Citation Nr: 1433464 Decision Date: 07/28/14 Archive Date: 08/04/14 DOCKET NO. 10-23 572 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right upper extremity. 2. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left upper extremity. 3. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right lower extremity. 4. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left lower extremity. 5. Entitlement to a rating in excess of 20 percent for type II diabetes mellitus with erectile dysfunction. 6. Entitlement to an initial rating in excess of 30 percent for diabetic nephropathy. 7. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 8. Entitlement to an initial rating in excess of 10 percent for status post surgical treatment for contracture of right ring finger secondary to traumatic scarring and Dupuytren's contracture with postoperative scarring and superficial nerve damage (a right ring finger disability). 9. Entitlement to an initial compensable rating for vertigo symptoms. 10. Entitlement to an initial compensable rating for bilateral hearing loss. 11. Entitlement to an effective date earlier than October 8, 2002 for the grant of service connection for tinnitus. 12. Entitlement to an effective date earlier than October 8, 2002 for the grant of service connection for a right ring finger disability. 13. Entitlement to an effective earlier than October 8, 2001 for the grant of service connection for vertigo symptoms. 14. Entitlement to an effective date earlier than September 29, 2008 for the grant of service connection for bilateral hearing loss. 15. Entitlement to a total disability rating based in individual unemployability (TDIU) due to service-connected disabilities prior to June 9, 2010. REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, Attorney ATTORNEY FOR THE BOARD L. Kirscher Strauss, Counsel INTRODUCTION The Veteran served on active military duty from September 1966 to June 1970. These issues come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. An August 2007 rating decision granted service connection for diabetic nephropathy and assigned an initial 30 percent rating; and peripheral neuropathy of the right upper extremity and right and left lower extremities, each rated as 10 percent disabling. The effective date for each of these disabilities was November 29, 2006. The August 2007 decision also continued a 20 percent rating for diabetes mellitus with associated erectile dysfunction and peripheral neuropathy of the left upper extremity. A March 2008 rating decision granted service connection for PTSD and assigned an initial 30 percent rating, effective July 30, 2007. In a September 2008 rating decision, the RO granted a separate compensable rating for peripheral neuropathy of the left upper extremity, assigning an initial 10 percent rating, effective from March 31, 2008. The decision also continued the previously assigned ratings for peripheral neuropathy of the right upper extremity, right and left lower extremities, diabetic nephropathy, and PTSD; and denied entitlement to a TDIU. In a March 2012 rating decision, the RO granted service connection for three issues that were previously on appeal before the Board, including tinnitus; bilateral hearing loss; status post surgical treatment for contracture of right ring finger secondary to traumatic scarring and Dupuytren's contracture with postoperative scarring and superficial nerve damage; and vertigo symptoms, which was rated as noncompensable since the claim was received in October 2002 and was associated with the service-connected diabetes mellitus. A notice of the decision was mailed to the Veteran and his attorney in January 2013, and a notice of disagreement was received from the Veteran's attorney on his behalf in January 2014, expressing disagreement with the assigned effective dates for each of the four disabilities determined to be service connected and with the initial rating assigned for each disability with the exception of tinnitus. The Board points out that the Veteran's vertigo symptoms were previously rated as part of his type II diabetes mellitus disability. Because the March 2012 RO decision separately granted service connection for vertigo symptoms secondary to the Veteran's type II diabetes mellitus disability and assigned a noncompensable rating, the issue of vertigo as a part of the type II diabetes mellitus disability is moot. Finally, the Board notes that in a January 2011 rating decision, the RO granted service connection for ischemic coronary artery disease and granted a 100 percent schedular rating, effective from June 9, 2010. Under 38 C.F.R. § 4.16(a) (2013), total disability ratings for compensation may be assigned "where the schedular rating is less than total," when the disabled person is, in the judgment of the rating agency, unable to follow a substantially gainful occupation as a result of a service-connected disability or service-connected disabilities. Since the RO awarded a 100 percent schedular rating for service-connected ischemic coronary artery disease, the matter of a total rating for compensation based upon individual unemployability from the effective date of June 9, 2010 is moot. Green v. West, 11 Vet. App. 472, 476 (1998) (citing Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994) ("a claim for [a total rating for compensation based upon individual unemployability] presupposes that the rating for the condition is less than 100%") and Holland v. Brown, 6 Vet. App. 443, 446 (1994) (100 percent schedular rating "means that a veteran is totally disabled")). However, because the Veteran's claim for a TDIU was received in March 2008, the issue of a TDIU from the receipt of his claim until prior to June 9, 2010 remains on appeal, and the Board has recharacterized this issue on appeal accordingly. In July 2013, the Veteran's VA vocational rehabilitation file was received by the RO in connection with the claims on appeal. A waiver of RO jurisdiction for this evidence was received in a written statement dated in July 2013 from the Veteran's attorney that is included in the record. The Board accepts this evidence for inclusion in the record on appeal. See 38 C.F.R. § 20.1304 (2013). The issues of entitlement to initial ratings in excess of 10 percent each for peripheral neuropathy of the right and left upper and lower extremities; an initial rating in excess of 10 percent for a right ring finger disability; initial compensable ratings for vertigo symptoms and bilateral hearing loss; effective dates earlier than October 8, 2002 for the grant of service connection for tinnitus and a right ring finger disability; an effective date earlier than September 29, 2008 for the grant of service connection for bilateral hearing loss; an effective date earlier than October 8, 2001 for vertigo symptoms; and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. A preponderance of the evidence is against a finding that diabetes mellitus requires a regulation of the Veteran's activities. 2. Erectile dysfunction associated with diabetes mellitus has been manifested by loss of erectile power and absence of ejaculation without penile deformity. 3. Diabetic nephropathy has not been manifested by constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension with diastolic pressure predominantly 120 or more. 4. PTSD has been manifested by flat mood and affect with slowed speech and movements and instances of blunted affect; below average concentration in August 2007; tense psychomotor activity; hesitant, whispered, slow speech; "blocking" thought process; and mildly impaired remote memory in February 2008. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for diabetes mellitus with erectile dysfunction have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.119, Diagnostic Code 7913, 4.115b, Diagnostic Code 7522 (2013). 2. The criteria for an initial rating in excess of 30 percent for diabetic nephropathy have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.115b, Diagnostic Code 7541 (2013). 3. The criteria for an initial rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VCAA Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126 (West 2002 & Supp. 2013)); see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a) (2013), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). In Pelegrini v. Principi, 17 Vet. App. 412 (2004), the United States Court of Appeals for Veterans Claims (Court) held, in part, that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. This decision has since been replaced by Pelegrini v. Principi, 18 Vet. App. 112 (2004), in which the Court continued to recognize that typically a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. Regarding the appeal for an increased rating for diabetes mellitus, the Veteran was provided VCAA notice in a February 2007 letter, advising him of what information and evidence is needed to substantiate his claim for an increased rating, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The letter included information regarding how disability evaluations and effective dates are assigned and the type of evidence that impacts those determinations. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The remaining issues decided herein arose from the initial award of service connection. In Dingess, the Court held that in cases in which service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490-91; see also 38 C.F.R. § 3.159(b)(3)(i) (2013). Thus, because the notice that was provided before service connection was granted was sufficient, VA's duty to notify in this case has been satisfied. See generally Turk v. Peake, 21 Vet. App. 565 (2008) (holding that where a party appeals from an original assignment of a disability rating, the claim is classified as an original claim, rather than as one for an increased rating); see also Shipwash v. Brown, 8 Vet. App. 218, 225 (1995); see also Fenderson v. West, 12 Vet. App. 119 (1999) (establishing that initial appeals of a disability rating for a service-connected disability fall under the category of "original claims"). The Board also finds that VA has complied with all assistance provisions of the VCAA. The Veteran was provided with numerous VA examinations. The evidence of record contains service treatment records, post-service VA and private treatment records, VA examination reports, vocational rehabilitation records, and lay statements from the Veteran. There is no indication of relevant, outstanding records that would support the Veteran's claims. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(1)-(3). VA has considered and complied with the VCAA provisions discussed above. The Veteran was notified and aware of the evidence needed to substantiate the claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran was an active participant in the claims process by submitting evidence and argument and has been represented by an attorney. Therefore, he was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication or to cause injury to the Veteran. Pelegrini, 18 Vet. App. at 121. Therefore, any such error is harmless and does not prohibit consideration of these matters on the merits. See Conway, 353 F.3d at 1374, Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Criteria & Analysis Ratings for service-connected disabilities are determined by comparing the veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2013). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Additionally, although regulations require that a disability be viewed in relation to its recorded history, 38 C.F.R. §§ 4.1, 4.2, when assigning a disability rating, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation during the relevant rating period. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods for each disability on appeal. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). When all the evidence is assembled, the determination must be made as to whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Diabetes Mellitus with Erectile Dysfunction The Veteran's type II diabetes mellitus with erectile dysfunction is rated as 20 percent disabling pursuant to 38 C.F.R. § 4.119, Diagnostic Code 7913 (2013). 7913 Diabetes mellitus Rating Requiring more than one daily injection of insulin, 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 100 Requiring insulin, 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 60 Requiring insulin, restricted diet, and regulation of activities 40 Requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet 20 Manageable by restricted diet only 10 Note (1): Evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under diagnostic code 7913. Note (2): When diabetes mellitus has been conclusively diagnosed, do not request a glucose tolerance test solely for rating purposes. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2013). The definition of "regulation of activities" in the criteria for a 100 percent rating, that is, the "the avoidance of strenuous occupational and recreational activities," also applies to the "regulation of activities" criterion for a 40 or 60 percent rating under Diagnostic Code 7913. In addition, the criterion of "regulation of activities" requires medical evidence that occupational and recreational activities have been restricted by the diabetes. Camacho v. Nicholson, 21 Vet. App. 360, 363-65 (2011). Moreover, because of the successive nature of the rating criteria, such that the evaluation for each higher disability rating includes the criteria of each lower disability rating, each of the criteria listed in the 40 percent rating must be met in order to warrant such a rating. The provisions of 38 C.F.R. § 4.7 pertaining to a higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating, do not apply. See Camacho at 366-67; see also Tatum v. Shinseki, 23 Vet. App. 152, 156 (2011) (where there are successive rating criteria as in DC 7913, to grant a higher rating where only two out of three criteria are met would eviscerate the need for different ratings since symptoms established for either rating might be the same). During a February 2007 VA diabetes mellitus examination, the Veteran denied any restriction of activities on account of his diabetes and related that his VA doctor told him that he only needed to be seen every six months. He reported controlling his diabetes with restricted diet and medications (Metformin and Glyburide). He denied any bladder or bowel functional impairment. He reported occasional erectile difficulties, but no treatment. Genitourinary examination of the genitalia was reported as entirely normal. The assessment was mild to moderate erectile dysfunction. Following a February 2007 VA eyes examination, the assessment was type II diabetes mellitus without diabetic retinopathy. The Veteran was afforded another VA examination in July 2008 to evaluate his diabetes mellitus. He reported that he had never been treated with insulin or hospitalized and that his current treatment included Metformin and Glyburide. The examiner remarked that the Veteran appeared to have poor knowledge of diabetes or its control. The Veteran indicated that he eats one meal per day and tries to avoid carbohydrates. He denied having any severe hypoglycemic episodes. The examiner also commented that the Veteran does no effective exercise because of peripheral neuropathy and low back problems. The examiner noted that diabetic retinal surveillance was negative for diabetic retinal vascular changes in July 2007 when evaluated by VA. He reported taking medication for [nonservice-connected] hypertension with blood pressures running borderline high. He denied exertional chest pain, dysrhythmia, heart murmur, varicose veins, or claudication-like symptoms. Regarding genitourinary symptoms, he reported a problem with epididymitis, apparently manifested by left testicular discomfort and dysuria. He described erectile dysfunction manifested by inability to achieve orgasm and eventually losing erection. Physical examination did not reveal deformity. On examination, he had a full stride, walking down the hall without evidence of a limp or problem with balance; and had a normal stance. Following a review of the claims file and physical examination, the impression was non-insulin dependent diabetes mellitus, type II. In September 2009, the Veteran's attorney filed a claim on behalf of the Veteran for special monthly compensation for loss of use of a creative organ and for a separate compensable rating for erectile dysfunction. The claim for special monthly compensation was granted in a March 2010 rating decision. Regarding the claim for a separate compensable rating for erectile dysfunction, the Board emphasizes that this issue is part of the Veteran's claim for an increased rating for diabetes mellitus because it is an established complication of his diabetes, and compensable complications of diabetes are to be evaluated separately unless used to support a 100 percent evaluation while noncompensable complications are considered part of the diabetic process under diagnostic code 7913. See 38 C.F.R. § 4.119, Diagnostic Code 7913, Note 1. In connection with the claim for special monthly compensation, the Veteran was afforded another VA genitourinary examination in March 2010. He described erectile dysfunction manifested by an absence of ejaculation and being incapable of penetration. The examiner indicated that the most likely etiology of the erectile dysfunction was diabetic neuropathy. Physical examination did not reveal any deformity. A September 2009 VA telephone note reflects the Veteran's report that he had been binging on sweets and carbs for the past several weeks as well as drinking beer, but that he had been trying to make improvements for the past two weeks. The nurse practitioner reinforced the reason for diet and exercise and the high likelihood that the Veteran would require insulin, which the Veteran wanted to "avoid at all costs." During a December 2009 VA annual examination, the Veteran was instructed on the importance of daily aerobic exercise such as walking to lower glucose. His gait was described as unremarkable. VA treatment records reflect that a record review for diabetic management recommendations was conducted in February 2010. An addendum note indicated that the Veteran should be contacted regarding very high blood sugar levels and to set up an appointment for diabetes education for insulin use. The next day, the Veteran indicated that he did not want to start insulin and wanted to discuss treatment options. During a March 2010 VA follow-up visit, the nurse practitioner noted that the Veteran had become very motivated to watch his diet more closely after receiving notification regarding A1c increase and probable insulin start. Education was provided regarding diet, exercise, and weight loss requirements to control his diabetes and hypertension. A May 2010 VA telephone note regarding the Veteran's reports of chest pain and pressure at rest and with exertion and exertional dyspnea reflects that he was instructed that he "HAS to control glucose and [blood pressure]." (Emphasis in original). The nurse practitioner also explained how out-of-control diabetes and hypertension speed up cardiac/vessel damage and organ failure. The Veteran remained unwilling to start insulin. A June 2010 VA annual diabetic eye examination found no diabetic retinopathy. During another VA telephone encounter in June 2010, the Veteran was again advised that he needs to work on his diabetes, hypertension, weight, and exercise patterns and informed about ways he could do so. He stated that he was using an exercise bike and was on a beta blocker, ace, and diuretic. An October 2010 letter from the Veteran's VA nurse practitioner notified him that that recent test results showed that he had really improved his overall blood sugar control. At an annual examination in December 2010, he was educated to get regular exercise. A February 2011 nurse practitioner note indicated that the Veteran's diabetes was not controlled and that he needed to come to the clinic for diabetes education. She contacted the Veteran by telephone the same month, and the Veteran reported that he started taking care of himself and was really taking his medications. He was scheduled for follow-up in three months. During a May 2011 optometry consultation, the Veteran reported stable vision and did not have complaints. A May 2011 follow-up telephone note reflects that the Veteran's lab results indicated diabetes control was improving. A June 2011 letter to the Veteran again advised him that his glucose/diabetes labs had improved. A July 2011 VA addendum note documents a phone call with the Veteran, during which he stated that his heart disease causes him not to be able to exercise and that it was physiologically impossible for him to control his diet. He stated he was told that he cannot eat sugar or carbohydrates and that he needed to stop eating fat. The Veteran was advised that he did not have to stop eating these foods, but needed to eat them in moderation. In another July 2011 addendum note, the Veteran's treating nurse practitioner indicated that she wanted the Veteran to start a supervised exercise program, beginning slowly with a physical therapist and geared toward acknowledging his heart disease concern. The assessment of a September 2011 VA optometry examination included no retinopathy. During a January 2012 annual VA examination, the Veteran was encouraged to get regular exercise. The plan included beginning nightly insulin to assist in glucose control. A February 2012 telephone note indicates that the Veteran reported receiving insulin in the mail, but it was his understanding from the last visit that he was not going to start insulin until after his next lab work or even later. An addendum documented that the Veteran was correct and that he was to wait until after the next labs to start insulin because of the changes he was making. The nurse practitioner indicated that the insulin was sent in error, and she instructed the Veteran to return it to the clinic. The Board has considered the medical and lay evidence of record, but finds that a rating in excess of 20 percent for diabetes mellitus is not warranted at any time during the course of the appeal. The medical evidence of record reflects that the Veteran's diabetes mellitus has been managed by oral hypoglycemic agent and restricted diet. These facts are consistent with the 20 percent rating currently assigned for diabetes mellitus. The Board acknowledges that the Veteran had been warned periodically beginning in September 2009 that he may need to start insulin. However, the Veteran made lifestyle changes and was able to avoid using insulin. The Board finds that the next higher, 40 percent, rating is not warranted because the medical evidence of record does not reflect that he was advised by treating medical professionals to regulate his activities or to avoid strenuous occupational and recreational activities. Rather, the medical evidence of record reflects that he was encouraged to exercise to control his diabetes and that the Veteran, in fact, improved his glucose levels. Having reviewed the medical and lay evidence of record, the Board also finds that the Veteran's erectile dysfunction associated with his service-connected diabetes mellitus does not warrant a separate, compensable rating. Regarding the Veteran's erectile dysfunction associated with his diabetes mellitus, Diagnostic Code 7522 provides a 20 percent rating for penis deformity with loss of erectile power. 38 C.F.R. § 4.115b, Diagnostic Code 7522. The evidence of record reflects erectile dysfunction manifested by loss of erectile power and absence of ejaculation, but documents no of penile deformity. As a result, a separate compensable rating is not warranted for erectile dysfunction. Diabetic Nephropathy The Veteran's diabetic nephropathy is rated as 30 percent disabling, pursuant to 38 C.F.R. § 4.115b, Diagnostic Code 7541, which directs that renal involvement in diabetes mellitus is rated as renal dysfunction. Renal dysfunction: Rating 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 100 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 80 Constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under diagnostic code 7101 (diastolic pressure predominantly 120 or more) 60 Albumin constant 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 30 Albumin and casts with history of acute nephritis; or, hypertension non-compensable under diagnostic code 7101 0 38 C.F.R. § 4.115b (2013). For VA compensation purposes, the term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 (2013). The minimum, 10 percent, rating for hypertension requires diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. During a February 2007 VA diabetes mellitus examination, the Veteran denied any weight change, which he reported as 235; any generalized loss of strength; exertional chest pain or increased shortness of breath on exertion; or ankle edema. He reported taking medication for the last 10 to 15 years for his nonservice-connected hypertension. Urinalysis revealed trace protein present with protein present at more than 6 mg/dL. Chemistry revealed BUN of 15 mg/dL and creatinine of 1.0 mg/dL. On examination his blood pressure was recorded as 154/96, 148/90, and 140/86. Other than findings pertinent to the Veteran's claim for increased ratings for peripheral neuropathy, examination of the extremities was reported as "otherwise normal." The diagnosis included nephropathy secondary to diabetes mellitus. The Veteran was afforded a VA diabetes mellitus examination in July 2008. The examining physician indicated that he reviewed the claims file and he noted that the Veteran was shown to have gross protein in his urine in April and May 2008. "Creatinine clearance was normal at 146 mL/min, but his microalbumin/creatinine ration is high at 71.31 mg/g (high is over 30), which indicates that he is significantly losing protein and might be interpreted as early diabetic nephropathy." On examination, he appeared muscular and obese, and his weight was recorded as 232 pounds. Blood pressure was 142/92, 142/92, and after deep breathing and relaxation, it dropped to 138/88. There was no evidence of clinical cardiomegaly. Liver and spleen were not palpable. There was no edema of the extremities and no evidence of major motor weakness or atrophy. The impression was early renal failure manifested by proteinuria. During a December 2009 VA annual examination, the Veteran denied any unintended weight loss or change in energy. Blood pressure was recorded as 130/68 and his weight was 241 pounds. Blood creatinine in November 2009 was 1.0 mg/dL. A February 2010 VA serum (blood) creatinine test was 1.0 mg/dL, and a March 2010 serum creatinine test was 1.1 mg/dL. During a November 2010 VA heart examination, the Veteran stated that he had been doing carpentry in September 2009 and noted weakness, fatigue, and chest pain; and the weakness and fatigue progressed. Subsequent work-up showed cardiovascular dysfunction. He denied any history of anorexia. It was noted that continuous medication was required for control of his hypertension. His blood pressure was measured as 124/78 and his weight was 237 pounds. The diagnosis was ischemic coronary artery disease, which the examiner opined could be aggravated by the Veteran's diabetes. During a December 2010 VA annual examination, the Veteran complained of increasing fatigue and weakness at times with more effort required to exercise. His weight was 236 pounds, blood pressure was 128/64, and blood creatinine was 1.0 mg/dL. There was no edema. On annual VA examination in January 2012, the Veteran complained of a lack of energy, but denied weakness or edema. His blood pressure was measured as 158/80, his weight was 244 pounds, and there was no edema. Lab results from January 2012 included blood creatinine of 1.1 mg/dL and 1+ protein in the urine. VA treatment records dated in March 2012 note that the Veteran had gone to the emergency room for swollen and red left lower leg and was diagnosed with cellulitis and treated with antibiotics. The Board has reviewed the medical and lay evidence of record and finds that an initial rating in excess of 30 percent for diabetic nephropathy is not warranted. Beginning in 1998, private treatment records and subsequent VA examination reports reflect diastolic blood pressure was predominantly 90mm. or greater and that the Veteran has used continuous medication for control of hypertension. These findings are consistent with the 10 percent rating criteria for hypertension under diagnostic code 7101. Therefore, the Board finds that the Veteran's diabetic nephropathy has been manifested by recurring protein or albumin in the urine with hypertension at least 10 percent disabling under diagnostic code 7101 (history of diastolic blood pressure predominantly 90mm. or greater requiring continuous medication for control). A higher, 60 percent, rating is not warranted at any time during the appeal because the evidence does not reflect constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension greater than 10 percent disabling under diagnostic code 7101. The Board points out that the edema and redness of the Veteran's left lower leg in March 2012 was specifically attributed to cellulitis. PTSD Service connection for PTSD was granted effective from July 30, 2007, which is the date the Veteran's claim was received by VA, based on a confirmed traumatic event, a plane crash resulting in one fatality, that occurred in December 1967 at the DaNang Air Base. His PTSD is rated as 30 percent disabling pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). He contends that his PTSD meets the criteria for a higher initial rating. General Rating Formula for Mental Disorders: Rating Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name 100 Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships 70 Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships 50 Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) 30 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). In assessing the evidence of record, the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). While the Rating Schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130 (2013). GAF scores ranging from 61 to 70 indicate some mild symptoms (e.g., depressed mood and mild insomnia or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 indicate moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peer or coworkers). The symptoms listed in the relevant rating criteria are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). When all the evidence is assembled, the determination must be made as to whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). VA treatment records dated prior to receipt of the Veteran's claim for service connection reflect that Xanax was prescribed by otolaryngologists for tinnitus. VA treatment records also reflect that PTSD screening was negative with the Veteran answering "no" to each of four questions in July 2003, January 2004, March 2005, August 2006, and July 2007, which was approximately two weeks prior to filing his claim for service connection for PTSD in July 2007. The screening tool asks In your life, have you ever had an experience that was so frightening, horrible, or upsetting that in the past month you... (1) Had nightmares about it or thought about it when you did not want to. (2) Tried hard to not think about it or went out of your way to avoid situations that reminded you of it. (3) Been constantly on guard, watchful or easily startled. (4) Felt numb or detached from others, activities or your surroundings. An August 2007 initial assessment from a private psychologist, P. Calvo, PsyD, reflects that the Veteran was seeking treatment to address challenges with features of PTSD such as exaggerated startle response; intrusive thoughts; distressing dreams; physiological and psychological reactivity to cues that remind him of Vietnam; avoidance behaviors associated to people, events, and places that remind him of Vietnam; anhedonia; poor concentration; and irritability and outbursts of anger. The Veteran denied a history of suicidal and homicidal ideation and reported having a strong support system at this time in his life. He also reported a choking incident at age three, which led to "mental dullness" and possible seizures. He related that after separation from military service, he worked as a bartender for four years before becoming a local and long distance truck driver for the next 25 years. On mental status examination, the Veteran was oriented within normal limits, concentration was below average relative to his peer group, short term recall was average, long term memory was intact, ability to use abstract reasoning was average, fund of knowledge was good, judgment was above average, presenting affect was sad and irritable and congruent to his depressed mood, and thought process was tight and goal-directed. The psychologist remarked that the Veteran's depression appeared to be strongly related to functional limitations. The diagnosis included PTSD, and Dr. Calvo assigned a GAF score of 55-65. The Veteran was afforded a VA PTSD examination in February 2008. He reported sometimes feeling nervous, lying awake for an hour, falling asleep for 20 or 30 minutes, and then waking up startled. He stated that he does not remember having nightmares and recalls a dream only once in a while, but reportedly talks in his sleep, telling people to take cover. He denied a history of suicide attempts, suicidal or homicidal thoughts, violence or assaultiveness, obsessive or ritualistic behavior, panic attacks, or episodes of violence. He stated that he was married in the 1970s and divorced in the 1980s with no children and that he had a girlfriend for the past seven years. He explained that he generally stays away from people and did not "have the ability to sustain relationships except with [his] girlfriend or wife." He stated that he and his wife divorced because she wanted more social relationships. He reported that he likes to fish and was thinking about taking up hunting; however, he stated that gunfire bothered him and he startled easily. He stated that he was no longer working as a long haul truck driver due to difficulty maintaining his diabetes under those driving conditions, and no one would hire him for local haul jobs. The Veteran described his mood as "melancholy for periods of four to six days" and feeling depression during the examination. He believed he had been "more depressed this year than in the past seven years, but" did not know why, thinking "the finances and not having a job." His thought content related to financial worries, low self-esteem, and being concerned about a lack of ability to communicate well or socialize. He stated, "I don't have the desire to invest myself in many people. I'm happy with my girl and my house and that's about it." On mental status examination, psychomotor activity was unremarkable, but tense; speech was hesitant, soft or whispered, slow, clear, and coherent; affect was blunted; attention was intact; thought process was "blocking;" intelligence was above average; judgment and insight were intact with the Veteran understanding the outcome of his behavior and that he had a problem; there were no hallucinations; proverbs were interpreted appropriately; remote memory was mildly impaired while recent and immediate memory were normal; impulse control was good; and he was able to maintain personal hygiene. A GAF score of 57 was assigned. The examining psychologist summarized that the Veteran met the diagnostic requirements for PTSD of moderate severity. He concluded that the primary impact appeared to have been on his emotional and social functioning, problems with social avoidance, and difficulties with intimacy. He noted that the Veteran was able to sustain stable employment as a truck driver until about four years ago. He described the Veteran's PTSD as chronic, but relatively stable with a good prognosis for improvement because the Veteran reported feeling "good" about the treatment he was beginning to receive. The examiner indicated that the effects of the Veteran's PTSD on occupational and social functioning were consistent with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to PTSD signs and symptoms, but with generally satisfactory functioning. The examiner cited specific examples such as "some difficulties with people, communication difficulty, concentrating remembering." The Veteran was afforded another VA PTSD examination in July 2008 with a psychiatrist. He reported experiencing financial difficulty since he stopped working and being unable to pay his credit card debt or to afford a bankruptcy lawyer. He stated that he spends his time with his girlfriend and that they go camping, do recreational fishing, and visit her family members. He also reported spending time on the computer and enjoying doing yard work, taking care of the garden. He denied having his own significant friends or contact with his own family members. The Veteran did not have any specific nightmares that he was able to recall during the evaluation, stating, "I do, but I don't remember. Most of the time I just wake up agitated with fast heart rate and sweating." He reported difficulty getting back to sleep. He stated that he dreams of incoming rockets and mortars once per year. He did not describe having flashbacks. He did endorse having intrusive distressing thoughts about his Vietnam experiences triggered by certain sounds. He reported being startled while working by loud crashes or bangs or by impacts that would cause the ground to shake; however, he was unable to recall a recent incident where this occurred. He endorsed avoidant behavior with no close relationships outside of the one with his girlfriend. He described irritability and anger, becoming verbally abusive, and depressed mood. He stated that he preferred to have his back to the wall, but managed to sit anywhere in restaurants regardless of the seat. The psychiatrist commented that it was significant to note that the Veteran did have his back to the walkway while in the waiting room, although there were other seats available. She also noted that the Veteran had been able to maintain full-time work with some disturbances in his occupational functioning, but not to the point of decrease in reliability or productivity. Objective findings on mental status examination included the following: clean hygiene and neat grooming; full orientation; maintained eye contact and cooperative behavior; motor movement without abnormalities; full range of affect appropriate for the content discussed; speech with normal rate, rhythm, tone, and volume; logical associations; stream of thought unremarkable for being tangential or circumstantial; no evidence of paranoid delusions; concentration and memory grossly intact; and good insight and judgment. He denied suicidal or homicidal ideation or psychotic symptoms of hallucinations, ideas of reference, or thought control. The psychiatrist concluded that the Veteran suffered from PTSD symptoms of moderate severity and assigned a GAF score of 57. She added that there appeared to be little to no change since the last VA examination for PTSD. She also indicated that the Veteran's symptoms of depression were more likely related to stage of life changes and physical illness to include diabetes than to PTSD. A record of marriage associated with the claims file reflects that the Veteran and his spouse were married in February 2009. During a September 2009 VA diabetic pharmacy consultation, the Veteran stated that he was having more nightmares now that his blood sugars had improved. The pharmacist indicated that the Veteran was on Terazosin for benign prostatic hypertrophy symptoms (BPH), but a trial of Prazosin would possibly address the BPH symptoms and nightmares. During a December 2009 VA annual examination, the Veteran reported that his sleep was fair to good, and he denied depression or anxiety symptoms. On mental status examination is mood and affect were congruent and appropriate to conversation; he remained calm and was able to clearly discuss concerns that were important to him. During a March 2010 routine VA clinic visit, the Veteran reported that his prostate medication was causing vivid dreams. A December 2010 VA annual examination report reflects the Veteran's complaints of increasing depression symptoms and sleeping poorly at times and anxiety symptoms. On examination, he was oriented and mood and affect were flat with slowed speech and movements. On VA annual examination in January 2012, the Veteran complained of a lack of energy and sadness and more depression regarding his chronic health problems. He denied suicidal or homicidal ideation. A review of systems was positive for PTSD, depression, and anxiety symptoms. On mental status examination, he was oriented and mood and affect were congruent and flat. Subsequent treatment records dated to March 2012 did not reflect complaints or treatment related to PTSD. The Board has considered the objective evidence of record as well as the contentions and supporting lay evidence from the Veteran, his former representative, and his attorney, and finds that the Veteran's PTSD is not so severe that a higher, 50 percent, disability rating is warranted at any time during the appeal. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the preponderance of the evidence reflects that the Veteran's PTSD symptoms have more nearly approximated the criteria for the initial 30 percent rating currently assigned. In this case, the Board finds that the Veteran's PTSD has been manifested objectively by flat mood and affect with slowed speech and movements with instances of flat affect; below average concentration in August 2007; tense psychomotor activity; hesitant, whispered, slow speech; "blocking" thought process; and mildly impaired remote memory in February 2008. These findings more nearly approximate the criteria contemplated for a 30 percent disability rating. The Board notes that in August 2007 and July 2008 objective evidence of sad and irritable affect congruent to depressed mood, or depressive symptoms were specifically attributed to functional or physical limitations and to stage of life changes and physical illness to include diabetes by the respective private and VA examiners. The Board finds that the preponderance of the competent and credible evidence of record does not demonstrate, or more nearly approximate, occupational and social impairment with reduced reliability and productivity, the criteria for the next higher, 50 percent, rating. While the Veteran contends that his PTSD symptoms were more severely disabling than what is reflected in the assigned 30 percent rating, a review of his private and VA psychological or psychiatric examinations and VA treatment records, in fact, shows that his symptoms have resulted in some consistent disturbances in mood and affect and slowed speech and movement with single instances of impairment in concentration, remote memory, and thought process. The Board finds that the next higher, 50 percent, rating has not been more nearly approximated because the objective medical evidence does not show such symptoms as circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation; or difficulty in establishing and maintaining effective work and social relationships that are characteristic of the 50 percent rating. Rather, the evidence of record reflects that the Veteran worked for 29 years after separation from service, 4 years as a bartender and 25 years as a truck driver. He did not describe PTSD symptoms interfering with work, he had repeatedly denied PTSD symptoms prior to filing his claim for service connection, and he told the February 2007 VA examiner that he was no longer working due to difficulty managing his diabetes. Also, VA treatment records reflect the Veteran's motivation to make lifestyle changes when he was advised that insulin may be required for his diabetes, and he was successful in his efforts. Similarly, while he has reported such symptoms as preferring to have his back to the wall, he acknowledged he could sit anywhere in restaurants regardless of the seat and was observed sitting with his back to the walkway while in the waiting room prior to the July 2008 VA examination even though other seats were available. In addition, while he has consistently described social isolation, the evidence reflects that he apparently married his girlfriend of many years during the course of this appeal and that he spends time with her family, reflecting an ability to establish and maintain effective relationships. In any event, the Board reiterates that when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Collectively, the aforementioned medical evidence reflects that, the Veteran's psychiatric symptoms have resulted in no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. This level of occupational and social impairment is consistent with the currently assigned 30 percent disability rating. The Board further finds that none of the GAF scores assigned at any point since the effective date of the award of service connection provides a basis for assigning a higher rating. GAF scores ranged from 55-65 on private examination in August 2007 to 57 on VA examinations in February and July 2008. GAF scores ranging from 51 to 60 are indicative of moderate symptoms such as flat affect or moderate difficulty in social functioning such as having few friends. The Board finds the GAF scores in the range of the mid to upper 50s and higher on private and VA examinations are consistent with objective findings regarding flat affect with slowed speech and movements with instances of other symptoms, such as impaired remote memory and below average concentration, and with the subjective reports regarding social withdrawal or avoidance, sleep disturbance and occasional nightmares, increased startle response, irritability and anger, and depressed or anxious mood. In any event, the Board emphasizes that a GAF score is not dispositive of the evaluation question; rather as indicated above, the symptoms shown provide the primary basis for an assigned rating. Here, as indicated above, the Veteran primarily exhibited symptoms typically associated with a 30 percent rating. In determining that the criteria for a 50 percent rating for the Veteran's psychiatric symptoms shown are not met, the Board has considered the rating criteria in the General Rating Formula for Mental Disorders not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating for PTSD. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Under the circumstances of this case, the Board finds that, since the July 2007 effective date of the award of service connection, the Veteran's PTSD symptomatology has not met or more nearly approximated the criteria for a 50 percent rating. See 38 C.F.R. § 4.7. As the criteria for the next higher, 50 percent, rating are not met, it follows that the criteria for an even higher rating (70 or 100 percent) likewise are not met. Extraschedular Consideration The Board has also considered whether each of the Veteran's disabilities decided herein presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extraschedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2013); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's diabetes with erectile dysfunction, diabetic nephropathy, and PTSD disability level and symptomatology, and provide for higher ratings for additional or more severe symptomatology than is shown by the evidence. In addition, the Veteran and his treatment providers have not identified exceptional or unusual symptoms or manifestations of his diabetes with erectile dysfunction, diabetic nephropathy, or PTSD. Thus, his disability picture is contemplated by the rating schedule, and the currently assigned schedular ratings of 20 percent for diabetes mellitus with noncompensable erectile dysfunction, 30 percent for diabetic nephropathy, and 30 percent for PTSD are, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). The Board has also considered 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 for any disability decided on appeal because as explained above, the medical and lay evidence of record did not support higher ratings than those already assigned. In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims for higher initial ratings than those assigned for diabetic nephropathy and PTSD, and against the claim for an increased rating for diabetes mellitus with erectile dysfunction, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Entitlement to a rating in excess of 20 percent for type II diabetes mellitus with erectile dysfunction is denied. Entitlement to an initial rating in excess of 30 percent for diabetic nephropathy is denied. Entitlement to an initial rating in excess of 30 percent for PTSD is denied. REMAND Having reviewed the medical and lay evidence of record, the Board finds that additional development is required before deciding the claims of entitlement to initial ratings in excess of 10 percent each for peripheral neuropathy of the right and left upper and lower extremities and for a TDIU. Peripheral Neuropathy of the Right and Left Upper and Lower Extremities In connection with a February 2007 VA examination, an electromyography (EMG) and nerve conduction velocity (NCV) study was performed. For the bilateral lower extremities, the EMG/NCV study revealed evidence for "some element of polyneuropathy with primary electrodiagnostic evidence of axonal loss." In a March 2007 addendum, the February 2007 VA examiner reviewed the EMG report and noted there was polyneuropathy in the lower extremities consistent with diabetic peripheral neuropathy. While the EMG/NCV report appears to reflect mild neuropathy of the bilateral lower extremities based on the neurologist's conclusion that there was "some element" of polyneuropathy, the Board requires a review of these reports and a medical opinion regarding the degree of paralysis. In connection with and prior to a July 2008 VA diabetes mellitus and peripheral nerves examination, the Veteran was afforded an EMG/NCV examination in June 2008. The impression was abnormal study of all limbs studied. Specific to the arms, the "electrodiagnostic study reveal[ed] evidence of moderately severe, bilateral carpal tunnel syndrome (median nerve entrapment at wrist) affecting sensory and motor components" with "mild bilateral proximal median neuropathy (pronator syndrome)." The right side was noted by the neurologist to be more involved than the left. The neurologist also indicated that there was no ulnar neuropathy, no cervical radiculopathy or plexopathy on either side, and no myopathy or motor neuron disease. The impression for the legs was mild, distal axonal polyneuropathy with elements of accompanying demylination with no peripheral nerve lesions in the legs, no plexopathy, and no motor neuron disease or myopathy. The July 2008 VA examiner reviewed the claims file, the June 2008 EMG/NCV report, obtained a subjective history regarding symptoms of upper and lower extremity neuropathy, and examined the Veteran. The examiner noted that the Veteran has had "relatively little in the way of upper extremity symptoms, although his current EMG shows carpal tunnel. He had some epicondylar muscle discomfort, particularly with twisting or lifting, but denie[d] wrist pain." There had been "no sensory symptoms in the fingers." The impression included bilateral carpal tunnel syndrome. Subsequently, the Veteran intermittently endorsed and denied neurological symptoms regarding his lower extremities during VA medical visits. However, during a May 2011 telephone call with VA medical personnel, he reported having more neuropathy in his feet and lower legs. In June 2010 correspondence, the Veteran's attorney asserted that the July 2008 VA examination, including the June 2008 EMG/NCV study, was inadequate because the examiner did not render a medical opinion regarding "any relationship or lack thereof between the diagnosed carpal tunnel syndrome and the Veteran's diabetes and/or peripheral neuropathy." The attorney also asserted that the [July 2008] examiner apparently made no specific findings regarding the Veteran's reported lower extremity symptoms. The Board finds that an additional VA peripheral nerves examination is required to assess the current severity of the Veteran's bilateral upper and lower extremity peripheral neuropathy and to review the February 2007 EMG/NCV evaluation and VA examination report and to provide a medical opinion regarding the degree of paralysis of the right and left lower extremities. The VA examiner should also provide a medical opinion as to whether any current bilateral carpal tunnel syndrome was caused or is aggravated by the service-connected diabetes mellitus or bilateral upper extremity peripheral neuropathy disabilities. See 38 C.F.R. § 3.310 (2013); Allen v. Brown, 7 Vet. App. 439 (1995). The RO should provide VCAA notice to the Veteran regarding establishing service connection for disability on a secondary basis. Prior to scheduling a VA peripheral nerves examination, ongoing pertinent treatment records from the White City VA Medical Center (VAMC) and Klamath Falls VA Community Based Outpatient Clinic (CBOC) dated from March 2012 to the present should be obtained and associated with the claims file. Issues from March 2012 Rating Decision In a March 2012 rating decision, the RO granted service connection for tinnitus, effective October 8, 2002; status post surgical treatment for contracture of right ring finger secondary to traumatic scarring and Dupuytren's contracture with postoperative scarring and superficial nerve damage, assigning a 10 percent rating effective October 8, 2002; vertigo symptoms, assigning a noncompensable rating effective October 8, 2001; and bilateral hearing loss, assigning a noncompensable rating effective September 29, 2008. In a January 2013 letter, the RO notified the Veteran of the decision. In January 2014, the Veteran's attorney submitted correspondence on the Veteran's behalf expressing disagreement with the initial ratings assigned for the right ring finger disability, vertigo symptoms, and bilateral hearing loss, and with the effective dates assigned for the grant of service connection for tinnitus, a right ring finger disability, vertigo symptoms, and bilateral hearing loss. This matter must be returned to the RO for appropriate consideration and issuance of a statement of the case with regard to these issues. Manlincon v. West, 12, Vet. App. 238 (1999). TDIU The Veteran's TDIU claim remains intertwined with the claims for higher ratings for peripheral neuropathy of the right and left upper and lower extremities, including the question of whether bilateral carpal tunnel syndrome is medically related to the Veteran's diabetes or peripheral neuropathy of the bilateral upper extremities, which are the subject of the present appeal and remand. Accordingly, adjudication of the TDIU claim must await development and readjudication of peripheral neuropathy claims. The Court has held that a claim that is inextricably intertwined with another claim that remains undecided and pending before VA must be adjudicated prior to a final order on the pending claim, so as to avoid piecemeal adjudication. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the case is REMANDED for the following action: 1. Provide VCAA notice to the Veteran regarding the information and evidence necessary to establish service connection for bilateral carpal tunnel syndrome, including on a secondary basis. 2. Obtain ongoing treatment records from the White City VAMC and Klamath Falls CBOC dated from March 2012 to the present and associate them with the claims file. 3. After the above development has been completed, schedule the Veteran for an examination to evaluate his peripheral neuropathy of the upper and lower extremities. The claims file and a copy of this remand must be made available to and be reviewed by the examiner in conjunction with the examination. The examiner must indicate in the examination report that the claims file was reviewed in conjunction with the examination. All indicated studies, tests and evaluations deemed necessary by the examiner should be performed. The results of such must be included in the examination report. The examiner is requested to review the February 2007 EMG/NCV evaluation and February 2007 VA examination report and to provide an opinion regarding the degree of paralysis of the right and left lower extremities shown at that time (mild incomplete paralysis, moderate incomplete paralysis, severe incomplete paralysis, or complete paralysis of the external popliteal nerve manifested by foot drop and slight droop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes). Regarding the bilateral carpal tunnel syndrome shown on EMG/NCV evaluation in June 2008, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any current bilateral carpal tunnel syndrome, began in service or is otherwise medically related to military service. If bilateral carpal tunnel syndrome did not begin in service and is not medically related to military service, the examiner should indicate whether any bilateral carpal tunnel syndrome is at least as likely as not (a 50 percent or greater probability) caused or aggravated by the Veteran's service-connected diabetes mellitus or diabetic neuropathy of the right and left upper extremities. If aggravated, specify to the extent possible the baseline of bilateral carpal tunnel syndrome prior to aggravation, and the permanent, measurable increase in bilateral carpal tunnel syndrome resulting from the aggravation. The examination report should include the complete rationale by the examiner for all opinions expressed. 4. Appropriate action should be taken pursuant to 38 C.F.R. § 19.26 in response to the January 2014 notice of disagreement, including issuance of an appropriate statement of the case, pertaining to the issues of entitlement to initial higher ratings for a right ring finger disability, vertigo symptoms, and bilateral hearing loss and to the issues of earlier effective dates for the grant of service connection for tinnitus, a right ring finger disability, vertigo symptoms, and bilateral hearing loss, so the Veteran may have the opportunity to complete the appeal by filing a timely substantive appeal. Thereafter, if a timely substantive appeal is filed, the case should be returned to the Board for appellate review. 5. After undertaking any other development deemed appropriate and ensuring that the requested actions are completed, the AOJ should readjudicate the claims of entitlement to initial ratings in excess of 10 percent each for peripheral neuropathy of the right and left upper and lower extremities and for entitlement to TDIU. If any benefit is not granted in full, the Veteran and his attorney should be furnished with a supplemental statement of the case and afforded an appropriate period of time for response. Thereafter, the case should be returned to the Board, if in order. The appellant has the right to submit additional evidence and argument on the 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). ______________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs