Citation Nr: 1803424 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 11-00 999 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for chronic right foot strain with metatarsalgia. 2. Entitlement to an initial rating in excess of 10 percent for chronic left foot strain with metatarsalgia. 3. Entitlement to service connection for a right ankle disorder claimed as secondary to service connected chronic right foot strain with metatarsalgia. 4. Entitlement to a temporary total rating for convalescence following right ankle surgery, pursuant to 38 C.F.R. § 4.30. 5. Whether new and material evidence has been received to reopen a claim for service connection for chronic lumbar spine musculoskeletal strain and degenerative disc disease, claimed as a lower back condition. 6. Entitlement to service connection for a lower back condition. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. Leifert, Associate Counsel INTRODUCTION The Veteran had active duty service from April 1968 to April 1970. The Veteran died in August 2011, and the appellant is his surviving spouse. This appeal to the Board of Veterans' Appeals (Board) arose from an April 2009 rating decision in which the RO, inter alia, granted service connection for chronic right and left foot strains with metatarsalgia and assigned an initial 10 percent rating for each foot, effective September 22, 2008. This rating decision also granted the Veteran's petition to reopen a claim for service connection for a low back strain but denied it on the merits. In July 2009, the Veteran filed a notice of disagreement (NOD). A statement of the case (SOC) was issued in December 2010, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in January 2011. This appeal also arose from a November 2009 rating decision in which the RO, inter alia, denied service connection for a right ankle disability secondary to a service-connected right foot condition, as well as a claim for a temporary total rating due to right ankle surgery, pursuant to 38 C.F.R. § 4.30. In January 2010, the Veteran filed an NOD. An SOC was issued in December 2010, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in January 2011. As the Veteran disagreed with the initial ratings assigned following the awards of service connection for his chronic right and left foot strain with metatarsalgia, the Board characterized these claims in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). As noted, the Veteran died during the course of the appeal, in August 2011. In July 2012, the appellant filed a VA Form 21-0847, Request for Substitution of Claimant Upon Death of Claimant, with the agency of original jurisdiction (AOJ). The AOJ determined that the appellant was a proper substituted claimant in February 2015. Accordingly, as the appellant has been substituted as the claimant in this case, the Veteran's appeals are continued. See 38 U.S.C.. § 5121A (2012). In June 2015, the appellant testified during a Board video-conference hearing before the undersigned Veterans Law Judge; a transcript of that hearing is of record. In August 2015, the Board remanded the claims on appeal to the RO, via the Appeals Management Center (AMC) in Washington, DC. After accomplishing further action, the AMC continued to deny the claims, and returned these matters to the Board.. Regarding the Board's characterization of the appeal concerning the Veteran's low back strain, it is noted that, regardless of the RO's action, the Board has a legal duty under 38 U.S.C.. §§ 5108 and 7104 (2012) to address the question of whether new and material evidence has been received to reopen a claim for service connection. That matter goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim on a de novo basis. See Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). As the Board must first decide whether new and material evidence to reopen the claim has been received-and, given the favorable disposition of the request to reopen-the Board has characterized the appeal as to a lower back conditions as encompassing the 5th and 6th matters set forth on the title page. While the Veteran previously had a paper claims file, this appeal is now being processed utilizing the Veterans Benefits Management System (VBMS), a paperless, electronic claims processing system. The Board notes that, in addition to the VBMS file, there is a separate, paperless, electronic Virtual VA (Content Legacy Manager) file associated with the instant claims. All records have been reviewed. The Board's decisions addressing all claims on appeal with the exception of the reopened claim for service connection for a lower back condition are set forth below. The reopened claim is addressed in the remand following the order; this matter is being remanded to the agency of original jurisdiction (AOJ) for further action. VA will notify the appellant when further action, on her part, is required. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each claim herein decided have been accomplished. 2. From the September 28, 2008 effective date of the award of service but prior to May 29, 2009, the Veteran's primary problem affecting each foot was pain with no weakness, stiffness, swelling, heat or redness, or fatigability, which more closely approximated "moderate" severity. 3. From May 29, 2009 up to the date of the Veteran's death in May 2011, each service-connected right and left foot disability was shown to cause limited motion in the ankle, pain to various aspects of the foot, and soft tissue edema; such symptoms more nearly approximated a "moderately severe" disability picture.. 3. The schedular criteria are adequate to rate each service-connected foot disability under consideration at all pertinent points. 4. The Veteran was hospitalized for his right ankle fracture in June 2009. 5. Although the evidence reflects that the Veteran incurred a right ankle fracture in June 2009, competent , probative evidence addressing the etiology of the Veteran's right ankle fracture indicates that such a disability was less likely than not due to or a result of his service-connected right foot disability. 6. In a July 2003 rating decision, the RO denied service connection for lower back strain. The Veteran filed an NOD in June 2004, and the RO issued an SOC in March 2006; however, later in March 2006, the Veteran submitted a letter effectively withdrawing the appeal as to his claim for service connection for lower back strain. 5. New evidence associated with the claims file since the July 2003 denial, by itself or considered with previous evidence of record, is both material and so significant that it must be considered in order to fairly decide the merits of the Veteran's lower back claim. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for chronic right foot strain with metatarsalgia, prior to May 29, 2009, are not met. 38 U.S.C.. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.27, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5284 (2017). 2. The criteria for a rating in excess of 10 percent for chronic left foot strain with metatarsalgia, prior to May 29, 2009, are not met. 38 U.S.C.. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.27, 4.40, 4.45, 4.71a, DC 5284 (2017). 3. The criteria for a rating of 20 percent, but not higher, for chronic right foot strain with metatarsalgia from May 29, 2009, are met. 38 U.S.C.. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.27, 4.40, 4.45, 4.71a, DC 5284 (2017). 4. The criteria for a 20 percent, but no higher, rating for chronic left foot strain with metatarsalgia, from May 29, 2009, are met. 38 U.S.C.. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.27, 4.40, 4.45, 4.71a, DC 5284 (2017). 5. The criteria for service connection for a right ankle disorder as secondary to service-connected chronic right foot strain with metatarsalgia are not met. 38 U.S.C.. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 6. The criteria for a temporary total rating for convalescence following right ankle surgery are not met. 38 U.S.C.. § 1155 (2012); 38 C.F.R. § 4.30 (2017). 7. The July 2003 rating decision in which the RO denied service connection for lower back condition is final. 38 U.S.C.. § 7105 (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). 8. As new and material evidence has been received, the criteria for reopening the claim for service connection for lower back condition are met. 38 U.S.C.. § 5108 (2012); 38 C.F.R. § 3.156(a) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a). After a complete or substantially complete application for benefits is received, notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Pelegrini v. Principi, 18 Vet. App. 112 (2004) and Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.. § 5103(a) and 38 C.F.R. § 3.159(b)). VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. VCAA compliant notice must be provided to a claimant before an unfavorable decision on a claim for VA benefits by the AOJ. Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. Given the favorable disposition of the Veteran's request to reopen the claim for service connection for lower back strain, the Board finds that all notification and development actions needed to fairly adjudicate these matters have been accomplished. As for the chronic right and left foot strain with metatarsalgia claims, whereas here, service connection has been granted and the initial rating and effective date have been assigned, the claim for service connection has been more than substantiated. It has been proven, thereby rendering 38 U.S.C.. § 5103 (a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional section 5103(a) notice. See Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Dingess, 19 Vet. App. at 490-91. Nonetheless, the SOC reflects notice of the criteria for higher ratings for the service-connected foot disabilities (the timing and form of which suffices for Dingess/Hartman) As regards the claim for service connection for a right ankle disorder and temporary total rating for convalescence following right ankle surgery, in a September 2009 pre-rating letter, the AOJ provided notice to the Veteran explaining what information and evidence was needed to substantiate his claims for service connection and secondary service connection, what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. The letter further provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. Moreover, neither the Veteran, the Appellant, nor any representative has alleged or demonstrated any prejudice with regard to the content or timing of the notice provided. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The record also reflects that, consistent with applicable duty-to-assist provisions, VA has made reasonable efforts to develop the claims herein decided, to include obtaining or assisting in obtaining all relevant records and other evidence pertinent to this matter. Pertinent medical evidence associated with the claims file consists of VA treatment records; private treatment records; and reports of January 2009 and October 2009 VA examinations , as well as a November 2016 VA medical opinion based on claims file review. Also of record and considered in connection with these claims is the transcript of the Board hearing, along with various written statements by the Veteran, the Appellant, and their representatives on their behalf. The Board finds that no further AOJ action on any of these claims, prior to appellate consideration, is required. As noted, the Appellant had an opportunity to orally advance her contentions during a Board hearing. During the Jure 2015 hearing, the undersigned identified the claims on appeal, to include those herein decided. Information was elicited regarding the nature of the disabilities and the Appellant's statements regarding the severity of the Veteran's bilateral foot problems and her beliefs as the etiology of his right ankle fracture and lower back strain. Although the undersigned did not explicitly suggest the submission of any specific additional evidence, on these facts, such omission was harmless. After the hearing, additional development of these claims was sought, as a result of which additional evidence was added to the claims file.. Thus, the hearing was legally sufficient. See 38 C.F.R. § 3.103(c)(2) (2017); Bryant v. Shinseki, 23 Vet. App. 488 (2010). As indicated above, in August 2015, the Board remanded the claims on appeal for additional development, and the record reflects compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). See also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) and Dyment v. West, 13 Vet. App. 141, 146-47 (1999) aff'd, Dyment v. Principi, 287 F.3d 1377 (2002) (holding that substantial, rather than strict, compliance is sufficient). The Board instructed the AOJ to send the Appellant a letter requesting sufficient information to obtain any additional evidence, obtain additional VA treatment records, obtain Social Security Administration records, and obtain a VA addendum opinion addressing the etiology of the Veteran's right ankle fracture. The Veteran has not identified any source of private treatment for which relevant records remain outstanding. After additional evidence was associated with the claims file, as the AOJ readjudicated the claim in a February 2017 SSOC. In summary, the duties imposed by the VCAA have been considered and satisfied. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim herein decided. As such, the Veteran is no prejudiced by the Board proceeding to a decision on the claim for which an appeal has been perfected, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Higher Ratings Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). When an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). However, where, as here, the question for consideration is entitlement to a higher initial rating assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Historically, the RO assigned separate 10 percent initial ratings for the Veteran's chronic right and left foot strain with metatarsalgia under DC 5284, which references other foot injuries. See 38 C.F.R. § 4.71a. Under DC 5284, foot injuries are rated as 10 percent disabling when moderate, as 20 percent disabling when moderately severe, and as 30 percent disabling when severe. 38 C.F.R. § 4.71a. With actual loss of use of the foot, a 40 percent rating is assigned. Id. Words such as "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. 4.6 (2017). Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in reaching a rating decision. 38 C.F.R. §§ 4.2, 4.6. The Board notes, that, when evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R.§§ 4.40 , 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Notably, pain, alone, does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Painful motion with joint or periarticular pathology and unstable joints due to healed injury are recognized as productive of disability entitled to at least a minimal compensable rating for the joint. 38 C.F.R. § 4.59 . The application of 38 C.F.R. § 4.59 is not limited to arthritis-related claims. See Burton v. Shinseki, 25 Vet. App. 1 (2011). A January 2009 VA examination report reflects that the Veteran walked one or two blocks a day, but that he was doing one mile a day on the treadmill until one month ago when his back pain worsened. The Veteran reported that while he spent most of his time watching television, he went out most days to go to the store or to the post office. He stated that he could walk a maximum of 50 to 100 yards, which was limited by his back. He could stand for ten minutes, which was limited by his foot pain. He could climb up one flight of stairs, lift and carry five pounds, and sit and drive 10 to 20 minutes, all of which were limited by his back. He reported that his chief complaints were back pain (10/10, but usually 3-5/10), left hip pain (7-8/10), foot pain (7-10/10), and dyspnea on exertion (3-4/10). He stated that his foot pain worsened with standing more than ten minutes or standing on a ladder, and had relief with rest. He used an over-the-counter Dr. Scholl's foam insert, but no braces, or custom or hard orthotics. The examiner noted that the Veteran had increased foot pain with position and activity with weight bearing and walking, but no other flare-ups, and that it would be mere speculation to estimate change in degrees of motion after an exacerbation. On physical examination, the Veteran walked with a cane and had a limp, which he primarily attributed to his back pain. The examiner stated that it would be mere speculation to estimate how much of his limp was related to his foot condition. The examiner noted that the Veteran had normal shoe wear pattern without breakdown and no callosities to indicate abnormal weight bearing. He noted that the Veteran could walk on his heels and toes. The Veteran had arches present in his feet with vertical calcaneus and Achilles with no significant deformities of the feet; and no significant problems with the skin, circulation or sensation. The examiner found that the Veteran's primary problem in his feet was pain, not weakness, stiffness, swelling, heat or redness, or fatigability. He noted that the Veteran had no significant problems at rest, but he did have pain with standing and walking. He had no specific objective evidence of painful motion, edema, instability, weakness, or tenderness in his feet, other than mild nonspecific tenderness across the forefoot bilaterally. He had intact skin and intact sensation in both feet, as well as good capillary refill and dorsalis pedis pulses present in both feet. The examiner noted no hammertoes, high arches, claw foot, pes planus, or other deformity. He had longitudinal and transverse arches, no forefoot or midfoot malalignment, and vertical Achilles and calcaneus. He also had no hallux valgus and no significant limitation of motion of the metatarsophalangeal joint of the great toe. VA treatment records dated in May 2009 reflect that the Veteran had pain in both feet that had recently worsened. The Veteran reported that he had tried to use supportive boots that had helped, but that over-the-counter inserts had not helped. He stated that he was on Coumadin so he could not take any pain medication, and that he felt unstable with walking and tended to sprain his ankles, although he denied recent sprains. Physical examination revealed intact neurovascular, soft tissue edema to the lateral right lateral ankle ligament area and sinus tarsi area, but no erythema or open lesions. There was pain to direct palpation over the right plantar medial calcaneal tubercle, and pain to the medial arch of the plantar fascia to both feet. There was no pain to lateral squeeze and limited motion to the bilateral ankle joints on extension of the knees. There was pain to direct palpation and lateral squeeze of the second interspaces bilaterally, as well as to the peroneal tendons, sinus tarsi area, and anterior talofibular ligament area of the right foot, and pain to the sinus tarsi of the left foot. X-rays were noted to reveal led well-defined infracalcaneal heel spur and retrocalcaneal heel spurs. The Veteran was diagnosed with bilateral plantar fasciitis with calcaneal spurs, bilateral neuromas of the second interspaces, ankle equinus, bilateral ankle pain with history of bilateral instability right more than left, and morbid obesity. During the Board June 2015 hearing, the Appellant testified that the Veteran had difficulty walking and used a cane for his feet and his back. She stated she would massage his feet to try to relieve the pain since he could not take pain medication. The Appellant stated that the Veteran experienced sharp, aching, burning pain that made it difficult for him to walk. She explained that he used ankle braces or high top shoes to support his ankles, and that he would have to get new shoes every two months because they wore out on the outer edge of both feet. She also stated that it was difficult for the Veteran to walk, and if he was barefoot and tried to turn his feet slightly, he was not "sure which way they were going to go." Based on consideration of the evidence of record, the Board finds that an initial rating in excess of 10 percent for service-connected chronic right or left foot strain with metatarsalgia is not warranted prior to May 29, 2009; and but that a 20 percent, but no higher, rating for each foot disability is warranted from May 29, 2009. For the pertinent period prior to May 29, 2009, the evidence shows that the Veteran's primary problem with his feet was pain, and not weakness, stiffness, swelling, heat or redness, or fatigability. The January 2009 VA examiner noted that the Veteran did not have hammertoes, high arches, claw foot, pes planus, or other deformity; and that he had no objective evidence of painful, motion, edema, instability, weakness, tenderness in his feet other than mild nonspecific tenderness across the forefoot bilaterally, hallux valgus, or significant limitation of motion of the metatarsophalangeal joint of the great toe. While the Veteran walked with a limp, he reported that it was due to his back pain and not his bilateral feet. Further, the VA examiner found that the Veteran had normal shoe wear pattern without breakdown and no callosities to indicate abnormal weight bearing. Collectively, this evidence indicates that the Veteran's symptoms more closely approximated moderate severity, pursuant to DC 5284. From May 29, 2009, however, the Veteran had soft tissue edema to the lateral right lateral ankle ligament area and sinus tarsi area; pain to the peroneal tendons, sinus tarsi area, and anterior talofibular ligament area of the right foot; pain to direct palpation over the right plantar medial calcaneal tubercle; pain to the medial arch of the plantar fascia to both feet; pain to direct palpation and lateral squeeze of the second interspaces bilaterally; and pain to the sinus tarsi of the left foot. Further, the Appellant testified that the Veteran had abnormal shoe wear pattern at the edges and had to buy new shoes every two months, and that he experienced sharp, aching, burning pain that made it difficult for him to walk. She also reported that the Veteran had started to use his cane due to his bilateral foot problems in addition to his back pain. Collectively, this evidence indicates that the Veteran's symptoms more closely approximated a moderately severe disability of each foot, consistent with a 20 percent, but no higher, rating under DC 5284. Overall severe disability or loss of use of either foot was not shown. The Board further notes that neither of the Veteran's disability is shown to have involved any other factor(s) warranting evaluation under any potentially applicable diagnostic code. The evidence of record is devoid of any findings of flatfoot, weak foot, claw foot, hallux valgus, hallux rigidus, hammer toe, malunion or nonunion of the metatarsal bones, Morton's neuroma, or other right foot deformity. Thus, a higher or separate rating under DC 5276, 5277, 5278, 5279, 5280, 5281, 5282,and/ or 5283, respectively, is not warranted. . The above determinations are based on consideration of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no point since the September 22, 2008, effective date of the award of service connection was the Veteran's right or left foot disability shown to present so exceptional or so unusual a picture as to render the applicable criteria inadequate, and to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extra-schedular consideration is a finding on the part of the AOJ or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996); Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the AOJ or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, 22 Vet. App. 111. In this case, the Board finds that the schedular criteria are adequate to rate the Veteran's chronic right and left foot strain with metatarsalgia at all pertinent points of the appeal. As discussed above, a comparison between the Veteran's symptoms and the criteria of the rating schedule indicates that the rating criteria reasonably describe his level of impairment. In this regard, all of the Veteran's bilateral foot disability symptomatology is contemplated by the rating criteria, to include those symptoms, such as pain and tenderness, which are not specifically enumerated. Also, as indicated, the rating schedule provides for a higher rating based on evidence demonstrating more severe impairment. The Board further notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. Here, however, the Veteran has not asserted, and the evidence of record does not suggest, that this appeal involves any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. Yancy v. McDonald, 27 Vet. App. 484, 495 (Fed. Cir. 2016) ("the Board is required to address whether referral for extra-schedular consideration is warranted for a veteran's disabilities on a collective basis only when that issue is argued by the claimant or reasonably raised by the record through evidence of the collective impact of the claimant's service-connected disabilities"). As such, further discussion of the holding in Johnson is unnecessary. As the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met, referral of the claim for extra-schedular consideration is not required. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board has resolved all reasonable doubt in the Veteran's favor in awarding the 20 percent rating for each foot disability from May 9, 2009, but finds that the preponderance of the evidence is against assignment of a rating for either foot in excess of 10 percent prior to that date, or a rating in excess of 20 percent from May 9, 2009. See 38 U.S.C.. § 5107(b) (2012); 38 C.F.R. §§ 3.102, 4.3 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). III. Service Connection and Temporary Total Rating Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or from aggravation of a preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). To establish entitlement to direct service connection, there must be: (1) competent and credible evidence confirming the Veteran has manifested the claimed disability at some point since the filing of the claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). See also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The determination as to whether elements are met is based on an analysis of all the evidence of record and the evaluation of its competency, credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Service connection also may be granted for disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). That regulation permits service connection not only for disability caused by service-connected disability, but for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In adjudicating a claim for VA benefits, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.. § 5107(b) (2012); 38 C.F.R. § 3.102 (2015); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). February 2000 private treatment records reflect that the Veteran had gout, which resolved, but he continued to experience pain in his right ankle. April 2003 VA treatment records indicate good dorsiflexion in his right ankle. A May 2009 VA examination report documents that the Veteran reported that he had a tendency to sprain his ankles because of his feet, but that he had not suffered a sprain in a while and that they were infrequent. VA treatment records dates in June 2009 reflect that the Veteran broke his right ankle when he went to stand up and rolled his ankle. X-rays revealed lateral malleolus unstable fracture. VA treatment records in May 2009 reflect that the Veteran reported that he felt unstable with walking and tended to sprain his ankles, although he denied recent sprains. Physical examination of the bilateral feet revealed intact neurovascular, soft tissue edema to the lateral right lateral ankle ligament area and sinus tarsi area, but no erythema or open lesions. There was no pain to lateral squeeze and limited motion to the bilateral ankle joints on extension of the knees. X-rays showed well-defined infracalcaneal heel spur and retrocalcaneal heel spurs. The Veteran was diagnosed with bilateral plantar fasciitis with calcaneal spurs, bilateral neuromas of the second interspaces, ankle equinus, bilateral lateral ankle pain with history of bilateral instability right more than left, and morbid obesity. An October 2009 VA examination report documents that the Veteran was status post fracture dislocation of the right lateral malleolus with open reduction internal fixation. The examiner noted that the Veteran was service-connected for right metatarsalgia and foot strain, and that his VA podiatrist noted prior to his ankle injury that he had been having unstable and rolling ankles. The examiner opined that with the currently available information, it was less likely than not that the Veteran's service-connected right foot metatarsalgia and foot strain caused his right ankle fracture. He concluded that "his existing ankle instability and morbid obesity more likely than not are directly related." During the June 2015 Board hearing, the Appellant testified that the Veteran had a tendency to sprain his ankles and felt unstable when walking. She explained that he had sharp, aching, burning pain in his foot, which made it difficult for him to walk, and that he had to wear ankle braces or shoes that would support his ankle. She stated that the instability of his foot was causing problems with his ankle. A November 2016 VA opinion indicates review of the claims file. The clinician noted that the Veteran had gained considerable weight over the years and weighed 360 pounds prior to his right ankle fracture. He also noted that the Veteran had no recollection of prior specific injuries to his right ankle before his fracture. The clinician opined that, based on the available evidence of record, it was less likely than not that the Veteran's service-connected right foot metatarsalgia and foot strain was related to his right ankle fracture. The clinician explained that morbid obesity, and lack of strength and conditioning, was more likely than not directly related to his right ankle fracture because of mechanical forces and weakness. The clinician also found that the Veteran less likely than not had significant pathology of the right ankle, or significant right ankle disorder, prior to his fracture as evidenced by his ankle x-rays which showed a fracture, but no arthritis. Based on the above-cited evidence, the Board finds that service connection for a right ankle disorder, as secondary to service-connected chronic right foot strain with metatarsalgia, is not warranted. Consequently, the Board also finds that entitlement to a temporary total rating for convalescence following right ankle surgery, pursuant to 38 C.F.R. § 4.30, is not established.. At the outset, the Board finds that the Veteran met the criteria for the first and second requirements for service connection, as he had a current disability of status post right ankle fracture and was service-connected for chronic right foot strain with metatarsalgia. As such, the claim turns on the question of whether the Veteran's service-connected right foot disability was medically-related to the Veteran's right ankle fracture. Here, however, the Board finds that competent, probative evidence weighs against finding that such a relationship existed. Here, the October 2009 and November 2016 VA opinion providers both referenced the VA podiatrist's note that the Veteran's complained of unstable ankles. The Board acknowledges that the May 2009 VA podiatrist noted that the Veteran had ankle equinus, lateral ankle pain with a history of instability greater on the right side, and limited motion to the ankle joint on extension. However, the podiatrist did not provide an opinion on whether the Veteran's right ankle problems were secondary to his service-connected right foot disability. Further, during a May 2009 VA examination, the Veteran reported that he had a tendency to sprain his ankles because of his feet, but that he had not suffered a sprain in a while and that they were infrequent. In addition, both the October 2009 and November 2016 VA opinion providers noted that the Veteran was morbidly obese, and opined that his service-connected right foot disability was less likely than not related to his right ankle fracture, and that his existing ankle instability and morbid obesity more likely than not were directly related. Specifically, the November 2016 VA examiner explained that morbid obesity, and lack of strength and conditioning, were more likely than not directly related to his right ankle fracture because of mechanical forces and weakness, and that the Veteran less likely than not had significant pathology of right ankle, or significant right ankle disorder, prior to his fracture, as evidenced by his ankle x-rays which showed a fracture, but no arthritis. The Board has also considered the Veteran's and the Appellant's statements. The Board notes that lay persons are competent to report matters within their personal knowledge, to include symptoms/manifestations experienced or observed, such as ankle instability and a rolled ankle. See Layno, 6 Vet. App. at 469. While the Veteran and the Appellant are each competent to report that the Veteran had these symptoms, the question of whether these problems are related to the Veteran's service-connected chronic right foot strain with metatarsalgia is a complex medical matter that relates to internal medical processes and extends beyond an immediately observable cause-and-effect relationship ; thus, such matter is of the type that the courts have found to be beyond the competence of lay witnesses. Compare Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr, 21 Vet. App. at 308-09; Falzone, 8 Vet. App. at 403 (lay person competent to testify to pain and visible flatness of his feet); with Clemons, 23 Vet. App. at 6 ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert, 21 Vet. App. at 462 (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). Thus, the Veteran and the Appellant's assertions as to the etiology of his right ankle disorder are not competent. For all the foregoing reasons, the Board finds that service connection for a right ankle disorder must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, supra. Finally, as regards the claim for entitlement to a temporary total rating for convalescence following right ankle surgery, pursuant to 38 C.F.R. § 4.30, the Board notes that that claim is dependent, in large part, upon an award of service connection for a right ankle disorder. As the Board has denied the claim for service connection for claimed right ankle disability, it follows that the claim for a temporary total rating for convalescence following surgery for the right ankle must also be denied. IV. Request to Reopen The Veteran's claim for service connection for lower back condition was previously denied in a July 2003 rating decision. The pertinent evidence then of record consisted of his service treatment records (STRs), private treatment records, the Veteran's lay statements, and an April 2003 VA spine examination. The RO noted that the Veteran's STRs had one entry referencing a pulled muscle in his back, but that the VA examiner had opined that his current chronic low back strain was not related to this single episode in service. On this basis, the RO denied the Veteran's claim. The Veteran filed an NOD in June 2004, and the RO issued an SOC in March 2006. However, later that same month, the Veteran submitted a letter withdrawing his claim for service connection for lower back strain. Under these circumstances, the Board finds that the July 2003 denial of the claim is final as to the evidence then of record and is not subject to revision on the same factual basis. 38 U.S.C.. § 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. However, under pertinent legal authority, VA may reopen and review a claim that has been previously denied if new and material evidence is submitted by or on behalf of the Veteran. 38 U.S.C.. § 5108; 38 C.F.R. § 3.156(a); see Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). The Veteran filed a petition to reopen his previously denied claim for service connection for lower back condition in September 2008. For petitions to reopen filed on and after August 29, 2001, 38 C.F.R. § 3.156(a) defines "new" evidence as evidence not previously submitted to agency decision makers and "material" evidence as 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 of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether new and material evidence has been received, VA must initially decide whether evidence received since the prior final denial is, in fact, new. This analysis is undertaken by comparing the newly received evidence with the evidence previously of record. After evidence is determined to be new, the next question is whether it is material. The provisions of 38 U.S.C.. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-83 (1996). Here, the last final denial of the claim is the April 2002 rating decision. Furthermore, for purposes of the "new and material" analysis, the credibility of the evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). Where VA has previously denied a claim because one element of service connection is missing, the case must be reopened when evidence potentially fulfilling the missing element is submitted. See Molloy v. Brown, 9 Vet. App. 513 (1996). Further, the United States Court of Appeals for Veterans Claims (Court) has interpreted the language of 38 C.F.R. § 3.156 (a) as creating a low threshold, viewing the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court has emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159 (c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." Id. The Board has considered pertinent evidence added to the claims file since the July 2003 rating decision and the March 2006 SOC issued in furtherance of the appeal of that decision wehich was ultimately withdrawn. Such evidence includes private and VA treatment records noting that the Veteran had experienced chronic back pain since service when he injured it picking up a "Ripping tooth" on a dozer, the report of a January 2009 VA foot examination noting that the Veteran had intermittent low back pain after service, as well as the Appellant's testimony to the Board that the Veteran's treating physician had said that muscle strains such as the Veteran's could reoccur even many years after his initial injury. Given the "low threshold" standard of Shade, and presuming the credibility of the evidence, the Board finds that the above-described evidence provides a basis for reopening the claim for service connection for lower back strain. The Veteran's documented reports, along with the January 2009 clinician's comment and the Appellant's testimony as to what a VA treatment provider told her are "new" in that they were not before agency decision makers at the time of the July 2003 final denial of the claim for service connection, and are not duplicative or cumulative of evidence previously of record. Moreover, this evidence is "material" in that it goes to the question of etiology of the Veteran's lower back condition. This evidence-while certainly not conclusive-relates to an unestablished fact necessary to substantiate the claim for service connection for lower back strain, and thus, when presumed credible, also raises a reasonable possibility of substantiating the claim. Under these circumstances, the Board concludes that the criteria for reopening the claim for service connection for a low back strain are met. See 38 U.S.C.. § 5108; 38 C.F.R. § 3.156. ORDER An initial rating in excess of 10 percent for chronic right foot strain with metatarsalgia, prior to May 29, 2009, is denied. An initial rating in excess of 10 percent for chronic left foot strain with metatarsalgia, prior to May 29, 2009, is denied. An 20 percent rating for r chronic right foot strain with metatarsalgia, from May 29, 2009, is granted, subject to the legal authority governing the payment of compensation. A 20 percent rating for chronic left foot strain with metatarsalgia, from May 29, 2009, is granted. subject to the legal authority governing the payment of compensation. Service connection for a right ankle disorder as secondary to service connected chronic right foot strain with metatarsalgia is denied. A temporary total rating for convalescence following right ankle surgery, pursuant to 38 C.F.R. § 4.30, is denied. As new and material evidence to reopen the claim for service connection for a low back strain has been received, to this limited extent, the appeal as to this matter is granted. REMAND The Board's review of the claims file reveals that additional AOJ action on the reopened claim for service connection for lower back condition is warranted. An April 2003 VA examination report documents the Veteran's August 1968 in-service low back injury with an assessment of "pulled muscle, left lower back." The Veteran reported that he had injured his back by attempting to lift a tool to attach to a bulldozer, which he was operating. In addition, the VA examiner noted the Veteran's post-service treatment records referencing a history of back problems, as well as the Veteran's post-service back injuries in 1976 and 1984 when he was roofing and a 100-pound sack hit him on the right shoulder and neck, resulting in an upper back injury. X-rays revealed possible minimal anterior spondylolisthesis of L5 on S1; mild degenerative changes, most prominent at the L2-3 level; chronic musculoskeletal strain of the lumbar spine; and mild degenerative disc disease of lumbar spine. The examiner stated that it was speculative to relate the Veteran's chronic lower back strain to his singular in-service injury, especially in view of the fact that the Veteran had subsequently worked at several rather labor intensive occupations and suffered a post-service episode in 1984 of re-injury to his back in an industrial accident. The Board finds that the April 2003 VA examination, to include the examiner's statements therein, is inadequate. Specifically, the examiner did not explain how the Veteran's 1984 post-service neck and upper back injury, which affect the cervical spine, resulted in the lumbar spine disabilities noted on the x-rays. Further, the VA examiner did not address the Veteran's statements that he had continuous low back pain since service, or the post-service treatment records noting that the Veteran had experienced low back pain since service, which had worsened after his 1984 post-service injury. Accordingly, on remand, the AOJ should obtain from an appropriate physician an addendum opinion an addressing the etiology of the Veteran's lower back condition. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence . . . is essential for a proper appellate decision"). Prior to arranging to obtain further medical opinion in connection with the claim, to ensure that all due process requirements are met, and that the record is complete, the AOJ should undertake appropriate action to obtain and associate with the electronic claims file all outstanding, pertinent records. In this regard, the AOJ should give the Appellant another opportunity to provide information and/or evidence pertinent to the remaining claim on appeal (to particularly include as regards any of the Veteran's private (non-VA) treatment), explaining that she has a full one-year period for response. See 38 U.S.C.. § 5103(b)(1) (2012); but see also 38 U.S.C.. § 5103(b)(3) (clarifying that VA may make a decision on a claim before the expiration of the one-year notice period). The AOJ should also invite the Appellant to obtain and submit a statement from E.P., ARNP, the Veteran's primary care nurse practitioner, addressing the etiology of the Veteran's lower back condition. Thereafter, the AOJ should attempt to obtain any additional evidence for which the Veteran provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties imposed by the VCAA. See 38 U.S.C.. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the AOJ of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the AOJ should also undertake any other development and/or notification action deemed warranted prior to adjudicating the remaining claim on appeal. Accordingly, this matter is hereby REMANDED for the following action: 1. Send to the Appellant and her representative a letter requesting that the Appellant provide sufficient information, and if necessary, authorization to obtain any additional evidence pertinent to the remaining claim on appeal that is not currently of record. Specifically request that the Appellant furnish, or furnish appropriate authorization to obtain, all outstanding, pertinent private (non-VA) records. Also invite the Appellant to obtain and submit a statement from E.P., ARNP, the Veteran's primary care nurse practitioner, addressing the etiology of the Veteran's lower back condition. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 2. If the Appellant responds, assist her in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Appellant of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 3. After all records and/or responses from each contacted entity have been associated with the claims file, arrange to obtain an addendum opinion addressing the etiology of the Veteran's lower back disability from an appropriate physician. The contents of the entire, electronic claims file (in VBMS and Virtual VA (Legacy Content Manager)), to include a complete copy of this REMAND, must be made available to the designated individual, and the opinion should include discussion of the Veteran's documented medical history and assertions. The examiner should provide an opinion, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's chronic lumbar spine musculoskeletal strain and degenerative disc disease had its onset during service, or is otherwise medically related to service, to include the August 1968 in-service low back strain therein. In addressing the above, the physician must consider and discuss all pertinent medical and other objective evidence of record, as well as all lay assertions. Notably, the absence of documented evidence of chronic low back disability in or shortly after service should not, alone, serve as the sole basis for a negative opinion. In this regard, the physician is advised that the Veteran was competent to report his symptoms and history and the appellant is competent her observations; such reports must be specifically acknowledged and considered in formulating the requested opinion. If lay assertions in any regard are discounted, the physician should clearly so state and explain why. All examination findings/testing results, along with complete, clearly-stated rationale for the conclusions reached, must be provided. 5. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. Stegall v. West, 11 Vet. App. 268 (1998). 6. After completing the requested actions, and any additional notification and/or development deemed warranted, the adjudicate the remaining claim on appeal in light of all pertinent evidence (to particularly include all that added to the VBMS and/or Virtual VA (Legacy Content Manager) file(s) and legal authority. 7. If the benefit sought on appeal remains denied, furnish to the appellant and her representative an appropriate SSOC that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response. The purpose of this REMAND is to afford due process, and to accomplish additional development and adjudication; it is not the Board's intent to imply whether the benefit requested should be granted or denied. The appellant need take no action until otherwise notified, but she may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 2012). ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs