Citation Nr: 1427642 Decision Date: 06/18/14 Archive Date: 06/26/14 DOCKET NO. 09-03 331A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial rating in excess of 60 percent for coronary artery disease (CAD), from September 1, 2007. 2. Entitlement to a rating in excess of 20 percent for diabetes mellitus, type II with glucosuria, and hypertension. 3. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right upper extremity. 4. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the left upper extremity. 5. Entitlement to a rating in excess of 10 percent for diabetic neuropathy of the right lower extremity. 6. Entitlement to a rating in excess of 10 percent for diabetic neuropathy of the left lower extremity. 7. Entitlement to an initial compensable rating for diabetic retinopathy. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD T. Adams, Counsel INTRODUCTION The Veteran served on active duty from May 1968 to May 1970. These matters are on appeal from a March 2008 decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In December 2010 the Veteran and his spouse testified before a Veterans Law Judge (VLJ) who has since retired. A transcript is of record. As VA regulations require that the VLJ who conducted the hearing must participate in any decision made on appeal, the Veteran was offered a new hearing before a new VLJ in a November 2013 letter. The letter noted that if no response was received within 30 days the Board would assume the Veteran did not want another hearing and proceed accordingly. The Veteran did not respond to the hearing clarification letter, and as such the Board will continue to adjudicate this appeal. In February 2011, this case was remanded for further development. Pursuant to that Remand, a May 2012 Decision Review Officer (DRO) decision granted service connection and assigned a noncompensable rating for diabetic retinopathy, effective from March 28, 2011. Accordingly, this matter is recharacterized as stated on the title page. However, as will be further addressed in the Remand section below, this matter requires further development. Additional evidence was included in the record after the agency of original jurisdiction (AOJ) last considered the issues on appeal in May 2012. However, in a November 2013 Informal Hearing Presentation, the Veteran, through his representative, waived AOJ consideration of that evidence. In the Introduction of the February 2011 Remand, the Board observed that in correspondence received in September 2010, the Veteran raised claims for service connection for acute renal failure, sleep apnea, back pain, and knee pain. At that time, issues of entitlement to service connection for acute renal failure, sleep apnea, a back disorder, and a knee disorder had not been adjudicated by the Agency of Original Jurisdiction (AOJ) and were referred to the AOJ for appropriate action. As it does not appear that these issues have yet been addressed, they are again referred to the AOJ. 38 C.F.R. § 19.9(b) (2013). In addition, in an October 2012 DRO decision, a TDIU was granted from March 26, 2010. The Veteran did not file a timely notice of disagreement with the effective date assigned. However, in the November 2013 Informal Hearing Presentation, the Veteran, through his representative, requested an effective date earlier than March 26, 2010, for the award of TDIU. As this matter has been raised by the record, but has not been adjudicated by the AOJ, the Board does have jurisdiction over this matter, and it is also referred to the AOJ for appropriate action. Id. The issue of entitlement to an initial compensable rating for diabetic retinopathy is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. The preponderance of the evidence indicates that the Veteran's coronary artery disease (CAD) has not resulted in chronic congestive heart failure, a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of less than 30 percent. 2. The preponderance of the evidence indicates that the Veteran's diabetes mellitus, type II has been manifested by the need for oral hypoglycemic agents and a restricted diet. 3. The preponderance of the evidence indicates that the Veteran's hypertension has not been manifested by diastolic pressure readings predominantly 100 or more, nor was systolic pressure predominantly 160 or more. 4. The preponderance of the evidence indicates that the Veteran's glucosuria has not been manifested by constant or recurrent albumin with hyaline and granular casts or red blood cells, transient or slight edema, or hypertension at least 10 percent disabling under Diagnostic Code 7101. 5. The Veteran underwent amputation of the left fourth toe with metatarsal involvement secondary to his service-connected diabetes mellitus. 6. Resolving any doubt in the Veteran's favor, his service-connected peripheral neuropathy of both the left and right upper extremity demonstrates moderate incomplete paralysis of all radicular groups. 7. The preponderance of the evidence indicates that the Veteran's service-connected diabetic neuropathy of the both the right and left lower extremity more closely approximates moderate incomplete paralysis of the posterior tibial nerve. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 60 percent for CAD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 4.7, 4.104, Diagnostic Codes (DCs) 7017 and 7005 (2013). 2. The criteria for a rating in excess of 20 percent for diabetes mellitus, type II, have not been met; the criteria for a separate compensable rating for glucosuria associated with diabetes mellitus have not been met; the criteria for a separate compensable rating for hypertension associated with diabetes mellitus have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.104, DC 7101, 4.115b, DC 7541, 4.119, DC 7913 (2013). 3. A separate 20 percent rating for amputation of the left fourth metatarsal secondary to service-connected diabetes mellitus is warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, DC 5172 (2013). 4. The criteria for a rating of 40 percent, but no greater, for peripheral neuropathy of the right (major) upper extremity, have been met. 38 U.S.C.A. §§ 1155, 5107 3A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.1-4.7, 4.124a, DCs 8513, 8515 (2013). 5. The criteria for a rating of 30 percent, but no greater, for peripheral neuropathy of the left (minor) upper extremity, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.1-4.7, 4.124a, DCs 8513, 8515 (2013). 6. The criteria for a rating in excess of 10 percent for peripheral neuropathy of the right lower extremity, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.1-4.7, 4.124a, DCs 8599-8525 (2013). 7. The criteria for a rating in excess of 10 percent for peripheral neuropathy of the left lower extremity, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.1-4.7, 4.124a, DCs 8599-8525 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VCAA Duties to Notify & to Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). None is found by the Board. The appeal for an increased rating for CAD arises from disagreement with the initial evaluation following the grant of service connection for CAD. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Regardless, the RO provided notice as to how VA assigns disability ratings in a letter sent to the Veteran in January 2008. With regard to the claims for an increased rating for diabetes mellitus, type II; peripheral neuropathy of the upper extremities, and diabetic neuropathy of the lower extremities, the RO advised the Veteran of what the evidence must show to establish entitlement to an increased rating in a notice letter sent in January 2008, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. Moreover, the RO explained how VA determines the disability rating and effective date of a disability once service connection has been established, which satisfied Dingess notice requirements. No further development is required regarding the duty to notify. Regarding VA's statutory duty to assist in claims development, the record reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the claims. Pertinent medical evidence associated with the claims files consists of service and VA treatment records and VA examinations in February 2008 and in March 2011, pursuant to the Board's February 2011 Remand. The Board finds that the February 2008 and March 2011 VA examinations are adequate for adjudication purposes. These VA examination reports are comprehensive and adequately address the Veteran's cardiac, diabetic, orthopedic, and neurologic symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board recognizes that the last pertinent VA examinations are now over three (3) years old. The mere passage of time since those examinations is not reason enough, alone, to require reexamination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). Here, there is no objective evidence indicating that there has been a material change in the severity of the cardiac, diabetic, orthopedic, and neurologic disabilities since the March 2011 VA examinations. The Veteran has not argued the contrary. The Veteran was afforded a hearing before a Veterans Law Judge in December 2010 in which he presented oral argument in support of his claims. The Veteran and his spouse testified. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2013) requires that the veterans law judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. The Board finds that both duties were met during the hearing. It was clear during the hearing that the Veteran had a full understanding of the issues on appeal. The Veteran's Law Judge elicited testimony regarding the severity of the Veteran's disabilities. The Veteran's testimony triggered the Board's decision to remand the matter to obtain the above-referenced VA examinations and additional treatment records. For the above reasons, the Board finds that, consistent with Bryant, VA has complied with the duties set forth in 38 C.F.R. § 3.103 (c) (2) and that the Board can adjudicate the claims based on the current record. It must be noted that neither the Veteran nor his representative have asserted that VA failed to comply with the provisions of 38 C.F.R. § 3.103(c) (2) nor identified any prejudice in the conduct of the Board's December 2010 hearing. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims adjudicated herein. VA has complied with all duties to notify and assist required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159. VA has also substantially complied with the Board's remand directives in further developing the Veteran's claims. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999). II. Increased Ratings Generally Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (2002). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). In cases in which a reasonable doubt arises as to the appropriate degree of disability to be assigned, such doubt shall be resolved in favor of the Veteran. See 38 C.F.R. § 4.3 (2013). VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App. 119 (1999). In this case, the evidence of record does not establish additional, distinct time periods in which the issue on appeal resulted in symptoms that would warrant staged ratings. 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. See 38 C.F.R. § 4.7 (2013). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). A. Coronary Artery Disease (CAD) Historically, the RO granted service connection and assigned a temporary total disability rating based on surgical or other treatment necessitating convalescence following coronary bypass surgery effective from May 29, 2007, the date of the claim for service connection, and assigned a 60 percent rating from September 1, 2007. Therefore, as the maximum rating has been assigned for the Veteran's CAD for the period from May 29, 2007, to August 31, 2007, the issue before the Board is the propriety of the 60 percent rating assigned for CAD from September 1, 2007. The Veteran's CAD has been rated as 60 percent disabling pursuant to 38 C.F.R. § 4.104, under Diagnostic Code 7005, which contemplates coronary artery disease. The record reflects that the Veteran underwent coronary bypass surgery which is considered by Diagnostic Code 7017. However, the rating criteria under either Diagnostic Code 7005 or Diagnostic Code 7017 are the same for a 30 percent rating, a 60 percent rating and a 100 percent rating. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year; or a workload of greater than 3 METs but not greater than 5 METs with dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Status post coronary bypass surgery resulting in chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent, is rated 100 percent disabling. 38 C.F.R. § 4.104, Diagnostic Codes 7005, 7017. One MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). Turning to the merits of the claim, on VA heart examination in February 2008, the Veteran presented with a history of a three-vessel bypass and graft in May 2007 and complained of constant incision pain. The Veteran complained of incision pain and a chest scar and of pain in the left lateral chest area. He denied having a heart attack, but complained of chest tightness and fatigue which led him to see a cardiologist. He was unable to walk more than one-half mile and was unable to ride a bicycle. However, he denied any angina. There was no evidence of trauma to the heart, cardiac neoplasm, myocardial infarction, congestive heart disease, rheumatic heart disease, hypertensive heart disease, syphilitic heart disease, endocarditis, pericarditis, syncope, angina, dizziness. However, he had constant fatigue and dyspnea that was mild on exertion. Due to the Veteran's recent CABG surgery, the examiner stated that it was not realistic to subject Veteran to a test that was not clinically indicated and may cause harm so he stated that exercise testing was medically contraindicated. The estimated level of activity resulting in dyspnea, angina, dizziness, or syncope was from 3 to 5 mets with ejection fraction from 60 to 65 percent. The examiner also estimated that per the Veteran's statement of abilities, he was unable to climb more than 10 stairs, walk more than one-half mile, push and pull more than 10 pounds, or ride a bicycle due to chronic fatigue and dyspnea. Testing for LV dysfunction indicated an ejection fraction of greater than 50 percent. Heart size was normal. The examiner diagnosed CAD status post times 3 vessel CABG which had no effect on recreation, traveling, feeding, bathing, dressing, toileting and grooming; a mild effect on shopping; and a severe effect on exercise and sports. In April 2008 statements in support of claim, the Veteran's friend stated that prior to the Veteran's CABG with 3-vessel bypass in May 2007, he was a very active individual. However, since the surgery, the Veteran had become extremely fatigued with even the slightest activity such as walking from the car to the house. She stated that the Veteran's physical condition had deteriorated significantly since his surgery. The Veteran's spouse stated that he slept a lot, was unable to complete tasks like washing his truck and mowing the lawn, and became dizzy when bending down. VA treatment records dated from September 2007 to June 2009 reflect an ejection fraction of no less than 42 percent. Specifically, a May 2009 stress test indicated diminished left ventricular systolic function with an ejection fraction of 42-45 percent. Diagnostic testing in June 2009 indicated chest pain, dyspnea, and rule out major stenosis. The conclusions were normal systemic pressures, normal systolic function including ejection fraction of 60 percent, and severe multiple vessel CAD. In an April 2010 statement, the Veteran's spouse stated that he experienced dizziness, chest discomfort, and fatigue. During the December 2010 hearing, the Veteran testified that he had additional heart surgery in November 2008. His wife testified that his heart condition had deteriorated since the placement of his stents and that he was unable to walk long distances without stopping due to dizziness, disorientation, and confusion. In March 2011 statements, the Veteran and his spouse stated that he had a very large, lumpy, and painful pink scar on his chest. It was noted that the Veteran had continued complaints of dyspnea, dizziness, and confusion. On VA heart examination in March 2011, the Veteran presented with a history of CABG surgery in May 2007, an angioplasty and coronary stent in 2008 and diagnostic cardiac catheterization in June 2009. There was no history of myocardial infarction, rheumatic fever, hypertensive heart disease, heart rhythm disturbance, valvular heart disease including prosthetic valve, congestive heart failure, other heart disease, syncope, fatigue, or dyspnea. No continuous medication for heart disease was required. There was no history of dyspnea, non-anginal chest pain, hemoptysis, fever, anorexia, or night sweats. There was a well-healed postoperative scar over the mid-sternum that was 12 inches long with no evidence of pain or keloid formation. Stress test indicated 3 to 5 METS and the Veteran's heart size was normal on echocardiogram. LV dysfunction was 45 percent. The examiner diagnosed CAD with history of CABG, PTCA, stents and stable exertional angina. Due to the Veteran's dyspnea and chest pain on exertion, the Veteran could only perform light chores around the house. On VA general medical examination in March 2011, the examiner opined that the severity of the Veteran's multiple multivessel CAD precluded substantially gainful or physical or sedentary employment. VA treatment records include an August 2012 report which is negative for heart failure and stated that in May 2011 LVEF was 40 to 45 percent with mildly depressed LV systolic function with EF of 45 percent. On review of the evidence, the Board finds that a rating in excess of 60 percent for the Veteran's service-connected CAD is not warranted at any time during the pendency of the Veteran's appeal. The evidence of record does not demonstrate chronic congestive heart failure, a workload of 3 METs or less, or left ventricular dysfunction with an ejection fraction of less than 30 percent. Crucially, the Board notes that records of VA treatment subsequent to the February 2008 VA examination reflect ejection fraction ranging from 42 to 60 percent. As noted above, the left ventricular ejection fraction has been in excess of 30 percent for the entire period of the appeal. Therefore, the Board finds that the medical evidence does not support the next higher schedular rating of 100 percent at any time during the pendency of the appeal, as the overall symptomatology more nearly approximates the criteria for a rating of 60 percent. Finally, the Board has considered whether a separate rating can be assigned for Veteran's chest scar which resulted from the 2007 surgery. However, a separate compensable rating for the Veteran's scar is not warranted as neither the February 2008 or March 2011 VA examination or treatment records have shown that the chest scar is deep or causes limited motion and cover areas at least six square inches (39 sq. cm.); is superficial and does not cause limited motion and cover areas of 144 square inches (929 sq. cm.) or greater; is superficial and unstable; or causes other disabling affects. Therefore, the criteria for a compensable rating for a surgical scar of the chest have not been met. 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805 (as in effect prior to October 23, 2008). See 73 Fed. Reg. 54,710 (Sept. 23, 2008). Therefore, the Board finds that the preponderance of the evidence is against the claim for an initial rating in excess of 60 percent for CAD, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. B. Diabetes Mellitus with Glucosuria and Hypertension The Veteran's diabetes mellitus, type II has been rated 20 percent disabling under Diagnostic Code 7913. Under this Diagnostic Code, a 20 percent rating is assigned for diabetes mellitus requiring insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet. A 40 percent rating is assigned for diabetes mellitus requiring insulin, a restricted diet, and regulation of activities. A 60 percent rating is assigned for diabetes mellitus requiring insulin, a restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A maximum 100 percent rating is assigned for diabetes mellitus requiring more than one daily injection of insulin, a restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Id. Note (1) to DC 7913 provides that compensable complications of diabetes will be evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Non-compensable complications are considered part of the diabetic process. Note (2) to DC 7913 states that, when diabetes mellitus has been diagnosed conclusively, a glucose tolerance test should not be requested solely for rating purposes. See 38 C.F.R. § 4.119, DC 7913, Notes (1), (2) (2013). "Regulation of activities" has been defined as the situation where the Veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,446 (May 7, 1996) (defining "regulation of activities," as used by VA in DC 7913). Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360 (2007). Turning to the merits of the claim, on VA diabetes mellitus examination in February 2008, the Veteran stated that his insulin requirements had changed since the last VA examination and that he was on 70/30 insulin with a fasting glucose around 140 on average. His course of treatment included two types of insulin. He had hypoglycemic reactions or ketoacidosis which did not require hospitalization. The Veteran did not attend visits to see a diabetic care provider for treatment of his diabetes. He was instructed to follow restricted or special diet with no restriction on the performance of strenuous activities. The Veteran's diabetes reportedly had no effect on chores, shopping, recreation, traveling, feeding, bathing, dressing, toileting, grooming, or driving and only a moderate effect on exercise and sports. In December 2010, the Veteran testified that he was on a restricted diet and took two forms of insulin. He indicated that he was required to exercise and had not been hospitalized due to his diabetes mellitus. On VA diabetes mellitus examination in March 2011, it was noted that his insulin requirements continued to gradually increase. However, there were no episodes of hypoglycemia reactions or ketoacidosis. He was instructed to follow a restricted or special diet and was unrestricted by his ability to perform strenuous activities. The examiner diagnosed poorly-controlled diabetes mellitus, type II, with microalbuminuria and glucosuria without evidence of significant renal impairment. On review of the evidence, the Board finds that a rating in excess of 20 percent for the Veteran's service-connected diabetes mellitus is not warranted at any time during the pendency of the appeal. The threshold requirement for a 40 percent rating is regulation of activities. Camacho v. Nicholson, 21 Vet. App. 360 (2007). In order to meet a higher rating of 40 percent, the Veteran must have been told to avoid any strenuous occupational or recreational activities. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2013). While the evidence shows that the Veteran was prescribed insulin and placed on a restricted diet, the evidence does not indicate that the Veteran has been prescribed or advised to avoid strenuous occupational and recreational activities, as is required in order to merit a higher rating of 40 percent. Rather, the evidence tends to indicate that physical activity and exercise were encouraged. Specifically, on VA examination in February 2008 and March 2011, the Veteran was not restricted in his ability to perform strenuous activities. In addition, there were no periods of ketoacidosis or hospitalization for treatment of his diabetes mellitus. Therefore, the Board finds that the medical evidence does not support a rating greater than 20 percent for the Veteran's service-connected diabetes mellitus at any time during the pendency of the appeal, as his overall symptomatology more nearly approximates the criteria for a rating of 20 percent. As regards hypertension, Diagnostic Code 7101 provides that a 10 percent rating is warranted for diastolic pressure predominately 100 or more; systolic pressure predominately 160 or more, or if there is a history of diastolic pressure predominately 100 or more and the individual requires continuous medication for control. 38 C.F.R. § 4.101. A review of VA treatment records dated from March 2007 to August 2012, and VA examinations in 2008 and 2011 reveal systolic pressure that ranged from 110 to 158, with a reading of 161 on only two occasions in June and October 2009. Diastolic pressure ranged from 62 to 93, with a reading of 98 on one occasion in May 2007. As the record does not reflect that the Veteran's diastolic pressure has predominantly been 100 or more of that his systolic pressure has predominantly been 160 or more, a separate compensable rating under DC 7101 is not warranted. As regards glucosuria or renal disease, renal dysfunction manifested by albumin and casts with history of acute nephritis; or, hypertension non-compensable under diagnostic code 7101, is rated noncompensable. Renal dysfunction with constant albumin or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under diagnostic code 7101 warrants a 30 percent rating. With constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under diagnostic code 7101, a 60 percent rating is warranted. Renal dysfunction with persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion warrants an 80 percent rating. Renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular warrants a 100 percent rating. 38 C.F.R. §§ 4.104, 4.115a, DCs 7101, 7541 (2013). Separate ratings are not to be assigned for disability from disease of the heart and any form of nephritis, on account of the close interrelationships of cardiovascular disabilities. 38 C.F.R. § 4.115. On VA genitourinary examination in February 2008, the examiner noted that VA labs reflected the presence of glucosuria and microscopic proteinuria on urine examination. The examiner diagnosed glucosuria and microscopic proteinuria. On VA genitourinary examination in March 2011, the Veteran presented with a history of several episodes of urinary tract infections between 1996 and 2000 and several episodes in 2002 and was told that infections were caused by high amount of glucose that was present in his urine. Glucosuria was documented on several occasions in 1996, 1999, and microalbuminuria was documented in 2002. In 2010, the Veteran's urine was positive for presence of microalbumin and glucose. There were no general systemic symptoms due to genitourinary disease, urinary symptoms, any urinary leakage, or hospitalization for recurrent UTIs. Nor was there any history of obstructive voiding, urinary tract stones, acute nephritis, hydronephrosis. There was evidence of renal dysfunction or renal failure, but dialysis was not required. Albumin was 2.8 and creatinine was 1.05. The examiner diagnosed glucosuria and microalbuminuria associated with diabetes mellitus, type II, and preserved renal function. On review of the evidence of record, the Board finds that the assignment of a separate compensable rating for the Veteran's glucosuria is not warranted. In this regard, the pertinent evidence of record does not reflect that the Veteran's glucosuria has been manifested by constant albumin or recurring albumin with hyaline and granular casts or red blood cells, or transient or slight edema or hypertension at least 10 percent disabling. Accordingly, a compensable rating is not warranted under DC 7541. Finally, in regards to the diabetic ulcer on the Veteran's left foot, on VA diabetes examination in March 2011, there was an open left diabetic foot ulcer on the plantar surface of the left foot around the metatarsal head. On VA general medical examination, there was a shallow plantar ulcer at the base of the 4th and 5th toe of the left foot. VA treatment records dated in August 2012 indicate a history of diabetic foot ulcer with osteomyelitis and indicate that the Veteran underwent amputation of the left fourth metatarsal secondary to osteomyelitis in May 2011. Diagnostic Code 5172 provides the rating criteria for amputation of the toes, other than the great toe, with removal of the metatarsal head. Where there is no metatarsal involvement a noncompensable (0) percent rating is assigned. Where there is involvement of one or two toes, a 20 percent rating is warranted. In this case, as the amputation of the Veteran's left fourth toe involved the metatarsal, a rating of 20 percent is warranted. However, the Board does not find that a separate compensable rating is warranted for the diabetic ulcer of the 4th or 5th toe of the left foot at any time during the appeal period because the evidence shows that there is no diabetic ulcer which is, or has been during the period of the claim, at least 39 square centimeters, unstable or painful, or which results in any limitation of function. 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805 (as in effect prior to and from October 23, 2008). While the Board finds that a separate 20 percent rating for amputation of the left fourth toe is warranted, the Board finds that the preponderance of the evidence is against the claim for a rating in excess of 20 percent for diabetes mellitus, type II, with glucosuria and hypertension, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. C. Peripheral Neuropathy Disability ratings with respect to neurological conditions ordinarily are assigned in proportion to the impairment of motor, sensory, or mental function. 38 C.F.R. § 4.12. In evaluating peripheral nerve injuries, attention therefore is given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory. Id. Special consideration is given to complete or partial loss of use of one or more extremities and disturbances of gait. 38 C.F.R. § 4.124a. Neuritis, whether cranial or peripheral, is rated on the scale provided for injury of the nerve involved. 38 C.F.R. § 4.123. The maximum evaluation for neuritis characterized by organic changes such as loss of reflexes, muscle atrophy, sensory disturbances, and constant pain which is at times excruciating is equal to that for severe incomplete paralysis of the nerve. Id. The maximum rating for neuritis not characterized by such organic changes is equal to that for moderately severe incomplete paralysis for the sciatic nerve and moderate severe incomplete paralysis for all other nerves. Id. Neuralgia, whether cranial or peripheral, characterized usually by a dull and intermittent pain also is rated on the scale provided for injury of the nerve involved. 38 C.F.R. § 4.124. The maximum evaluation is equal to that for moderate incomplete paralysis of the nerve. Id. If tic doulourex or trifacial neuralgia is present, however, the rating may equal complete paralysis of the nerve. Id. Partial loss of use of one or more extremities from neurological lesions further is rated by comparison with mild, moderate, and severe incomplete paralysis or complete paralysis of the peripheral nerves. 38 C.F.R. § 4.124a. Peripheral Neuropathy of the Left and Right Upper Extremity The Veteran maintains that his service-connected neuropathy of the left and right lower extremity is more severe than what is reflected by the currently assigned disability ratings. He has been assigned a 10 percent rating for each extremity under Diagnostic Code 8515 for peripheral neuropathy of both arms associated as neurological complications of his service-connected diabetes mellitus. Diagnostic Code 8515 provides the rating criteria for paralysis of all the median nerve, and therefore neuritis and neuralgia of those nerves. 38 C.F.R. § 4.124a, Diagnostic Codes 8515, 8615, 8715. For impairment of an upper extremity, the disability rating assigned depends on whether the extremity is the major extremity or the minor extremity. The major extremity is the one predominantly used by the Veteran. Only one extremity may be considered major. 38 C.F.R. § 4.69. In this regard, the Board notes that the RO has rated the right upper extremity as the Veteran's dominant extremity, but upon review of the evidence of record it is unclear whether the Veteran's right upper extremity is in fact the dominant extremity. Nonetheless, as the Veteran has not contended or denied that his right arm is not the dominant extremity, the Board will consider it as such for the purpose of evaluating the ratings assigned for the right upper extremity. Assignment of a disability rating for the Veteran's peripheral neuropathy of the right upper extremity therefore concerns his major upper extremity, while assignment of a disability rating for this disability of the left upper extremity concerns his minor upper extremity. Under DC 8515, a 10 percent rating for mild incomplete paralysis. For moderate incomplete paralysis, a 20 percent rating is authorized for the minor extremity, while a 30 percent rating is authorized for the major extremity. Severe incomplete paralysis warrants a 40 percent rating in the minor extremity, and a 50 percent rating in the major extremity. Where the evidence suggests that the Veteran has complete paralysis, a 60 percent rating is warranted for the minor extremity, and a 70 percent rating for the major extremity. 38 C.F.R. § 4.124a, DC 8515 (2013). Medical records indicate that the Veteran is right-hand dominant. In this case, the Board has considered whether another rating code is "more appropriate" than the one used by the RO, Diagnostic Code 8515. Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Here, as the medical evidence shows involvement of the radial, median, and peripheral nerves in the bilateral upper extremities, the Board finds that Diagnostic Code 8513, dealing with paralysis of all radicular groups, is the most beneficial. In addition to Diagnostic Code 8513, Diagnostic Code 8510 provides the rating criteria for paralysis of the upper radicular group (fifth and sixth cervical), and therefore neuritis and neuralgia of that nerve pursuant to Diagnostic Codes 8610 and 8710, respectively. The middle radicular group specifically is addressed by Diagnostic Code 8511 for paralysis, 8611 for neuritis, and 8711 for neuralgia. The lower radicular group specifically is addressed by Diagnostic Code 8512 for paralysis and 8612 for neuritis, and 8712 for neuralgia. 38 C.F.R. § 4.124a. Each of these codes provides a 20 percent evaluation for mild incomplete paralysis in the minor or major extremity. A 30 percent rating requires moderate incomplete paralysis in the minor extremity, whereas the same in the major extremity warrants a 40 percent rating. Severe incomplete paralysis results in a 40 percent rating for the minor extremity and a 50 percent rating for the major extremity. The highest respective ratings of 60 percent regarding the minor extremity and 70 percent regarding the major extremity are reserved for complete paralysis. With respect to the upper radicular group, complete paralysis occurs when all shoulder and elbow movements are lost or severely affected but hand and wrist movements are not affected. With respect to the middle radicular group, complete paralysis means adduction, abduction, and rotation of the arm, flexion of the elbow, and extension of the wrist is lost or severely affected. With respect to the lower radicular group, complete paralysis means all intrinsic muscles of the hand, and some or all of the flexors of the wrist and fingers, are paralyzed (substantial loss of use of the hand). 38 C.F.R. § 4.124a. With respect to diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis for a particular nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. When the involvement is bilateral, the ratings should be combined with application of the bilateral factor. 38 C.F.R. § 4.124a. The terms "mild," "moderate," and "severe" under Diagnostic Code 8513 are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Turning to the merits of the claims, on VA peripheral nerves examination in February 2008, the Veteran complained of constant pain in his arms that interfered with all aspects of daily living, including any exercise and sleep. Muscle strength of the Veteran's upper extremities was 5 and the sensory examination of the upper extremities was considered normal. The neuropathy affected the radial and ulnar nerves. On reflex examination, the Veteran's upper extremities were 2+. There was no muscle atrophy; abnormal muscle tone or bulk; tremors, tics, or other abnormal movements; or function of the joint that was affected by the nerve disorder. The examiner diagnosed bilateral upper extremity peripheral neuropathy with no effect on his recreation, traveling, feeding, bathing, dressing toileting and grooming; a mild effect on chores and shopping; and a severe effect on sports and exercise. In a September 2010 statement, the Veteran stated that he was unable to drive because his hands fell asleep when he gripped the steering wheel. During the December 2010 hearing, the Veteran described the peripheral neuropathy in his upper extremities as severe, stating that he could not grip anything, experienced loss of strength, experienced numbness in his hands, and had shooting pains in his fingers. The VLJ observed that the Veteran was able to make a fist and extend all of his fingers on both hands; he was within about one-half inch of being able to touch the thumb to the palm in both hands. He denied any weakness in his wrists or locking of his hand and testified that he was able to "pick up a gallon of milk." On VA diabetes and peripheral nerve examination in March 2011, the Veteran presented with complaints of numbness and loss of strength in his hands. There was no history of hospitalization due to peripheral nerve trauma or neoplasm. There was stiffness, tremors, and pain in the hands and tremors, and paresthesias. Reflex examination was 1+ (hypoactive) in the upper extremities. Sensory examination of the upper extremities revealed normal vibration, position sense, and light tough without dyesthesias. Pain/pinprick was decreased in the palm and affected the median nerve. Tremor in the upper extremities was described as fine involuntary jerky movements at rest in both hands. There were no electromyography findings. The examiner diagnosed diabetic peripheral neuropathy in the bilateral upper extremities. The Veteran stated that he was unable to drive due to decreased sensation, numbness, and throbbing pain in his hands. On VA general medical examination in March 2011, the examiner opined that the severity of the Veteran's peripheral diabetic neuropathy of the upper extremities precluded substantially gainful or physical or sedentary employment. On review of the evidence of record, the Board finds that the Veteran's bilateral arm disabilities are manifested by no more than moderate incomplete paralysis of the radial and ulnar nerves which warrants an increased rating of 40 percent for the right (major) upper extremity and 30 percent for the left (minor) upper extremity. The Veteran has consistently reported subjective symptoms of numbness, pain, and weakness of his hands. In December 2010, the Veteran testified that his hands became numb while driving. However, the Veteran indicated that he was able to "pick up a gallon of milk" and demonstrated the ability to make a fist. While the 2011 VA general medical examiner opined that the Veteran was unable to drive due to his service-connected bilateral arm disability, there is no evidence of record, even giving consideration to the Veteran's lay statements and the 2008 and 2011 VA examination reports, that the Veteran has experienced any additional symptomatology beyond that which has been described above that would rise to the level of severe neurological impairments. As such, higher ratings of 30 and 40 percent for the minor and major upper extremity, respectively, is warranted pursuant to DC 8513. The Board has also considered whether higher ratings may be assigned for the Veteran's disabilities under any other diagnostic code during the pendency of the appeal. In this regard, the Board notes that the Veteran would not fare better had the Board applied any other diagnostic code. Here, ratings of 40 and 30 percent each for the major and minor extremity, respectively, have been assigned under the applicable diagnostic codes relevant to all radicular groups, including the upper, middle, and lower radicular groups. See Diagnostic Codes 8510, 8511, 8512, 8513, 8610, 8611, 8612, 8613, 8710, 8711, 8712, and 8713. Nor would the Veteran fare better had the better employed any other diagnostic code for the pendency of the appeal. In this regard, ratings of 30 and 40 percent for the left and right upper extremities, respectively, for moderate incomplete paralysis are also assigned under the applicable diagnostic codes relevant to the upper, middle, and lower radicular groups. Id. Thus, higher ratings would not be warranted under any other diagnostic code for the Veteran's bilateral upper extremity disabilities. Diabetic Neuropathy of the Left and Right Lower Extremity The Veteran's service-connected neuropathy of the left and right lower extremity has been assigned rating of 10 percent for each extremity, pursuant to Diagnostic Codes 8599-8520. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. Diagnostic Code 8525 provides the rating criteria for paralysis of the posterior tibial nerve, and therefore neuritis and neuralgia. Complete paralysis of all muscles of the sole of the foot, frequently with painful paralysis of a causalgic nature; toes cannot be flexed; adduction is weakened; and plantar flexion is impaired, a 30 percent disability rating is warranted. Incomplete paralysis resulting in severe impairment warrants a 20 percent disability rating, and moderate or mild impairment warrants a 10 percent evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8525. Further, Diagnostic Code 8625 refers to neuritis of the posterior tibial nerve and Diagnostic Code 8725 refers to neuralgia of the posterior tibial nerve. Id. Turning to the merits of the claims, on VA peripheral nerves examination in February 2008, the Veteran presented with complaints of constant pain in his legs which interfered with all aspects of daily living, including exercise and sleep. Muscle strength of the lower extremities and sensory examination was normal for vibration and pain with decreased light touch; the disability affected his posterior tibial nerves. Reflex examination was 2+ in the lower extremities without evidence of muscle atrophy; abnormal muscle tone or bulk; or tremors, tics, or other abnormal movements or function of the joint. The examiner diagnosed bilateral lower extremity peripheral neuropathy which had a mild effect on chores and shopping, a severe effect on exercise and sports, and no effect on recreation, traveling, feeding, bathing, dressing, toileting, and grooming. In a September 2010 statement, the Veteran complained of occasional cramping and locking of his toes and of numbness and tingling in his legs. VA treatment records include a November 2010 report which includes findings of paresthesias and burning sensations in the feet. The assessment was high risk type II diabetic with autonomic and sensory neuropathy. In December 2010, the Veteran testified that his disability caused daily numbness in his feet which caused him to fall. The Veteran described the severity of his disability as "absolutely severe." He testified that he experienced numbness and occasional pain in his feet. When he walked he was unable to feel the ground which caused him to get "tangled up" and sometimes fall. On VA diabetes mellitus and peripheral nerve examination in March 2011, the Veteran presented with complaints of paresthesias, loss of sensation, pain, and dyesthesias in the lower extremities. There was no history of hospitalization due to peripheral nerve trauma or neoplasm. There was paresthesias and pain in the feet. Reflex examination was 1+ in the lower extremities. Balance was poor due to lost proprioception and position sense. Gait abnormality was described as unsteady, partly due to a knee-high specialty boot on the left leg/foot. Sensory examination of the lower extremities indicated decreased vibration, absent pain/pinprick and light tough in the dorsal and plantar surface. Position sense was absent from the toes. There was no dyesthesias. Motor examination was 5 (active movement against full movement) throughout with normal muscle tone and no evidence of atrophy. The examiner noted that the Veteran was unable to drive due to the loss of feeling in his feet. On VA general medical examination in March 2011, the examiner opined that the severity of the Veteran's peripheral diabetic neuropathy of the lower extremities precluded substantially gainful or physical or sedentary employment. On review of the evidence of record, the Board finds that ratings in excess of 10 percent for the Veteran's bilateral lower extremity disability are not warranted. Essentially, the subjective and objective evidence of record indicates that the Veteran's bilateral lower extremity disability is, at most, moderate in nature, which warrants a 10 percent rating under DC 8525. The Veteran's disabilities are primarily manifested by subjective complaints of numbness and pain in his lower extremities, mainly in his feet, which affect his ability to drive and walk. However, VA examinations in 2008 and 2011 revealed normal motor function without evidence of atrophy. While sensory examination indicated slight impairment, there were no objective findings of dyesthesias. There is no evidence of record, even given consideration to the Veteran's lay statements, the December 2010 hearing testimony, and 2008 and 2011 VA examination reports, that the Veteran has experienced any additional symptomatology beyond that which has been described above that would rise to the level of severe neurological impairments. The preponderance of the evidence does not indicate that the Veteran's bilateral lower extremities symptomatology more closely approximate severe incomplete paralysis of the posterior tibial nerve. As such, disability ratings in excess of 10 percent are not warranted. The Board has also considered whether higher ratings may be assigned for the Veteran's disabilities under any other diagnostic code during the pendency of the appeal. In this regard, Diagnostic Codes 8520 (sciatic nerve), 8521 (external popliteal nerve), 8524 (internal popliteal nerve) and 8526 (anterior crural nerve) provide 20 percent ratings for moderate incomplete paralysis. However, the medical evidence of record does not indicate any impairment or involvement of these sciatic, external or internal popliteal, or anterior crural nerve. Nor is he entitled to increased ratings under Diagnostic Codes 8522 (musculocutaneous nerve) or 8523 (anterior tibial nerve) which both provide for a noncompensable rating for mild incomplete paralysis and a 10 percent rating for moderate incomplete paralysis of these nerves as the Veteran is now in receipt of a 10 percent rating for mild neurological impairment of each lower extremity. Finally, as Diagnostic Codes 8527 (internal saphenous nerve), 8528 (obturator nerve), 8529 (external cutaneous nerve of thigh), or 8530 (ilio-inguinal nerve) provide a maximum rating of 10 percent for severe to complete paralysis of the nerve, consideration of these diagnostic codes would be of no benefit to the Veteran. D. Additional Considerations In reaching the above conclusions, the Board has also not overlooked statements from the Veteran, his spouse, and his friend in support of his claims. In this regard, the Veteran is competent to report on factual matters of which he has first-hand knowledge, e.g. complaints of dyspnea and fatigue and pain, numbness, and tingling in the Veteran's upper and lower extremities. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, while the Board may consider the subjective statements of the Veteran, his spouse, and his friend regarding the severity of the disabilities, the Board notes that with respect to the Rating Schedule, the criteria set forth therein generally require medical expertise which neither the Veteran, his spouse, or his friend has been shown to have. See King v. Shinseki, 700 F.3d 1339, 1344 (Fed. Cir. 2012). Furthermore, the Board finds the objective medical findings and opinions provided by the expert of record should be accorded the greater probative weight. Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches . . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [Board as] adjudicators."). The above determination is based upon consideration of applicable rating provisions. It should also be noted that there is no showing that the Veteran's disabilities have reflected so exceptional or unusual a disability picture as to warrant the assignment of any higher evaluations on an extra-schedular basis. See 38 C.F.R. § 3.321(b) (1). In this case, there has been no showing that the Veteran's coronary artery disease; diabetes mellitus, type II with glucosuria and hypertension, peripheral neuropathy of the upper extremities, and diabetic neuropathy of the lower extremities could not be contemplated adequately by the applicable schedular rating criteria discussed above. Given that the applicable schedular rating criteria are adequate, the Board need not consider whether the Veteran's disability picture includes such exceptional factors as periods of hospitalization and interference with employment. Referral for consideration of the assignment of a disability rating on an extraschedular basis is not warranted. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Further, the Veteran has been awarded a TDIU primarily due to his coronary artery disease and neurological disabilities of the upper and lower extremities pursuant to 38 C.F.R. § 4.16(a), further indicating that he had been adequately rated under the regular schedular standards. As the rating schedule is adequate to evaluate the disability, referral for extra-schedular consideration is not in order. As noted in the Introduction, the Board observed that the Veteran was granted a TDIU from March 26, 2010, but seeks an earlier effective date for the award of TDIU which has been referred it to the AOJ for adjudication. In light of the foregoing, the Board finds that with regard to peripheral neuropathy of the Veteran's upper extremities, entitlement to a higher rating of 30 percent for the minor (left) extremity and a rating of 40 percent for the major (right) extremity is warranted. A separate 20 percent rating for amputation of the left fourth toe is also warranted. However, the claims for an initial rating of 60 percent for coronary artery disease, a rating in excess of 20 percent for diabetes mellitus with glucosuria and hypertension, and ratings in excess of 10 percent for diabetic neuropathy of the right and left lower extremity must be denied. Since the preponderance of the evidence is against the claims for an increased rating for coronary artery disease and diabetic neuropathy of the lower extremities, the benefit of the doubt doctrine is not for application with regard to these claims. 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has additionally considered the assignment of staged ratings, under Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 21 Vet. App. 505 (2007), but concludes that they are not warranted. ORDER An initial rating in excess of 60 percent for coronary artery disease, from September 1, 2007, is denied. A rating in excess of 20 percent for type II diabetes mellitus, with glucosuria, and hypertension, is denied. A rating of 40 percent, but no higher, for peripheral neuropathy of the right upper extremity, is granted, subject to the law and regulations governing payment of monetary benefits. A rating of 30 percent, but no higher, for peripheral neuropathy of the left upper extremity, is granted, subject to the law and regulations governing payment of monetary benefits. A rating in excess of 10 percent for diabetic neuropathy of the right lower extremity, is denied. A rating in excess of 10 percent for diabetic neuropathy of the left lower extremity, is denied. A separate 20 percent rating for amputation of the left fourth toe is granted, subject to the law and regulations governing payment of monetary benefits. REMAND With respect to the claim for a compensable rating for diabetic retinopathy, historically, a March 2008 rating decision granted service connection for retinopathy as secondary to diabetes mellitus, type II, effective from October 15, 2007. A May 2012 DRO decision granted service connection and assigned a noncompensable rating for diabetic retinopathy, effective from March 28, 2011, the date of the VA eye examination. The body of the decision states that a VA eye examination would be scheduled to determine the severity of the complication. However, it does not appear that the Veteran has undergone additional VA eye examination and the record does not show that he has been granted an initial compensable rating for his diabetic retinopathy. Accordingly, the case is REMANDED for the following actions: 1. Obtain a complete copy of the VA treatment records since August 2012. If the records are not available, or if the search for the records yields a negative result, that fact should be clearly documented on the Veteran's electronic claims file that has been uploaded to the Veteran's electronic Virtual VA claims file, and the Veteran notified of the efforts made to obtain such records. 2. On completion of the above, schedule an appropriate a VA examination to determine the current severity of his diabetic retinopathy. The claims folder should be provided to the examiner for review of pertinent documents. The examination report should reflect that such a review was conducted. All necessary tests and studies should be accomplished and all clinical findings reported in detail. The examiner should also provide an opinion concerning the impact of the service-connected diabetic retinopathy on the Veteran's ability to work. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 3. Thereafter, the issue on appeal should be readjudicated. If the benefits sought on appeal are not granted to the Veteran's satisfaction, he and his representative should be provided with a supplemental statement of the case (SSOC) and afforded the appropriate opportunity to respond thereto. The SSOC should contain, among other things, a summary and discussion of the relevant evidence received since the SSOC was issued in May 2012. The case should then be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the ultimate outcome of the case. The appellant 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). 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 Supp. 2013). ______________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs