Citation Nr: 1120959 Decision Date: 05/31/11 Archive Date: 06/06/11 DOCKET NO. 09-39 879 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a lip scar (previously claimed as facial injury residuals). 3. Entitlement to service connection for a heart disorder. 4. Entitlement to service connection for amblyopia, right, bilateral optic nerve head drusen, bilateral nuclear sclerotic cataracts, and bilateral presbyopia, to include as secondary to service-connected diabetes mellitus Type II. 5. Entitlement to an increased rating for service-connected diabetes mellitus Type II, currently evaluated as 20 percent disabling. 6. Entitlement to an initial compensable evaluation for service-connected right (major) upper extremity peripheral neuropathy secondary to service-connected diabetes mellitus Type II. 7. Entitlement to an initial compensable evaluation for service-connected left upper extremity peripheral neuropathy secondary to service-connected diabetes mellitus Type II REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Tanya A. Smith, Counsel INTRODUCTION The Veteran had active service from February 1969 to September 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from February 2009, May 2009, and September 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The Veteran in the instant case has elected to participate in the Expedited Claims Adjudication (ECA) Initiative with respect to the issues of whether new and material evidence has been submitted to reopen claims of entitlement to service connection for PTSD and lip scar. See ECA Agreement and Waiver of Rights, dated in August 2009. The ECA is a pilot program designed to expedite the processing of claims and appeals by obtaining claimants' waivers of certain statutory and regulatory response periods, and by utilizing the Board's statutory authority to pre-screen cases to determine the adequacy of the record for decisional purposes. The case has been processed under regulations governing the ECA. See 38 C.F.R. §§ 20.1500-20.1510 (2010). In an October 2009 letter, the RO determined that the Veteran's claim for service connected alcoholism was denied because there is no basis for entitlement under the law. The Veteran was not apprised of his appellate rights in connection with this determination. Accordingly, corrective action should be taken. The issues of entitlement to service connection for an acquired psychiatric disorder to include PTSD, a lip scar, and bilateral eye disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. The December 1984 RO rating decision that denied service connection for an acquired psychiatric disorder to include PTSD is final. 2. The evidence received since the December 1984 rating decision includes evidence that is neither cumulative nor redundant, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim for service connection for an acquired psychiatric disorder to include PTSD. 3. The July 2005 RO rating decision that declined to reopen a previously denied claim of entitlement to service connection for a lip scar is final. 4. The evidence received since the July 2005 rating decision includes evidence that is neither cumulative nor redundant, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim for service connection for lip scar. 5. The medical evidence of record shows that the Veteran is not currently diagnosed with a chronic heart disorder. 6. The Veteran's diabetes mellitus does not necessitate regulation of his activities and has not resulted in hypoglycemic reactions requiring hospitalizations. 7. The Veteran's right (major) upper extremity peripheral neuropathy is manifested by decreased sensation which more nearly approximates mild incomplete paralysis of the musculocutaneous nerve. 8. The Veteran's left upper extremity peripheral neuropathy is manifested by decreased sensation which more nearly approximates mild incomplete paralysis of the musculocutaneous nerve. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen the claim of entitlement to service connection for an acquired psychiatric disorder to include PTSD. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (2010). 2. New and material evidence has been received to reopen the claim of entitlement to service connection for a lip scar. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (2010). 3. A heart disorder was not incurred in or aggravated by active service, and its incurrence or aggravation during active service may not be presumed. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2010). 4. The criteria for a rating in excess of 20 percent for diabetes mellitus Type II have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1-4.14, 4.119, Diagnostic Codes 7913 (2010). 5. The criteria for an initial compensable evaluation for right (major) upper extremity peripheral neuropathy secondary to diabetes mellitus Type II have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1- 4.14, 4.119, Diagnostic Code 8517 (2010). 6. The criteria for an initial compensable evaluation for left upper extremity peripheral neuropathy secondary to diabetes mellitus Type II have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1- 4.14, 4.119, Diagnostic Code 8517 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2010)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2010). The notice requirements of the VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2010); 38 C.F.R. § 3.159 (2010). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Such notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). Moreover, such notice errors may instead be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (reaffirming that the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). As the Board finds that new and material evidence has been submitted to reopen the claims of entitlement to service connection for an acquired psychiatric disorder to include PTSD and a lip scar, no further discussion of VCAA compliance is necessary. In regard to the heart, diabetes, and peripheral neuropathy claims, the Board observes that in December 2008, March 2009, and April 2009 VCAA letters, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate the claims as well as what information and evidence must be submitted by the Veteran and the types of evidence that will be obtained by VA. The VCAA letters advised the Veteran how disability evaluations and effective dates are assigned, and the type of evidence that impacts those determinations. The claims were last readjudicated in statements of the case issued in July 2009 and August 2009. The Board finds that VA's duty to notify has been met. The record also reflects that VA has made reasonable efforts to assist the Veteran in the development of his claims. Specifically, the information and evidence that have been associated with the claims file includes service treatment records, post-service VA and private treatment records, and reports of VA/fee-basis examinations. In regard to the diabetes and peripheral neuropathy claims, the Board finds the January 2009 VA fee-basis examination and April 2009 VA examination are adequate for evaluation purposes because the examiners reviewed the claims file or were otherwise "informed of the relevant facts," considered the contentions of the Veteran, and addressed the relevant rating criteria. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In regard to the heart claim, the April 2009 VA examination report reflects that the Veteran advised the examiner that he was neither diagnosed nor being treated for a heart disorder and that he did not wish to pursue a claim for a heart disorder at that hospital visit. Therefore, the VA examiner did not proceed with the scheduled examination. The May 2009 rating decision relayed the events that reportedly occurred at the VA examination. In no subsequent statement has the Veteran disputed the occurrence of these events. Given these facts, VA is under no further obligation to afford the Veteran an examination in connection with his heart claim. As discussed above, the Veteran was notified and aware of the evidence needed to substantiate his claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process, identifying relevant records and submitting evidence. Thus, he has been provided with a meaningful opportunity to participate in the claims process and has done so. The Board finds that VA's duty to assist has been met. II. New and Material Evidence A decision of the RO becomes final and is not subject to revision on the same factual basis unless a notice of disagreement is filed within one year of the notice of decision. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.302, 20.1103 (2010). If a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C.A. § 5108 (West 2002); see Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). VA must review all of the evidence submitted since the last final rating decision in order to determine whether the claim may be reopened. See Hickson v. West, 12 Vet. App. 247, 251 (1999). For purposes of determining whether new and material evidence has been received to reopen a finally adjudicated claim, the recently submitted evidence will be presumed credible. See Kutscherousky v. West, 12 Vet. App. 369, 371 (1999) (per curiam) (holding that the "presumption of credibility" doctrine continues to be binding precedent); Justus v. Principi, 3 Vet. App. 510, 513 (1992). But see also Duran v. Brown, 7 Vet. App. 216, 220 (1994) (VA is not required to consider the patently incredible to be credible). New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2010). 1. PTSD In a May 1984 rating decision, the RO noted that service treatment records were negative for PTSD and PTSD was not diagnosed on VA examination. Rather, dysthymic disorder, avoidant personality disorder, and depressive neurosis were identified on VA examination. In a December 1984 rating decision, the RO considered additional evidence submitted by the Veteran and recognized that the prior rating decision "did not code out the claim of [service connection] for PTSD" in error. The RO noted that service connection for a chronic acquired psychiatric condition was not established since the evidence did not support this disability and there was no diagnosis of PTSD. In the notice of decision letter dated in December 1984, the RO advised the Veteran of the denial and explained his procedural and appellate rights. The Veteran did not appeal the decision and it became final. 38 U.S.C.A. § 7105(c) (West 1991); 38 C.F.R. §§ 3.104, 19.118, 19.153 (1982). The relevant evidence of record at the time of the December 1984 rating decision included service treatment records which showed no psychiatric complaints. Records from Northcentral Montana Community Mental Health Center and Valley General Hospital included an October 1980 Intake Summary that noted diagnoses of marital maladjustment, alcoholism, and explosive personality. A 1981 psychological report noted impressions of probable chronic alcoholism and recent depression. An April 1981 discharge summary noted final diagnoses of alcoholism, explosive personality, and marital maladjustment. A March 1983 psychiatric evaluation noted diagnostic impressions of chronic alcoholism, in remission, dysthymic disorder, and avoidant personality disorder. Dr. B.E. indicated that the Veteran did not appear to have post-traumatic stress syndrome. Dr. B.E. noted that the Veteran served in an artillery unit and did not seem to be exposed to any serious traumatic experiences but that it might be significant that his drinking and drug problems started in Vietnam and so his diagnosis might have to be revised. The August 1983 VA Agent Orange examination report showed the Veteran reported that he was attending a Vietnam Veterans therapy group at a mental health center. A November 1983 VA consultation report showed the Veteran reported that he was not wounded in Vietnam but there were a couple of times he faced life threatening situations when he came under attack from rocket fire. No men from his Battery were killed or wounded and he did not see any men killed or wounded. A January 1984 VA clinical record noted diagnoses of depressive neurosis, and alcohol dependence and drug abuse, in remission. Golden Triangle Community Mental Health Center records dated in December 1983 and February 1984 noted diagnoses of chronic alcoholism in remission, dysthymic disorder, personality disorder, and marital maladjustment. Statements from the Veteran received in November 1984 showed he reiterated that he was never wounded in Vietnam but he was emotionally scarred. He did not see any "direct action," but he was involved in a lot of "support type missions." He recalled an incident that involved the killing and dragging of a Vietnamese soldier. He had recurring dreams based on this incident. He also recalled an incident in which three rockets hit his compound, landing 50 yards away. He claimed he was never the same after that incident. The DD Form 214 showed the Veteran served in the Republic of Vietnam from July 1969 to September 1970. He was awarded the Republic of Vietnam Campaign Medal, Vietnam Service Medal, and Army Commendation Medal. His military occupational specialty was Field Artillery Basic. Personnel records showed that he served in the 11th Campaign (unnamed). Receipt of the Vietnam Cross of Gallantry with palm was noted to be pending. The record of assignments indicated that he served in Vietnam with the C Battery 2nd Battalion 94th Artillery. His principal duties were cannoneer and heavy truck driver. The Veteran's claim to reopen was received in June 2009 ("PTSD due to combat in Vietnam"). Relevant evidence received subsequent to the December 1984 rating decision includes statements dated in 2004, 2009, and 2010 in which he continued to describe his claimed stressors. He submitted a list of dates on which his unit was purportedly subjected to incoming enemy rockets and mortar rounds. He provided the website where he obtained the information. The Veteran also submitted articles, including articles pertaining to the new PTSD regulations. Lay statements from the Veteran's buddies and family members dated in 2009 describe their observations of the Veteran and personal Vietnam experiences. The Veteran also submitted evidence in March 2010 consisting of statements (J.G.), a compact disc of pictures, and a timeline of events for the period from July 1970 to June 1971 pertaining to a Counteroffensive, Phase VII the 2/94th took part in according to an unofficial account obtained from the Internet. J.G. reported that he served with the Veteran and recalled that they were constantly under alert because of incoming rockets and artillery fire. They were also always under attack with land mines. Other evidence includes VA treatment records dated from June 2006 to July 2009 which contain an active problem list that includes PTSD. A June 2009 record by Dr. N. notes an assessment of alcohol dependence in sustained remission on Axis I. A September 2009 VA PTSD examination report shows the examiner noted that the Veteran only met the DSM-IV criteria A for PTSD. The examiner provided a diagnosis of "Subthreshold PTSD" on Axis I and assigned a Global Assessment of Functioning (GAF) score of 75. Of the evidence added to the record since the unappealed December 1984 RO decision, the Board finds that the VA treatment records and the September 2009 VA PTSD examination report are new, in that they were not previously of record. This evidence is also material as it relates to the prior basis for denial of the claim. For purposes of reopening the claim, the credibility of the VA treatment records listing PTSD as one of the Veteran's active problems is presumed. Kutscherousky, 12 Vet. App. at 371. As for the VA diagnosis of subthreshold PTSD, the diagnosis suggests the presence of some psychiatric symptoms that may otherwise be related to incidents of the Veteran's military service. Additionally, the Veteran submitted new details on his claimed stressors, which had not been conceded by the RO at the time of the December 1984 rating decision, and therefore are material to the claim. Accordingly, new and material evidence has been received, and the claim is reopened. 2. Lip Scar (previously claimed as facial injury residuals) In determining whether new and material evidence is required, the focus of the Board's analysis must be on whether the evidence presented truly amounts to a new claim "based upon distinctly diagnosed diseases or injuries" (Boggs v. Peake, 520 F.3d 1330, 1337 (Fed. Cir. 2008)), or whether it is evidence tending to substantiate an element of a previously adjudicated matter. See Velez v. Shinseki, 23 Vet. App. 199, 204 (2009). Here, however variously described throughout the years, the Veteran is ultimately seeking service connection for a laceration of the lip. Thus, new and material evidence is required. In a May 1984 rating decision, the RO denied service connection for facial injury residuals on the basis that service treatment records were negative for the claimed condition and no facial injury residuals were identified on the VA examination. In the notice of decision letter dated in June 1984, the RO advised the Veteran of the denial and explained his procedural and appellate rights. The Veteran did not appeal the decision and it became final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 19.118, 19.153 (1982). In a July 2005 rating decision, the RO declined to reopen the Veteran's claim on the basis that new and material evidence had not been submitted. The RO noted that there continued to be no medical evidence showing treatment for an injury to the face in service. In the notice of decision letter dated in July 2005, the RO advised the Veteran of the denial and enclosed VA Form 4107, which explained the Veteran's procedural and appellate rights. The Veteran did not appeal the decision and it became final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2010). The relevant evidence of record at the time of the July 2005 rating decision included the Veteran's original March 1983 claim in which he maintained that he sustained the claimed injury when he was hit by a canister in the face (requiring four stitches) in 1970. The service treatment records associated with the claims file at that time did not document the claimed incident. The August 1983 Agent Orange examination report showed that on a review of the Veteran's mouth and throat, his lips were normal. A November 1983 VA consultation report showed that the Veteran reported that he sustained the laceration to his lip. In a February 2005 statement, the Veteran indicated that the injury occurred in 1969. In a June 2005 statement, T.O. reported that he served in country with the Veteran and recalled that the Veteran sustained an injury to his "face/lip" that the Veteran attributed to having an artillery shell casing hit him in the face. T.O. noted that he was not present at the time of the injury but he recalled seeing the Veteran's injured face in November 1969. The Veteran's claim to reopen was received in July 2009. Relevant evidence received subsequent to the July 2005 rating decision includes statements dated in 2009 in which the Veteran continued to describe the claimed laceration to his lip. The injury occurred while cleaning a deuce and a half truck. The Veteran also submitted an article concerning correcting military records. In December 2009, the Veteran provided a copy of a service treatment record (DA Form 2658, Health Record-Abstract of Service) he maintained he obtained from the National Personnel Records Center (NPRC). The record noted that the Veteran sustained a laceration of the upper lip treated with sutures in November 1969. Of the evidence added to the record since the unappealed July 2005 RO decision, the Board finds that the copy of a November 1969 service treatment record showing in-service treatment for an injury to the lip is new, in that it was not previously of record. It is material as it relates to a prior basis for denial of the claim. For purposes of reopening the claim, the credibility of the newly submitted evidence is presumed. Kutscherousky, 12 Vet. App. at 371. Thus, new and material evidence has been received, and the claim is reopened. In so finding, the Board is cognizant that at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim, notwithstanding the rules of finality. 38 C.F.R. § 3.156(c) (2010). For reasons detailed in the Remand, at this time the Veteran's claim will be considered a reopened claim and not a reconsideration of the previously filed claims. III. Service Connection (Heart Disorder) Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2010). In order to establish service connection for a claimed disorder, the following must be shown: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b) (2010). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d) (2010). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and arteriosclerosis becomes manifest to a compensable degree within one year from the date of termination of such service, such disease shall be presumed to have been incurred in or aggravated by service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.307, 3.309 (2010). The Veteran has appealed a claim for service connection for a heart disorder. As previously discussed, the April 2009 VA examination report reflects that the Veteran advised the examiner that he was neither diagnosed nor being treated for a heart disorder and that he did not wish to pursue a claim for a heart disorder at that hospital visit. As such, a heart evaluation was not conducted at that time. Service treatment records show no relevant complaints, and the post-service medical evidence shows the Veteran is not currently diagnosed with a chronic heart disorder. In particular, the August 1983 VA Agent Orange examination report and radiographic report noted that the Veteran's heart was normal. Records from Dr. R.J. include a September 2003 stress test that was negative for the presence of ischemia. An electrocardiograph (EKG) revealed normal findings. In May 2004, a VA EKG consult noted that the Veteran had sinus bradycardia otherwise normal EKG. No underlying pathology was identified in regard to this finding. Thereafter, a February 2007 VA treatment record noted that the cardiac examination was normal. An August 2007 VA treatment record showed that on a review of systems, the Veteran denied any chest pain or palpitation. The cardiac examination was noted as normal. The January 2009 VA fee-basis examination report shows the examiner denied that there was any heart complication associated with the Veteran's diabetes. Evidence associated with the claims file after the issuance of the August 2009 statement of the case shows the Veteran continued to deny symptoms and the cardiac exams continued to be normal. See September 2009 VA treatment records. The Veteran submitted an article in November 2009 which detailed the addition of ischemic heart disease to the list of presumptive diseases associated with herbicide exposure. (The Board agrees with the RO that the foregoing evidence did not require the issuance of a supplemental statement of the case. See 38 C.F.R. § 19.31 (2010).) The Veteran has not specifically identified any symptoms he believes are manifestations of heart disease, so there is no lay evidence of readily observable features or symptoms of illness for consideration. Ultimately, the question of whether the Veteran suffers from heart disease is a medically complex question beyond the reach of his competency. The medical evidence of record shows that the Veteran is not diagnosed with chronic heart disease. Entitlement to service- connected benefits is specifically limited to cases where there is a current disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As no current disability is shown, service connection for a heart disorder is not warranted. IV. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2010). Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1 (2010). Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2010); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2010); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2010); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10 (2010). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 1. Diabetes Mellitus Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Id.; Powell v. West, 13 Vet. App. 31, 35 (1999). Nevertheless, the Board acknowledges that a veteran 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). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. In an October 2003 rating decision, the RO granted service connection for diabetes mellitus Type II and assigned a 20 percent rating under Diagnostic Code 7913 effective July 25, 2003, the date of receipt of the Veteran's claim. In December 2008, the Veteran filed the instant claim for an increased rating. The Veteran reported that his medication level had been increased recently. Diabetes mellitus requiring insulin and restricted diet, or oral hypoglycemic agent and restricted diet warrants a 20 percent rating. A 40 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. Diabetes mellitus 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 warrants a 60 percent rating. A total evaluation of 100 percent is assigned for diabetes mellitus 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. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2010). Compensable complications of diabetes are to be evaluated 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. 38 C.F.R. § 4.119, Note (1) (2010). Separate ratings for complications of diabetes have been established for peripheral neuropathy of the upper extremities. The report on the January 2009 VA fee-basis examination does not indicate that the claims file was made available to Dr. P.D. for a review. Nevertheless, a review of the report shows Dr. P.D. asked questions related to the history of the Veteran's disability (detailed below), and the Veteran's responses were consistent with the history reflected in the record. Thus, Dr. P.D. was informed of the relevant facts. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303 (2008). Moreover, as the current claim is one for an increased rating, the current medical reports are of primary concern. On review of the history of the disability, the Veteran reported that he was diagnosed with diabetes in 2003 and episodes of high and low blood sugar reactions only occurred in the first year of diagnosis. The Veteran denied ever being hospitalized for the episodes. He denied that he was on a restricted diet or had weight loss or weight gain since his last exam. His treatment consisted of taking Lisinopril (5mg daily) and Metformin (1000mg twice daily). He visited his diabetic care provider every 3 to 4 months. There were no restrictions on his activities. Diagnostic tests revealed a normal kidney function. Dr. P.D. indicated that the Veteran's hypertension was not a complication of the diabetes because there was no renal involvement. Dr. P.D. also reported that the Veteran's diabetes had no effect on his usual occupation and daily activities. The April 2009 VA examination report continues to show the Veteran has no neurologic symptoms referable to the lower extremities. VA treatment records dated from August 2007 to June 2009 show that on a review of systems, the Veteran denied weight loss, weakness, anorexia, fever, chills, and night sweats. His medication regimen consisted of Lisinopril (5mg daily) and Metformin (1000mg twice daily). In March 2009, Glipizide (5mg daily) was added to his regimen. In June 2009, the Veteran complained of midmorning hypoglycemic symptoms (he was not checking his blood glucose). He indicated that he was getting less exercise since his retirement. He was advised to continue with his medications and walk 30 minutes daily, and he was to return in three months. Evidence associated with the claims file after the issuance of the July 2009 statement of the case consists of VA treatment records dated in September 2009. The Veteran had no new complaints and his medication regimen remained unchanged. He also reported that he just bought a bike that he was starting to ride; he enjoyed getting more exercise. The Veteran also submitted an article in October 2009 and noted that he had diabetes. (The Board agrees with the RO that the foregoing evidence did not require the issuance of a supplemental statement of the case. See 38 C.F.R. § 19.31 (2010).) Regulation of activities is defined by Diagnostic Code 7913 as the "avoidance of strenuous occupational and recreational activities." Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360, 363-64 (2007). The foregoing evidence clearly shows that no treating physician or VA examiner has indicated that the Veteran's diabetes precludes him from engaging in strenuous occupational and recreational activities. To the contrary, VA treatment records show that regular exercise was recommended. Thus, the evidence fails to show that the severity of the Veteran's diabetes is such that a restriction of his activities is required. Also, the Veteran's complaints of midmorning hypoglycemic symptoms in June 2009 did not require hospitalization. As far as the increase in the Veteran's medications (the addition of Glipizide in March 2009), this is not a basis for a higher rating as it is not the type of indicator demonstrative of worsening diabetes to the degree as contemplated under higher evaluations under Diagnostic Code 7913. Accordingly, the Veteran is not entitled to a rating in excess of 20 percent under Diagnostic Code 7913 The Board has not assigned staged ratings as the factual findings do not show distinct time periods that the Veteran's disability warranted different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). 2. Right (major) and Left Upper Extremity Peripheral Neuropathy Where the claimant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). In the appealed May 2009 rating decision, the RO granted service connection for right (major) and left upper extremity peripheral neuropathy secondary to service-connected diabetes mellitus Type II, assigning each extremity a noncompensable evaluation under Diagnostic Code 8517 effective March 9, 2009, the date of receipt of the claim. Peripheral neuropathy is not specifically listed in the rating schedule; therefore, it is rated analogous to a disability in which not only the functions affected, but anatomical localization and symptoms, are closely related. 38 C.F.R. § 4.20 (2010). The Veteran's peripheral neuropathy of the upper extremities is rated by analogy to incomplete paralysis of the musculocutaneous nerve under Diagnostic Code 8517. Under Diagnostic Code 8517, a noncompensable evaluation is prescribed for mild incomplete paralysis of the musculocutaneous nerve of both the major and minor extremities. Moderate incomplete paralysis of the musculocutaneous nerve warrants a 10 percent evaluation for both the major and minor extremities. Severe incomplete paralysis of the musculocutaneous nerve warrants a 20 percent evaluation for both the major and minor extremities. 38 C.F.R. § 4.124a, Diagnostic Code 8517 (2010). The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. Id. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. Id. Furthermore, neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123 (2010). The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. 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. 38 C.F.R. § 4.124 (2010). The January 2009 VA fee-basis examination report shows that on a review of systems, the Veteran complained of tingling and numbness. The neurologic examination, however, revealed the following: normal left upper extremity motor function; normal right upper extremity motor function; normal left upper extremity sensory function; and normal right upper extremity sensory function. The April 2009 VA examination report reflects that the examiner reviewed the claims file. The Veteran reported the onset of the neuropathy one and a half years ago manifested by numbness and tingling in his hands. The symptoms were intermittent at onset and have progressed over time. He now had a pins and needles sensation along with numbness every day. He had no complaints of pain. He was not currently receiving treatment. The motor examination revealed upper extremity muscle and grip strength measuring 5/5 bilaterally. The sensory function report revealed decreased sensory to pain and light touch. The affected nerve was the digital cutaneous nerve. There was no muscle atrophy, abnormal muscle tone or bulk, or abnormal movements. The function of any joint was not affected by the nerve disorder. His gait and balance were normal. The Veteran reported that he retired in 2008. There were no effects of the disorder on his usual daily activities. The examiner provided a diagnosis of peripheral neuropathy of the bilateral upper extremities secondary to diabetes. The Board notes at the outset that as the affected nerve is the digital cutaneous nerve, the currently assigned diagnostic code 8517 is appropriate. The examination findings show that the impairment of the nerve is wholly sensory absent any motor deficits and pain. Thus, the rating should be for the mild, or at most, the moderate degree. The Veteran still retains sensation described as "decreased," and so he does not have a total loss of sensation. However unpleasant the tingling sensation may be, these findings show that the peripheral neuropathy associated with the Veteran's upper extremities more nearly approximates mild incomplete paralysis of the musculocutaneous nerve. Accordingly, the Veteran is not entitled to initial compensable evaluations under Diagnostic Code 8517. The Veteran's disabilities have not been shown to be manifested by greater than the criteria associated with the ratings assigned under the designated diagnostic code during any portion of the appeal period. Accordingly, staged ratings are not in order and the assigned ratings are appropriate for the entire period of the veteran's appeal. Fenderson, 12 Vet. App. at 126. 3. Extraschedular Rating and TDIU Consideration has also been given regarding whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits or to the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2010); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1)(2010); Thun, 22 Vet. App. at 116. The schedular evaluations in this case are not inadequate. An evaluation in excess of the assigned ratings is provided for certain manifestations of the service-connected disabilities, but the evidence reflects that those manifestations are not present in this case. As noted above, the Veteran complains that the medication used to control his diabetes was increased, and that he experiences sensory impairment in his upper extremities. His symptoms and the type of resulting functional impairment described by him are contemplated in the rating criteria. He has not described any exceptional or unusual features or symptoms of the disabilities. As the Board finds that the Veteran's disability picture is contemplated by the rating schedule, the inquiry ends and the Board need not consider whether the disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Accordingly, referral for consideration of an extra-schedular rating is not warranted. Finally, the Board also recognizes that the Court of Appeals for Veterans Claims has clarified that a claim for a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities exists as part of a claim for an increase (whether in an original claim or as part of a claim for increased rating). Rice v. Shinseki, 22 Vet. App. 447 (2009). A TDIU claim is considered reasonably raised when a veteran submits medical evidence of a disability, makes a claim for the highest rating possible, and submits evidence of service-connected unemployability. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). On several occasions the Veteran has reported that he is retired. He has never contended that any of his service-connected disabilities renders him unemployable, and the record does not otherwise show evidence of such. For these reasons, the Board finds that a claim for TDIU has neither been raised by the Veteran nor by the record. In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine. The preponderance of the evidence, however, is against the Veteran's claims so that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER New and material evidence having been received, the claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD is reopened, and the claim is granted to this extent only. New and material evidence having been received, the claim of entitlement to service connection for a lip scar (previously claimed as facial injury residuals) is reopened, and the claim is granted to this extent only. Service connection for a heart disorder is denied. A rating in excess of 20 percent for service-connected diabetes mellitus Type II is denied. An initial compensable evaluation for service-connected right (major) upper extremity peripheral neuropathy secondary to service-connected diabetes mellitus Type II is denied. An initial compensable evaluation for service-connected left upper extremity peripheral neuropathy secondary to service-connected diabetes mellitus Type II is denied. REMAND After a review, the Board observes that further development is required prior to adjudicating the Veteran's remaining claims. Acquired Psychiatric Disorder, to include PTSD As noted above, the credibility of the VA treatment records noting an active problem list that included PTSD was presumed only for the purpose of determining whether the case should be reopened. Once the evidence is found to be new and material and the case is reopened, the presumption that it is credible and entitled to full weight no longer applies. The Board observes that the listed diagnosis of PTSD is not elsewhere supported by a physician's medical report. As observed by the September 2009 VA examiner, VA physician Dr. N. in June 2009 [and apparently in December 2004 and February 2005] the only diagnosis was alcohol dependence in remission. The record, however, does reflect a diagnosis of subthreshold PTSD on Axis I by the VA examiner, and the assignment of a GAF score of 75, which can reflect slight impairment in functioning. The currently provided diagnosis suggests the Veteran is experiencing some psychiatric distress due to in-service events absent an explanation from the VA examiner to the contrary. Service connection may be established for any acquired chronic psychiatric disability, however described, that results from disease or injury incurred in service. As such, the Board needs clarification from the examiner of the meaning of the diagnosis and if such represents a chronic psychiatric disorder that is otherwise related to events in the Veteran's military service. The Board is also cognizant that during the course of the appeal, VA amended its adjudication regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor. See Stressor Determinations for Posttraumatic Stress Disorder, 75 Fed. Reg. 39,843 (July 13, 2010), amended by 75 Fed. Reg. 41,092 (July 15, 2010) (codified at 38 C.F.R. § 3.304(f)(3)). The medical evidence, however, does not currently show a diagnosis of PTSD by a VA psychiatrist or psychologist so the new rule is not applicable. The Board also observes that the RO maintained that the Veteran served in a combat field artillery unit and received the Vietnam Cross of Gallantry, and therefore, conceded the occurrence of the claimed stressors. The personnel records, however, only note the pending status of that award. The DD Form 214 does not indicate the Veteran ultimately received the award. Moreover, without corroboration of the claimed stressors, the basis for the award will need to be consistent with the stressors the Veteran claims caused his claimed psychiatric disability. This issue will only become relevant if the VA examiner finds that the Veteran suffers from a chronic psychiatric disorder that is otherwise related to events in the Veteran's military service. Lastly, as alluded to above, the September 2009 VA PTSD examination report and the October 2009 statement of the case reference medical reports dated in December 2004 and February 2005 by Dr. N. that are not in the claims file. To ensure a complete record, the Board finds that all VA records pertaining to any treatment the Veteran received for the claimed condition should be obtained and associated with the claims file. Lip Scar As noted above, the credibility of the November 1969 service treatment record was presumed only for the purpose of determining whether the case should be reopened. Once the evidence is found to be new and material and the case is reopened, the presumption that it is credible and entitled to full weight no longer applies. The record reflects that the Veteran's original service treatment records were associated with the claims file in April 1983. Other DA Form 2658 (Health Record-Abstract of Service) records contained in the Veteran's original service treatment records identify him by name and service number. In contrast, the November 1969 DA Form 2658 does not identify the Veteran by name and/or service number. Given such circumstances, the Board must verify the authenticity of the record through the NPRC. If verified as authentic, then the Veteran should be afforded a VA examination to determine if residuals of the in-service laceration to the lip are present. Bilateral Eye Disability The Veteran seeks service connection for a bilateral eye disorder and has not set forth any specific contentions in this regard. He underwent a VA eye examination in connection with his claim in April 2009. The VA examiner provided the following diagnoses: diabetes mellitus without diabetic retinopathy of both eyes; amblyopia of the right eye limiting best corrected visual acuity to 20/40; bilateral optic nerve head drusen not related to diabetes mellitus; bilateral mild to moderate nuclear sclerotic cataracts age related; and bilateral presbyopia age related. The VA examiner commented that the amblyopia was "long standing since childhood." The foregoing diagnoses were rendered without the benefit of a review of the claims file. Service treatment records show the Veteran entered service with a bilateral eye defect (near vision) for which he was assigned a physical profile of "2." There are records on eye check-ups he received in service. An April 1969 ophthalmologic consultation report notes a finding of esophoria but amblyopia is not identified. Thus, the VA examiner was not informed of all the relevant facts when he rendered the above diagnoses so the examination is inadequate. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295, 303 (2008); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). For these reasons, the Board finds that the examination report should be returned to the VA examiner for a nexus opinion to include a review of the claims file. Accordingly, the case is REMANDED for the following action: 1. Obtain all VA treatment records pertaining to any treatment the Veteran has obtained for his claimed psychiatric disorder, including the December 2004 and February 2005 medical reports by Dr. A.N. from the VA Nebraska-Western Iowa Health Care System. 2. Return the September 2009 VA PTSD examination report along with the claims file to the conducting VA examiner for clarification of the diagnosis provided. Specifically, the VA examiner should explain the meaning of the diagnosis of "subthreshold PTSD" and clarify whether although the Veteran's psychiatric symptoms do not reflect the full spectrum of PTSD, does he otherwise suffer from a chronic acquired psychiatric disability due to the claimed stressor events. The examiner must provide a supporting rationale for the opinion expressed. If this examiner is not available, arrange for the Veteran's claims file, including the September 2009 VA PTSD examination report, to be reviewed by another appropriate examiner to obtain the opinion requested above. 3. If, and only if, the VA examiner relates a chronic acquired psychiatric disability to the Veteran's military service, undertake appropriate measures to confirm the Veteran's receipt of the Vietnam Cross of Gallantry and the basis for the award. Undertake any other indicated development as the result of the foregoing development. 4. Verify the authenticity of the November 1969 DA Form 2658 provided by the Veteran through the NPRC and include a request for outstanding service treatment records. 5. If, and only if, the authenticity of the November 1969 DA Form 2658 has been verified, schedule the Veteran for a VA examination to determine the nature of any lip disorder, and to provide an opinion as to its possible relationship to service. The claims file should be reviewed by the examiner, and the examination report should reflect that this was done. Following review of the claims file and examination of the Veteran, the examiner should opine as to whether it is at least as likely as not (50 percent probability or greater) that any current lip disorder is a residual of an incident of the Veteran's military service. The examiner must provide a supporting rationale for the opinion expressed. 6. Return the April 2009 VA eye examination report along with the claims file to the conducting VA examiner for a nexus opinion. (A) In regard to the diagnosed amblyopia: (i) Is it at least as likely as not (50 percent probability or greater) that the current amblyopia is etiologically related to any in-service findings documented in the service treatment records; if yes, (ii) Did the eye disorder pre-exist service? If yes, (iii) Did the eye disorder undergo an increase in severity (i.e., permanent worsening) in service? If yes, (iv) Is the increase in severity of the eye disorder due to the natural progress of the disease? (B) In regard to the other diagnosed eye disorders (optic nerve head drusen, nuclear sclerotic cataracts, and presbyopia), is it at least as likely as not (50 percent probability or greater) that any of these disorders are related to the Veteran's service. The examiner must provide a supporting rationale for the opinion expressed. If the examiner is unable to answer any applicable question, then he/she should so indicate and provide a rationale for why an answer could not be provided. If this examiner is not available, arrange for the Veteran's claims file, including the April 2009 VA eye examination report, to be reviewed by another appropriate examiner to obtain the opinions requested above. 7. Thereafter, readjudicate the claims. If the benefits sought on appeal remain denied, the Veteran and his representative should be issued a supplemental statement of the case, and given an opportunity to respond before the case is returned to the Board. The Veteran 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. 2010). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs