Citation Nr: 1001209 Decision Date: 01/08/10 Archive Date: 01/15/10 DOCKET NO. 07-17 671 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to a compensable evaluation for a skin disability. 2. Entitlement to a compensable evaluation for a left wrist ganglion disability. 3. Entitlement to service connection for a back disability. 4. Entitlement to service connection for diabetes mellitus. 5. Entitlement to service connection for peripheral neuropathy, to include as secondary to diabetes mellitus. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD David Ganz, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1970 to September 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which, in pertinent part, continued the Veteran's 0 percent ratings for dermatitis of the groin and left wrist ganglion disability, and denied service connection for a back disability, diabetes mellitus, and peripheral neuropathy. The Veteran testified before the undersigned Veterans Law Judge at a hearing at the RO in November 2009. A transcript of the hearing is of record. At the November 2009 Board hearing the Veteran withdrew his claims for service connection for chloracne, dermatitis of the underarms, feet, arms, legs, and body, sinusitis, high cholesterol, bilateral hearing loss, depression, congestive heart failure, degenerative arthritis at levels C3-7, pain in arms, shoulders, fingers, wrist, and elbow, excessive perspiration, and whether new and material evidence had been submitted to reopen previously denied claims of service connection for loss of smell and residuals, right arm injury. See 38 C.F.R. § 20.204(b)(1). Hence, these claims are no longer on appeal. The issues have been recharacterized to comport to the medical evidence of record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). 38 U.S.C.A. § 7107(a)(2) (West 2002 and Supp. 2009). The issues of entitlement to service connection for a back disability, diabetes mellitus, and peripheral neuropathy, to include as secondary to diabetes mellitus, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's skin disability affects more than 40 percent of his entire body. 2. The Veteran's left wrist ganglion disability is not characterized by a cyst that is deep, that is superficial and exceeds 144 square inches, that is unstable, that is painful on examination, or that causes a compensable degree of limitation of motion or ankylosis of the wrist joint; nor does it involve degenerative arthritis. CONCLUSION OF LAW 1. The schedular criteria for a maximum 60 percent evaluation for a skin disability are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2009); 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code (DC) 7806 (2009). 2. The criteria for a compensable evaluation for a left wrist ganglion disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2009); 38 C.F.R. §§ 4.3, 4.7, 4.71(a), 4.118, Diagnostic Codes (DCs) 5214 and 5215, 7801-7805, and 7819 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSION Notice and Assistance Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159. The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant with pre-adjudication notice by letters dated in February 2005 and April 2005, and post- adjudication notice by letter dated in May 2006. While notice pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006) was not provided prior to the initial adjudication, the claimant has had the opportunity to submit additional argument and evidence, and to meaningfully participate in the adjudication process. The claim was subsequently readjudicated in an April 2007 statement of the case (SOC), and October 2008 and June 2009 supplemental statements of the case (SSOCs), following the provision of notice. The Veteran has not alleged any prejudice as a result of the untimely notification, nor has any been shown. The notification substantially complied with the specificity requirements of Dingess v. Nicholson, 19 Vet. App. 473 (2006) identifying the five elements of a service connection claim, and; Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim, and the relative duties of VA and the claimant to obtain evidence. In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notices. See Shinseki v. Sanders, 129 U.S. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). VA has obtained service treatment records (STRs), assisted the Veteran in obtaining evidence, and afforded the Veteran medical examinations as to the severity of his service connected disabilities. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claim file; and the Veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Analysis The Veteran seeks higher evaluations for his skin and left wrist disabilities. He contends that his service connected disabilities warrant compensable ratings. In December 1982, the RO granted service connection for dermatitis of the groin, assigning a 0 percent evaluation effective September 29, 1981, under 38 C.F.R. § 4.118, DC 7899-7806, and service connection for ganglion, left wrist, assigning a 0 percent evaluation effective September 29, 1981, under 38 C.F.R. § 4.118, DC 7819. The RO continued the Veteran's current non compensable ratings under the same diagnostic codes in the rating decision currently on appeal. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations 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. See 38 C.F.R. § 4.97. During an appeal of a disability rating, either from an initial rating assigned on granting of service connection or on appeal of a subsequent denial of an increased rating, it may be found that there are varying and distinct levels of disability impairment severity during an appeal. So, staged ratings (different disability ratings during various time periods) are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When all the evidence is assembled, VA is responsible for determining 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 a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Skin Disability The Veteran's skin disability is rated under DC 7806. Under Diagnostic Code 7806, a noncompensable rating is warranted if less than 5 percent of the entire body or less than 5 percent of the exposed areas are affected; and, no more than topical therapy required during the past 12-month period. A 10 percent rating is warranted for dermatitis or eczema that is at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. More than 40 percent of the entire body or more than 40 percent of exposed areas, affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period warrants a 60 percent rating. 38 C.F.R. § 4.118. A VA examination was conducted in March 2005. A physical examination revealed that the Veteran had extensive keratosis pilaris of his arms, shoulders, buttocks, and legs with mild hyperhydrosis of the palms and soles. There was a large area on his buttocks at the cleft that extends 2.5 inches on either side of the gluteal cleft that is scaling, and this was found to be potassium hydroxide (KOH) positive on scraping. There are no exposed areas involved, so no percentages established, and total percentage of his entire body that is affected would be something less than 5 percent. Diagnoses of keratosis pilaris, mild hyperhydrosis, evidence of prior tinea cruris manifested by hyperpigmentation of the upper inner aspect of the thighs, active tinea corporis manifested by KOH positive scraping from his buttocks, and mild active tinea pedis manifested by KOH positive scrapings from his right foot, were given. A VA examination was conducted in March 2007. The examiner noted that he conducted the March 2005 VA examination. We are to examine the Veteran and determine whether dermatitis of the underarms, feet, arms, legs, and body is of the same etiology of the dermatitis of the groin found in service. The Veteran's groin was clear of lesions on his last examination in 2005 and is clear of lesions today. He reports using Curel lotion, Vaseline, doxycycline, antifungal powder, and Lamisil for treatment. A physical examination revealed that the Veteran maintains the keratosis pilaris on his back, buttocks, outer arms, and minimally on the thighs, which approximates 23 percent of the body surface. The legs have no lesions present, only hyperpigmentation where the process was, which would represent less than 5 percent of body surface area. Today's examination of his buttocks revealed that they cleared from the previously described fungal rash, but the tinea pedis on his feet is much more severe than in 2005 with generalized scaling and involves approximately 4 percent of his body surface. The skin on his legs is diffusely dry with mild desquamation in an ichthyotic pattern, which would represent 18-20 percent of the body surface area. Diagnoses of residual hyperpigmentation of the legs and buttocks secondary to prior fungal disease, keratosis pilaris with xerosis of body skin, which lends further credence to the suspicion that he is atopic, tinea pedis, more severe than in 2005, and no armpit disease present other than residual hyperpigmented area, were given. The examiner noted that it would be mere speculation to state whether these conditions are of the same etiology as what he was for seen for during service. If the groin problem was fungal during service, then the buttocks fungus and the foot fungus would be part of that same condition, however it would not be part of the keratosis pilaris or xerosis of the skin. In April 2007, the March 2007 VA examiner provided an addendum opinion. The examiner noted that unlike the previous examination, he now has and has reviewed the Veteran's claim file. The examiner noted that without the claim file it would have been speculation to state whether the Veteran's current skin conditions were the same as his service connected dermatitis of the groin. The examiner noted and thoroughly discussed the Veteran's treatment for skin conditions involving his groin during and after service. The examiner noted that his previous diagnoses stand as written. The generalized dryness that was described while he was in service continues and persists and I suspect that he probably is an atopic patient and what we saw described in service is certainly what we are seeing now. That would also fit with the keratosis pilaris of his arms, which is an atopic disorder. So of the conditions listed, I suspect the leg condition, the hyperhidrosis, the armpit problems, and generalized xerosis are certainly compatible with the conditions that were noted during service. Considering what is reported in the record, all of the conditions are of different etiologic sources; [however] I would give the Veteran the benefit of the doubt that these are one and the same conditions today as they were then. The April 2007 addendum to the March 2007 VA examination clearly indicates that the Veteran has one skin disability, which began in service and has continued to the present. The Veteran's service-connected skin disability is therefore not limited merely to dermatitis of his groin, but involves the keratosis pilaris on his back, buttocks, outer arms, and thighs, which approximates 23 percent of the body surface, the tinea pedis on his feet, which involves approximately 4 percent of his body surface, and the skin on his legs, which would represent 18-20 percent of the body surface. Therefore, because the most recent VA examination shows that the Veteran's various skin conditions are manifestations of a larger service-connected single skin disability that involves more than 40 percent of his entire body the assignment of the maximum 60 rating is warranted. See 38 C.F.R. § 4.118, DC 7806. Given the award of the maximum schedular rating for the Veteran's skin disability, apparently present throughout the period of the appealed claim, staged ratings are not for application. See Hart, 21 Vet.App. at 508. II. Left Wrist Ganglion Disability The Veteran's left wrist ganglion disability is rated under DC 7819. Diagnostic Code 7819, benign skin neoplasms, is to be rated under DCs 7801-7805, or as impairment of function. 38 C.F.R. § 4.118. The diagnostic codes pertaining to the function of the wrist are DCs 5214 and 5215, and, if they involve degenerative arthritis or a disability listed in DCs 5013-5024, DC 5003. 38 C.F.R. § 4.71(a). In rating a musculoskeletal disability, functional loss due to pain is a factor. Other factors include less movement than normal, weakened movement, excess fatigability, pain on movement, and painful motion. 38 C.F.R. § 4.40, 4.45, and 4.59. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). VA treatment records dated in September 2004 note that the Veteran reported that he had a ganglion cyst on the dorsum of his left wrist, but that it has resolved recently, and that a physical examination revealed that the Veteran does not have a palpable ganglion cyst at this time. He does have some mild tenderness to palpitation along his radiocarpal joint. Otherwise he is neurovascularly intact. An assessment of left ganglion was given. A VA examination was conducted in March 2005. The Veteran had complaints of his left dorsal wrist ganglion. He reports that he has some pain in his left wrist with some daily activities and with motion of his wrist. There are not any symptoms of any kind of inflammatory arthritis or constitutional symptoms. A physical examination revealed that he can dorsiflex his wrist to 70 degrees, palmar flex to 80 degrees, and can respectively radial and ulnar deviate the wrist from 0 to 20 degrees and from 0 to 45 degrees. With motion of his left wrist, he does not grimace and does not appear to be in pain, however he states he does feel some pain in his wrist at that time. Also with palpitation at the distal carporadial joint, he does state that he has wrist pain. There is no grimacing on this. There may be a small cystic area in his left wrist. X-rays of the bilateral wrist do not show any degenerative joint disease, other lesions, or abnormalities. An assessment of left dorsal wrist ganglion was given. There was no limitation to the range of motion concerning the DeLuca provision. It is feasible that after large use his range of motion may be limited by pain, however any attempt to express this in terms of additional limitation of motion cannot be determined with any degree of medical certainty. A scar not involving the head, face, or neck can be rated under Diagnostic Codes 7801, 7802, 7803, 7804, and/or 7805. 38 C.F.R. § 4.118. However, assigning multiple ratings for the Veteran's left wrist ganglion disability would constitute prohibited pyramiding. 38 C.F.R. § 4.14. Under Diagnostic Code 7801, scars, other than of the head, face or neck, that are deep or that cause limited motion warrant a 10 percent rating when they cover an area or areas exceeding 12 square inches. 38 C.F.R. § 4.118. Under DC 7802 a 10 percent rating is warranted for a scar, other than on the head, face, or neck, that is that is superficial and nonlinear and exceeds an area of 144 square inches. Under DC 7803 a 10 percent rating is warranted for a scar that is superficial and unstable, and under DC 7804 a 10 percent rating is warranted for a scar that is painful on examination. There is no medical evidence of record indicating that the Veteran's left wrist ganglion disability involves an actual ganglion cyst, however even if it does, there is no medical evidence indicating that it is deep and nonlinear, is 12 square inches or more, or is unstable. Furthermore, the September 2004 VA treatment report notes only that the Veteran had some mild tenderness to palpitation along his radiocarpal joint, and does not indicate that he has a ganglion cyst, which is itself painful. Likewise, the March 2005 VA examination report notes only that with palpitation at the distal carporadial joint the Veteran reported that he has some wrist pain, and does not indicate that he has a ganglion cyst, which is itself painful. Therefore, the Veteran's left wrist ganglion disability does not warrant a compensable rating under DCs 7801-7804. See Id. Diagnostic Code 7805 addresses scars and indicates they can be rated on limitation of function of the affected part. 38 C.F.R. § 4.118, DC 7805. The codes relating to the function of the wrist are DCs 5214 and 5215. 38 C.F.R. § 4.71a. DC 5003 is not applicable because there is no medical evidence of record indicating that the Veteran's left wrist ganglion disability involves degenerative arthritis or a condition listed in DCs 5013-5024. Under DC 5214, compensable ratings are warranted for favorable, unfavorable, and positions other than favorable ankylosis of the wrist. Id. The Veteran has never been diagnosed with, nor does he contend, that his left wrist has any type or degree of ankylosis. Therefore, the Veteran's left wrist disability is not entitled to higher rating under DC 5214. Id. Limitation of wrist motion is rated under Diagnostic Code 5215, and provides for a 10 percent rating for limitation of motion of the wrist where dorsiflexion is less than 15 degrees or where palmar flexion is limited in line with forearm. Id. The March 2005 VA examination report indicates that the Veteran can dorsiflex his wrist to 70 degrees, and palmar flex to 80 degrees. 38 C.F.R. § 4.71, Plate I (2004), reflects that normal dorsiflexion of the wrist is 0 to 70 degrees, and the normal palmar flexion is to 80 degrees. Thus, the VA examination of record clearly indicates that the Veteran's left wrist does not have dorsiflexion less than 15 degrees or palmar flexion that is in line with the forearm, and hence his left wrist disability does not warrant a compensable rating under DC 5215. The disabling effects of pain have been considered in evaluating the Veteran's service-connected left wrist disability, as indicated in the above discussions. See DeLuca, supra. The Veteran's complaints of pain during his VA examination, and the examiner's observations of pain and painful motion, were considered in the level of impairment and loss of function attributed to his disability. At no time during the pendency of this claim has the Veteran's left wrist disability met or nearly approximated the criteria for a compensable rating, and staged ratings are not for application. See Hart, 21 Vet. App. at 505. The Veteran genuinely believes that the severity of his left wrist disability merits a higher rating. However, as a layperson, lacking in medical training and expertise, the Veteran cannot provide a competent opinion on a matter as complex as the severity of his service-connected disability, and his views are of no probative value. And, even if his opinion was entitled to be accorded some probative value, it is far outweighed by the detailed opinions provided by the VA medical professional, which show that the criteria for a rating in excess of 0 percent for his left wrist disability have not been met. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Gilbert, 1 Vet. App. 49; 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.71a. The preponderance of the evidence is against the claim; there is no doubt to be resolved; and an increased rating for a left wrist disability is not warranted. See Gilbert, 1 Vet. App. at 53-56; 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has considered whether the Veteran's disability picture warrants a compensable rating on an extraschedular basis. The regulation permits extra-schedular rating when "the schedular evaluations are found to be inadequate ... [because] the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). The rating schedule, however, is meant to compensate for the average impairment in civil occupations generally resulting from disability. 38 C.F.R. § 3.321. In this case, the Veteran has not alleged any hospitalization and has presented no evidence indicating any marked interference with employment as a result solely of his skin or left wrist disabilities. ORDER Entitlement to a 60 percent evaluation for a skin disability is granted. Entitlement to a compensable evaluation for a left wrist ganglion disability is denied. REMAND The Veteran seeks service connection for a back disability, diabetes mellitus, and peripheral neuropathy. The Veteran claims that he has had problems with, and taken medications for, his back from service to the present time. Generally, to prevail on a claim of service connection on the merits, there must be medical evidence of (1) current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence or other competent evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). If a Veteran was exposed to an herbicide agent during active military, naval, or air service, Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes) shall be service-connected, even though there is no record of such disease during service. 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e), including Type II diabetes mellitus, shall have become manifest to a degree of 10 percent or more at any time after service. 38 C.F.R. § 3.307(a)(6)(ii). Service connection may also be granted for a disability which is proximately due to and the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Secondary service connection requires evidence of a connection to a service- connected disability. See Reiber v. Brown, 7 Vet. App. 513 (1995). Regarding the Veteran's claim of service connection for a back disability, April 2009 VA treatment records indicate that the Veteran received treatment for chronic low back pain. June 1975 STRs indicate that the Veteran complained of pain back, and it was noted that the source of the spasticity was a right back muscle. An impression of musculoskeletal pain was given. March 1981 STRs indicate complaints of muscle spasm in the back, and an assessment of spasm was given. It appears that the Veteran was prescribed medication for his back. Thus, the record contains competent medical evidence of current treatment for back pain, in service treatment for back pain and spasms, and credible testimony indicating that the Veteran has had a long standing history of back problems. There is insufficient medical evidence for the Board to decide the Veteran's claim on a direct basis and a VA medical examination must be provided. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159 (c). Regarding the Veteran's claim for diabetes mellitus, although the Veteran's Air Force personnel records, which does show that he was awarded the Vietnam Service Medal, does not show he served in the country of Vietnam, he credibly testified that in September 1972 he flew from Clark Air Force Base to Saigon, Vietnam, where he stayed overnight. The Board therefore concedes that the Veteran was in the country of Vietnam for purposes of the application of the presumptions of 38 C.F.R. §§ 3.307 and 3.309. March and April 2005 VA treatment records note that the Veteran participated in an Agent Orange examination and that his fasting glucose was elevated. It was noted that he has diabetes. A December 2006 VA treatment record notes that the Veteran has no history of diabetes mellitus. September 2008 and April 2009 VA treatment records note an active problem of only hyperglycemia. There is no evidence of record indicating that the Veteran receives any treatment for diabetes mellitus. 38 C.F.R. § 3.307 requires that Type II diabetes mellitus become manifest to a degree of 10 percent or more at any time after service before presumptive service connection is granted. See also 38 C.F.R. § 3.309(e). Thus, because it is unclear whether the Veteran has diabetes mellitus, a VA examination should be conducted to determine this. 38 C.F.R. § 3.159 (c). Regarding his claimed peripheral neuropathy disability, December 2006 VA treatment records note a past medical history of peripheral neuropathy and that motor nerve conduction studies of the lower extremities were abnormal and April 2009 VA treatment records note an active problem of lumbar radiculopathy. The Veteran claims that his current peripheral neuropathy is secondary to his diabetes mellitus. Because the Veteran's service connection claim for diabetes mellitus is being remanded, and because adjudication of that claim will impact the adjudication of the Veteran's peripheral neuropathy claim, these claims are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the Veteran's service connection claim for peripheral neuropathy also must be remanded. The appellant is hereby notified that it is his responsibility to report for the examination(s) and to cooperate in the development of the case, and that the consequences of failure to report for a VA examination(s) without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158 and 3.655. Accordingly, the case is REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). Expedited handling is requested.) 1. Schedule the Veteran for a VA medical examination to determine the nature and etiology of his claimed back disability. Following a thorough examination, the examiner should provide an opinion as to whether it is at least as likely as not that any identified back disability is related to service. The examiner must note and specifically address in his opinion the Veteran's STRs indicating treatment for back problems during service. 2. Schedule the Veteran for a VA medical examination to determine whether he has or does not have diabetes mellitus. All necessary tests and/or examinations should be conducted. The examiner is asked to state whether the Veteran currently has Type II diabetes mellitus, and if so, its severity. The examiner should state specifically whether it is at least of such severity as to be manageable by restricted diet only. See 38 C.F.R. § 4.119, DC 7913. 3. After the completion of #2, the claim for diabetes mellitus should then be readjudicated. If, and only if, the Veteran is granted service connection for diabetes mellitus, schedule him for a VA medical examination to determine the nature and etiology of his peripheral neuropathy disability. Following a thorough examination, the examiner the should provide an opinion as to whether it is at least as likely as not that any identified peripheral neuropathy disability is the result of, or is otherwise related to, the Veteran's service-connected diabetes mellitus. A complete rationale must be provided for all medical opinions. The claim folder must be made available to each examiner for review in conjunction with the examination(s). 4. Thereafter, if necessary, any additional development deemed appropriate should be accomplished. The claims should then be readjudicated. If any of the claims remain denied, the RO should issue a supplemental statement of the case (SSOC) containing notice of all relevant actions taken on the claim, to include a summary of the evidence and applicable law and regulations considered pertinent to the issues currently on appeal, and allow an appropriate period of time for response. 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. 2009). ______________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs