Citation Nr: 1803275 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 13-20 355 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for a thoracolumbar spine disability. 2. Entitlement to service connection for degenerative joint disease with ligament derangement, right knee. 3. Entitlement to service connection for degenerative joint disease with ligament derangement, left knee. 4. Entitlement to increased rating for surgical scars, status post left inguinal herniorrhaphy. 5. Entitlement to service connection for an acquired psychiatric disorder to include major depressive disorder or posttraumatic stress disorder (PTSD). 6. Entitlement to service connection for bilateral hearing loss. 7. Entitlement to an initial compensable evaluation for bilateral pulmonary nodules effective June 17, 2010 and an evaluation in excess of 10 percent from August 7, 2014 to December 19, 2016. 8. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to December 19, 2016. REPRESENTATION Veteran represented by: Christopher L. Loiacono, Agent ATTORNEY FOR THE BOARD M. Gonzalez, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1974 to January 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from May 2011 and September 2012 rating decisions from the Department of Veterans (VA) Regional Office (RO) in Milwaukee, Wisconsin. In May 2017, the Veteran testified during a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The Veteran seeks entitlement to service connection for a psychiatric disability. Evidence shows diagnoses of major depressive disorder, generalized anxiety disorder, and PTSD. As such, the Board has characterized the Veteran's claim as entitlement to service connection for an acquired psychiatric disability, to include major depressive disorder or PTSD. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009) (Where the evidence submitted in support of a claim reasonably raises the issue of a related condition, it is error for VA not to consider a claim for the related condition); see also Brokowski v. Shinseki, 23 Vet. App. 79, 86 (2009). A May 2013 rating decision granted service connection for tinnitus and assigned a 10 percent disability rating effective June 7, 2010. As this represents a full grant of the benefit sought, that issue is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). In May 2017 the RO increased the Veterans service-connected bilateral pulmonary nodules to 10 percent effective August 7, 2014 and assigned an evaluation of 100 percent from December 19, 2016. As higher ratings for this disability may be assignable and the claimant is presumed to seek the maximum available benefit, the claims for a higher rating prior to December 19, 2016 remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). As a 100 percent rating is in place for a single disability beginning December 19, 2016, the issue of entitlement to a TDIU beginning that date is moot. As such, the issue has been recharacterized as shown on the title page. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. During his May 9, 2017 Board hearing, prior to the promulgation of a decision in the appeal, the Veteran requested to withdraw the issues of entitlement to service connection for thoracolumbar spine disability, right and left knee degenerative joint disease with ligament derangement, and an increased rating for surgical scars, status post left inguinal herniorrhaphy. 2. The probative, competent evidence supports a finding that the Veteran has a psychiatric disorder related to his active duty service. 3. The probative, competent evidence is against a finding that the Veteran's bilateral hearing loss is related to active duty service. 4. From June 17, 2010 the Veteran's service-connected bilateral pulmonary nodules was manifested by a Forced Vital Capacity (FVC) of 84 and Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of 128; from August 7, 2014 the Veteran's service-connected bilateral pulmonary nodules is best represented by a DLCO of 75.5 percent predicted. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a substantive appeal by the Veteran as to the issues of entitlement to service connection for thoracolumbar spine disability, right and left knee degenerative joint disease with ligament derangement, and an increased rating for surgical scars, status post left inguinal herniorrhaphy have been met. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 2. The criteria for service connection for an acquired psychiatric disorder (diagnosed as major depressive disorder and an anxiety disorder) are met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.125 (2017). 3. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 4. The criteria for a compensable evaluation for bilateral pulmonary nodules effective June 17, 2010 and an evaluation in excess of 10 percent from August 7, 2014 to December 19, 2016, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.96, 4.97, Diagnostic Code 6833 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Withdrawn Issues The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or by his or her authorized representative. Id. In the present case, the Veteran, at his May 2017 Board hearing, withdrew the issues of entitlement to service connection for thoracolumbar spine disability, right and left knee degenerative joint disease with ligament derangement, and an increased rating for surgical scars, status post left inguinal herniorrhaphy; hence, there remain no allegations of errors of fact or law for appellate consideration regarding those issues. Accordingly, the Board does not have jurisdiction to review the appeal as to those issues and they are dismissed. Issues on Appeal 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). Service Connection The Veteran asserts that his psychiatric disability and bilateral hearing loss are related to his active duty service. Generally, to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). A. Psychiatric Disorder During his May 2017 Board hearing the Veteran testified that he witnessed people drowning in service and that he had to recover drowned bodies. He testified that as a result he began to have nightmares in service that he was drowning; he testified that he continues to have such nightmares. Service treatment records reflect that in December 1975 the Veteran was clinically evaluated after being absent without leave (AWOL) twice. The examiner reported that the Veteran had chronic adjustment difficulties since entry into the Coast Guard. On mental status evaluation he reported that the Veteran described transient, episodic, psychotic processes including depersonalization, derealization, thought broadcasting, and confusion. The Veteran had occasional suicidal ideation, but no intent or plan, and abstraction ability was markedly impaired. The examiner diagnosed personality disorder, borderline type, with schizoid features. The Veteran was recommended for administrative separation. At separation the Veteran's psychiatric examination was noted as abnormal and the examiner noted the Veteran had a personality disorder. In September 2012 the RO made a Formal Finding of Stressor Unavailability and determined that the information required to corroborate the stressful events described by the Veteran was insufficient to send to the Joint Service Records Research Center or make a meaningful search of the Marine Corps or National Archive Records Administration. At the February 2011 VA examination the examiner diagnosed major depressive disorder, recurrent, moderate; generalized anxiety disorder; and alcohol abuse. He assigned an overall global assessment of functioning (GAF) score of 60 as representative of moderate symptoms and moderate impairment in functioning as indicated by little social interaction and occupational difficulty. During examination the Veteran reported that problems with depression and anxiety have come up periodically, most recently after losing his job in 2008 and becoming increasingly hampered by bilateral knee pain over the last few years. The examiner opined that it was less likely than not that the Veteran's current diagnoses are related to the mental health diagnosis in service. The examiner explained that based on the evidence and the examiner's experience with clinical evaluations, and since the Veteran specifically reported that his current psychiatric symptoms are directly related to specific, recent stressors in his life such as unemployment, financial worry, and increased health problems, this indicated that the current mental health problems are unrelated to the Veteran's in-service personality disorder from 36 years ago. In September 2014 the Veteran underwent a private neuropsychiatric evaluation. The reviewing treatment provider explained that the Veteran does have mild cognitive dysfunction, major depression, generalized anxiety, but no PTSD. The treatment provider opined that it was at least as likely as not that the Veteran's symptoms of depression and anxiety are related to his service. The treatment provider reported that he did not find any evidence of PTSD associated with the Veteran's time in service. During a June 2017 private psychological evaluation the examiner explained that the Veteran met the clinical criteria for PTSD and major depressive disorder, recurrent, moderate, with anxious distress. The examiner related that the Veteran's current mental health diagnoses are related to the in-service events of pulling dead bodies from the water. He reported that it is evident from the Veteran's testimony and the medical record that the Veteran had no history of mental illness or treatment prior to service; however, after the Veteran experienced traumatic events in service he was diagnosed with mental illness and medically discharged. The examiner explained that in view of the fact that the Veteran has no reported traumatic events that could have contributed to his diagnosis of PTSD and depression since his discharge, it is at least as likely as not that his psychiatric impairment had its onset in service. The evidence of record contains conflicting medical evidence pertaining to whether the Veteran has a current psychiatric disorder related to service. In weighing opinions, the Board has the authority to consider the weight and probative value of evidence in the light of its own inherent characteristics and its relationship to other items of evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In evaluating the probative value of competent medical evidence, the U.S. Court of Appeals for Veterans Claims (Court) has stated that the probative value of a medical opinion is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Further, the credibility and weight attached to these opinions are within the province of the adjudicator. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). As such, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); see also Wensch v. Principi, 15 Vet. App. 362, 367 (2001). All of the examiners diagnosed a current psychiatric disorder relating to depression and anxiety after review of the Veteran's medical history and an in-person examination. The VA examiner only failed to relate the Veteran's in-service personality disorder diagnosis and treatment to his current disability citing recent stressors in his life such as unemployment, financial worry, and increased health problems as the basis for his disorder. While the September 2014 treatment provider did not provide a clear rationale as to why the Veteran's symptoms of depression and anxiety are related to his service, the June 2017 examiner noted that the Veteran was free of mental defects upon entering service, determined that his current psychiatric disorders are a result of his in-service experience dragging bodies from the water, and related that the Veteran had no reported traumatic events that could have contributed to his diagnosis of PTSD (an anxiety disorder) and depression since his discharge; as such he opined it was at least as likely as not that his disabilities are related to service. Thus, the Board finds the February 2011 VA examiner opinion and June 2017 private treatment examiner opinion both supported with reasoned medical explanations and equally probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Accordingly, resolving all doubt in the Veteran's favor, the Board finds that the evidence is at least in equipoise as to whether the Veteran has a current psychiatric diagnosis related to service. B. Hearing Loss The Veteran asserts that noise exposure from firing .45 caliber pistols without hearing protection and working in the engine room of an ice breaker led to his bilateral hearing loss. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). The United States Court of Appeals for the Federal Circuit held that continuity of symptomatology under 38 C.F.R. § 3.303(b) applies only to chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1338 (2013). Bilateral hearing loss is considered an organic disease of the nervous system and qualifies as a chronic disease under 38 C.F.R. § 3.309; see also Fountain v. McDonald, 27 Vet. App. 258 (2015). For VA compensation purposes, impaired hearing will be considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2017). Hearing loss is not shown to be present during service or in the year following separation from service, thus, in-service incurrence cannot be presumed. See 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a). The evidence of record contains a current diagnosis of bilateral hearing loss which meets the criteria for a hearing disability for VA purposes. See Degmetich v. Brown, 104 F.3d 1328, 1333 (Fed. Cir. 1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). Military personnel records demonstrate that the Veteran was a fireman and electrician's mate, which carries a moderate probability of noise exposure. Service treatment records indicate that the Veteran underwent a whispered voice test at enlistment. Audiometry testing was not completed. No defects were noted at enlistment. On separation in December 1975, examination showed the Veteran's ears were normal and audiogram showed puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 5 10 15 LEFT 5 5 5 15 20 As previously noted, the Veteran testified that he was regularly exposed to high noise levels while firing pistols and working in an engine room. His descriptions of his noise exposure are consistent with his circumstances of service and are competent and credible. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (2006) (noting that the Board must determine whether lay evidence is credible due to possible bias, conflicting statements, and the lack of contemporaneous medical evidence, although that alone may not bar a claim for service connection). Accordingly, the Board finds the Veteran's competent statements to be credible evidence of in-service noise exposure. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994); see also Caluza v. Brown, 7 Vet App. 498, 506 (1995). Thus, the remaining question is whether the Veteran's current hearing loss is related to his in-service noise exposure. During the March 2011 VA examination the examiner noted the Veteran's in-service noise exposure and post-service occupational noise exposure working over 20 years as a truck driver. In an addendum opinion, after a thorough review of the claims file, the examiner opined that there was no objective audiometric or written evidence to support a nexus of causation for noise exposure in service. He explained that given that there is no evidence that the Veteran's hearing was abnormal at separation or within one year of service, and given his many years of noise exposure in his non-military occupation, it was less likely than not the hearing loss was caused by military noise exposure. He further explained that based on the 2005 Institute of Medicine's Report on military noise exposure, which concluded that noise-induced hearing loss occurs immediately, there is no scientific support for delayed onset noise-induced hearing loss weeks, months, or years after the exposure event. As there is no medical evidence in significant conflict with the opinion of the VA examiner the most probative medical evidence is against the claim. The Veteran is competent to attest to the presence of observable symptoms, such as difficulty hearing. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Board finds that the Veteran's statement regarding decreased hearing ability is both competent and credible, however, the Board finds the medical opinion more probative than the Veteran's lay statements as the opinion was offered by a medical professional after examination of the Veteran and consideration of the history of the disability, and as the opinion is supported by a clear rationale. Importantly, the examiner explained that the Veteran's hearing loss could not be scientifically supported as the medical literature indicates that noise-induced hearing loss occurs immediately. As such, the preponderance of the evidence is against a finding that the Veteran has bilateral hearing loss related to service. Thus, the claim for service connection is denied. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran's service-connected bilateral pulmonary nodules is evaluated by analogy under Diagnostic Code 6833, which assigns ratings based upon the General Rating Formula for Interstitial Lung Disease. 38 C.F.R. § 4.97. To warrant a 10 percent rating the evidence would need to FVC of 75 to 80 percent predicted, or; DLCO (SB) of 66 to 80 percent predicted. For a 30 percent rating the evidence would need to show FVC of 65 to 74 percent predicted, or; DLCO (SB) of 56 to 65 percent predicted. For a 60 percent rating the evidence would need to show FVC of 50 to 64 percent predicted, or; DLCO (SB) of 40 to 55 percent predicted, or; maximum exercise capacity of 15 to 20 ml/kg/min oxygen consumption with cardiorespiratory limitation. For a 100 percent rating the evidence would need to show FVC less than 50 percent predicted, or; DLCO (SB) less than 40 percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption with cardiorespiratory limitation, or; cor pulmonale or pulmonary hypertension, or; requires outpatient oxygen therapy. Id. Under 38 C.F.R. § 4.96, there are special provisions for the application of evaluation criteria for diagnostic codes 6600, 6603, 6604, 6825-6833, and 6840-6845. In general, Pulmonary Function Tests (PFTs) are required to evaluate respiratory conditions except in certain situations. If a DLCO (SB) test is not of record, evaluation should be based on alternative criteria as long as the examiner states why the DLCO (SB) test would not be useful or valid in a particular case. 38 C.F.R. § 4.96. When the PFTs are not consistent with clinical findings, evaluation should generally be based on the PFTs. Post-bronchodilator studies are required when PFTs are done for disability evaluation purposes with some exceptions; when evaluating based on PFTs. Post-bronchodilator results are to be used unless they are poorer than the pre-bronchodilator results, then the pre-bronchodilator values should be used for rating purposes. When the results of different PFTs (FEV-1 (Forced Expiratory Volume)), FVC, etc.) are disparate, the test result that the examiner states most accurately reflects the level of disability should be used for evaluation, and if the FEV-1 (Forced Expiratory Volume in one second) and the FVC are both greater than 100 percent, a compensable evaluation based on a decreased FEV-1/FVC ratio should not be assigned. Id. During February 2011 VA examination the Veteran reported his lung disability symptoms included daily cough and shortness of breath. He reported his symptoms onset in February 2010. Pulmonary test results demonstrated 84 percent predicted for FVC and DLCO of 128 percent predicted; FEV1 was 104 percent. The examiner reported that spirometry, lung volumes, and diffusion capacity was within normal limits. In August 2014 private treatment pulmonary test results demonstrated FVC of 62 percent predicted and DLCO of 75.5 percent predicted; FEV1 was 66.8 percent. The examiner reported that spirometry demonstrated reduced FVC and reduced FEV1, the FEV1/FVC ratio was normal, and the contour of the expiratory flow-volume loop was normal. Notably, he reported that the study suggested a mild restrictive process and no evidence of expiratory airflow limitation. In a June 2015 statement the Veteran's private treatment provider reported that he recently underwent pulmonary testing. Post bronchodilator testing revealed an FEV-1 of 67 percent and DLCO scores were 76 percent predicted. None of the other medical evidence reflects pulmonary function tests with FVC or DLCO (SB) percent predicted results, maximum exercise capacity of 15 to 20 ml/kg/min oxygen consumption with cardiorespiratory limitation, the presence of cor pulmonale or pulmonary hypertension, or that the Veteran required outpatient oxygen therapy. As noted above, the Veteran is competent to attest to things he experiences through his senses. See Jandreau, 492 F.3d 1372. In this case the Veteran has daily cough and shortness of breath. The lay statements do not indicate that the Veteran has FVC or DLCO (SB) percent predicted scores or a maximum exercise capacity test results indicative of higher ratings. For the period beginning August 7, 2014, the Board has placed greater probative weight on the measurements of the Veteran's DLCO (SB) percent predicted result as a more accurate and objective measure of the severity of his disability based on the clinical findings by the private treatment provider, reporting that the study suggested a mild restrictive process and no evidence of expiratory airflow limitation, and the provider has greater training and expertise than the Veteran in evaluating a pulmonary disorder. As the preponderance of the evidence is against a finding that the Veteran's disability more nearly approximates the criteria for higher ratings, higher ratings are not warranted. 38 C.F.R. §§ 4.3, 4.7 (2017). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER The appeal as to the issues of entitlement to service connection for thoracolumbar spine disability, right and left knee degenerative joint disease with ligament derangement, and an increased rating for surgical scars, status post left inguinal herniorrhaphy is dismissed. Service connection for an acquired psychiatric disorder (diagnosed as major depressive disorder and anxiety disorder) is granted. Service connection for bilateral hearing loss is denied. Entitlement to an initial compensable evaluation for bilateral pulmonary nodules effective June 17, 2010 and an evaluation in excess of 10 percent from August 7, 2014 to December 19, 2016 is denied. REMAND VA will grant a TDIU when the evidence shows that a Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). On the Veteran's September 2012 application for TDIU he indicated he was unemployable as a result of his psychiatric condition and thoracolumbar spine condition. At the June 2017 private psychological evaluation the private treatment provider reported that since 2009 the Veteran has experienced episodes of extreme depression, approximately one time a month, where he remains home, ignoring most activities of daily living, including self-care and personal hygiene, for up to three days at a time. He explained that the Veteran experiences total occupational and social impairment due to his symptoms that include periodic impairment and inability to perform activities of daily living; including maintaining his personal hygiene, near-total social withdrawal, suicidal ideation, and near-continuous depression affecting his ability to function independently, appropriately, and effectively. In light of the award for service connection for major depressive disorder and anxiety disorder, the issue of entitlement to a TDIU prior to December 19, 2016 must be remanded so that a disability rating can be assigned for the psychiatric disability (the Veteran currently does not meet the schedular requirements for a TDIU during this period per 38 C.F.R. § 4.16(a) (2017)) and the recently submitted evidence considered in the TDIU determination. Accordingly, the case is REMANDED for the following action: 1. Issue a rating decision promulgating the grant of service connection for a psychiatric disorder and assign a disability rating and effective date of service-connection for that disability. 2. If the Veteran does not meet the schedular disability rating requirements for consideration of a TDIU under 38 C.F.R. § 4.16(a), the AOJ should determine whether the matter should be referred to the Director of Compensation Service for extraschedular TDIU consideration. 3. After the above development has been completed, and any other development deemed necessary, the issue of entitlement to a TDIU prior to December 19, 2016 must be adjudicated. If entitlement to a TDIU is not granted, provide the Veteran and his representative with a supplemental statement of the case, and allow an appropriate opportunity to respond before returning the matter to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by Court 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