Citation Nr: 1016809 Decision Date: 05/06/10 Archive Date: 05/19/10 DOCKET NO. 06-17 481 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to an increased rating for diabetes mellitus, currently evaluated as 20 percent disabling. 2. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy, right upper extremity. 3. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy, left upper extremity. 4. Entitlement to an increased rating for peripheral neuropathy, right lower extremity, currently rated as 10 percent disabling. 5. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy, left lower extremity. 6. Entitlement to an initial evaluation in excess of 30 percent for coronary artery disease. 7. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus. 8. Entitlement to service connection for hepatitis C. 9. Entitlement to an effective date earlier April 8, 2005 for the grant of service connection of coronary artery disease. 10. Entitlement to a higher initial rating for peripheral vascular disease, right lower extremity. 11. Entitlement to a higher initial rating for peripheral vascular disease, left lower extremity. ATTORNEY FOR THE BOARD D. Johnson, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1968 to March 1970. This case comes before the Board of Veterans' Appeals (Board) on appeal from various decisions rendered by the New Orleans, Louisiana Regional Office (RO) of the Department of Veterans Affairs (VA). The Board notes that a total disability rating based on individual unemployability (TDIU) and eligibility for Dependents' Educational Assistance (DEA) were granted in an April 2008 rating decision, effective from April 8, 2005. The Veteran disagreed with the effective dates assigned in his August 2008 notice of disagreement (NOD). However, he did not submit a substantive appeal following the RO's issuance of a statement of the case (SOC) in July 2009. Therefore, those issues are not before the Board at this time. The issues of earlier effective dates for peripheral neuropathy of the bilateral upper and lower extremities are not addressed in this appeal. Service connection for peripheral neuropathy of the bilateral upper and left lower extremities was granted in an August 2005 rating decision. In an April 2006 NOD, the Veteran requested 20 percent ratings for the service-connected peripheral neuropathy. In another NOD received in May 2006, the Veteran expressed disagreement with the "back date" and "percentages assigned." Multiple issues were identified, including the increased ratings for peripheral neuropathy. However, the Veteran specified that he was requesting "back pay" only for "the heart condition alone." Subsequently, the RO awarded earlier effective dates for the peripheral neuropathy (bilateral upper extremities and the left lower extremity) on the basis of clear and unmistakable error in the August 2005 decision. The Board observes no further communication from the Veteran indicating disagreement with the revised effective dates assigned. Moreover, in a August 2009 VA Form 646 received from the Veteran's representative, all issues currently remaining on appeal were specifically identified and discussed -earlier effective dates for peripheral neuropathy were not included. Thus, the Board finds that the issues of earlier effective dates for peripheral neuropathy of the bilateral upper and lower extremities are not on appeal. The issue of entitlement to service connection for hepatitis C is addressed in the REMAND portion of this decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Diabetes mellitus requires a restricted diet, oral hypoglycemic agents, and restriction of activities. Insulin is not required. 2. Peripheral neuropathy of the bilateral upper and lower extremities has been manifested by no more than mild, incomplete paralysis throughout the entirety of the appeal period. 3. The Veteran's coronary artery disease, status post coronary artery bypass, disability is manifested by no more than workload of greater than 5 metabolic equivalents (METs) but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. 4. Competent medical evidence of record supports the conclusion that the Veteran's hypertension is aggravated as a result of his service-connected diabetes mellitus. 5. There is no evidence of an unadjudicated formal or informal claim for entitlement to service connection for coronary artery disease, including as secondary to service- connected diabetes mellitus, prior to April 8, 2005. 6. In August 2008, prior to the promulgation of a decision in this appeal, the Board received notification from the Veteran requesting withdrawal of his appeal as it related to increased ratings for peripheral vascular disease, left and right lower extremities. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.119, Diagnostic Code 7913 (2009). 2. The criteria for an initial rating in excess of 10 percent, for peripheral neuropathy right upper extremity have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.124A, Diagnostic Code 8615 (2009). 3. The criteria for an initial rating in excess of 10 percent, for peripheral neuropathy left upper extremity have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.124A, Diagnostic Code 8615 (2009). 4. The criteria for an increased rating, for peripheral neuropathy right lower extremity, currently rated at 10 percent have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.124A, Diagnostic Code 8520 (2009). 5. The criteria for an initial rating in excess of 10 percent, for peripheral neuropathy left lower extremity have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.124A, Diagnostic Code 8520 (2009). 6. The criteria for an initial evaluation in excess of 30 percent for coronary artery disease have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.104, Diagnostic Code 7005 (2009). 7. The criteria for service connection hypertension have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2009). 8. The criteria for an effective date prior to April 8, 2005 for the grant of service connection for coronary artery disease are not met. 38 U.S.C.A. § 5110 (West 2008); 38 C.F.R. §§ 3.400 (2009). 9. The criteria for the Veteran's withdrawal of the appeal on the claim of entitlement to an increased rating for peripheral vascular disease, right lower extremity have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.204 (2009). 10. The criteria for the Veteran's withdrawal of the appeal on the claim of entitlement to an increased rating for peripheral vascular disease, left lower extremity have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.204 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2008); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2009). Under 38 U.S.C.A. § 5103, VA must notify the claimant of any information or evidence not of record that is necessary to substantiate the claim, and what parts of that information or evidence VA will seek to provide, and what parts VA expects the claimant to provide. 38 C.F.R. § 3.159(b) (2009). VA must provide such notice to a claimant prior to an initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (AOJ). See Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004). For claims pending before VA on or after May 30, 2008, 38 C.F.R. 3.159 was amended to eliminate the requirement that VA request that a claimant submit any evidence in his or her possession that might substantiate the claim. 73 Fed. Reg. 23,353 (Apr. 30, 2008). The Court has also held that that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (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/Hartman v. Nicholson, 19 Vet App 473 (2006). The Veteran's claim for increased ratings for peripheral neuropathy, of the bilateral upper extremities and left lower extremity; coronary artery disease; and earlier effective date for coronary artery disease all arise from his disagreement with the initial evaluations and effective dates assigned following the grant of service connection for those disabilities. Once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Veteran received initial VCAA notice pertaining to his claim of service connection for hypertension by way of August 2004 correspondence. The Veteran received initial VCAA notice pertaining to his increased rating claims for diabetes mellitus and peripheral neuropathy, right lower extremity, by way of April 2005 correspondence. These letters notified the Veteran of VA's responsibilities in obtaining information to assist him in completing his claims, and identified his duties in obtaining information and evidence to substantiate his claims. Additional letters sent in May 2006, November 2006 and July 2009 provided notice of the type of evidence necessary to establish disability ratings or effective dates for the disabilities under consideration, pursuant to the recent holding in the Dingess decision. The Veteran's statements also evidence his awareness of the type of evidence necessary to substantiate his claims for increased ratings. The only deficiency with regard to notice in this case is some of the VCAA notice was received following the initial adjudication of the claims. However, this timing deficiency was cured by readjudication of the claims in the two July 2009 supplemental statements of the case (SSOC). Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Duties to Assist VA has also made reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate his claims. 38 U.S.C.A. § 5103A (West 2002). The information and evidence associated with the claims file consist of the Veteran's service treatment records, VA and private treatment records, and records from his Social Security Administration (SSA) disability file. The Veteran was also afforded VA examinations in connection with his claims. There is no evidence or contention that the disabilities on appeal have changed since the last examinations. Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994)(A veteran is entitled to a new examination where there is evidence that the condition has worsened since the last examination). The Board therefore finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Increased Ratings Disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7 (2009). The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West 12 Vet. App. 119, 126 (1999). The Veteran is presumed to be seeking the maximum benefit allowed by law and regulation. AB v. Brown, 6 Vet. App. 35, (1993). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). Hence, different ratings may be warranted for different time periods in an increased rating claim. The appropriate period for consideration begins one year prior to the date of claim. Id. I. Diabetes Mellitus Background The Veteran's service-connected diabetes mellitus is currently rated as 20 percent disabling, pursuant to 38 C.F.R. § 4.119, DC 7913. He contends that he is entitled to an increased rating. Ratings for diabetes mellitus are governed by criteria and set forth in 38 C.F.R. § 4.119, Diagnostic Code 7913. A rating of 10 percent is assigned for diabetes mellitus that is managed by a restricted diet only. A rating of 20 percent is assigned for diabetes mellitus requiring insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet. A rating of 40 percent is assigned for diabetes mellitus requiring insulin, a restricted diet, and regulation of activities. A rating of 60 percent is assigned for diabetes mellitus requiring insulin, restricted diet, and regulation of activities and involving episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or visits to a diabetic care provider twice a month plus complications that would not be compensable if separately evaluated. A rating of 100 percent is assigned for diabetes mellitus requiring more than one daily injection of insulin, a restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) and involving 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. 38 C.F.R. § 4.119, Diagnostic Code 7913. Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. See Note 1 to Code 7913. Analysis A July 2004 VA outpatient treatment record indicates that the Veteran's diabetes mellitus disability was controlled with oral medications. The Veteran underwent a VA examination in May 2005. The examination report indicates there had been no episodes of hypoglycemic reactions or ketoacidosis. The Veteran had gained 10 pounds since his last examination. He was following a restricted diet and had been told to regulate his activities. He was unable to engage in strenuous activities. There was no visual, cardiac, diabetic nephropathy, skin or gastrointestinal symptoms related to diabetes mellitus. Erectile dysfunction was present, but the examiner stated that the likely cause was vascular disease. No other diabetic complications were noted. VA outpatient treatment records are negative for any evidence of use of insulin for diabetes mellitus. The Veteran's prescribed medications lists only show use of two oral hypoglycemic agents for diabetes mellitus. The Board finds that the criteria for a 40 percent rating under Diagnostic Code 7913 have not been met. In reaching this conclusion, it is noted that the criteria for a higher rating under this diagnostic code are conjunctive not disjunctive-i.e. there must be insulin dependence and restricted diet and regulation of activities. Here, the medical evidence of record demonstrates that the Veteran's service-connected diabetes mellitus is currently treated by diet, oral hypoglycemic agents and regulation of activities. He is not shown to have been prescribed insulin by any physician. Rather, he is only noted to currently use two oral hypoglycemic agents for management of his diabetes mellitus. In light of the foregoing, the Board concludes that the evidence is against the assignment of an evaluation in excess of 20 percent for diabetes mellitus under Diagnostic Code 7913 for any period under consideration. Hart v. Mansfield, 21 Vet. App. 505 (2007). II. Peripheral Neuropathy 38 C.F.R. § 4.124 provides guidance for rating neurologic disabilities. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. See nerve involved for diagnostic code number and rating. Tic douloureux, or trifacial neuralgia, may be rated as complete paralysis of the affected nerve. 38 C.F.R. § 4.124 (2009). The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. Background A December 2003 VA outpatient treatment record shows the Veteran complained of leg cramps at night. A March 2004 treatment record shows he denied calf tenderness but neuropathy was noted. An April 2004 note reflects a complaint of numbness and pain in both lower extremities, left leg and foot worse than the right. These symptoms reportedly interfered with walking and sleeping, but the Veteran was able to maintain a normal gait without need of an ambulatory aid. Objectively, there was full range of motion, hairless skin, negative Hoffman's sign and adequate pulses. The diagnosis was intermittent claudication. Another September 2004 clinical note reflects that the Veteran had a steady gait, with no pronator drift. No clubbing, cyanosis, edema or palmar erythema was seen in the extremities. At a VA examination in October 2004, the Veteran reported numbness in the left leg and difficulty walking beginning 6-7 years prior. Vascular studies at that time were consistent with vascular insufficiency, affecting the left leg. He also had tenderness of his toes, swelling of that extremity, and change in skin texture-but no change in skin color or decreased hair growth. Mild numbness and tingling affecting the right foot also reportedly began 6 years ago earlier. He also reported involvement of his hands, right greater than left and particularly affecting the pinky and ring fingers on the right. Physical examination revealed 5/5 strength in the bilateral upper extremities; right lower extremity iliopsoas were 4+/5; quads and hams 4+/5; dorsiflexion and plantar flexion were 3/5. Reflexes are 1+ and symmetric throughout with absent ankle jerks. Sensory examination showed no decreased vibration in the bilateral lower extremities. The examiner opined that given the constellation of symptoms and asymmetry, the predominant pathology of the left lower extremity was likely vascular insufficiency. The mild complaints related to the right foot and bilateral hands likely represented a mild polyperipheral neuropathy secondary to the diabetes. Some of the right hand complaints (and particularly the nocturnal symptoms) were likely due to transient and compressive neuropathy of the ulnar nerve. A December 2004 outpatient treatment record shows an evaluation of pedal pulses, monofilament tests for feet sensation and visual inspection of feet were normal. The Veteran underwent a VA examination in May 2005. Current symptoms included daily sharp, shooting pain, numbness and paresthesias in the bilateral feet and hands. He denied weakness, fatigue, tremors, stiffness, or paralysis, dyesesthesias, or functional loss. On physical examination, muscle strength in the bilateral upper and lower extremities was 5/5. Sensory examination of the bilateral lower extremities revealed decreased vibration and position sense in the peripheral sensory nerves of the bilateral feet. Light touch was absent in the toes. Sensory examination of the bilateral upper extremities revealed normal vibration and position sense in the sensory nerves. Light touch and pain were decreased in the bilateral hands. There was no muscle atrophy, or abnormal muscle tone or bulk. Abnormal movements were not present. There also was no abnormal plantar reflex; impairment of joint function; or residuals of a benign or malignant neoplasms of a nerve. Deep tendon reflexes were 2+ in the triceps, biceps, brachioradialis, and left knee jerk. Right knee jerk was 1+. Ankle jerk deep tendon reflexes were 0 bilaterally. The diagnosis was peripheral neuropathy, bilateral upper and extremities. The etiology was diabetes mellitus. No nerve dysfunction was noted. The Veteran underwent a VA examination for his diabetes mellitus in May 2005. The sensory examination revealed pulses in the bilateral upper and lower extremities were normal. Sensory loss of touch, pain, and position was present in the bilateral big toes and bilateral hands on the left and right sides. Deep tendon reflexes, left and right sides were 2+ in the triceps, biceps, brachioradialis, and knee jerk. Ankle jerk was 0 in the left and 1+ in the right. Analysis Peripheral neuropathy, bilateral upper extremities The RO granted service connection for peripheral neuropathy of the left and right upper extremities in an August 2005 rating decision, and awarded an initial 10 percent rating, pursuant to DC 8615, effective from April 8, 2005. In an April 2008 rating decision, the RO corrected clear and unmistakable error (CUE) in the 2005 decision and awarded an earlier effective date of October 26, 2004. The Veteran desires higher ratings. The criteria for evaluating disability of the median nerve are found at 38 C.F.R. § 4.124a, Diagnostic Code 8615. Diagnostic Code 8615 provides for a 70 percent rating for complete paralysis of the major median nerve and a 60 percent rating for the minor median nerve with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective; absence of flexion of index finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. 38 C.F.R. § 4.124a, Diagnostic Code 8615 A 50 percent rating is warranted for severe incomplete paralysis of the major median nerve; 40 percent is warranted for the minor median nerve. Id. A 30 percent rating is warranted for moderate incomplete paralysis of the major median nerve; 20 percent is warranted for the minor median nerve. Id. A 10 percent rating is warranted for mild incomplete paralysis of the major or minor median nerve. Id. At worst, the Veteran's peripheral neuropathy of the left and right hands has been subjectively manifested by pain, tingling and numbness, (i.e. paresthesias), in the bilateral hands. The Board notes that a higher evaluation for either upper extremity would require at least moderate, incomplete paralysis. Objective findings show decreased sensation to touch and pain, but not position sense. However, pulses have been consistently reported as normal and there has been no motor loss or other functional impairment. Muscle strength has remained normal. No other neurologic or orthopedic abnormalities have been reported at any time over the course of the appeal. Given the mild to moderate level of pain and the absence of other findings, the disability does not rise to the level of moderate incomplete paralysis. Therefore, initial ratings in excess of 10 percent, for peripheral neuropathy of the left and right upper extremities under DC 8615, are not warranted for any period under consideration. Hart v. Mansfield, 21 Vet. App. 505 (2007); see also 38 U.S.C.A. § 5107(b). Peripheral neuropathy, bilateral lower extremities The RO granted service connection for peripheral neuropathy of the right lower extremity in a November 2004 rating decision, and awarded an initial 10 percent rating, pursuant to DC 8520, effective from March 1, 2004. The RO granted service connection for peripheral neuropathy of the left lower extremity in an August 2005 rating decision, and awarded an initial 10 percent rating, also pursuant to DC 8520, but effective from April 8, 2005. In an April 2008 rating decision, the RO corrected clear and unmistakable error (CUE) in the 2005 decision and awarded an earlier effective date of October 26, 2004. The Veteran desires higher ratings. The criteria for evaluating disability of the sciatic nerve are found at 38 C.F.R. § 4.124a, Diagnostic Code 8520. Under this Code, where paralysis is complete; the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely), an 80 disability evaluation is warranted. Severe incomplete paralysis with marked muscular atrophy warrants a 60 percent disability evaluation. A 40 percent evaluation is warranted for moderately severe incomplete paralysis. A 20 percent evaluation is warranted for moderate incomplete paralysis, and a 10 percent disability evaluation would be warranted for mild incomplete paralysis. 38 C.F.R. § 4.124a, Diagnostic Code 8520. At worst, the Veteran's peripheral neuropathy of the left and right lower extremities has been manifested by pain, tingling and numbness, (i.e. paresthesias), and decreased sensation to touch, pain, and position sense in the bilateral feet. A higher evaluation would require at least moderate, incomplete paralysis. However, pulses have been consistently reported as normal and there has been no motor loss or other functional impairment. No other neurologic or orthopedic abnormalities have been reported at any time over the course of the appeal. Given the mild to moderate level of pain and the absence of other findings, the disability does not rise to the level of moderate incomplete paralysis. Therefore, initial ratings in excess of 10 percent, for peripheral neuropathy of the left and right lower extremities under Diagnostic Code 8520, are not warranted for any period under consideration. Hart v. Mansfield, 21 Vet. App. 505 (2007); see also 38 U.S.C.A. § 5107(b). Consideration has also been given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, a review of the record fails to reveal any additional functional impairment associated with the Veteran's peripheral neuropathy of the bilateral upper and lower extremities that warrants further consideration of alternate rating codes. III. Coronary Artery Disease The RO granted service connection for coronary artery disease in a March 2006 rating decision and awarded an initial 30 percent rating, pursuant to 38 C.F.R. § 4.104, DC 7005, effective from April 8, 2005. The Veteran desires a higher initial disability rating. Disability ratings of the cardiovascular system are addressed under 38 C.F.R. § 4.104. Such provides that one MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2). Diagnostic Code 7005 provides that a 30 percent rating is warranted with documented coronary artery disease resulting in a workload of greater than 5 METs but not greater than 7 METs that results in dyspnea, fatigue, angina, dizziness, or syncope; or, there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. 38 C.F.R. § 4.104, DC 7005. A 60 percent rating is warranted where there is more than one episode of acute congestive heart failure in the past year; or where a workload of greater than 3 METS but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Id. A 100 percent rating requires chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. The Veteran underwent a VA examination in January 2006. He was noted to have a medical history that included coronary artery disease in 2004, with coronary artery bypass graft in October 2004. He also had an angioplasty in 2005. Current physical examination revealed no history of angina, dyspnea, syncope, or fatigue. The Veteran reported daily dizziness. There was a reported history of myocardial infarction but the date was unknown. There was a possible silent myocardial infarction noted on a 2003 electrocardiogram (EKG). The current severity of the coronary artery disease was mild. There was no history of congestive heart disease. The Veteran's stress test showed an estimated Met of 6. The left ventricle ejection fraction (LVEF) was 50 percent. The heart size was normal. A January 2006 echo showed normal volumes and good left ventricular function. The ejection fraction was 68 percent. The examiner opined that the coronary artery disease was as least as likely as not caused by or related to the service-connected diabetes mellitus. A letter dated in October 2006, from a private cardiologist, indicated that a current carotid ultrasound revealed mild to moderate disease of the left carotid artery. An echocardiogram revealed intact left ventricular function. Based on the available evidence, the Board finds that the Veteran is not entitled to an initial rating in excess of 30 percent for his service-connected coronary artery disease disability. In this regard, the Board notes that the Veteran's coronary artery disease disability has been manifested by a workload of 6 METs and a normal ejection fraction of 68 percent, without evidence of congestive heart failure or left ventricle dysfunction. There is no evidence that a workload of greater than (or less than) 3 METS but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent or less in the entire record. Such findings would warrant a higher evaluation of 60 percent. Therefore, the criteria for an initial rating in excess of 30 percent have not been met at any time during the appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Service Connection for Hypertension Background Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. Establishing service connection generally requires (1) medical evidence of a 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 of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Where, a Veteran engaged in combat, satisfactory lay evidence that an injury or disease was incurred in service will be accepted as sufficient proof of service connection where such evidence is consistent with the circumstances, conditions, or hardships, of service. 38 U.S.C.A. § 1154(b) (West 2002). Section 1154(b) sets forth a three step sequential analysis that must be undertaken when a combat Veteran seeks benefits under the method of proof provided by the statute. First, it must be determined whether the Veteran has proffered "satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease." Second, it must be determined whether the proffered evidence is "consistent with the circumstances, conditions, or hardships of such service." Finally, if the first two requirements are met, VA "shall accept the Veteran's evidence as "sufficient proof of service connection," even if no official record exists of such incurrence exists. In such a case a factual presumption arises that that the alleged injury or disease is service connected. Collette v. Brown, 82 F.3d 389, 393 (Fed. Cir. 1996); 38 C.F.R. § 3.304 (2009). With chronic diseases shown as such in service, or within the presumptive period after service, so as to permit a finding of service connection, subsequent manifestation of the same chronic disease at any later date, however remote, are service connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). Service connection for a "chronic disease," including certain tropical diseases, may be granted if manifest to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Additionally, service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). For purposes of VA compensation, the term "hypertension" means that the diastolic blood pressure is predominantly 90 mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, note following Diagnostic Code 7101. Service treatment records contain no findings of hypertension. The Veteran's blood pressure was 132/76 during a March 1968 induction examination. A separation examination is not of record. Post-service medical records are negative for blood pressure readings prior to December 2003. The Veteran underwent a VA examination in November 2004. His claims file was reviewed by the examiner. The examiner noted that diabetes mellitus and hypertension were both discovered five years earlier (1999). He also noted the Veteran's past history of smoking since age of 13 or 14, and lack of family history of hypertension. The examiner's diagnosis was hypertension well-controlled currently. He opined that hypertension occurred concurrently with the diabetes mellitus, and while diabetes mellitus did not cause the hypertension, it has caused it to be "more difficult to control." He explained further that the hypertension was also related to the Veteran's arteriosclerosis; which the Veteran developed as a complication of smoking. Therefore, in his opinion, diabetes mellitus was less likely as not caused by hypertension, but was more likely than not to have contributed to the severity of the hypertension. Analysis The Veteran contends that hypertension was caused or aggravated by his service-connected diabetes mellitus. The evidence clearly establishes that the Veteran has a current diagnosis of hypertension. There was no diagnosis of hypertension in service, and only one blood pressure reading was noted. Thus, there is insufficient evidence to establish that a hypertension condition in service. 38 C.F.R. § 3.303(b). Service connection on a direct basis would therefore require a continuity of symptomatology or evidence otherwise linking current hypertension to service. Post-service hypertension was demonstrated nearly 30 years after service and there is no other evidence of a continuity of symptomatology. There is also no competent medical opinion directly linking hypertension to service. The VA examiner's opinion is not a model of clarity, but it can be read as stating that current hypertension is likely aggravated, at least in part, by the service connected diabetes mellitus disability. The examiner also noted that there was at least some relation between the Veteran's hypertension and arteriosclerosis (coronary artery disease), a service-connected disorder. Thus, it is possible that service connection may be established pursuant to 38 C.F.R. § 3.310(a). For the Veteran to prevail in his claim, it must only be demonstrated that there is an approximate balance of positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for benefits to be denied. Gilbert v. Derwinski, 1 Vet. App. 49, at 54 (1990). The preponderance of the evidence is not against the instant claim. In light of the positive VA medical opinion which suggests that hypertension is at least aggravated by service- connected diabetes mellitus, the Board finds that the evidence supports a finding of service connection. All reasonable doubt has been resolved in favor of the Veteran. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102. Earlier Effective Date Background The assignment of effective dates of awards is generally governed by 38 U.S.C.A. § 5110 and 38 C.F.R. § 3.400. Unless specifically provided otherwise, the effective date of an award based on an original claim for service connection or a claim reopened after final adjudication "shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefore." 38 U.S.C.A. § 5110(a). The implementing regulation clarifies this to mean that the effective date of an evaluation and an award of compensation based on an original claim or a claim reopened after final disallowance "will be the date of receipt of the claim or the date entitlement arose, whichever is the later." 38 C.F.R. § 3.400. With a claim for service connection, the effective date of an award will be (1) the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service or (2) the date of receipt of claim or date entitlement arose, whichever is later. 38 C.F.R. §3.400(b)(2)(i). A specific claim in the form prescribed by VA must be filed in order for benefits to be paid to any individual under the laws administered by VA. See 38 U.S.C.A. § 5101(a) (West 2002); 38 C.F.R. § 3.151(a) (2009). Analysis The Veteran contends he is entitled to an effective date prior to April 8, 2005 for the grant of service connection for coronary artery disease, as secondary to service- connected diabetes mellitus. He contends that the effective date should be in 2001, presumably when his SSA records show evidence of the disability. The Board notes that the Veteran did not file a formal claim for service connection for coronary artery disease, nor is there any prior communication in the record that could be considered an informal claim for VA compensation for the same, prior to April 8, 2005. A claim for a heart condition secondary to diabetes mellitus was received at VA on April 29, 2005. A July 2004 VA outpatient treatment record shows a diagnosis of coronary artery disease and myocardial infarction. SSA records reflect that the Veteran was disabled due to peripheral vascular disease and atherosclerotic heart disease; these disabilities were noted to have begun in June 2003. While various VA and private treatment records show diagnoses and treatment for coronary artery disease prior to April 8, 2005; a treatment record cannot by itself constitute a claim for service connection. MacPhee v. Nicholson, 459 F.3d 1323 (Fed. Cir. 2006) (medical records cannot constitute a claim for service connection). The Veteran was afforded a VA examination in February 2006. At this examination, he reported prior diagnoses and treatment for coronary artery disease and peripheral vascular disease in October 2004. He also reported a past surgical history of triple bypass surgery, stent placements, and cardiac angioplasty in 2004 and 2005. Based on the VA examiner's positive nexus opinion between diabetes mellitus and coronary artery disease, the RO granted service connection for the coronary artery disease as secondary to the service-connected diabetes mellitus disability, pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 7005, effective from April 8, 2005. The first clinical evidence of a causal relationship between coronary artery disease and the service-connected diabetes mellitus disability was not until the February 2006 VA examination. Therefore, this is the first date entitlement arose. As indicated, the effective date of an award based on an original claim for service connection "shall not be earlier than the date of receipt of application therefore." 38 U.S.C.A. § 5110(a). The date of receipt of a claim for service connection was April 29, 2005. Therefore, there is simply no basis upon which to justify granting an effective date earlier than April 8, 2005, for the grant of service connection for coronary artery disease, to include as secondary to service-connected diabetes mellitus. Withdrawn Claims Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. An appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or by his or her authorized representative. Id. The Veteran has withdrawn his appeal as it pertains to the issues of increased ratings for peripheral vascular disease, right lower and left lower extremities. Hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review those claims and they are dismissed. ORDER An increased rating for diabetes mellitus is denied. An initial evaluation in excess of 10 percent for peripheral neuropathy, right upper extremity is denied. An initial evaluation in excess of 10 percent for peripheral neuropathy, left upper extremity is denied. An increased rating for peripheral neuropathy, right lower extremity is denied. An initial evaluation in excess of 10 percent for peripheral neuropathy, left lower extremity is denied. An initial evaluation in excess of 30 percent for coronary artery disease is denied. Service connection for hypertension, to include as secondary to service-connected diabetes mellitus, is granted. An effective date earlier than April 8, 2005 for the grant of service connection of coronary artery disease is denied. The appeal on the claim of entitlement to a higher initial rating for peripheral vascular disease, right lower extremity is dismissed. The appeal on the claim of entitlement to a higher initial rating for peripheral vascular disease, left lower extremity is dismissed. REMAND The Board finds that the claim for service connection for hepatitis C requires further development. The Board initially notes that the record contains a diagnosis of this disability, and that risk factors for hepatitis C include intravenous drug use, blood transfusions before 1992, hemodialysis, intranasal cocaine, high-risk sexual activity, accidental exposure while a health care worker, and various kinds of percutaneous exposure such as tattoos, body piercing, acupuncture with non-sterile needles, shared toothbrushes or razor blades. VBA Letter 211B (98-110), November 30, 1998. In addition, the Veteran maintains that he was exposed during the process of receiving inoculations with the use of an injector device, and there is nothing in the record that contradicts the Veteran's assertions. Thus, the Board finds that the Veteran should be afforded an appropriate examination as to this claim, making sure that the VA examiner is requested to state whether it is at least as likely as not that the Veteran's hepatitis C is related to any of the risk factors the Veteran was exposed to during service. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be afforded an appropriate VA examination to determine the nature and etiology of his hepatitis C. The claims file should be made available to the VA examiner for review in connection with the examination. All indicated studies should be conducted, to include enzyme immunoassay (EIA) and recombinant immuoblot assay (RIBA-2) testing, and all findings should be reported in detail. If hepatitis C is found to be present, the examiner should thoroughly review the Veteran's history of risk factors associated with hepatitis C (prior to, during, and after service), such as the Veteran's receipt of inoculations during service with an injector device, and render an opinion as to whether it is at least as likely as not (50 percent probability or greater) that he contracted hepatitis C during service. The examiner should provide a complete rationale with respect to his or her opinion. 2. The RO/AMC should read all medical opinions obtained to ensure that the remand directives have been accomplished, and should return the case to the examiner if all questions posed are not answered. 3. Finally, readjudicate the issue on appeal. If the benefits sought on appeal are not granted, issue a supplemental statement of the case, and give the Veteran an appropriate amount of time to respond. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ____________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs