Citation Nr: 1806795 Decision Date: 02/01/18 Archive Date: 02/14/18 DOCKET NO. 10-36 129 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an initial disability rating in excess of 10 percent prior to July 24, 2017, and 20 percent thereafter, for status post lumbar surgery with degenerative joint disease and intervertebral disc syndrome (IVDS). 2. Entitlement to a disability rating in excess of 10 percent prior to July 24, 2017, and 20 percent thereafter, for degenerative arthritis of the cervical spine. 3. Entitlement to a compensable initial disability rating for status post right thumb surgery with degenerative joint disease. 4. Entitlement to a compensable initial disability rating for status post hammertoe surgery of the right fifth digit. 5. Entitlement to a compensable initial disability rating for status post hammertoe surgery of the left fifth digit. 6. Entitlement to a compensable initial disability rating for gastroesophageal reflux disease (GERD), prior to July 24, 2017, and in excess of 10 percent thereafter. REPRESENTATION Veteran represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD Jeremy J. Olsen, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from September 1987 to September 2009. These matters come before the Board of Veterans' Appeals (Board) on appeal of rating decisions issued in January 2010 and February 2015 by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. These matters were previously before the Board in March 2017, at which time they were remanded for further development. Since that remand, in a November 2017 rating decision, the VA Appeals Management Center awarded service connection for a right leg disability, a matter which was previously before the Board. As this action was a full grant of a benefit being sought on appeal, the appeal as to that issue is terminated and it is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). In that same decision, the Veteran was granted a 20 percent disability rating for status post lumbar surgery with degenerative joint disease and IVDS, and for degenerative arthritis of the cervical spine, both effective July 24, 2017. The Veteran has not expressed satisfaction with the ratings assigned for either of the disabilities, for the assigned periods; therefore, the issues have been characterized to reflect that "staged" ratings are assigned, and that each stage remains on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). FINDINGS OF FACT 1. For the initial rating period prior to July 24, 2017, the Veteran's status post lumbar surgery with degenerative joint disease and IVDS was manifested by a decreased range of motion and pain, more nearly approximating flexion greater than 60 degrees, without muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spine contour. 2. Subsequent to July 24, 2017, the Veteran's status post lumbar surgery with degenerative joint disease and IVDS has not manifested forward flexion of 30 degrees or less due to pain or favorable ankylosis of the entire thoracolumbar spine. 3. Prior to July 24, 2017, the Veteran's cervical spine disability was manifested by subjective complaints of pain and stiffness and objective findings of forward flexion in excess of 30 degrees; there was no evidence of disc disease with incapacitating episodes. 4. For the entire appeal period, the Veteran's status post right thumb surgery with degenerative joint disease is manifested by pain and limitation of motion, resulting in no more than mild functional loss, without symptomatology that more nearly approximates limitation of thumb motion resulting in a gap of more than 2 inches (5.1 cm) between the thumb pad and the fingers with the thumb attempting to oppose the fingers, or unfavorable ankylosis. 5. The Veteran's service-connected bilateral hammertoe affects only the fifth digit on each foot. 6. From July 24, 2017, the Veteran's cervical spine disability has been manifested by subjective complaints of pain and stiffness and objective findings of forward flexion in excess of 15 degrees; there is no evidence of disc disease with incapacitating episodes. 7. As of May 15, 2015, the Veteran experienced nausea, vomiting, epigastric burning, and dysphagia due to his service-connected GERD. 8. At no point during the appeal did the Veteran's GERD produce symptoms which caused considerable impairment of health. CONCLUSIONS OF LAW 1. For the initial rating period prior to July 24, 2017, the criteria for a disability rating in excess of 10 percent for status post lumbar surgery with degenerative joint disease and IVDS, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107, 7104 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5243 (2017). 2. Subsequent to July 24, 2017, the criteria for a rating in excess of 20 percent for status post lumbar surgery with degenerative joint disease and IVDS have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107, 7104 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5243 (2017). 3. The criteria for an initial rating in excess of 10 percent for degenerative arthritis of the cervical spine, prior to July 24, 2017, are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5242-5241)(2017). 4. The criteria for a rating in excess of 20 percent for degenerative arthritis of the cervical spine, from July 24, 2017, are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5242-5241)(2017). 5. The criteria for an initial 10 percent rating, but no higher, for status post right thumb surgery with degenerative joint disease have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5228 (2017). 6. The criteria for a compensable disability rating for service-connected bilateral hammertoe are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.31, 4.40. 4.45, 4.71a, DC 5282 (2017). 7. As of May 15, 2015, the criteria for an initial disability rating of 10 percent, but no higher, for GERD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7346 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). Neither the Veteran in this case nor his representative has referred to any deficiencies in either VA's duty to notify or to assist; therefore, the Board may proceed to the merits of the claims. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct.3, 2016) (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 [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). Additionally, the Board finds that the development requested in the March 2017 remand has been accomplished. In this regard, in that remand, the RO was instructed to update the Veteran's treatment records and to arrange for him to undergo VA examinations. Additional medical records were added to the file and, in July 2017, the Veteran underwent multiple VA examinations. Therefore, the Board finds that there has been substantial compliance with the instructions of its March 2017 remand. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). Analysis Decisions rendered by the Board of Veterans' Appeals must be based on the entire record, with consideration of all evidence therein. 38 U.S.C. § 7104. The law requires only that the Board address its reasons for rejecting evidence which is favorable to the claimant. Timberlake v. Gober, 14 Vet. App. 122 (2000). While the Board must review the entire record, it does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. While the Veteran's entire history is reviewed when assigning a disability evaluation, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, the United States Court of Appeals for Veterans Claims (Court) has since held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2017). The Court has held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. 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. Burton v. Shinseki, 25 Vet. App. 1 (2011). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Back The Veteran's status post lumbar surgery with degenerative joint disease and IVDS (hereinafter, "lumbar spine disability") has been rated under Diagnostic Code 5243 for IVDS. A review of the medical evidence of record also demonstrates that Diagnostic Code 5003 for degenerative arthritis of the spine is also applicable. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The General Rating Formula provides a 10 percent rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of entire spine. Note (2) provides that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. See also Plate V, 38 C.F.R. § 4.71a. When rating degenerative arthritis of the spine (DC 5242), in addition to consideration of rating under the General Rating Formula, rating for degenerative arthritis under DC 5003 should also be considered. 38 C.F.R. § 4.71a. In June 2009, the Veteran underwent a VA back examination. At that time, he reported stiffness, numbness, and chronic pain. There was no loss of bladder or bowel control. The pain was elicited by physical activity and stress. The Veteran was unable to run, lift weights, jump, sit, walk or stand for more than 30 minutes. The Veteran's posture and walk were found to be normal, and no assistive devices were required for ambulation. On examination, there was no evidence of radiating pain on movement, tenderness, or muscle spasm. No ankylosis was present. Range of motion was measured at 90 degrees flexion, 30 degrees extension, right and left lateral flexion at 30 degrees, and right and left rotation at 30 degrees. The joint function of the spine was additionally limited by pain after repetitive use, without fatigue, weakness, lack of endurance and incoordination. There was no additional limitation in degree. IVDS was noted, without lumbosacral motor weakness or associated bowel, bladder or erectile dysfunction. X-ray imaging showed degenerative disc disease. In multiple statements to VA, the Veteran described severe back pain. He indicated that he was unable to lift or bend due to the pain. In turn, this made activities such as gardening impossible. In February 2010, the Veteran was seen at a private hospital for lower back pain. He denied numbness, weakness or paresthesia. His symptoms were worsened by lifting, bending, sitting, coughing or standing and improved by heat and medication. The back pain would "come and go." On examination, there was no tenderness or muscle spasm. Lateral rotation and forward flexion were not painful. Extension resulted in pain. In April 2010, the Veteran was seen at a private emergency room for a lumbosacral strain. In September 2010, he was seen at an Army hospital with complaints of pain in his back. At that time, tenderness was noted and pain was elicited by flexion. A full range of motion of the spine was demonstrated. In September 2010, the Veteran presented at the emergency department of a private hospital for the evaluation of lower back pain of 5 days' duration. The Veteran reported that his back pain was worsened by walking. The Veteran was prescribed medication and released. In April 2012, the Veteran was seen at a private emergency department for lower back pain, after his primary care doctor was unavailable. It was determined that the Veteran had pulled a muscle doing yardwork the day before. On examination, there was some tenderness in the lower back and the Veteran was diagnosed with lumbosacral strain. The evidence of record shows that, as of August 2013, the Veteran's back pain was being treated with injections. In April 2016, the Veteran underwent a VA back examination. At that time, the diagnosis of degenerative arthritis of the spine was confirmed. The Veteran denied flare-ups, but indicated that he was precluded from repetitive bending and heavy lifting due to his back. On examination, range of motion was measured at 80 degrees flexion and 30 degrees extension. Right and left lateral flexion was 30 degrees, and right and left lateral rotation was 20. Pain was noted, but neither it nor the measured range of motion was found to contribute to functional loss. The Veteran was able to perform repetitive use testing with at least 3 repetitions, without additional loss of function or range of motion. Muscle spasm of the back was noted, but it did not result in abnormal gait or abnormal spine contour. Localized tenderness and guarding were absent. There was no ankylosis present. In July 2017, the Veteran again underwent a VA back examination. He reported continued pain which occurred when he sat, stood or walked for too long. He reported decreased activity due to the pain. Range of motion testing showed flexion at 60 degrees, extension at 25, right lateral flexion at 20, left lateral flexion at 30, right lateral rotation at 25 and left lateral rotation at 30. The examiner determined that this range of motion itself contributed to a functional loss, in that the Veteran had difficulty reaching and bending. There was evidence of pain with weight bearing, and objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the spine. The Veteran was able to perform repetitive use testing with at least three repetitions without loss of function or range of motion. Guarding was found in all directions of range of motion; muscle spasm was absent. There was no ankylosis present. The examiner confirmed the Veteran's diagnosis of IVDS and noted there had been no episodes of acute signs and symptoms due to the condition which required bed rest prescribed by a physician, or treatment by a physician, within the past year. It was noted that the Veteran used a brace, constantly, when ambulating outside the home. Upon review of all the evidence of record, both lay and medical, the Board finds that a rating in excess of 20 percent is not warranted for the period prior to July 24, 2017. The evidence of record shows that the Veteran has not met the criteria for a 20 percent rating, as outlined in DC 5243; that is, demonstrated forward flexion of the lumbar spine greater than 30 percent but not greater than 60 percent, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spine contour. In the VA examinations prior to July 2017, forward flexion was measured at 90 degrees (June 2009) and 80 degrees (April 2016). In addition, the June 2009 examiner expressly found that there was no muscle spasm or guarding present. The April 2016 examiner found that there was muscle spasm, but there was no resulting abnormal gait or spine contour. Thus, the criteria for a rating in excess of 20 percent for the lumbar spine disability for the period prior to January 24, 2017, have not been met. For the period subsequent to that date, the Board finds that the criteria for an increased, 40 percent rating have also not been met. In order to qualify for a 40 percent rating after that date, the evidence of record would need to demonstrate forward flexion of the thoracolumbar spine at 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. The evidence clearly shows that the Veteran's forward flexion was 60 degrees when last measured, and that there is no evidence in the record of ankylosis at any point. Therefore, the Board finds that an increased rating for the Veteran's back disability, under DC 5243, is not warranted. The Board has also considered the Veteran's reported impairment of function, such as limited ability to walk long distances, stand for prolonged periods of time, lift objects or bend, and a decreased range of motion due to pain. Even considering additional limitation of motion or function of the lumbar spine due to pain or other symptoms such as weakness, fatigability, or incoordination, the evidence still does not show that the lumbar spine disability more nearly approximates the criteria for a higher rating of 20 percent. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, supra. However, as noted above, each of the VA examiners conducted repetitive testing and none found additional limitation in motion. Thus, any additional limitation due to pain does not more nearly approximate a finding of limitation of flexion of the thoracolumbar spine to degree that would warrant a higher rating at any time during the appeal. 38 C.F.R. § 4.45, 4.59, 4.71a, Diagnostic Code 5243; DeLuca, supra; Mitchell, supra. As such, a higher rating based on pain and functional loss is not warranted. Next, the Board has considered whether a higher rating is warranted under Diagnostic Code 5243, as it pertains to the Veteran's diagnosed IVDS. The Formula for Rating IVDS provides a 10 percent rating for incapacitating episodes having a total duration of at least 1 week but less than 2 weeks during the past 12 months. A 20 percent rating requires incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating requires incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months. A 60 percent rating requires incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. For purposes of this Formula, an incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1). The Board finds that the lay and medical evidence of record does not demonstrate that the Veteran has sustained any incapacitating episodes during the past 12 months at any point during the appeal. Therefore, the Board finds that a higher rating is not warranted under Diagnostic Code 5243 for IVDS. Finally, the Board observes that the Veteran was found to have degenerative arthritis of the lumbar spine. Diagnostic Code 5003 allows for the assignment of a disability rating when there is X-ray evidence of such, with involvement of 2 or more major joints or 2 or more minor joint groups, with evidence of occasional incapacitating exacerbations. However, because limitation of motion of the lumbar spine has been rated under DC 5243, a separate rating for the same painful limitation of motion or limitation of motion during flare-ups under DC 5003 is prohibited because it constitutes pyramiding with ratings under the General Rating Formula, which rates on limitation of motion and the same or similar impairments that limit the same functions of the back. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Therefore, for these reasons, the Board finds that the weight of the evidence is against a finding that the Veteran's lumbar spine disability warrants an evaluation in excess of 10 percent prior to July 24, 2017, and in excess of 20 percent thereafter. Neck The rating for the Veteran's degenerative arthritis of the cervical spine (hereinafter, "cervical spine disability") has been assigned under 38 C.F.R. § 4.71a, DC 5237. Under DC 5237, a 10 percent rating is warranted when there is forward flexion of the cervical spine greater than 30 degrees but not greater than 20 degrees, or a combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour or, vertebral body fracture with loss of 50 percent or more of height. A rating of 20 percent is warranted where forward flexion of the cervical spine is found to be greater than 15 degrees, but not greater than 30 degrees or combined range of motion of the cervical spine not greater than 170 degrees, or muscle spasm or guarding enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis. A 30 percent rating is assignable where forward flexion of the cervical spine is 15 degrees or less; or, when there is favorable ankylosis of the entire cervical spine. A higher, 40 percent, rating is assignable for unfavorable ankylosis of the entire cervical spine. For the maximum, 100 percent rating, there must be unfavorable ankylosis of the entire spine. See 38 C.F.R. § 4.71a, DCs 5235-5243. Under the rating schedule, forward flexion to 45 degrees, extension and lateral rotation to 45 degrees, and rotation to 80 degrees bilaterally are considered normal range of motion of the cervical spine. "Combined range of motion" is the sum of the ranges of forward flexion, extension, left and right lateral flexion, and left and right lateral rotation. Normal combined range of motion of the cervical spine is 340 degrees. 38 C.F.R. § 4.71a, General Rating Formula, Note 2, and Plate V. In June 2009, the Veteran underwent a VA neck examination. He reported stiffness and numbness of the neck, without loss of bladder and bowel control. Pain was present in the neck, and elicited by physical activity and stress. The pain radiated to the Veteran's left arm, hand and fingers. The pain was elicited by physical activity, stress, and movement. It was treated with over-the-counter medication. Examination showed no evidence of radiating pain on movement or muscle spasm. There was no evidence of tenderness, and no ankylosis present. Range of motion testing showed flexion at 45 degrees, extension at 45 degrees, right and left lateral flexion at 45 degrees each, and right and left rotation both at 80 degrees. The joint function of the spine was additionally limited by pain after repetitive use, but not by fatigue, weakness, lack of endurance and incoordination. There was no additional limitation in degree. X-ray testing showed the presence of degenerative arthritis. In March 2010, the Veteran was seen for treatment related to his hand. At that time, the neck was examined and found to have full range of motion. In May 2012, the Veteran was seen at VA for a physical. At that time, examination of his neck showed no loss of range of motion or pain. In September 2012, the Veteran emailed his doctor with complaints of neck pain of multiple-day duration. In August 2014, the Veteran again underwent a VA examination of his neck. At that time, the diagnosis of degenerative arthritis was confirmed. The Veteran denied flare-ups. Range of motion testing showed forward flexion at 40 degrees, right and left lateral flexion at 45 degrees or greater, Right lateral rotation at 75 degrees, and left lateral rotation at 80 degrees. Testing revealed no evidence of painful motion. The Veteran was able to perform repetitive-use testing with 3 repetitions without any additional limitation in range of motion. There was no tenderness, pain to palpation, guarding or muscle spasm. Muscle strength was normal, and radiculopathy was absent. IVDS of the cervical spine was not found. The examiner found that the Veteran's posture was within normal limits, as was his gait. The examiner found that there were no contributing factors such as weakness, fatigability, incoordination or pain that could additionally limit the functional ability of the cervical spine. In September 2014, the Veteran was treated for neck pain. At that time, flexion in his neck was measured at 50 degrees, extension was 45 degrees, and left and right rotation was at 60 degrees each. X-ray testing showed moderate degenerative joint disease of the neck. Poor forward posture and tightness in all neck potions were noted. In a December 2014 statement, the Veteran explained that he experienced severe neck pain and loss of range of motion, which caused him to have problems when driving a car. In December 2014, the Veteran began physical therapy for his neck. In a March 2015 physical therapy treatment note, the Veteran's neck range of motion was measured at 30 degrees of extension, while flexion and rotation were within full limits. The author of the note indicated that the Veteran displayed a "markedly greater" range of motion while observed in the clinic, compared to his range of motion while under direct examination. In March 2015, the Veteran underwent a physical at VA. At that time, he reported experiencing neck pain. In June 2015, the Veteran underwent an examination of his neck. At that time, the Veteran reported stiffness of the neck and a decreased range of motion. Range of motion testing showed forward flexion and extension at 45 degrees, right and left lateral flexion at 45 degrees each, and right and left lateral rotation at 45 degrees each, as well. The Veteran was able to perform repetitive-use testing without a change in range of motion. Pain was noted, both in weight bearing and non-weight bearing. Localized tenderness was noted. Guarding was present, and bilaterally symmetric. Gait and spinal contour were normal. Functional loss was noted as less movement than normal, excess fatigability, and pain on movement. Increased pain was found when the joint was used repeatedly over a period of time. No muscle atrophy or ankylosis was present. Radiculopathy was noted in the upper extremities. IVDS of the cervical spine was noted, and was treated with physical therapy and medication. The examiner found that the total duration of all incapacitating episodes in the previous year was at least 6 weeks. Imaging studies at the time showed arthritis. The Veteran was diagnosed with severe spondylosis of the cervical spine. Also in June 2015, the Veteran was seen for the treatment of neck pain. In a January 2017 statement, the Veteran indicated that it took him 20 minutes to get out of bed each morning, due to his neck pain, and that he was unable to sit for longer than 20 minutes without experiencing neck pain. In April 2017, the Veteran was seen at VA for neck pain, which was treated with a TENS unit. In July 2017, the Veteran underwent a VA neck examination. At that time, he reported experiencing flare-ups which caused increased pain, as well as numbness in his hands. The Veteran found it difficult to drive, as he was unable to turn his head. Range of motion testing showed forward flexion at 20 degrees, extension at 40 degrees, right and left lateral flexion at 25 degrees each, and right and left lateral rotation at 45 degrees. Pain was noted on examination, which caused functional loss. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. Guarding was noted, but it did not result in an abnormal gait or abnormal spine contour. Mild radiculopathy was noted in the upper extremities. Ankylosis was absent. IVDS was confirmed, without any episodes of acute signs and symptoms which required bed rest prescribed by a physician and treatment by a physician in the previous 12 months. The Veteran used no assistive devices. Degenerative joint disease was noted. Based on the evidence above, the Board finds that a rating higher than 10 percent is not warranted for the period prior to July 24, 2017. In order to meet the criteria for a 20 percent rating, forward flexion of the cervical spine is greater than 15 degrees but not greater than 30 degrees. The Veteran's forward flexion was measured at 45 in June 2009, 40 in August 2014, 50 in September 201, 30 in December 2014 (with allegations of malingering), and 45 in June 2015. As the Veteran's cervical flexion was greater than 30 degrees at all points prior to July 24, 2017, a higher rating for the cervical spine is not warranted during this time period. With regard to the rating for the Veteran's cervical spine disability after July 24, 2017, the Board finds that a rating in excess of the assigned 20 percent is also not warranted. As noted, under the General Rating, the next higher 30 percent rating is assignable where forward flexion of the cervical spine is 15 degrees or less; or, when there is favorable ankylosis of the entire cervical spine. Significantly, none of the medical evidence of record documents findings of ankylosis of the cervical spine. Furthermore, none of the evidence of record documents findings of forward flexion of the cervical spine of 15 degrees or less. The only forward flexion measurement taken in this time period was taken at the July 2017 VA examination, and it was found to be 20 degrees. Based on that measurement, the 20 percent was granted as of the date of the examination. As the Veteran's cervical flexion is greater than 15 degrees beginning July 24, 2017, a higher rating for the cervical spine is not warranted during this time period. The Board has also considered whether a higher disability rating is warranted at any point during the appeal, based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, supra; Mitchell, supra. As noted in the various reports above, the Veteran was able to accomplish the noted range of motion, even with pain. While VA examiners and treating doctors found pain to be present, at times causing functional loss, the Board finds that the Veteran's currently-assigned ratings contemplate the effects of complaints of pain. Accordingly, the Board finds that consideration of other factors of functional limitation does not support the grant of any higher rating than the ones already assigned, as there is no evidence that pain effectively resulted in cervical spine forward flexion limited to 30 degrees prior to July 24, 2017 or 15 degrees beginning on that date. As such, the Board finds that there exists no basis for the assignment of any higher rating for the Veteran's cervical spine disability under DeLuca. With respect to IVDS, the record reflects that the Veteran has been diagnosed IVDS of the cervical spine. Other than the June 2015 examination, there has been no indication that at any point during the appeal period the Veteran has had any incapacitating episodes of IVDS in a 12 month period. No other lay statements or clinical reports, to include the VA outpatient reports, or private treatment reports, indicate that the service-connected cervical spine disability has resulted in incapacitating episodes of IVDS having a total duration of at least two or four weeks during a 12 month period. As for the June 2015 examination, in which the examiner found that the Veteran had been prescribed bed rest for over 6 weeks in the previous year, such a finding is not borne out by the medical evidence of record, to specifically include treatment records documenting the year prior to the examination. See Horn v. Shinseki, 25 Vet. App. 231, 239 (2012); LeShore v. Brown, 8 Vet. App. 406 (1995). Therefore, the Board finds that there were no incapacitating episodes of any duration during the appeal period and a higher rating based on IVDS is not warranted. Additionally, the General Rating Formula for Diseases and Injuries of the Spine indicates that all neurologic abnormalities associated with a service-connected spine disability shall be separately evaluated under an appropriate DC. 38 C.F.R. § 4.71a, DCs 5235-5242, Note (1). Here, there are indications that the Veteran experiences radiculopathy that is related to his cervical spine disability. However, he is separately service connected for the disability and, as such, no further discussion of a separate evaluation is warranted. Finally, the Board notes that the Veteran was found to have degenerative arthritis of the cervical spine at multiple points throughout the appeal. As noted above, Diagnostic Code 5003 allows for the assignment of a disability rating when there is X-ray evidence of such. Here, limitation of motion of the cervical spine has been rated under DC 5237, and thus a separate rating for the same painful limitation of motion under DC 5003 is prohibited because it constitutes pyramiding with ratings under the General Rating Formula. 38 C.F.R. § 4.14; Esteban, supra. Right Thumb The Veteran's service-connected status post right thumb surgery with degenerative joint disease (hereinafter, "right thumb disability") is rated under 38 C.F.R. § 4.71a, DC 5228. Under DC 5228, a noncompensable disability rating is warranted for limitation of motion of the major thumb with a gap of less than 1 inch between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A 10 percent disability rating is warranted under DC 5228 for limitation of motion of the major thumb with a gap of one to two inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A maximum 20 percent rating under DC 5228 is warranted for limitation of motion of the major thumb with a gap of more than two inches between the thumb pad and the ringers, with the thumb attempting to oppose the fingers. In determining disability ratings, DC 5228 makes no differentiation between the major and minor hands. In addition, as there is x-ray evidence of degenerative arthritis in the Veteran's right thumb, the Board will also consider a rating under Diagnostic Code 5003. Under that code, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. When, however, the limitation of motion is non-compensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joints or two or more minor joint groups, will warrant a rating of 10 percent; in the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings will not be combined with ratings based on limitation of motion. Under 38 C.F.R. § 4.45 (f), for the purpose of rating disability from arthritis, the only major joints are the shoulder, elbow, wrist, hip, knee and ankle. Additionally groups of multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities; the interphalangeal, metatarsal and tarsal joints of the lower extremities; the cervical vertebrae; the dorsal vertebrae; and the lumbar vertebrae, are considered groups of minor joints, ratable on parity with major joints. 38 C.F.R. § 4.45 (f). Compensable evaluations are also warranted with objective evidence of ankylosis of the thumb. See 38 C.F.R. § 4.71a, Diagnostic Code 5224. In June 2009, the Veteran underwent a VA examination. At that time, the Veteran reported constant pain in his right thumb, which was elicited by physical activity and relieved by rest and over the counter medication, as needed. He also reported a loss of mobility due to the pain, and weakness. The Veteran was unable to open containers easily, or grip with his right thumb. On examination, there was no gap between the pad of the right thumb and fingers. Range of motion testing showed pain upon flexion. The joint function of the right thumb was found to be limited by pain after repetitive use. X-rays taken at the time revealed degenerative joint disease. In July 2017, the Veteran again underwent a VA examination of his right thumb. At that time, the Veteran reported that he was unable to use his thumb to tie his shoes. Range of motion testing was abnormal, and found to contribute to functional loss. A gap of 2 centimeters was found between the thumb pad and fingers of the right hand. Pain was noted on examination, and found to cause functional loss. No ankylosis was found. X-ray testing showed degenerative joint disease. Based on the foregoing, and resolving all doubt in the Veteran's favor, the Board finds that an initial 10 percent rating is warranted for the Veteran's right thumb disability. As noted above, a compensable, 10 percent rating is warranted under Diagnostic Code 5228 for a gap of at least 1 to 2 inches (2.5 to 5.1 cm) between the thumb pad and the fingers with the thumb attempting to oppose the fingers. In this case, the gap between the Veteran's right thumb pad and fingers was found to be less than 1 inch. However, the Board must take into account the additional limitations the Veteran experiences due to such symptoms as pain. DeLuca, supra; Burton, supra; 38 C.F.R. §§ 4.40, 4.59. It is the intention of the rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. §4.59. In this regard, both the June 2009 and July 2017 VA examinations revealed objective evidence of pain, along with a limitation of right thumb flexion. Furthermore, Veteran has consistently reported having pain and difficulty grasping objects throughout the pendency of the appeal. As such, the Board accepts that the Veteran has additional limitations on the functionality of his thumb due to such symptoms as pain. Accordingly, a 10 percent rating is warranted under Diagnostic Code 5228 based on a limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5228. In assigning this 10 percent rating, the Board has given consideration to the Veteran's complaints of pain affecting his thumb. In increased rating claims, an appellant's lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See e.g., Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010); see also Washington v. Nicholson, 21 Vet. App. 191, (2007) (to the effect that "as a layperson, the appellant is competent to provide information regarding the visible, or otherwise observable, symptoms of disability"). However, the record clearly indicates that a higher disability rating is not warranted under Diagnostic Code 5228. In order to assign the next-higher, 20 percent rating under this diagnostic code, the medical evidence must show a gap of more than 2 inches between the Veteran's right thumb pad and fingers when attempting to oppose his fingers. As noted above, the gap between the Veteran's right thumb pad and opposing fingers was measured in July 2017 at less than an inch. Thus, he does not meet the criteria for a higher rating under Diagnostic Code 5228. Similarly, a disability rating in excess of 10 percent is not warranted any other applicable diagnostic code. The Veteran does not have ankylosis of the thumb, as noted in the June 2009 and July 2017 VA examinations. As such, a rating in excess of 10 percent for ankylosis, under Diagnostic Code 5224, is not warranted. The Board finds that a compensable rating under Diagnostic Code 5003 is also not appropriate in this case. While there is evidence of arthritis, the Board highlights that that the Veteran has been granted a compensable rating based on a limitation of motion of his right thumb. Moreover, the thumb constitutes only one minor joint group. See 38 C.F.R. § 4.45. Diagnostic Code 5003 requires X-ray evidence of arthritis in two minor joint groups in order for a 10 percent rating to be assigned. Therefore, even with demonstrated arthritis, a compensable disability rating cannot be assigned under Diagnostic Code 5003. Bilateral Hammertoes The Veteran's service-connected bilateral hammertoes are rated under Diagnostic Code 5282. Under that code, hammertoe of a single toe of the foot is rated as noncompensably disabling, or 0 percent. Unilateral hammertoe of all toes, without claw foot, is rated 10 percent disabling. 38 C.F.R. § 4.71a. The 10 percent rating is the highest available under the code. In June 2009, the Veteran underwent a VA examination. The Veteran reported pain in both small toes, of a constant nature. There was no weakness, stiffness or fatigue. Examination of the feet showed no edema, disturbed circulation, weakness, atrophy of the musculature, tenderness, heat, redness or signs of deformity. There was no pes planus, pes cavus, Morton's metatarsalgia, hallux valgus or hallux rigidus. No functional limitation of standing or walking was found, and no corrective shoe wear was necessary. X-ray imaging showed abnormalities, due to the surgery to the little toe, bilaterally. In July 2017, the Veteran again underwent a VA examination in relation to his toes. At that time, the Veteran reported improved pain but a complete loss of active range of motion of the fifth digits. Examination showed hammertoes which had been corrected, surgically, without residuals signs or symptoms. Pain was noted on examination, which was found to contribute to functional loss. There was less movement than normal, with pain on weight bearing. Flare-ups were absent. The Board finds that the evidence of record does not support a finding that a compensable rating is warranted under DC 5282. As noted above, in order to justify an increase to 10 percent disabling, the evidence must show the presence of unilateral hammertoe of all toes, without claw foot. 38 C.F.R. § 4.71a. Critically, VA examination and treatment records indicate that the Veteran's hammertoe is present only in the fifth digit of each foot. The evidence does not demonstrate, nor has the Veteran contended, that he suffers from hammertoe of more than one toe. As such, a compensable rating is not warranted for bilateral hammertoe based upon the applicable diagnostic criteria. The weight of the evidence is also against a finding of a higher rating under any other Diagnostic Code. The Veteran is separately service connected for flat foot. The record shows no diagnosis of weak foot or claw foot, so evaluation under Diagnostic Codes 5276-5278 is not warranted. In addition, there exists no evidence of any malunion or nonunion of the feet, so evaluation under DC 5283 is, likewise, not warranted. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, a compensable evaluation for the Veteran's service-connected hammertoes is not warranted based on functional loss due to pain or weakness. While the Veteran has reported pain throughout the appeal, such complaints do not, when viewed in conjunction with the other evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. See Deluca, supra. The July 2017 VA examiner, while acknowledging the presence of pain, specifically found that there was no weakness, fatigability, pain or incoordination that significantly limited the Veteran's functional ability during flare-ups or when the foot was used over a period of time. As such, a compensable rating is not warranted based on functional loss due to pain or weakness. Thus, the Board finds that the preponderance of the evidence is against a compensable disability rating for bilateral hammertoes. GERD The Veteran's service-connected GERD is rated under 38 C.F.R. § 4.114, Diagnostic Code 7399-7346 (rated by analogy to a hiatal hernia). The Board notes that GERD is not among the listed conditions in the Rating Schedule. When an unlisted condition is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2017)(when an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" by using the first two digits of that part of the rating schedule which most closely identifies the part, or system, of the body involved and adding "99" for the unlisted condition). Under Diagnostic Code 7346, a 10 percent disability rating is warranted for a hiatal hernia with two or more of the symptoms required for a 30 percent rating, which are of lesser severity than is required for a 30 percent rating. A 30 percent rating requires persistently recurrent epigastric distress with dysphagia (trouble swallowing), pyrosis (heartburn), and regurgitation accompanied by substernal, arm, or shoulder pain, which is productive of considerable impairment of health. A 60 percent rating requires symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Disability ratings assigned under Diagnostic Codes 7301 to 7329 (inclusive), 7331, 7342, and 7345 to 7348 (inclusive) will not be combined with each other. Instead, a single disability rating will be assigned under the diagnostic code which reflects the veteran's predominant disability picture with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114, Diagnostic Code 7346. In December 2014, the Veteran underwent a VA examination for GERD. At that time, the Veteran reported experiencing reflux. He denied dysphagia, pyrosis or regurgitation. No arm or shoulder pain was reported. Examination showed no scars, stricture, spasm or acquired diverticulum. In a March 2015 VA treatment note, the Veteran reported that his GERD symptoms had improved with the use of medication. He reported severe reflux at that time. In a May 2015 VA treatment note, the Veteran was seen with complaints related to GERD. He reported nausea, vomiting, epigastric burning, and dysphagia. Examination showed a possible stricture. He was prescribed Tylenol for treatment of the symptoms experienced. A June 2015 esophagogastroduodenoscopy (EGD) revealed a normal hypopharynx, esophageus, stomach and duodenum. The Veteran was found to have mild systemic disease, well controlled by medication. It was recommended that the Veteran continue his medication and alter his diet. In his January 2017 substantive appeal, the Veteran appears to contest the VA's finding that his GERD was related to his hypertension medication, a fact noted in the February 2015 rating decision which granted service connection. The Veteran indicated that his GERD was not caused by the medication, as GERD had been present since the 1990's, before he took such medications. The Board notes that to the extent the Veteran disagrees with the basis on which he was granted service connection, or the effective date of such, such points are moot, as service connection for GERD has been established, with an effective date of June 27, 2014, the date the claim for service connection was received by VA. See 38 U.S.C. § 5110 (a) (2012); 38 C.F.R. § 3.400 (2017)(the effective date of an award of service connection is the date the claim was received or the date entitlement arose, whichever is later). In July 2017, in response to the Board's March 2017 remand, the Veteran underwent a VA GERD examination. At that time, he reported persistently recurrent epigastric distress, dysphagia, reflux, regurgitation, and substernal pain. He indicated that the condition caused sleep disturbances on 4 or more occasions per year; nausea on 4 or more occasions per year; and vomiting twice a year. On examination, no esophageal stricture, spasm of esophagus, or an acquired diverticulum of the esophagus was noted. In a December 2017 statement, the Veteran indicated that no matter how much medication he took, his GERD was not improving. Based on the evidence of record, the Board finds that the Veteran arguably met the criteria for a 10 percent rating as of May 15, 2015. On that date, the medical evidence of record shows he was experiencing nausea, vomiting, epigastric burning, and dysphagia. Under DC 7346, a 10 percent disability rating is warranted for a hiatal hernia with two or more of the symptoms required for a 30 percent rating. Here, the Veteran was experiencing epigastric distress with dysphagia and heartburn. There were no reports of regurgitation accompanied by substernal, arm, or shoulder pain, which is productive of considerable impairment of health; thus, while the Veteran meets the criteria of a 10 percent rating as of that date, he does not meet the criteria for a 30 percent rating. Similarly, he does not meet the rating criteria for a higher, 30 percent rating at any point after May 15, 2015. While he reported epigastric distress with dysphagia and substernal pain at the July 2017 VA examination, there was no indication that his GERD was productive of considerable impairment of health. At that examination, he reported occasional sleep disturbances, nausea and vomiting, each lasting less than a day and occurring at various points throughout the previous year. A review of the medical treatment notes of record show no health impairment due to GERD, other than the constant use of medication. The record shows multiple visits to the Veteran's primary care physician for medication refills and issues related to his joints, rather than GERD; his gastrointestinal system was examined in November 2017 and found to be normal. Thus, the Board finds that while the Veteran experiences GERD symptoms on occasion throughout the year, they do not cumulatively produce considerable impairment to his health and a rating in excess of 10 percent is not warranted at any time during the period after May 15, 2015. 38 C.F.R. §§ 4.3, 4.7. Other Considerations Finally, in assessing the severity of the Veteran's multiple service-connected disabilities listed above, the Board has considered his assertions regarding his symptoms, including pain, which he is competent to provide. See e.g. Layno v. Brown, 6 Vet. App. 465, 470 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and have been contemplated by the disability ratings that have been assigned. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the Veteran's disabilities. As such, while the Board accepts the Veteran's statements with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected disabilities. The Board has considered whether further staged ratings under Hart, supra, are appropriate for the Veteran's disabilities; however, the Board finds that his symptomatology has not approximated the criteria for increased ratings at any point in the appeal period other than as set forth above. Therefore, staged ratings are not warranted. In reaching each of the foregoing conclusions concerning the Veteran's claims for increased ratings for his service-connected disabilities, the Board has taken into consideration the doctrine of reasonable doubt. 38 U.S.C. § 5107 (b). However, excluding the increased rating granted for the Veteran's right thumb and GERD, the Board finds that the preponderance of the evidence is against each of the Veteran's claims, and the doctrine of reasonable doubt is not for application herein. See Gilbert, supra; Ortiz, supra. ORDER An initial disability rating in excess of 10 percent prior to July 24, 2017, and 20 percent thereafter, for status post lumbar surgery with degenerative joint disease and intervertebral disc syndrome (IVDS), is denied. A disability rating in excess of 10 percent prior to July 24, 2017, and 20 percent thereafter, for degenerative arthritis of the cervical spine, is denied. An initial disability rating of 10 percent, for status post right thumb surgery with degenerative joint disease, is granted. A compensable initial disability rating for status post hammertoe surgery of the right fifth digit is denied. A compensable initial disability rating for status post hammertoe surgery of the left fifth digit is denied. A disability rating of 10 percent for gastroesophageal reflux disease (GERD) is warranted from May 15, 2015. A compensable initial disability rating for GERD prior to May 15, 2015, and in excess of 10 percent thereafter, is denied. ____________________________________________ R. FEINBERG Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs