Complete; the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost, Sharp and radiating pain in the back, arms, legs or shoulders that may worsen with certain activities, even something as simple as coughing or sneezing, Weakness, fatigue, or loss of reflexes in the arms or legs, Numbness or tingling of the skin, pins and needles, or other abnormal sensations (paresthesia) in the arms or legs. What Does Your VA Disability Rating Mean? Radiculopathy VA Rating Criteria Explained, VA Rating for Radiculopathy Lower Extremity, VA Rating for Radiculopathy Upper Extremity, Other Possible Causes or Radiculopathy in Veterans, How Veterans Get a Radiculopathy Diagnosis, VA Disability Rating for Radiculopathy: Special Monthly Compensation for Loss of Use of Hand or Foot. One of the most commonly affected nerves is the sciatic nerve, which causes pain down the back of the thigh into the calf and foot. Lumbar myelopathy is rare but is worth mentioning due to the severity of the condition. Which VA Diagnostic Codes Will Give You The Highest VA Disability Rating. Bone spurs are areas of extra bone growth and they can form It covers vertebrae T1-T12. For example, someone with radiculopathy may also develop arthritis or degenerative disc disease. Heres the brutal truth about VA disability claims: We use cookies to ensure that we give you the best experience on our website. Click the button below to start for FREE. See 38 C.F.R. Secondary Service Connection for Radiculopathy. On occasion, these discs slip out of place or become damaged However, it is important to note that your mental health can also be adversely affected. Brian Reeseis a VA benefits expert, author of the #1 Amazon Bestseller You Deserve It: The Definitive Guide to Getting the Veteran Benefits Youve Earned, andfounder of VA Claims InsiderThe Most Trusted Name in Education-Based Resources for Veterans.. Unfortunately, I was in an accident while on duty, and it injured my back. Today,Brian Reesethe VA Claims Insider reveals and explains the 72 Best Federal Veteran Benefits from A to Z. extension movement but limit rotation. Because of the change of walking gait, often spinal discs can deteriorate more quickly, leading to pain. Because Medical Nexus Evidence is needed to satisfy the third evidentiary element that must be satisfied to prove your secondary VA claim on an at least as likely as not basis. One of the most common secondary conditions related to a back problem is radiculopathy, a type of nerve disability, including sciatica. This data may be used to help optimize our websites and make them easier for you to navigate. are often affected by urinary frequency or incontinence. as Sciatica, is rated under diagnostic codes 8520, 8620, and 8720. Pittsburgh, PA: 201 Penn Center Boulevard, Suite 400, Pittsburgh, PA, 15235 You can file a new, secondary service-connection. Depending on the loss of feeling in your elbow vs. your dominant hand, you might get a different VA rating. However, this condition typically worsens over time, especially if not treated. Radiculopathy is commonly known as a pinched nerve. It can cause sharp pain, weakness, loss of reflexes, or numbness throughout your spine and extremities. Washington, D.C.: 1776 I Street, NW, 9th Floor, Washington, D.C 20006 When radiculopathy occurs in the lower back, it is known as ? New and relevant evidence can be used not only in filing a claim, but also to appeal a negative decision, or to reopen an old claim. VA then assigns a rating based on the levels of functioning and severity, and the affected nerve group. Hi veterans, Brian Reese here with VA Claims Insider, and in this Ultimate Guide, Im going to reveal and explain the Top 100+ VA Disability List of Secondary Conditions. Examples of in-service incidents may include breaking or dislocating a vertebra or suffering physical back strain while training, operating a weapon, lifting equipment, jumping, or completing other military exercises. connected, to include Radiculopathy. lead to narrowing of the space around the nerve roots and subsequent nerve The pinched nerve can cause pain and discomfort for veterans who experience it, and the pain is often experienced as numbness, tingling, or weakness. Do You Qualify for Long Term Disability Benefits? Youve been successfully subscribed to our newsletter! the thoracic area of the spine, which is your middle to upper back. in the spine due to inflammation from osteoarthritis, trauma, and/or other Veterans may be able to claim not only service-connected disability benefits but also secondary service-connection that the Department of Veterans Affairs might have missed. These cookies allow the website to remember choices you make to give you better functionality and personal features. His eBook, the9 Secrets Strategies for Winning Your VA Disability Claimhas been downloaded more than 300,000 times in the past three years and is the #1 rated free VA disability claims guide for veterans. The Appeals Modernization Act (AMA) regulates appeals for denials. I See The Value- How Do I File A Secondary VA Claim? Did you know there are HUNDREDS of common secondary VA claims that you can get service connected by law? HERE to Read About VA Disability Ratings for Spinal Conditions <<. The sciatic nerve is rated under diagnostic codes 8520, 8620, and 8720. involvement; when bilateral, combine with application of the bilateral factor. Common symptoms include: Numbness radiating from the spinal area Physical weakness or pain Radiculopathy is a pinched nerve. Essentially, the spine pinches the root of the nerve. While we still have our home base in Florida, The type of pain can vary from numbness, tingling or burning, and can also range in severity from mild to severe. A higher rating than those currently assigned is only -Tactical Mike. While we still have our home base in Florida, If a veteran with a service-connected back condition also feels numbness, tingling, or pain down one or both of his legs, buttocks, hips, shoulders, arms, or chest, they might be able to claim radiculopathy . These tissues include bones of the spinal vertebrae, tendons and intervertebral discs. For a limited time, you can book a free, no-obligation VA Claim Discovery Call with one of our experts. These symptoms start in your spine and extend into your extremities. An increased rating percentage will make that out of pocket cost worth it. Brooklyn, NY: 300 Cadman Plaza West, One Pierrepont Plaza, 12th Floor, Brooklyn, NY, 11201 But keep in mind, it is not unusual for radiculopathy to affect more than one nerve. Amy Mallette is a Claims Advocate for Hill and Ponton. How to File a Claim on VA.gov (step-by-step)! amputation stump with prosthesis. Can My Disability Rating Be Reduced By The VA? Back conditions are one of the most common medical complaints that the Department of Veterans Affairs sees. Cervical radiculopathy describes a compressed nerve root in His frustration with the8-step VA disability claims processled him to createVA Claims Insider,which provides U.S. military veterans with tips, strategies, and lessons learned for successfully submitting or re-submitting a winning VA disability compensation claim. Our firm was founded in 1986 in Orlando, Florida. If you have both a service-connected back condition and radiculopathy you may be entitled disability benefits for your radiculopathy. The vet may be accompanied by a witness, and they may bring notes about their symptoms and experiences into the exam room. AtVA Claims Insider, we help fellow Veterans celebrateLIFE CHANGEby getting them the VA disability rating and compensationYOU DESERVEby law. Incomplete paralysis of the sciatic nerve (sciatica), if veterans suffer from various back conditions that may or may not be service However, I began to realize the strangest thing: my left hand was numb! See the above sectionSecondary Service Connection for Radiculopathy. Without these cookies, services you have asked for cannot be provided. disease of the lumbar spine, and radiculopathy of the left and right lower Columbus, OH: 100 E. Campus View Boulevard, Suite #250, Columbus, OH, 43235 These secondary conditions can be claimed for additional benefits if the veteran is able to prove that they resulted from the primary condition. disabling. Radiculopathy is a "pinched nerve." Essentially, the spine pinches the root of the nerve. An example is combat PTSD due to constant rocket and mortar attacks in Afghanistan. The Atlas is ring-shaped, and it supports the skull. Richmond, VA: 7400 Beaufont Springs Drive, Suite 300, Richmond, VA, 23225 This will effectively increase your VA disability rating. You can open a new VA claim on the VA.gov website, and file a claim for Migraines Secondary to Tinnitus, and get service connected and rated at 0%, 10%, 30%, or 50% for your Migraine (Headaches), depending on the Frequency, Severity, and Duration of your symptoms as well as how your symptoms negatively affect your work, life, and/or social functioning. to the thoracic spines strength. The MRI does that for them. disabling. and Radiculopathy secondary to lower back pain. Often we have clients with 20% ratings for back disabilities who could qualify for higher ratings for their serious impairments. Copyright 2023 VA Claims Insider, LLC. for Cranial and Peripheral Nerve Condition can be found HERE. This means you do NOT currently have the VA disability rating and compensation YOU deserve, and you could be missing out on thousands of dollars of tax-free compensation and benefits each month. the Thoracic Spine. Keep in mind that a VA rating for radiculopathy is normally determined as a secondary condition, contingent on another spinal disability. We know the pain of feeling stuck, frustrated, and alone, and we want to make this process as easy and painless as possible for you. If you have pain with certain movements, this may help your doctor identify the affected nerve root. Radiculopathy is caused by compressed nerves in the spine and results in pain, numbness, tingling, or weakness along the nerve. If accepted into our ELITE membership program, youll get free up-front access and permission to use $13,119 worth of proprietary VA claim resources, including access to our network of independent medical professionals for medical examinations, disability evaluations, and credible Medical Nexus Letters, which could help you get a HIGHER VA rating in LESS time. Generally, VA disability ratings for back pain range from 10% to 100% and depend upon the frequency, severity, and duration of symptoms, including Painful Motion, Limitation of Range of Motion (ROM), and Functional Loss or Impairment. Many back and neck issues are rated under these generic terms. VA Claims: Sleep Apnea Secondary To PTSD. The VA Rating Decision will indicate if a condition is related to another service-connected disability, such as Peripheral Neuropathy of the Lower Extremity secondary to Diabetes Mellitus. We will discuss this below for your VA claims. These cookies are essential so that you can move around the website and use its features. severe, with marked muscular atrophy is rated as 60 percent disabling. The VA disability appeals process is often long and arduous. Remember, radiculopathy is probably going to be a secondary VA claim. And, youll get to work with a Veteran Coach (VC) who will lead you to VA claim success. Another possible cause of radiculopathy that may lead to The size and shape of each lumbar vertebra is designed to Youll also learn about VA secondary conditions as well as HOW to get your secondary VA claims service connected so you might become eligible for VA disability benefits under the law. Cincinnati, OH: 300 E Business Way, Suite 200, Summit Woods Corporate Center, Cincinnati, OH, 45241 In 2022, VA ratings for Radiculopathy typically range from 0% to 70%, depending upon the severity of your symptoms. The degree of severity, represented by a percentage, corresponds to the monthly compensation a vet receives. show the remaining conditions as secondary to multiple sclerosis. Generally, VA measures severity by first determining if the veteran suffers from: However, symptoms often overlap, and evaluations of paralysis, neuritis, and neuralgia can be confusing and inconsistent. We are sorry that this post was not as useful for you! 4.124a, Diagnostic Code 8510. However, a few years after he was granted service connection, he was diagnosed with radiculopathy of his lower extremities due to his service-connected degenerative disc disease. paralysis under Diagnostic Code 8510. percent disabling for both the major and minor side. vertebrae into many different areas of your body. Portland, OR: 650 N. E. Holladay Street, Suite 1600, Portland, OR, 97232 There are some good news however because veterans may be eligible to receive disability compensation for conditions the VA recognizes as a secondary due to your service-connected back condition. If a nerve condition affects both sides of the body (such as both arms or legs), VA should issue a rating for each side and an additional bilateral factor. Myelopathy is a back condition that is caused from a previous trauma or injury. In my experience, this type of service connection is uncommon. I have a cervical sprain rated at 20% and a thoracolumbar sprain also rated at 20%. Signup to never miss a beat with special offers, blog updates, exclusive trainings, and more delivered right to your inbox! Pro Tip: A Nexus Letter is HIGHLY RECOMMENDED to help establish secondary service connection. Schedule for Rating Disabilities apply: These six back conditions can often lead to pinched or damaged a bulging orherniated The sciatic nerve, which is the largest nerve in your body, known What is service connection through aggravation, and can it apply to radiculopathy? This storage is often necessary for basic functionality of the web site or the storage may be used for the purposes of marketing, analytics, and personalization of the web site such as storing your preferences. In addition, I have four ratings for secondary radiculopathy (10% each for lower extremities and 20% each for upper extremities). When the involvement is wholly sensory, the rating should be In accordance with 38 CFR 3.310 current disability condition that is proximately due to or the result of a service-connected disease or injury shall also be service connected. narrowing of foramina is bone spurs. The determination will be made on the basis of the actual How to Get a 100 Percent VA Rating (if deserved)! There are three types of radiculopathy: Lumbar . What Does Your VA Disability Rating Mean? The AMA has been the VAs appeal system since 2019. The middle and upper back area is your thoracic spine and See 38 C.F.R. The first cervical vertebra (C1) is called the Atlas. infections and various cancerous and noncancerous growths in the spine that may Box 449, Deland, FL 32721, Orlando, FL: 605 E. Robinson Street Suite 635, Orlando, FL 32801 Calluses. Dont delay! wider and broader than similar components in the cervical and thoracic regions. Urinary dysfunctions are issues that often fly under the radar in veterans. Cleveland, OH: 600 Superior Ave. East, Fifth Third Building, Suite 1300, Cleveland, OH, 44114 A few examples of these secondary conditions or complications are radiculopathy, myelopathy, urinary incontinence and/or frequency along with mental health conditions as well. The VA can order a clarification from the examiner, or even order a new exam with a different examiner. A showing of causation requires that the secondary VA disability claim is proximately due to or aggravated by another service-connected disability. Patients also may experience numbness, weakness, or loss of reflexes in the legs. Brian Reeseis a VA benefits expert, author of the #1 Amazon Bestseller You Deserve It: The Definitive Guide to Getting the Veteran Benefits Youve Earned, andfounder of VA Claims InsiderThe Most Trusted Name in Education-Based Resources for Veterans.. This problem is most likely to occur in your lower back, but Radiculopathy is a nerve condition that can cause pain, numbness, and weakness in the arms and legs. These structures make the thoracic spine more stable than They are not intended as a guarantee that we will obtain the same or similar results in every case we undertake. The symptoms and location can vary, and the particular area and nerve affected can impact a veterans VA disability rating for radiculopathy. As a fellow disabled Veteran this is shameful and Im on a mission to change it. paralysis of the radicular group of the major extremity, and a 40 percent If your service-related stenosis causes a secondary condition, that condition would be rated separately by the VA. Secondary Service Connection and related conditions that can be secondary VA claims are the primary focus of this eBook! the neck (cervical spine). likely to occur. This refers to disabilities or death that result from hospital care, medical or surgical treatment, or examination by a VA medical professional or facility, or due to participation in a program of vocational rehabilitation. For veterans looking to increase their VA rating for a radiculopathy condition, knowledge is key. Subscribe to our newsletter and join 15,472 other subscribers. well as different names depending on where in the spine it occurs. As a Claims Advocate, she works with attorneys and peers to review and gather evidence to help veterans receive the benefits they so deserve. Amy joined Hill & Ponton in June of 2019 with that same goal. the lower back area is your lumbar spine. How to Get a 100 Percent VA Rating (if deserved)! yet assertive representation for our clients. Radiculopathy is a condition that occurs when the nerves in the spinal cord are damaged, irritated, or compressed. Examples of in-service incidents may include: Veterans do not necessarily need to trace their radiculopathy to one single active-duty incident. Your VA doctor or private physician may take several steps Extraschedular Ratings for VA Disability Claims. Please call for an appointment before visiting: Mail Processing Center: P.O. (Of course, I would first see if the VA or your private health insurance is willing to pay for it). spine to the pelvis. Together, the Atlas and Axis enable the head to rotate and For example, does your service connected knee injury cause you to overuse your other knee? Once the regional office (RO) issues its determination, the veteran has a year to file an appeal. These cookies collect information about how you use our website. Underfederal law, a preexisting condition is presumed aggravated if that condition: A veteran need not show that a certain incident during service aggravated the disabilityonly that it became worse during service. The secondary conditions are one of the main reasons you want to work with a certified VA disability lawyer. Pro Tip: While you are not required to provide a Nexus to establish presumptive service connection, its highly recommended that you at least write a personal statement as to WHY you think your disability meets the legal requirements for presumptive service connection. This website adheres to the W3Cs AA Accessibility guidelines. The highest possible VA disability rating for Radiculopathy, across all radicular groups, with complete paralysis, is 90%. Additionally, a secondary disability claim can increase your benefits if a new condition arises from your current service-connected disability. The skilled attorneys at Chisholm Chisholm & Kilpatrick LTD may be able to help you navigate it. Service Connection by Aggravation: What If You Were Diagnosed With Radiculopathy Before Service? Developed new symptoms? However, a VA rating for Sciatica can range from 10% to 80%, depending upon the severity of symptoms. Furthermore, a veteran may receive separate VA ratings of The sacrum fits between the two hipbones connecting the Similarly, does your Traumatic Brain Injury cause depression? The MRI gives a rater proof of any damage to the spine, and that damage is typically where your radiculopathy starts. These cookies are necessary for the website to function and cannot be switched off in our systems. Youre telling the VA that your current disability condition is the direct result of your active duty military service. Symptoms of radiculopathy include radiation of pain from the lower back down into the legs, often described as a sharp-shooting, electric pain. The rating is 20% for mild symptoms and up to 50% for severe symptoms. control sensations in your arms and hands, this is where the symptoms are most 60 percent rating for the minor side. Chicago, IL: 332 S. Michigan Avenue, Floors 8 and 9, Chicago, IL 60604 Cervical radiculopathy is when a veteran has a pinched nerve in their neck. C. Lumbar radiculopathy: This starts in the lower back. It contains vertebrae L1-L5. Subsequently, I learned I had radiculopathy in my hand. (b) Complete paralysis of the external popliteal nerve (common peroneal) and consequent, footdrop, accompanied by characteristic organic changes including trophic and circulatory disturbances and other concomitants confirmatory of complete paralysis of this nerve, will be taken as loss of use of the foot. When you visit web sites, they may store or retrieve data in your web browser. A common cause of radiculopathy is . Otherwise, the denial stands. Are You Stuck, Frustrated, and Underrated? Nerve roots split from the cord and travel between the Not so fast. Dear Veteran, Heres the brutal truth about VA disability claims: According to our data, 8/10 (80%) of veterans reading this message right now are underrated by the VA. A secondary disability is. Aggravation ratings work slightly differently than primary and secondary service connection ratings, depending on the initial severity of the condition compared to the present level of severity. You file for radiculopathy ratings after you are already rated for the back or neck. By continuing to use our website, you agree to these updates. T1 is Radiculopathy is most often rated under CFR 38, Part 4, VA Schedule of Ratings, diagnostic codes 8510, 8610, and 8710 for the upper and middle radicular groups. Whether you are filing a new claim or dealing with a denied claim, the highly experienced staff at Hill and Ponton is here to advise, support, and represent you. Tucson, AZ: One South Church Avenue, 12th Floor, Tucson, AZ, 85701 Copyright 2023 Hill & Ponton, P.A.. All Rights Reserved. Thickening (ossification) of the spinal ligaments may also It can cause sharp pain, weakness, loss of reflexes, or numbness throughout your spine and extremities. Contact Us We have updated our Privacy Policy. For sciatica, for example, in radiculopathy of the lower back, the VA appliesrating criteriaspecific to the sciatic nerve (diagnostic code 8720), and assigns a disability percent rating on whether the neuralgia is moderate or mild. Myelopathy is often accompanied by radiculopathy, but is a separate condition. There are three key elements that must be satisfied to prove VA secondary service connection under the law: The FIRST part can be satisfied with any existing medical evidence in service treatment records, VA medical records, or any private medical records. Brian isalso the CEOofMilitary Disability Made Easy, which is the worlds largest free searchable database for all things related to DoD disability and VA disability claims and has served more than 4,600,000 military members and veterans since its founding in 2013. Each of these is a secondary VA claim. compression. For instance, which pages you go to most. Top 72 Federal Veteran Benefits From A to Z (2024 Edition), Can I Get a VA Rating for Depression Secondary to Tinnitus? 5110(g) and . Cookies help us deliver the best experience on our website. A 2023 Guide to VA Disability Rates & Pay Schedules, Individual Unemployability Rating Calculator, List of Blue Water Navy Ships Exposed to Agent Orange (Interactive Vietnam Map), Social Security Disability Benefits Guide, commonly affected nerves is the sciatic nerve, which causes pain down the back of the thigh into the calf and foot, Veteran with low back conditions such as degenerative disc disease, back injuries, it is common for other parts of the body or bodily functions to be affected by secondary conditions to back pain, https://www.ncbi.nlm.nih.gov/books/NBK430837/, www.hopkinsmedicine.org/health/conditions-and-diseases/myelopathy, Veteran Substance Abuse and VA Disability Benefits, Secondary Service Connection for Medical Issues Related to Back Problems. Philadelphia, PA: 1 International Plaza, Suite 550, Philadelphia, PA, 19113 Hear from fellow Veterans just like you, with many of our Business Development Representatives having gone through our programs. Examples of secondary conditions associated with neck pain include radiculopathy, due to a compressed nerve in the cervical spine, and migraine headaches . Toe Deformities. Amy Mallette, Claims Advocate Updated: June 21, 2020. Veterans must prove secondary service connection if their first service-connected condition causes a different disability or makes an existing disability worse. For example, a veteran is service-connected for degenerative disc disease of the lumbar spine. All information these cookies collect is aggregated and therefore anonymous. Top 72 Federal Veteran Benefits From A to Z (2024 Edition), How to Download Your VA Benefit Letters Online (5-Step Process). . Many It is possible to prove service-connection for radiculopathy. Brian is a Distinguished Graduate of Management from theUnited States Air Force Academy, Colorado Springs, CO and he holds an MBA from Oklahoma State Universitys Spears School of Business, Stillwater, OK, where he was a National Honor Scholar (Top 1% of Graduate School class). Pittsburgh, PA: 201 Penn Center Boulevard, Suite 400, Pittsburgh, PA, 15235 VA ratings for upper extremity radiculopathy is rated Today,Brian Reesethe VA Claims Insider reveals and explains the 72 Best Federal Veteran Benefits from A to Z. Immediately below the sacrum are five additional bones, If these conditions are directly linked to a combat-related disability, they would also be considered combat-related. There is a Today Im talking about my va claim and how to connect sleep apnea secondary to PTSD. Finally, we invite you to contact us and we welcome your calls, letters and electronic mail. Under these characterizations, each nerve has its own disability rating for each level of severity. This condition is commonly caused byback conditionssuch as herniated discs, stenosis, and bone spurs. There are many reasons why veterans would want to obtain a current VA disability letter with What is Radiculopathy for VA Disability Rating Purposes? But first, lets explore how the VA looks at Radiculopathy or more, will be taken as loss of use of the hand or foot involved. nerve roots, which can cause significant pain known as Radiculopathy. Due to the nature of back injuries, it is common for other parts of the body or bodily functions to be affected by secondary conditions to back pain. Pro Tip: A medical nexus letter is highly recommended to help you prove secondary service connection under the law. pursuant to 38 C.F.R. Examples include certain chronic debilitating diseases, diseases specific to radiation exposure, diseases associated with herbicide agents (to include Blue Water Veterans), Persian Gulf War Veterans, and Camp Lejeune Veterans. 4.23) are rated as 70 percent We advocate for the disabled. The most trusted name in education-based resources for Veterans. Let us know. To succeed with this service-connection claim, a vet must show a current medical diagnosis of radiculopathy that is linked to the in-service occurrence of the radiculopathy, or an in-service incident that caused or aggravated the radiculopathy. This information is not a substitute for legal advice. Increasingly, the examiners useDisability Benefits Questionnaires, which independent medical experts can also fill out. Since 2016, VA Claims Insider has helped thousands of Veterans just like you get the VA rating and compensation they deserve in less time. To clarify, I have a combined 40% for back and neck sprains. This can develop from a condition such as spinal stenosis, degenerative disc disease, and in some cases neurologic conditions. Lumbar radiculopathy is a common condition among veterans. Symptoms of radiculopathy include radiation of pain from the lower back down into the legs, often described as a sharp-shooting, electric pain. 203, San Jose, CA 95134 In moderate neuralgia, typical of a radiculopathy diagnosis, a veteran experiences numbness, and tingling, and moderate to severe pain. Imaging tests, such as an X-ray, CT scan or MRI scan, are used to better see the structures in the problem area. Rating nerve conditions also involves identifying the nerve involved. turn. your spinal cord runs through a canal in the center of these bones. The term incomplete paralysis, with this and other Contactour office for a free case evaluation today at800-544-9144. For VA disability purposes, the four regions listed below will be considered when it comes to your final VA rating for Radiculopathy. Los Angeles, CA: 10880 Wilshire Blvd., Ste 1101, Los Angeles, CA 90025 Radiculopathy is typically caused by changes in the tissues surrounding the nerve roots. Other key evidence may include a medical experts professional opinion that the service-connected condition (low back strain, for example) caused the radiculopathythus indicating a secondary service-connected disability. Cincinnati, OH: 300 E Business Way, Suite 200, Summit Woods Corporate Center, Cincinnati, OH, 45241 The examiners report to the VA Regional Office (RO), where the decision is made.
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