Citation Nr: 1801923 Decision Date: 01/10/18 Archive Date: 01/23/18 DOCKET NO. 09-37 906 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jonathan M. Estes, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1969 to April 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in March 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. In May 2011, the Veteran testified at a Board video-conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In October 2011, the Board remanded the instant matter for additional development. Thereafter, in a November 2014 decision, the Board, as relevant, denied the Veteran's claim for service connection for an acquired psychiatric disorder, to include PTSD. He appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In February 2016, the Veteran and the Secretary of VA (the parties) filed a Joint Motion for Partial Remand (JMPR). Later that month, the Court granted the motion, and vacated and remanded the November 2014 Board decision to the extent that it denied service connection for an acquired psychiatric disorder, to include PTSD. Consequently, in July 2016 and May 2017, the Board remanded the case to address the concerns noted in the JMPR. The case now returns to the Board for further appellate review. FINDINGS OF FACT 1. Prior to and during the pendency of the claim, the Veteran does not have a current diagnosis of an acquired psychiatric disorder, to include PTSD, other than alcohol dependence. 2. Service connection may not be granted for alcohol dependence on the basis of service incurrence or aggravation as a matter of law. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder, to include PTSD, have not been met. 38 U.S.C. §§ 105, 1101, 1110, 1112, 1116, 5107 (2012); 38 C.F.R. §§ 3.102, 3.301, 3.303, 3.304, 3.307, 3.309, 4.125 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Further, neither the Veteran nor his representative has alleged any deficiency with respect to VA's duties to notify or assist. See Scott, supra (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 duty to assist argument). II. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). Additionally, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, to include psychoses, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§1101, 1112; 38 C.F.R. §§3.307, 3.309. Psychoses include brief psychotic disorder, delusional disorder, psychotic disorder due to general medical condition, psychotic disorder not otherwise specified (NOS), schizoaffective disorder, schizophrenia, schizophreniform disorder, shared psychotic disorder and substance-induced psychotic disorder. 38 C.F.R. § 3.384 (2014). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, as discussed below, as the Veteran does not have diagnoses of psychoses, service connection on a presumptive basis, to include based on a continuity of symptomatology, is not warranted. The Board notes that the Veteran served in Vietnam from April 1970 to April 1971. Therefore, he is presumed to have been exposed to herbicide agents coincident with such service. In this regard, VA regulations provide that a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975 shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. See 38 C.F.R. §§ 3.307(a)(6)(iii); see also VAOPGCPREC 7-93. The presumptions for diseases related to herbicide exposure are codified in 38 U.S.C. § 1116 and 38 C.F.R. §§ 3.307 and 3.309, based on an analysis of scientific evidence. However, the presumption only exists for those diseases listed in 38 C.F.R. §§ 3.307 and 3.309(e) and psychiatric disorders are not included as a presumptive diseases. Should service connection not be warranted under a presumptive basis, direct service connection can be established by showing that the disease or malady was otherwise incurred during or aggravated by service. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In addition to the general laws and regulations pertaining to service connection, service connection for PTSD requires in particular, medical evidence diagnosing the condition; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). For cases certified to the Board prior to August 4, 2014 (such as the Veteran's), the diagnosis of PTSD must be in accordance with the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV). 38 C.F.R. § 4.125(a) (2013); Schedule for Rating Disabilities-Mental Disorders and Definition of Psychosis for Certain VA Purposes, 79 Fed. Reg. 45,093 (Aug, 4, 2014) (Applicability Date) (updating 38 C.F.R. § 4.125 to reference DSM-V). If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(2). VA's General Counsel has held in a precedent opinion that "the ordinary meaning of the phrase 'engaged in combat with the enemy,' as used in 38 U.S.C.A. § 1154(b), requires that a veteran participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality." The determination as to whether evidence establishes that a veteran engaged in combat with the enemy must be resolved on a case-by- case basis with evaluation of all pertinent evidence and assessment of the credibility, probative value, and relative weight of the evidence. VAOGCPREC 12-99 (Oct. 18, 1999). When the claimed stressor is not related to combat, the veteran's lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor. Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). In such cases, the record must contain service records or other corroborative evidence that substantiates the veteran's testimony or statements as to the occurrence of the claimed stressors. See West (Carlton) v. Brown, 7 Vet. App. 70, 76 (1994); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). However, in July 2010, the evidentiary standard outlined in 38 C.F.R. § 3.304(f)(3) for establishing in-service stressors in claims for PTSD was relaxed. The new regulations provide that if a stressor claimed by a veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 75 Fed. Reg. 39,843, 39,852 (July 13, 2010); 38 C.F.R. § 3.304(f)(3). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). At his Board hearing and in documents of record, the Veteran alleges that he has an acquired psychiatric disorder, to include PTSD, that is directly related to his military service, to include his time in Vietnam. In this regard, he claims that, during such service, he was in imminent fear for his life and was cognizant that he was brought there as a replacement for military members who were killed or were sent home. He stated that, on his first day in Vietnam, he was talking to a Sergeant who was killed later that same day. He also testified that he was a direct target since his military occupational specialty was artillery. Therefore, the Veteran alleges that such experiences ultimately resulted in an acquired psychiatric disorder. However, the Board finds that service connection for an acquired psychiatric disorder is not warranted as, prior to and during the pendency of the claim, the competent and probative evidence of record fails to establish that the Veteran has a current diagnosis of an acquired psychiatric disorder, to include PTSD, other than alcohol dependence. Moreover, service connection may not be granted for alcohol dependence on the basis of service incurrence or aggravation as a matter of law. In this regard, the Board finds that, while the Veteran's private physicians have diagnosed PTSD, such diagnoses are accorded less probative weight than the November 2011, August 2016, and May 2017 VA opinions that determined the Veteran did not meet the criterion for such a diagnosis. Additionally, the August 2016 and May 2017 opinions refute the validity of the earlier PTSD diagnoses. In this regard, in a July 2008 letter, Dr. Edwards, D. Min., stated he had "provided individual counseling to [the Veteran] for issues relating to his experience during the Viet[n]am Era." He included an Axis I PTSD diagnosis. A June 2009 diagnostic slip from Dr. L'Herisson, Ph.D., indicates an Axis I diagnosis of 309.81, which correlates to PTSD in the DSM-IV. Similarly, in September 2009, Dr. L'Herisson reported that the Veteran called in May 2009 to schedule his first appointment for June 2009 and presented as "nervousness and stressful" as initial symptoms for PTSD. He then attended five counseling sessions. The Veteran reported that when he was a radio transmitter operator for light artillery he was given the wrong coordinates and he believes they shot in the wrong direction and he wonders what happened. The Veteran further reported that he missed a sergeant who was kind to him and who was killed in a helicopter that was shot down. Dr. L'Herisson noted the Veteran's family and work life. She assigned an Axis I diagnosis of 309.81 (PTSD) "per [the Veteran's] initial phone call." It was stated that the Veteran hoped to be given full consideration for treatment for PTSD and any complications resulting from his war experiences. In February 2012, Dr. Edwards stated that the Veteran had six counseling sessions with him, but the notes had been misplaced or lost. His statements consist of what he could recollect from the sessions. He related that the Veteran reported that his experiences in the Republic of Vietnam were affecting his marriage and he was having difficulty with co-workers. He also had nightmares and sleep issues. Dr. Edwards stated that it was more than likely that the Veteran had "severe PTSD as a direct result from his experience in a war zone while serving in the United States Army during the Viet[n]am Era." In contrast, the November 2011, August 2016, and May 2017 VA opinions did not diagnose PTSD, but instead noted alcohol dependence (2011) and a phase of life problem (2016). Further, the August 2016 and May 2017 opinions refute the validity of the earlier diagnoses of PTSD. In this regard, the November 2011 VA examiner addressed each criterion needed for a diagnosis for PTSD as defined in the DSM-IV. Specifically, a diagnosis of PTSD in accordance with the DSM-IV requires that 6 criteria be met. Criterion A addresses the nature of the traumatic event; criterion B addresses re-experiencing the event; criterion C addresses avoidance of stimuli associated with the event and numbing of general responsiveness; criterion D addresses persistent symptoms of increased arousal; criterion E addresses the duration of the disturbance (symptoms in criteria B, C, and D), and criterion F requires that the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Relevant to criterion A, the examiner determined that the Veteran was exposed to a traumatic event where both of the following was present: the Veteran experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and the Veteran's response involved intense fear, helplessness, or horror. For criterion B, the examiner found that the traumatic event was persistently re-experienced by recurrent distressing dreams of the event or intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. However, the examiner found that the Veteran did not meet criterion C because there was no persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness. Similarly, for criterion D, while the Veteran needed two or more persistent symptoms of increased arousal, not present before the trauma, the Veteran only had one, exaggerated startle response. Relevant to Criterion E and F, as the examiner determined that the Veteran did not meet the criteria for a diagnosis of PTSD, he did not address the duration or severity of the symptoms. Based on the foregoing, the VA examiner concluded that the Veteran did not presently meet the criteria for a diagnosis of PTSD, nor was there clinical presentation consistent with sub-threshold PTSD. Specifically, she stated that the Veteran reported one criterion A stressor during military service involving fear of hostile military/terrorist activity: his constant fear of death in multiple firefights at night. In addition, the Veteran endorsed nightmares and psychological reactivity related to this criterion A stressor and he indicated experiencing an exaggerated startled response. However, the Veteran did not endorse any persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness. The examiner stated that the Veteran did not witness the death of his sergeant and this reported in-service stressor did not meet criterion A for PTSD. She also stated that the October 2011 Board remand specifically asked about the incident where the Veteran may have relayed the wrong coordinates to his gunners but she stated that the Veteran did not report PTSD symptoms related to this experience. The examiner also stated that it was "possible that the Veteran's diagnostic presentation may change in the future depending on stressors and resources." Furthermore, she only commented on whether the Veteran currently met the criteria for a diagnosis of PTSD, and did not address the prior diagnoses of PTSD rendered by the Veteran's private treatment providers. Therefore, the Veteran was afforded another VA examination in August 2016. At such time, the examiner did not diagnose the Veteran with an acquired psychiatric disorder, including PTSD; rather, she only noted that the Veteran had a phase of life problem. The examiner acknowledged that the Veteran did incur fear of hostile military activity in Vietnam, which was very stressful, but that he did not have significant sequela as a result, nor any social or occupational impairment. Furthermore, the examiner explained that the Veteran had a phase of life problem, which she noted was not a mental disorder, due to his retirement and declining health in which he was having a hard time finding meaning or purpose in daily activities, and that it was not related to his service. The examiner also addressed the Veteran's mental history throughout the period on appeal, including his prior PTSD diagnoses. The examiner stated that her evaluation matched the November 2011 examination that did not find PTSD. She found that the objective evidence of no treatment history or documented complaints, other than from the private providers, and no occupational or social impairment, yielded no support for a PTSD diagnosis at any time during the appeal period. With regard to the previous medical records that noted that the Veteran met the criteria for a diagnosis of PTSD, the examiner opined that such diagnoses were inaccurate. Specifically, she noted that Dr. Edwards, who provided the July 2008 and February 2012 diagnoses of PTSD, was a ministry counselor and not a licensed psychologist or other mental health professional. She further noted that Dr. Edwards provided the diagnosis from recollection of the Veteran's case since he had lost his records from when he saw the Veteran for 6 sessions and that he did not provide a rationale or documentation of all the symptoms met and related impairment to support such diagnosis. In regard to Dr. L'Herisson, who provided the September 2009 diagnosis, the examiner noted that she also failed to provide symptoms and related impairment to support her diagnosis; rather, she just described the traumatic stressors and stated that the Veteran had a diagnosis of PTSD. Furthermore, in support of her finding that the Veteran did not meet the criteria for PTSD at the time of the examination, or at any time, the examiner explained that the objective evidence of no treatment history or documented complaints, other than from the aforementioned private providers, and no occupational or social impairment, yielded no support for a PTSD diagnosis. As the August 2016 VA examiner used the DSM-5, rather than the DSM-IV, criteria in evaluating the Veteran, the Board remanded the matter in order to obtain an addendum opinion as to whether the Veteran had a diagnosis pursuant to the DSM-IV related to his military service. In May 2017, the examiner provided an addendum opinion, which reaffirmed that the Veteran did not meet the criteria for a diagnosis of PTSD under the DSM-IV. She again noted his previous diagnoses of PTSD, but reiterated that she was not satisfied with the authenticity of the examiners' diagnostic conclusions for the reasons she articulated in her August 2016 opinion. She again noted the previous diagnosis of alcohol dependence, and explained that the Veteran's current phase of life problem is neither a mental disorder nor related to his service. The Board accords great probative weight to the November 2011, August 2016, and May 2017 VA examiners' opinions that the Veteran does not meet the diagnostic criteria for a diagnosis of PTSD at any point pertinent to the appeal. In this regard, while the November 2011 VA examiner only addressed whether the Veteran met the diagnostic criteria for PTSD at the time he was examined, the August 2016/May 2017 VA examiner considered whether the Veteran met the criteria for such a diagnosis under the DSM-IV and DSM-5 at any point pertinent to the appeal. Furthermore, the latter examiner fully addressed the validity of the diagnoses of PTSD rendered by the Veteran's private treatment providers. In offering such opinions, the examiners offered a clear conclusion with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). In contrast, the Board accords no probative weight to private treatment providers' diagnoses of PTSD rendered in June 2008, September 2009, and February 2012. In this regard, are conclusory and did not identify how each criterion necessary for such a diagnosis were met. the Board observes that if a Veteran has received a diagnosis of PTSD from a competent medical professional, VA must assume that the diagnosis was made in accordance with the appropriate psychiatric criteria in regard to the adequacy of the symptomatology and the sufficiency of the stressor. Cohen v. Brown, 10 Vet. App. 128, 153 (1997). VA can only reject such a diagnosis on a finding that the preponderance of the evidence is against (1) the PTSD diagnosis, (2) the occurrence of the in-service stressor, or (3) the connection of the current condition to the in-service stressor. The adequacy of a stressor, sufficiency of symptomatology, and diagnosis are all medical determinations. Cohen, 143-44. In this instance, the Board finds that PTSD diagnoses rendered by the Veteran's private treatment providers are not probative. Specifically, such private diagnoses include only a brief discussion of the circumstances of the Veteran's Vietnam service and a conclusory finding of a PTSD diagnosis without a complete discussion of how each criterion was met. In this regard, a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Further, in regard to the Veteran's representative's argument that his private treatment providers' diagnoses should be afforded great probative weight in light of their treatment of the Veteran, the Board notes that the Court has also expressly declined to adopt a "treating physician rule" which would afford greater weight to the opinion of a Veteran's treating physician over the opinion of a VA or other physician. See Guerrieri v. Brown, 4 Vet. App. 467, 471-73 (1993). Moreover, as discussed above, the August 2016/May 2017 VA examiner specifically addressed the validity of such prior diagnoses and determined that they were inaccurate. Furthermore, while the Veteran is competent to describe his in-service experiences and his current symptomatology, he is not competent to render a diagnosis of an acquired psychiatric disorder as medical expertise is required. In this regard, the question of a psychiatric diagnosis involves a medical subject beyond an immediately observable cause-and-effect relationship. Specifically, it requires knowledge of the impact of witnessing traumatic events on the psyche and must be made in conformance with the DSM-IV. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, the Board finds that the only probative evidence addressing whether the Veteran has a current diagnosis of an acquired psychiatric disorder are the November 2011, August 2016, and May 2017 VA opinions, which found that the Veteran did not have an Axis I diagnosis other than alcohol dependence. Pertinent to a claim for service connection, such a determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the Court held that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. Additionally, any diagnosis prior to the time of appeal must be considered as relevant evidence in the Board's decision. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; see also Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that a symptom, without a diagnosed or identifiable underlying malady or condition, does not, in and of itself, constitute a "disability" for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), vacated in part and remanded on other grounds sub. nom. Sanchez-Benitez v. Principi, 239 F. 3d 1356 (Fed. Cir. 2001). In the instant case, the probative evidence of record fails to demonstrate a current diagnosis of an acquired psychiatric disorder, to include PTSD, other than alcohol dependence at any point during the pendency of the claim. While the Board has also considered the Court's holding in Romanowsky, supra, there is also no probative evidence of a recent diagnosis of an acquired psychiatric disorder, to include PTSD, prior to the Veteran's claim. Furthermore, with regard to the diagnosis of alcohol dependence rendered at the November 2011 VA examination, the Board notes that, for claims filed after October 31, 1990, service connection may not be granted for substance abuse on the basis of service incurrence or aggravation. 38 U.S.C. §§ 105, 1110; 38 C.F.R. § 3.301(a); VAOPGCPREC 2-98. However, the law does not preclude a veteran from receiving compensation for an alcohol or drug abuse disability acquired as secondary to, or as a symptom of, a service-connected disability. Allen v. Principi, 237 F.3d 1368 Fed. Cir. 2001). In this case, the Veteran's alcohol dependence has not been related to a service-connected disability. Therefore, service connection cannot be granted for alcohol dependence. For the foregoing reasons, the claim for service connection for an acquired psychiatric disorder, to include PTSD, must be denied. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for an acquired psychiatric disorder, to include PTSD, is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs