Citation Nr: 1804056 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 14-07 013 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a cervical spine disorder. 2. Entitlement to service connection for a left arm and elbow disorder, to include as secondary to a service-connected disability. 3. Entitlement to service connection for a left hand disability, to include as secondary to a service-connected disability. 4. Entitlement to service connection for a lumbar spine disorder. 5. Entitlement to service connection for a psychiatric disorder, to include depression, posttraumatic stress disorder (PTSD), and sleep disturbance. 6. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: Colorado Division of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Orfanoudis, Counsel INTRODUCTION The Veteran had active service from August 1986 to May 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in Denver, Colorado, that, in pertinent part, denied the above issues on appeal. In August 2017, the Veteran testified at a personal hearing over which the undersigned Veterans Law Judge presided while at the RO. A transcript of that hearing has been associated with his claims file. The provisions of 38 C.F.R. § 3.103(c)(2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the above hearing, the undersigned clarified the issues on appeal and inquired as to the etiology, continuity, and severity of the Veteran's asserted symptoms. The Veteran was offered an opportunity to ask the undersigned questions regarding his claim. Neither the Veteran nor his representative has asserted that VA failed to comply with these duties; they have not identified any prejudice in the conduct of the Board hearing. The Board, therefore, concludes that it has fulfilled its duty under Bryant. A claim for service connection is manifested by symptoms of a disability regardless of how those symptoms are diagnosed or labeled. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (a claim for benefits based on PTSD encompassed benefits based on other psychiatric disabilities). Therefore, the Board has recharacterized the issue regarding service connection for a psychiatric disorder as one encompassing a psychiatric disorder, to include depression, PTSD, and sleep disturbance. The Veteran's claims file has been converted into a paperless claims file via the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems. All records in such files have been considered by the Board in adjudicating this matter. The issue of service connection for a psychiatric disorder is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Degenerative joint and disc disease of the cervical spine is manifested as a result of the Veteran's duties as an F-14 pilot. 2. Left upper extremity radiculopathy is due to the service-connected degenerative joint and disc disease of the cervical spine. 3. Left hand radiculopathy is due to the service-connected degenerative joint and disc disease of the cervical spine. 4. A lumbar spine disability did not have its clinical onset in service; was not manifested by arthritis within one year following separation from service; and is not otherwise related to active service. 5. Resolving all reasonable doubt in the Veteran's favor, tinnitus is related to in-service acoustic trauma. CONCLUSIONS OF LAW 1. The criteria for service connection for degenerative joint and disc disease of the cervical spine have been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 2. The criteria for service connection for left upper extremity radiculopathy, secondary to service-connected degenerative joint and disc disease of the cervical spine, have been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.310 (2017). 3. The criteria for service connection for left hand radiculopathy, secondary to service-connected degenerative joint and disc disease of the cervical spine, have been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.310 (2017). 4. The criteria for service connection for a lumbar spine disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 5. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C. §§ 5100, 5102- 5103A, 5106, 5107, 5126 (West 2012), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2017), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. See Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. By letters dated in September 2012, October 2012, and July 2013 the Veteran was notified of the evidence not of record that was necessary to substantiate his claims. He was told what information that he needed to provide, and what information and evidence that VA would attempt to obtain. He was also provided with the requisite notice with respect to the Dingess requirements. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied. Next, the VCAA requires that VA make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The Veteran's relevant service, VA, and private medical treatment records have been obtained. There is no indication of any additional, relevant records that the RO failed to obtain. The Veteran has been medically evaluated. In sum, the Board finds that the duty to assist and duty to notify provisions of the VCAA have been fulfilled and no further action is necessary under the mandates of the VCAA. Service Connection Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C. §§ 1110, 1131 (West 2012); 38 C.F.R. §§ 3.303, 3.304 (2017). In order to prevail on the issue of service connection for any particular disability, there must be evidence of a current disability; evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence, or in certain circumstances, lay evidence, of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). Service connection for certain chronic diseases, such as arthritis and certain organic diseases of the nervous system, may also be established based upon a legal "presumption" by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112 (West 2012); 38 C.F.R. §§ 3.307, 3.309 (2017). The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (rejecting the argument that continuity of symptomatology in § 3.303(b) has any role other than to afford an alternative route to service connection for specific chronic diseases). In addition, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2017). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2017). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) (2017); Allen v. Brown, 7 Vet. App. 439 (1995). VA has amended 38 C.F.R. § 3.310 to explicitly incorporate the holding in Allen, except that it will not concede aggravation unless a baseline for the claimed disability can be established with evidence created prior to any aggravation. 38 C.F.R. § 3.310(b). Cervical Spine Disorder and Left Upper Extremity and Hand Radiculopathy The Veteran contends that he has a cervical spine disorder, along with related radiculopathy of the left upper extremity and hand, that is manifested as a result of his period of active service. During the August 2017 Board hearing, as well as in various correspondence submitted during the pendency of this appeal, the Veteran has asserted that the circumstances of his service as a Navy F-14 pilot resulted in being subjected to significant gravitational forces that negatively impacted his cervical spine. He added that he treated his cervical spine symptoms both during and after service with over-the-counter pain and anti-inflammatory medication. He further indicated that his symptoms had progressively increased in severity ever since, and have included pain and numbness of the left hand and upper extremity. The Veteran's statements were corroborated by his spouse in correspondence dated in September 2012 and February 2013. A review of the Veteran's service treatment records does not show any treatment for symptoms associated with a cervical spine disorder during his period of active service. His service personnel records, however, do confirm his military occupational specialty as a Naval Aviator. Following service, private medical records from Swedish Medical Center dated in March 1995 show that the Veteran was evaluated for reported cervical spine symptoms. It appears that a magnetic resonance imaging study of the cervical spine was conducted. A VA examination report dated in September 2013 shows that the Veteran was diagnosed with degenerative joint and disc disease of at C5-6 and C6-7 with mild left C6-C7 sensory radiculopathy. The VA examiner opined that this condition was not likely related to a specific exposure event experienced by the Veteran during service in Southwest Asia. Rather, the VA examiner concluded that the cervical spine disorder was a biomechanical condition, that was the natural progression of biomechanical injuries incurred from extensive mechanical stresses and torques associated with the Veteran's duties as an F-14 pilot. The VA examiner added that the pain and numbness in the left upper extremity and hand were neurological findings of sensory radiculopathy originating in the cervical spine due to the cervical spine degenerative disc disease with associated sensory radiculopathy. A private medical record from A. J. S., M.D., dated in July 2017, shows that the Veteran was said to have flown F-14 planes for eight years. It was indicated that six months after service he was found to have herniated disk with diffuse degenerative disease, that was confirmed by radiological findings in July 2017. Dr. S. concluded that the intense stress on the area during active duty was the genesis of the current disability. Having carefully considered the evidence of record, the Board finds that service connection for a cervical spine disability is warranted. Here, both the VA examiner in September 2013 and Dr. S. in July 2017 concluded that the circumstances of the Veteran's service as a Naval F-14 pilot resulted in his cervical spine disability, or was at least a factor in its development. Moreover, the VA examiner concluded that the secondary left upper extremity and hand pain and neuropathy were due to radiculopathy from the cervical spine degenerative disc disease. There is no competent medical evidence of record to rebut the opinions in favor of the Veteran's claim or otherwise diminish their probative weight. As such, service connection for degenerative joint and disc disease of the cervical spine and secondary left upper extremity and hand radiculopathy is warranted. Lumbar Spine Disorder The Veteran contends that he has a lumbar spine disorder that is manifested as a result of his period of active service. During the August 2017 Board hearing, the Veteran asserted that the circumstances of his service as a Navy F-14 pilot resulted in being subjected to significant gravitational forces that, because of airplane seats that were not favorable, negatively impacted his lumbar spine. The Veteran's statements were corroborated by his spouse in correspondence dated in September 2012 and February 2013. A review of the Veteran's service treatment records does not show any treatment for symptoms associated with a lumbar spine disorder during his period of active service. His service personnel records, however, do confirm his military occupational specialty as a Naval Aviator. Following service, the September 2013 VA examination report shows that the Veteran was diagnosed with degenerative joint and disc disease at L3-4 without radiculopathy. The VA examiner opined that the low back disorder was not likely related to a specific exposure event experienced by the Veteran during service in Southwest Asia, but that it was a biomechanical condition that began after service while flying for a commercial airline. The medical evidence of record confirms that the Veteran currently has low back disability manifested by degenerative joint and disc disease of the lumbar spine. Therefore, the next question with respect to general direct service connection is whether the Veteran incurred or aggravated an injury or disease during service. Service treatment records are silent as to any reported symptoms or treatment for a lumbar spine disorder during active service. Moreover, there is no evidence of record establishing a nexus between the Veteran's current lumbar spine disorder and his period of active service. The only medical evidence of record attributes the low back disorder to post-service employment as a commercial airline pilot. The Board finds probative the opinion of the VA medical examiner as it was definitive, based upon a review of the Veteran's entire claims file and post-service diagnostic studies, and supported by a complete rationale. As such, the opinion is found to carry significant probative weight. The Veteran has not provided any competent medical evidence to contradict the opinion of the VA examiner or otherwise diminish its probative weight. The Board recognizes the competent assertions of the Veteran and his spouse. Lay evidence is competent regarding features or symptoms of injury or disease when the features or symptoms are within the personal knowledge and observations of the witness. See Buchanan v. Nicholson, 451 F.3d 1331,1336 (Fed. Cir. 2006); Jandreau, 492 F.3d at 1377; Davidson, 581 F.3d. at 1313. The lay evidence is certainly competent as to the events and symptoms of which there was personal knowledge; and in this regard the Board finds these accounts credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, it is the province of trained health care professionals to enter conclusions that require medical expertise, such as opinions as to diagnosis and causation. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). Turning to direct service connection through chronicity, it is clear that chronicity is not applicable in this case. No chronic disease is shown during service. Lumbar spine problems do not appear to have been present in the nearly 19 years from service separation to the September 2013 VA examination. While there is evidence of chronic cervical spine disability as established above, there is no such evidence regarding the lumbar spine. The probative medical evidence, as discussed above, indicates that the current lumbar spine disorder is the result of post-service employment. Given the medical evidence against the claim, for the Board to conclude that the Veteran's low back disorder was incurred during service would be speculation, and the law provides that service connection may not be based on a resort to speculation or remote possibility. 38 C.F.R. § 3.102 (2017); Obert v. Brown, 5 Vet. App. 30, 33 (1993). Accordingly, the Veteran's claim of entitlement to service connection for a lumbar spine disorder must be denied. Although he is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit-of-the-doubt doctrine is not helpful to a claimant where, as here, the preponderance of the evidence is against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Tinnitus The Veteran asserts that he has tinnitus that is manifested as a result of his period of active service. During the August 2017 Board hearing, he described that his symptoms began in service as a result of his duties as a Navy F-14 pilot and as head Landing Signal Officer for his squadron. He described that he was exposed to the loud noise of jet engines taking off and landing approximately 30 feet away from him. He added that while he had the use of foam inserts in his ears for hearing protection, it was insufficient given the extent of the noise exposure. He added that he began experiencing ringing in his ears during active service, and that he has continued to have ringing ever since. The Veteran's statements were corroborated by his spouse in correspondence dated in September 2012 and February 2013. A review of the Veteran's service treatment records does not show any treatment for symptoms associated with tinnitus during his period of active service. His service personnel records, however, do confirm his military occupational specialty as a Naval Aviator, as such, in-service injury via hazardous noise exposure would be consistent with the circumstances of such service. Following service, a VA examination report dated in August 2013 confirms that the Veteran has a diagnosis of tinnitus. The VA examiner opined that the Veteran did not have a significant pure tone threshold shift beyond normal variability/normal progression while in service, therefore, the reported tinnitus was less likely as not caused by or a result of noise exposure while in service. The Veteran and his spouse have consistently asserted that he has experienced tinnitus ever since his separation from service. The Board observes that, by its nature, tinnitus is a ringing in the ears that can only be detected by the Veteran. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) (providing that ringing in the ears is capable of lay observation). The United States Court of Appeals for Veterans Claims (Court) has held that, where there is of record lay evidence of in-service tinnitus and of tinnitus ever since service and evidence of a current diagnosis, such evidence suffices to indicate that disability may be associated with active service. As such, the Veteran's statements and testimony as to when the ringing in the ears began is important and credible evidence going toward the matter of when the condition began. Given the nature of tinnitus, the Veteran is the only one who is competent to state when he began to perceive such symptoms. The Veteran has credibly stated that his tinnitus began in service and that it has continued thereafter. Here, given the findings of established noise exposure in service and the Veteran's own competent lay testimony of chronic symptoms of tinnitus in service and thereafter, resolving doubt in the Veteran's favor, service connection for tinnitus is warranted. ORDER Service connection for degenerative joint and disc disease of the cervical spine is granted. Service connection for left upper extremity radiculopathy, secondary to service-connected degenerative joint and disc disease of the cervical spine, is granted. Service connection for left hand radiculopathy, secondary to service-connected degenerative joint and disc disease of the cervical spine, is granted. Service connection for a lumbar spine disorder is denied. Service connection for tinnitus is granted. REMAND Unfortunately, a remand is required in this case as to the issue of service connection for a psychiatric disorder, to include depression, PTSD, and sleep disturbance. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. VA has a duty to make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C. § 5103A(a) (West 2012); 38 C.F.R. § 3.159(c), (d) (2017). The Veteran seeks service connection for a psychiatric disorder, to include depression, PTSD, and sleep disturbance. He has asserted a number of stressful events which he says resulted in the onset of his PTSD, to specifically include an incident in September 1993 in which a fellow service member was killed in an aviation mishap while service aboard the USS Abraham Lincoln (CVN-72). In September 2013, the United States Army and Joint Services Records Research Center (JSSRC) verified the Veteran's reported stressful event. A VA examination report dated in August 2013 shows that the VA examiner considered all of the Veteran's reported stressful events, but concluded that there was no sign of any anxiety, depression, psychosis or any other diagnosis on Axis I. and that the Veteran did not suffer from PTSD. A private medical record from D. W. M., received in October 2017, shows that following a brief interview with the Veteran and review of results from a PCL-M (PTSD Checklist-Military version), the Veteran was said to be experiencing and displaying symptoms that support a diagnosis of PTSD as per the DSM-V. It was also noted that the Veteran had not experienced any pre-service trauma that would indicate complex PTSD. Service connection for PTSD may be granted if: (1) A VA psychiatrist or psychologist, or contract equivalent, confirms that the claimed stressor is adequate to support a diagnosis of PTSD; (2) the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service; and (3) the Veteran's symptoms are related to the claimed stressor as determined by the examining VA physician. See 38 C.F.R. § 3.304 (f) (2017). In this case, the Veteran has not been diagnosed with PTSD by a VA examination, but rather was found to have no current disability. A private therapist has since suggested that the Veteran has a diagnosis of PTSD. In light of the foregoing, the Board finds that a remand in in order so as to afford the Veteran a new VA examination by a VA psychiatrist in order to obtain a medical opinion as to whether any currently diagnosed psychiatric disorder was incurred in or aggravated by active service. The VA examiner must determine whether the Veteran has symptomatology that satisfies the required criteria under DSM-V for a diagnosis of PTSD as defined under 38 C.F.R. § 4.125, and if so, whether any such diagnosed disorder is related to the asserted in-service stressful events which are consistent with the Veteran's military occupational specialty and incidents of service. Additionally, as service connection has now been established for a cervical spine disability, and as the Veteran and his spouse have suggested that he has some symptoms associated with a psychiatric disorder as a result of the pain associated with the service-connected disability, on remand, an a opinion should also be offered as to whether the Veteran has a psychiatric disorder, to include depression and sleep disturbance, that is secondary to the service-connected cervical spine disability. Finally, as this matter is being remanded for the reasons set forth above, any additional VA treatment records of the Veteran for his psychiatric disorder should also be obtained. See 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(b); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following action: 1. The AOJ shall ask the Veteran to identify all locations of VA treatment or evaluation for his asserted disability and contact each VA medical facility identified by the Veteran to obtain ongoing medical treatment records pertaining thereto. All records obtained must be associated with the Veteran's claims file. 2. The AOJ shall schedule the Veteran for a VA psychiatric examination, with a VA psychiatrist, to determine the nature and likely etiology of the claimed psychiatric disorder, to include PTSD, depression, and sleep disturbance. The entire claims file, including a copy of this Remand, must be made available to the examiner for review. All tests deemed necessary by the examiner must be undertaken. Based on the examination and record review, the examiner shall provide an opinion as to the following: (a) Is it at least as likely as not that the Veteran has symptomatology that satisfies the required criteria under DSM-V for a diagnosis of PTSD as defined under 38 C.F.R. § 4.125. If so, the examiner is directed to opine to ascertain whether it is at least as likely as not that the PTSD is related to the in-service stressful events that are consistent with the incidents of the Veteran's service. The examiner is directed to specifically comment upon the medical findings of record pertaining to a diagnosis of PTSD related to an in-service stressor event, and express his or her agreement or disagreement therewith. (b) For any other diagnosed psychiatric disorder: (i) Is it at least as likely as not that such had its onset in service, had its onset in the year immediately following any period of service, or is otherwise the result of a disease or injury in service? (ii) Is it at least as likely as not that the Veteran's diagnosed psychiatric disorder was caused (in whole or in part) by a service-connected disability, to specifically include the cervical spine disability? (iii) Is it at least as likely as not that the Veteran's diagnosed psychiatric disorder is aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by a service-connected disability to specifically include the cervical spine disability? If the Veteran's current psychiatric disorder is aggravated by a service-connected disability, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. The absence of evidence of treatment for a particular psychiatric disorder in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. 3. The AOJ will then readjudicate the Veteran's claim. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case. An appropriate period of time should be allowed for response. Thereafter, if appropriate, the case is to be returned to the Board, following applicable appellate procedure. The Veteran need take no action until he is so informed. He has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The purposes of this remand are to obtain additional information and comply with all due process considerations. No inference should be drawn regarding the final disposition of this claim as a result of this action. This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ B. T. KNOPE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs