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Whether new and material evidence has been received to reopen the claim for entitlement to service connection for a lung disability (claimed as bronchitis). 2. Entitlement to service connection for a lung disability, to include chronic obstructive pulmonary disease, to include as secondary to service-connected dermatophytosis. 3. Whether new and material evidence has been received to reopen the claim for entitlement to service connection for atrial fibrillation (a heart disability). 4. Entitlement to service connection for a disability manifested by headaches. 5. Entitlement to service connection for a bilateral knee disability. 6. Entitlement to service connection for a bilateral hip disability. 7. Entitlement to service connection for a low back disability. 8. Entitlement to service connection for a neck disability. 9. Entitlement to service connection for tinnitus. 10. Entitlement to service connection for obstructive sleep apnea. 11. Entitlement to service connection for an acquired psychiatric disability, to include anxiety and depression, as secondary to service-connected dermatophytosis. REPRESENTATION Veteran represented by: J. Michael Woods, Attorney ATTORNEY FOR THE BOARD R. Scarduzio, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1952 to October 1953. This matter comes before the Board of Veterans' Appeals (Board) from October 2013 and February 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Board has expanded the Veteran's claim for service connection to include consideration of whether service connection is warranted for any acquired psychiatric disability. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issues of entitlement to service connection for a lung disability and the reopening of service connection for a heart disability are addressed in the REMAND portion of the decision below, and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. An August 1985 rating decision denied the Veteran's claim for entitlement to service connection for a lung disability; the Veteran did not appeal that decision in a timely manner and no new and material evidence was submitted within one year of the rating decision. 2. The evidence added to the record since the August 1985 rating decision is not cumulative or redundant of the evidence previously of record and relates to unestablished facts necessary to substantiate the claims of entitlement to service connection for a lung disability. 3. The evidence is against a finding that the Veteran has a current headache disability that was caused or aggravated by military service. 4. The evidence is against a finding that the Veteran has a current bilateral knee disability that was caused or aggravated by military service. 5. The evidence is against a finding that the Veteran has a current bilateral hip disability that was caused or aggravated by military service. 6. The evidence is against a finding that the Veteran has a current low back disability that was caused or aggravated by military service. 7. The evidence is against a finding that the Veteran has a current neck disability that was caused or aggravated by military service. 8. The evidence is against a finding that the Veteran has tinnitus that was caused or aggravated by military service. 9. The evidence is against a finding that the Veteran's obstructive sleep apnea was caused or aggravated by military service. 10. The Veteran's depressive disorder was aggravated by his service-connected dermatophytosis. CONCLUSIONS OF LAW 1. The August 1985 rating decision is final. 38 U.S.C. § 4005(c) (1982); 38 C.F.R. §§ 3.104, 19.129, 19.192 (1985); currently, 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). 2. New and material evidence has been received to reopen the claim of entitlement to service connection for a lung disability. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The criteria for service connection for a disability manifested by headaches have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 4. The criteria for service connection for a bilateral knee disability have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 5. The criteria for service connection for a bilateral hip disability have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 6. The criteria for service connection for a low back disability have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 7. The criteria for service connection for a neck disability have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 8. The criteria for service connection for tinnitus have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 9. The criteria for service connection for obstructive sleep apnea have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 10. The criteria for service connection for depressive disorder on the basis of aggravation by a service-connected disability have been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). I. New and Material Evidence - Lung Disability Generally, if a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108 (2012). New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2017). The threshold to reopen the claim is low. See Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of evidence is presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Veteran has asserted throughout his various appeals related to this issue, that he suffers from what he originally claimed as a bronchial condition as a result of a service-connected disability of the left foot. The record reflects that the Veteran was treated in-service for a fungal infection after stepping on some coral in the United States Navy. It is the Veteran's contention that this fungal infection has resulted in a lung disability. Upon VA examination in June 1985, while no fungal infection was found, an X-ray report of the lungs indicated a large mass lesion in the upper segment of the right lobe. The examiner noted a 1976 surgery on the Veteran's right lung to remove a cyst of unknown etiology. In August 1985, the Veteran's claim was denied by the RO, finding insufficient evidence to establish that the lung disability was related to the Veteran's military service, as service treatment records were silent for a lung or bronchial condition. The Veteran did not appeal the August 1985 rating decision or submit material evidence within one year of the notification of the decision. Therefore, the decision is final. See 38 U.S.C. § 4005(c) (1982); 38 C.F.R. §§ 3.104, 19.129, 19.192 (1985); currently, 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). The evidence received since the August 1985 rating decision includes evidence that is both new and material to the claims. See 38 C.F.R. § 3.156. Specifically, although the Veteran's more recent VA and private treatment records no longer reference or contain treatment for the June 1985 diagnosis of a mass lesion in the upper segment of the right lobe, recent VA treatment records do indicate a diagnosis of chronic obstructive pulmonary disease (COPD). Treatment and surgical records pertaining to the Veteran's 1976 lung surgery, which were not previously of record, have also been submitted. Additionally, the Veteran has asserted the alternative theory that his disability was caused or aggravated by his service-connected fungal infection of the feet. The new evidence raises a reasonable possibility of substantiating the claim as it addresses a possible link between the Veteran's disability and service, and therefore addresses one of the reasons for the previous denial. Such evidence is presumed credible solely for the purpose of determining whether new and material evidence has been submitted. See Justus, 3 Vet. App. at 513. Accordingly, the claim for service connection for a lung disability, to now include as secondary to service connected dermaphytosis, is reopened. In evaluating the evidence and rendering a decision on the merits, the Board is required to assess the credibility and probative value of proffered evidence in the context of the record as a whole, and the Justus presumption of credibility no longer attaches. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Thus, evidence that is sufficient to reopen a claim may not be sufficient to grant the benefit being sought. See generally Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). As explained in the REMAND section below, the Board has determined that additional development is necessary before the merits of the Veteran's claim for service connection for a lung disability can be addressed. II. Service Connection Service connection will be granted on a direct basis if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303(a) (2017). 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 claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may 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. 38 C.F.R. § 3.303(d). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board must assess the credibility and weight of all the 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. See Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Additionally, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Further, it is the Board's responsibility to evaluate the entire record on appeal. 38 U.S.C. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Headaches, Bilateral Knee, Bilateral Hip, Low Back, Neck, and Tinnitus The Veteran has asserted that he currently suffers from headache, bilateral knee, bilateral hip, low back, and neck disabilities, as well as tinnitus. However, the evidence is negative for any treatment records indicating that he has such disabilities for service connection purposes. While the Veteran's VA treatment records list a history of degenerative joint disease, no specific joint disability is ever indicated. The Board notes that the Veteran does have a history of problems with pain in his feet, including neuropathy. Multiple treatment records dated throughout the course of the appeal note normal extremities (with the exception of the Veteran's feet), with no swollen joints or limitation of motion. The record also reflects no general complaints of musculoskeletal problems, including back or neck pain, nor do they indicate a complaint, treatment, or history of tinnitus or a disability manifesting as headaches. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. § 1131. In the absence of proof of a current diagnose of the claimed disabilities, service connection for those disabilities cannot be established. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Veteran has been afforded the opportunity to submit evidence in support of his claim. The Board emphasizes that the duty to assist is a two-way street. If the Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the relevant evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Veteran has not identified any specific outstanding records that indicate he has the above disabilities for which he is claiming service connection. The Board acknowledges the Veteran's lay assertions regarding the existence of these disabilities. However, the statements do not establish any current disability. The Veteran, as a lay person, has not shown that he has specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, a diagnosis of a disability causing headaches, as well as knee, hip, back, and neck disabilities are not capable of lay observation, and require medical expertise to determine. Accordingly, an opinion by the Veteran as to diagnosis of any of the above disabilities is not competent medical evidence. While tinnitus is a condition that can be observed by a lay person, in this case the Veteran has not relayed that he experiences any of the symptomatology of tinnitus and has instead simply put in a claim for benefits for tinnitus. In addition, the problem list in his medical records does not include tinnitus. Simply put, none of the lay or medical evidence actually identifies symptomatology that could reasonably be found to represent a diagnosis of tinnitus. Without competent evidence of symptomology related to tinnitus, a disability manifesting in headaches, or knee, hip, back, and neck disabilities, the preponderance of the evidence is against the Veteran's claims for service connection. Obstructive Sleep Apnea VA treatment records reflect that the Veteran has a current diagnosis of obstructive sleep apnea. The Veteran contends that his sleep apnea is related to service, without clear explanation of the basis of his belief. Upon review of all the evidence of record, lay and medical, the Board finds that service connection is not warranted. Service treatment records and in-service medical examinations are negative for any treatment or complaints of symptoms of a sleep disorder or sleep apnea. A diagnosis of sleep apnea does not appear in the Veteran's treatment records until 2013, five decades after his release from active service. The Board has considered the Veteran's lay statements regarding his belief that his sleep apnea is related to service. As a lay person, however, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex disorder of obstructive sleep apnea. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service). Sleep apnea is a medically complex disease process because of its multiple possible etiologies, requires specialized testing to diagnose (such as with a sleep study), and manifests symptomatology that may overlap with other disorders. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a condition capable of lay diagnosis). The etiology of the Veteran's current sleep apnea is a complex medical question involving internal and unseen system processes unobservable by the Veteran. Simply put, there is no competent and probative evidence suggesting that the Veteran has sleep apnea that is related to his service. Given the foregoing, the Board finds that the preponderance of the evidence is against the claim for service connection for sleep apnea, and the claim must be denied. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 55-57. Acquired Psychiatric Disorder The Veteran also seeks service connection for an acquired psychiatric disorder. For the reasons that follow, the Board finds that service connection is warranted. The Board notes that the Veteran's private and VA treatment records note diagnoses of depression and anxiety. In June 2013, the Veteran submitted a statement from his private physician, Dr. B.F., indicating he was being treated with Bupropion (an antidepressant). The Veteran was afforded a VA examination in August 2013 to address his assertion that he was suffering from depression as due to his declining health, specifically his service-connected foot disabilities. The Veteran reported anxiety and that he first noticed depression after returning from service. It was noted that the Veteran was agitated at times during the interview. The examiner also noted that the Veteran was not taking antidepressants, but rather Lorazepam for anxiety. The examiner diagnosed the Veteran with anxiety disorder, manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The examiner did not, however, diagnose the Veteran with depression. The examiner opined that the Veteran did not describe symptoms consistent with depressive disorder, and that his agitation was more likely due to his declining physical stamina and apparent cognitive confusion. As such, the examiner was not able to attribute the Veteran's symptoms with his in-service fungal infection, stating that it would be resorting to mere speculation, and it was therefore less likely than not that the Veteran's claimed condition was proximately due to or the result of his service-connected disability. The Board notes that no reference was made to the Veteran's private treatment for depression or the June 2013 statement of his private physician that he was being treated with daily doses of Bupropion, an antidepressant. Although the VA examiner opined in the negative, the Board notes that there is also favorable evidence in support of the Veteran's claim. The Veteran submitted a "buddy statement" from his spouse dated March 2015. Mrs. [REDACTED] stated the Veteran was healthy, happy, enjoyed working, and was "full of life" prior to his military service. Upon return from service, however, Mrs. [REDACTED] stated that the Veteran was nervous, had difficulty adjusting to life, and lacked motivation. She asserted that the limitations of his foot disabilities affected his mood and made him irritable, thus affecting his employment. She also stated that, presently, the Veteran is anxious and "lies around all day." The Veteran also submitted the August 2015 opinion of a private psychologist, who also completed an examination and VA disability benefits questionnaire (DBQ) in conjunction with the opinion. The psychologist did diagnose the Veteran with unspecified depressive disorder, manifested by occupational and social impairment with deficiencies in most areas. The Veteran was noted as socially isolated and withdrawn, with symptoms such as depressed mood, chronic sleep impairment, flattened affect, disturbances of motivation or mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances. After examination of the Veteran and review of his claims file and medical history, as well as citing several medical journal articles pertaining to the relationship between medical issues and psychiatric disorders, the psychologist opined that the Veteran suffered from an unspecified depressive disorder that was aggravated by his service connected foot disabilities, noting a causal relationship between medical and psychiatric difficulty. The psychologist explained that individuals with medical issues and depressive disorder debilitation can become disabled due to the holistic effect of medical and psychiatric disturbances, just as Veteran's service-connected dermatophytosis and depressive disorder renders him incapacitated. Based on the foregoing, the Board finds the probative evidence is in favor of the Veteran's claim. While the August 2013 VA examiner provided a negative opinion, the Board finds the opinion is of less probative value than that of the August 2015 private medical opinion. While finding that the Veteran had only a diagnosis of anxiety, the VA examiner failed to address the Veteran's private treatment for depression and treatment with an antidepressant. The examiner also could not provide an appropriate nexus opinion as it would be resorting to mere speculation. The Veteran's private psychologist, however, considered all the evidence of record, including the Veteran's lay statements and private treatment for depression, addressed the appropriate legal standard, and provided an adequate rationale for her opinion. The Board acknowledges that the Veteran failed to report for an additional VA examination for his claim in October 2016. In this case, however, the remaining evidence of record is adequate to allow the Board to decide the claim, and any additional examination is unnecessary. The Board further recognizes that the private psychologist also opined that the Veteran's depressive disorder is directly related to service; however, this opinion and the lay statements of symptoms continuing since service are in direct conflict with the normal psychiatric evaluation reported at the Veteran's separation examination. The separation examination findings are given more probative weight at they were made by a medical professional based on input from the Veteran at the time he was actually serving and not years after the fact. Thus, service connection on a direct basis is not warranted. Accordingly, and resolving all reasonable doubt in favor of the Veteran, service connection is warranted on the basis of aggravation of a depressive disorder by service-connected dermatophytosis. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 53-56. ORDER New and material evidence has been received to reopen the claim of entitlement to service connection for a lung disability and, to that extent only, the appeal is granted. Entitlement to service connection for a disability manifested by headaches is denied. Entitlement to service connection for a bilateral knee disability is denied. Entitlement to service connection for a bilateral hip disability is denied. Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a neck disability is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for obstructive sleep apnea is denied. Entitlement to service connection for depressive disorder is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND While the Board regrets additional delay, since it has reopened the service connection claim for a lung disability, additional information is needed before deciding the claim. The Veteran asserts that a lung disability, to include his currently diagnosed COPD and the 1985 assessed moderate obstructive defect with mass lesion, is secondary to his service-connected fungal infection of the feet. Specifically, the Veteran has submitted several statements that he believes his fungal infection, which began as "jungle rot" when he stepped on coral while on active duty in the United States Navy, has caused a lifetime of medical problems, including his 1976 lung surgery and his current COPD. As this theory of secondary service connection has yet to be explored by any VA examiner, a VA examination and opinion is necessary before the claim is adjudicated. See McLendon, 20 Vet. App. 79. In addition, with respect to the issue of reopening the service connection claim for a heart disability, the Veteran's original claim asserted that private physicians informed him that his heart disability was secondary to his lung disability. The Board notes that VA treatment records reflect current diagnoses of atrial fibrillation, cardiomyopathy, and congestive heart failure. In November 2001, the Veteran's service connection claim was denied by the RO, finding insufficient evidence to establish that the disability was related to the Veteran's military service. Additionally, since the Veteran was not service connected for a lung disability at the time, the claim was also denied on the theory of secondary service connection. As such, the Board finds that the issue of reopening a claim of service connection for a heart disability is inextricably intertwined with the remanded claim for service connection for a lung disability because a hypothetical grant of the latter service connection claim could significantly change the adjudication of the issue of reopening of service connection for a heart disability. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a veteran's claim for the second issue). Consideration of the issue of reopening service connection for a heart disability must, therefore, be deferred until the intertwined issues are either resolved or are prepared for appellate consideration. Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Ask the Veteran to identify any outstanding treatment records relevant to his claims for service connection. All identified VA records should be added to the claims file, to include any additional treatment records dated since October 2015. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of any lung disability. All indicated tests and studies are to be performed. The claims folder should be made available to the examiner and a detailed history should be obtained. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion regarding the following: a) Whether the Veteran has a current lung disability that at least as likely as not (50 percent or greater probability) had its onset during or is otherwise related to the Veteran's military service, to include his in-service fungal infection. b) Whether it is at least as likely as not (50 percent probability or greater) that a lung disability was (i) caused by or (ii) aggravated (i.e., worsened beyond its natural progression) by his service-connected dermatophytosis. A rationale for all opinions expressed should be provided. 3. After completing the above actions, and any other development deemed necessary, the AOJ should readjudicate the claims on appeal, including the claim to reopen service connection for a heart disability. If any benefit sought on appeal remains denied, a supplemental statement of the case must be provided to the Veteran. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ Nathan Kroes Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs