Citation Nr: 1237302 Decision Date: 10/31/12 Archive Date: 11/09/12 DOCKET NO. 09-35 407 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim for entitlement to service connection for diabetes mellitus, type II. 2. Entitlement to an initial evaluation in excess of 10 percent for service-connected residuals of injury to the right hand. 3. Entitlement to an evaluation in excess of 40 percent for service-connected prostatitis. 4. Entitlement to an initial evaluation in excess of 60 percent for service-connected hypertensive heart disease. 5. Entitlement to service connection for diabetes mellitus, type II, to include as due to herbicide exposure and secondary to service-connected hypertension. 6. Entitlement to service connection for a left hand disability. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Arif Syed, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1957 to July 1960 and from December 1961 to November 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January and June 2009 decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In his January 2010 substantive appeal (VA Form 9), the Veteran requested a personal hearing before a Veterans Law Judge. In August 2012, a hearing was scheduled, but the Veteran failed to report. As no further communication from the Veteran with regard to a hearing has been received, the Board considers his request for a hearing to be withdrawn. See 38 C.F.R. §§ 20.702(d), (e); 20.704(d), (e) (2011). In a rating decision dated October 2011, the RO awarded the Veteran a 10 percent disability rating for his service-connected residuals of right hand injury effective August 17, 2011, and awarded him a 40 percent disability rating for his service-connected prostatitis effective June 17, 2009. However, as these increases did not constitute a full grant of the benefits sought, the Veteran's claims for higher evaluations remain in appellate status. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). The issues of entitlement to an evaluation in excess of 30 percent for service-connected seborrheic dermatitis and entitlement to a compensable evaluation for service-connected hemorrhoids were raised by the Veteran, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issues of entitlement to an increased disability rating hypertensive heart disease as well as entitlement to service connection for diabetes mellitus, type II, and for a left hand 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, DC. FINDINGS OF FACT 1. In an unappealed April 2003 rating decision, the RO denied the Veteran's claim of entitlement to service connection for diabetes mellitus, type II. 2. The evidence received since the April 2003 rating decision, by itself or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the claim for service connection for diabetes mellitus, type II. 3. The competent and probative evidence shows that the Veteran's residuals of injury to the right hand is manifested by pain, limitation of motion, and decreased grip strength. There is no evidence of ankylosis of any portion of the Veteran's right hand. 4. The Veteran's prostatitis is manifested primarily by daytime voiding intervals less than one hour; the use of an appliance in association with his prostatitis is not required; the prostatitis is not manifested by renal dysfunction. 5. The evidence does not show that the Veteran's service-connected right hand disability and prostatitis are so exceptional or unusual that referral for extraschedular consideration by designated authority is required. CONCLUSIONS OF LAW 1. The April 2003 rating decision is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2011); 38 C.F.R. § 3.104 (2012). 2. Since the April 2003 rating decision, new and material evidence has been received with respect to the Veteran's claim of entitlement to service connection for diabetes mellitus, type II; therefore, the claim is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 3. Prior to August 17, 2011, the criteria for an initial evaluation of 10 percent, and no greater, for residuals of injury to the right hand have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5216-5230 (2012), 4.73, Diagnostic Codes 5299-5309 (2012). 4. From August 17, 2011, the criteria for an initial evaluation in excess of 10 percent for residuals of residuals of injury to the right hand have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5216-5230 (2012), 4.73, Diagnostic Codes 5299-5309 (2012). 5. Prior to June 17, 2009, the criteria for an evaluation of 40 percent, and no greater, for prostatitis have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.114, 4.115b, Diagnostic Code 7527 (2012). 6. For the period from June 17, 2009, the criteria were not met for a rating in excess of 40 percent for prostatitis. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.114, 4.115b, Diagnostic Code 7527 (2012). 7. Application of extraschedular provisions for the service-connected right hand disability and prostatitis is not warranted. 38 C.F.R. § 3.321(b) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks entitlement to service connection for diabetes mellitus, type II, as well as entitlement to increased disability ratings for a service-connected right hand disability and prostatitis. Implicit in his diabetes claim is the contention that new and material evidence which is sufficient to reopen the previously-denied claim has been received. In the interest of clarity, the Board will discuss certain preliminary matters. The issues on appeal will then be analyzed and a decision rendered. The Veterans Claims Assistance Act of 2000 The Board has given consideration to the Veterans Claims Assistance Act of 2000 (VCAA). The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also defines the obligations of VA with respect to its statutory duty to assist a claimant in the development of his claim. See 38 U.S.C.A. §§ 5103, 5103A (West 2002). For a claim to reopen, such as the Veteran's claim of service connection for diabetes mellitus, the VCAA appears to have left intact the requirement that a veteran must first present new and material evidence in order to reopen a previously and finally denied claim under 38 U.S.C.A. § 5108 before the Board may determine whether the duty to assist is fulfilled and proceed to evaluate the merits of that claim. It is specifically noted that nothing in the VCAA shall be construed to require VA to reopen a claim that has been disallowed except when new and material evidence is presented or secured, as described in 38 U.S.C.A. § 5108. See 38 U.S.C.A. § 5103A(f) (West 2002). Once the claim is reopened, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a veteran's claim for benefits under a law administered by the Secretary, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A (West 2002). Therefore, the VCAA duty to notify currently applies to the issue on appeal; the standard of review and duty to assist do not apply to the claim unless it is reopened. See Holliday v. Principi, 14 Vet. App. 280 (2000) [the Board must make a determination as to the applicability of the various provisions of the VCAA to a particular claim]. Notice The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2010), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. In Kent v. Nicholson, 20 Vet. App. 1 (2006), the United States Court of Appeals for Veterans Claims (the Court) specifically addressed VCAA notice requirements in the context of a veteran's request to reopen a previously and finally denied claim. The Court found that VA must notify a claimant of the evidence and information that is necessary to reopen the claim, and must provide notice that describes what evidence would be necessary to substantiate the element or elements required to establish service connection that were not found in the previous denial. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). In the case at hand, the record reflects that the originating agency provided the Veteran with notice, to include the effective-date element of the claim, by letters mailed in April 2008 and May 2009, prior to the initial adjudication of his claims. Additionally, the April 2008 VCAA letter informed the Veteran as to the reason his diabetes mellitus claim was previously denied: "[y]our claim was previously denied because condition neither occurred in nor was caused by service. Therefore, the evidence you submit must be new and relate to this fact." As such, the Veteran was adequately advised of the basis for the previous denial and of what evidence would be new and material to reopen the claim. See Kent, supra. Duty to assist As alluded to above, under the VCAA, VA's statutory duty to assist a claimant in the development of a previously finally denied claim does not attach until the claim has been reopened based on the submission of new and material evidence. Once a claim is reopened, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claimant's claim for benefits under a law administered by VA, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. See 38 U.S.C.A. § 5103A (West 2002). In the instant case, the Board finds reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claims. There is no reasonable possibility that further assistance would aid in substantiating the claims. The pertinent evidence of record includes the Veteran's statements, service treatment records, as well as VA and private treatment records. The Veteran was afforded VA examinations for his right hand disability and prostatitis in April 2009 and August 2011. The examination reports reflect that the examiners interviewed and examined the Veteran, reviewed his past medical history, documented his current medical conditions, and rendered appropriate diagnoses consistent with the remainder of the evidence of record. Furthermore, these examination reports contain sufficient information to rate the Veteran's right hand and prostatitis disabilities under the appropriate diagnostic criteria. The Board therefore concludes that the VA examination reports are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) [holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate]. The Board is cognizant of the fact that although the Veteran's claims folder was available during the April 2009 VA examination, it is unclear whether it was available during the August 2011 VA examination. However, such did not have an adverse effect on the adequacy of the examination. Notably, as previously indicated, the examiner fully considered the Veteran's complaints, to include his complaints of functional impairment with regard to his right hand disability and voiding dysfunction. Examinations were then performed that addressed all the relevant rating criteria. The Board finds that under the circumstances of this case, VA has satisfied the notification and duty to assist provisions of the law and that no further action pursuant to the VCAA need be undertaken on the Veteran's behalf. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2012). The Veteran has been accorded the opportunity to present evidence and argument in support of his claims. He has retained the services of a representative. He failed to report for his scheduled hearing before a Veterans Law Judge. Accordingly, the Board will proceed to a decision as to the issues of whether new and material evidence has been submitted to reopen a claim for entitlement to service connection for diabetes mellitus, type II, as well as entitlement to increased disability ratings for a right hand disability and prostatitis. Service connection for diabetes mellitus, type II Pertinent legal criteria Generally, service connection may be granted for disability or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). For certain chronic disorders, including diabetes mellitus, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). To establish a right to compensation for a present disability, a veteran must show: (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'-the so-called 'nexus' requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact or chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b) (2012). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6)(iii). If so, the veteran is thereby entitled to a presumption of service connection for certain disorders listed under 39 C.F.R. § 3.309(e). These diseases are chloracne; type II diabetes; Hodgkin's disease; chronic lymphocytic leukemia; multiple myeloma; non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy (defined as transient peripheral neuropathy that appears within weeks or months of exposure to an herbicide agent and resolves within two years of the date of onset); porphyria cutanea tarda; prostate cancer; respiratory cancers; AL amyloidosis, and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e) (2012). The Secretary of the Department of Veterans Affairs has determined that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for: hepatobiliary cancers; oral, nasal, and pharyngeal cancer; bone and joint cancer; skin cancers (melanoma, basal, and squamous cell); breast cancer; female reproductive system cancer (cervix, uterus, ovary); testicular cancer; urinary bladder cancer; renal cancer; leukemia (other than chronic lymphocytic leukemia); abnormal sperm characteristics and infertility; spontaneous abortion; neonatal or infant death and stillbirth in offspring of exposed individuals; low birthweight in offspring of exposed individuals; birth defects (other than spina bifida) in offspring of exposed individuals; childhood cancer (including acute myelogenous leukemia) in offspring of exposed individuals; neurobehavioral disorders (cognitive and neuropsychiatric); movement disorders, including Parkinson's disease and amyotrophic lateral sclerosis; chronic peripheral nervous system disorders; respiratory disorders; gastrointestinal, metabolic, and digestive disorders (changes in liver enzymes, lipid abnormalities, ulcers); immune system disorders (immune suppression, autoimmunity); circulatory disorders; endometriosis; and effects of thyroid homeostasis; gastrointestinal tumors (esophagus, stomach, pancreas, colon, rectum); and brain tumors, or any other disability not specified. See Notice, 72 Fed.Reg. 32395-407 (June 12, 2007); see also Notice, 68 Fed.Reg. 27630 -27641 (May 20, 2003); see also Notice, 67 Fed. Reg. 42600 (June 24, 2002); Notice, 66 Fed. Reg. 2376 (Jan. 11, 2001); Notice, 64 Fed.Reg. 59232 (Nov. 2, 1999). Notwithstanding the foregoing, the United States Court of Appeals for the Federal Circuit has determined that the Veterans' Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, § 5, 98 Stat. 2724, 2727- 29 (1984), does not preclude a veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed.Cir. 1994). The Court has specifically held that the provisions of Combee are applicable in cases involving Agent Orange exposure. McCartt v. West, 12 Vet. App. 164, 167 (1999). In general, rating decisions that are not timely appealed are final. See 38 U.S.C.A. § 7104 (West 2002); 38 C.F.R. § 20.1103 (2011). Pursuant to 38 U.S.C.A. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. New evidence is defined as evidence not previously submitted to agency decision-makers. 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. See 38 C.F.R. § 3.156(a) (2012). An adjudicator must follow a two-step process in evaluating a previously denied claim. First, the adjudicator must determine whether the evidence added to the record since the last final decision is new and material. If new and material evidence is presented or secured with respect to a claim that has been finally denied, the claim will be reopened and decided upon the merits. Once it has been determined that a claimant has produced new and material evidence, the adjudicator must evaluate the merits of the claim in light of all the evidence, both new and old, after ensuring that the VA's statutory duty to assist the appellant in the development of his claim has been fulfilled. See 38 U.S.C.A. § 5108 (West 2002); Elkins v. West, 12 Vet. App. 209 (1999); Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). In Shade v. Shinseki, 24 Vet. App. 110 (2010), the Court held that once new and material evidence has been presented as to an unestablished fact from a previously denied claim for service connection, the claimant will be entitled to the full benefits of the Secretary's duty to assist, including a medical nexus examination, if one is warranted; it does not require new and material evidence as to each previously unproven element of a claim. After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Claim to Reopen The RO denied service connection for diabetes mellitus, type II, in an April 2003 rating decision based on a finding that "this condition neither occurred in nor was caused by service." The Veteran did not appeal the April 2003 rating decision and the decision became final. At the time of the prior final rating decision in April 2003, the record included the Veteran's service treatment records, postservice records, and the Veteran's statements. The Veteran's service treatment records are absent complaints of or treatment for diabetes mellitus. A postservice VA treatment record dated August 2001 documented a diagnosis of diabetes mellitus, type II. Further, the Veteran submitted statements from himself and his wife indicating that he was exposed to herbicides during service in Thailand and Vietnam. If new and material evidence is presented or secured with respect to a claim that has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C.A. § 5108. Therefore, in order to reopen the claim, the evidence must show that the Veteran's diabetes mellitus is related to his military service. Since the April 2003 rating decision, in December 2007, the Veteran has applied to reopen his claim of entitlement to service connection for diabetes mellitus, to include as secondary to his service-connected hypertension. In the January 2006 rating decision, the agency of original jurisdiction (AOJ) reopened and denied the claim. Notwithstanding the RO's actions, it is incumbent on the Board to adjudicate the new and material issue before considering the claim on its merits. The question of whether new and material evidence has been received is one that must be addressed by the Board. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996) [before considering a previously adjudicated claim, the Board must determine that new and material evidence was presented or secured for the claim, making RO determination in that regard irrelevant]. In reviewing the evidence added to the claims folder since the April 2003 denial, the Board finds that additional evidence has been submitted which is sufficient to reopen the Veteran's claim, specifically evidence demonstrating a relationship between the Veteran's current diabetes mellitus and his military service. In particular, the Veteran submitted a statement from L.K. dated May 2008, who served with the Veteran in Thailand. L.K. reported that he also served with the Veteran in South Vietnam, and was exposed to herbicides during this period. Further, the Veteran submitted an Internet article dated March 2008 which indicated that the Veteran's unit that served in Thailand also served in South Vietnam. The May 2008 statement from L.K. and March 2008 Internet article had not been submitted before. Thus, they are new. The statement from L.K. and Internet article indicate that the Veteran served in Vietnam during his military service and was therefore exposed to herbicides. The Veteran's previous claim was denied because there was no evidence of an inservice disease or injury. The new evidence thus relates to an unestablished fact necessary to substantiate the claim. The credibility of the newly submitted evidence is presumed in determining whether or not to reopen a claim. Justus v. Principi, 3 Vet. App. 510 (1992). Thus, this evidence raises a reasonable possibility of substantiating the claim. See 38 C.F.R. § 3.156(a) (2012). Accordingly, the additional evidence is also material. As new and material evidence has been received, the claim for service connection for diabetes mellitus is reopened. As was indicated in the above VCAA discussion, VA's statutory duty to assist the Veteran in the development of his claim attaches at this juncture. For the reasons explained in the remand section below, the Board finds that additional development is necessary before a decision on the merits of the reopened claim may be rendered. In addition, the standard of review changes at this point. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012). In evaluating the evidence and rendering a decision on the merits, the Board is required to assess the credibility and, therefore, the probative value of proferred evidence in the context of the record as a whole. The Justus presumption of credibility no longer attaches. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Although the evidence discussed above is adequate for the limited purpose of reopening the claim, this does not necessarily make it sufficient to allow the grant of the benefits sought. See generally Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998) [material evidence is evidence that would contribute to a more complete picture of the circumstances surrounding the origin of a veteran's injury or disability, even where it would not be enough to convince the Board to grant the claim]. The Board finds that additional evidentiary development is required. This will be discussed in the remand section below. Higher evaluation for right hand disability Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2012). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2012). The Court has held that an appeal from an initial rating is a separate and distinct claim from a claim for an increased rating. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007) [holding, "staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings"]. The evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. See 38 C.F.R. § 4.10 (2012). Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. See 38 C.F.R. § 4.40 (2012). Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. See 38 C.F.R. § 4.45 (2012). Here, the Veteran's disability is the result of a FOOSH injury (fall on out stretched hand) that occurred when he became dizzy due to his hypertension. The Veteran's right hand disability is rated under Diagnostic Code 5024-5309. The former evaluates for limitation of motion due to tenosynovitis, and the latter rates for muscle injury. Diagnostic Code 5024 is found within 38 C.F.R. § 4.71a. Significantly, the provisions of 38 C.F.R. § 4.71a expressly provide for the application of different rating criteria depending upon whether a Veteran's minor (non-dominant) or major (dominant) side is being evaluated. See 38 C.F.R. § 4.69. Because the Veteran in this case is right-hand dominant, his residuals of injury disability affects his major, dominant side. Generally, muscle group damage is categorized as slight, moderate, moderately severe and/or severe and evaluated accordingly under 38 C.F.R. § 4.56 (2012). With respect to Diagnostic Code 5309, however, different criteria apply. As indicated in that code, Muscle Group IX consists of the intrinsic muscles of hand, the thenar eminence, short flexor, opponens, abductor and adductor of the thumb, the hypothenar eminence, and the short flexor, opponens and abductor of the little finger. The forearm muscles act in strong grasping movements and are supplemented by the intrinsic muscles in delicate manipulative movements. The hand is so compact a structure that isolated muscle injuries are rare, being nearly always complicated with injuries of bones, joints, tendons, etc. Thus, injury to Muscle Group IX should be rated on limitation of motion, with a minimum 10 percent assigned. 38 C.F.R. § 4.73, Diagnostic Code 5309, Note. The rating schedule provides that arthritis due to trauma, substantiated by X-ray findings, should be rated under the criteria for degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Codes 5010 (Arthritis Due to Trauma), 5003 (Degenerative Arthritis). Degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate Diagnostic Codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Codes 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. A higher rating of 20 percent is available when there is arthritis in more than one major joint or 2 or more groups of minor joints with occasional incapacitating exacerbations. Diagnostic Code 5003, 38 C.F.R. § 4.71a. Staged ratings are currently in effect for the Veteran's residuals of right hand injury: the disability has been rated as noncompensable prior to August 17, 2011, and 10 percent thereafter. Even so, VA must consider all the evidence of record to determine when an ascertainable increase occurred in the rated disability. See Hazan v. Gober, 10 Vet. App. 511 (1997); see also Swanson v. West, 12 Vet. App. 442 (1999). The Veteran was afforded a VA examination in April 2009 where he reported he had difficulty closing his right hand due to an injury to the hands in 2006. Notably, he also reported an overall decrease in hand strength and dexterity as well as swelling in all fingers including the thumb. Upon physical examination of the Veteran's right index finger, the VA examiner documented normal range of motion findings of the Veteran's distal interphalangeal joint (DIP), proximal interphalangeal joint (PIP), and metacarpal phalangeal (MP) joint. Although objective evidence of pain was noted, such was not reported after repetitive motion. Additionally, the gap between the index finger and proximal transverse crease of the hand on maximal flexion of the finger was less than one inch. Range of motion testing of the right long finger was normal for the DIP and MP joints, but abnormal for the PIP joint. However, the gap between the long finger and proximal transverse crease of hand on maximal flexion of finger was less than one inch, and no objective evidence of pain on motion was noted. The examiner further reported limitation of motion with regard to the Veteran's right ring finger and little finger, although no objective evidence of pain following repetitive motion was documented. The examiner also reported no ankylosis of any of the digits. He also reported angulation of 30 degrees of the right little finger at the PIP joint. With respect to strength for pushing, pulling, and twisting, he reported decreased strength of 4/5 in the right hand. There was no objective evidence of decreased dexterity for twisting, probing, writing, touching, and expression. The examiner diagnosed the Veteran with a fall on outstretched hand injury. A VA treatment record dated July 2010 documents the Veteran's treatment for pain in his right hand. The examining physician noted no swelling, warmth, or effusion of the hand. However, she reported that the Veteran had slight thickening that was tender to palpation along the rays of his little and ring fingers. Moreover, the MPs hyperextended passively, and the PIP joints to long, ring, and small fingers did not fully extend. An X-ray of the Veteran's right hand revealed no significant radiographic abnormality. The Veteran was diagnosed with early Dupuytren's nodules of the right palm without contracture. The examining physician reported that the Veteran's hand contractures in his PIP joints were from his arthrofibrosis and separate from the signs of Dupuytren's disease. The Veteran was afforded a VA hand and finger Disability Benefits Questionnaire (DBQ) examination in August 2011. He continued his complaints of pain in the right hand as well as difficulty grasping objects and was not able to lift objects over five pounds. He did not report flare-ups of the right hand. The examiner noted that the Veteran did not use assistive devices for the right hand disability. Upon physical examination of the Veteran's right hand, the VA examiner reported limitation of motion of the index finger, long finger, ring finger, and little finger. However, there was no gap pad between the thumb pad and the fingers. There was also a gap of less than one inch between the fingertips and the proximal transverse crease of the palm and no objective evidence of painful motion. Further, no limitation of extension or evidence of painful motion of the index finger or long finger was reported, and the Veteran was able to perform repetitive-use testing with three repetitions with no additional limitation of motion and no gap between the thumb pad and the fingers post-test. With regard to finger flexion, the examiner reported a gap of less than one inch between the fingertips and the proximal transverse crease of the palm in attempting to touch the palm with the fingertips post-test. Moreover, there was no limitation of extension for the index finger or long finger post-test. The examiner further reported that the Veteran did not have any functional loss or functional impairment of any of the fingers or thumbs, or additional limitation in range of motion of any of the fingers or thumbs following repetitive-motion testing. The Veteran did not evidence tenderness or pain to palpation for the joints or soft tissue of the right hand. Hand grip testing was 3/5. The examiner noted that the Veteran did not have ankylosis of the thumb or fingers. He also reported that there was no functional impairment of the Veteran's hand, finger or thumb that required amputation. Finally, he noted that imaging studies of the right hand did not reveal arthritis. He diagnosed the Veteran with arthrofibrosis of the four fingers, status post fall on outstretched hand injury. As x-rays do not disclose degenerative arthritis, Diagnostic Code 5003 does not apply. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). Diagnostic Codes 5216 through 5223 rate ankylosis for multiple digits of the hand. However, there is no evidence of ankylosis of the fingers on the right hand and therefore Diagnostic Codes 5216 though 5223 do not apply. Diagnostic Code 5227 rates ankylosis of the ring finger or little finger as noncompensable regardless of whether the digit is attached to the dominant or nondominant hand. 38 C.F.R. § 4.71a, Diagnostic Code 5227 (2012). A note to Diagnostic Code 5227 states the rater should consider whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits, or interference with the overall function of the hand. Furthermore, amputation of the ring finger is evaluated under Diagnostic Code 5155. There is no indication any of the Veteran's fingers are amputated or approximate amputation. Since there is no objective evidence of neuropathy, rating any of the fingers of the left hand under Diagnostic Codes 8514, 8515, and 8516 are not for application. They would rate complete or incomplete paralysis of the hand based on whether there is injury to the radial, median, or ulnar nerve, respectively. 38 C.F.R. § 4.124a, Diagnostic Codes 8514, 8515, and 8516 (2012). With regard to establishing loss of function due to pain, it is necessary that complaints be supported by adequate pathology and be evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. The Veteran contends that residuals of his right hand injury have caused him pain. Specifically, he stated that this causes decreased grip. Pertinently, the medical evidence of record, to include the April 2009 VA examination, support his contention. As discussed above, grip strength testing of the right hand at that time was 4/5. The Board adds that the Veteran was awarded a 10 percent disability rating from August 17, 2011 based on evidence documenting a decreased grip. As such, the Board finds that, based on the Veteran's credible report of right hand pain and decreased pain, a 10 percent rating is warranted prior to August 17, 2011 for functional loss due to muscle injury. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, supra. However, the Board finds the evidence to be against the Veteran's claim of entitlement to an initial rating in excess of 10 percent during any period during the course of the appeal. In this regard, there is no indication that pain causes functional loss greater than that contemplated by a 10 percent evaluation. As discussed above, the Veteran's current rating of 10 percent was assigned under Diagnostic Code 5309, which provides for a minimum 10 percent disability rating based on limitation of motion. In this case, however, the competent and probative evidence reveals that, throughout the entirety of the appeals period, the Veteran has been found to have normal range of motion of the right thumb and fingers. Moreover, X-ray evidence during the August 2011 VA examination specifically noted the absence of arthritis. Based, however, on the continuing presence of decreased grip strength noted in particular during the April 2009 and August 2011 VA examinations which indicates at least some slight muscle damage, as well as objective examination findings of pain on motion, the Board finds that the 10 percent disability rating is warranted based on a slight to moderate muscle disability throughout the course of the appeal. See 38 C.F.R. § 4.56(d)(1) and (2), supra. Higher evaluation for prostatitis The law and regulations pertaining generally to disability ratings have been set forth above and will not be repeated here. A request for an increased rating must be viewed in light of the entire relevant medical history. See 38 C.F.R. § 4.1 (2012); see also Peyton v. Derwinski, 1 Vet. App. 282, 287 (1991). However, where entitlement to compensation has already been established and 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). In Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court held that "staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings." Prostatitis is rated on the basis of voiding dysfunction or urinary tract infection, whichever is predominant. 38 C.F.R. § 4.115b, Diagnostic Code 7527. With respect to voiding dysfunction, the Veteran's prostatitis, will be rated as urine leakage, frequency, or obstructed voiding. When there is continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence, a 20 percent rating is warranted, when the Veteran is required to wear absorbent materials which must be changed less than two times per day. A 40 percent rating is warranted, when the Veteran is required to wear absorbent materials which must be changed two to four times per day. A 60 percent rating is warranted when the Veteran is required to wear absorbent materials which must be changed more than four times per day. In cases of urinary frequency, a 10 percent rating is warranted when there is a daytime voiding interval between two and three hours, or; when the Veteran awakens to void two times per night. A 20 percent rating is warranted when there a daytime voiding interval between one and two hours, or; when the Veteran awakens to void three to four times per night. A 40 percent rating is warranted when there a daytime voiding interval of less than one hour, or; when the Veteran awakens to void five or more times per night. With respect to voiding obstruction, a noncompensable rating is warranted when there is obstructive symptomatology with or without stricture disease requiring dilatation one to two times per year. A 10 percent rating is warranted when there is marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: Post void residuals greater than 150 cc Uroflowmetry; markedly diminished peak flow rate (less than 10 cc/sec) Recurrent urinary tract infections secondary to obstruction Stricture disease requiring periodic dilatation every 2 to 3 months A 30 percent rating is warranted for voiding dysfunction when there is urinary retention requiring intermittent or continuous catheterization. With respect to urinary tract infections, a 10 percent rating is warranted when the infection requires long-term drug therapy with one to two hospitalizations per year and/or requiring intensive management. A 30 percent rating is warranted for recurrent symptomatic infection requiring drainage/frequent hospitalization (greater, than two times a year), and/or requiring continuous intensive management. Otherwise, rate as renal dysfunction. With respect to renal dysfunction, a 30 percent rating is warranted when albumin is constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under 38 C.F.R. § 4.104, Diagnostic Code 7101. A 60 percent rating is warranted when there is constant albuminuria with some edema; or, a definite decrease in kidney function; or, hypertension rated at least 40 percent disabling under 38 C.F.R. § 4.104, Diagnostic Code 7101. An 80 percent rating is warranted when there are persistent edema and albuminuria with BUN of 40 to 80mg%; or, a creatinine of 4 to 8mg%; or, generalized poor health, characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent schedular rating is warranted for renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. Hypertension is rated in accordance with 38 C.F.R. § 4.104, Diagnostic Code 7101. For VA rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 mm or greater. Isolated systolic hypertension means that the systolic blood pressure is predominantly 160 or greater with a diastolic blood pressure of less than 90 mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. A 10 percent rating is warranted when the diastolic pressure is predominantly 100 or more, or; when the systolic pressure is predominantly 160 or more. A 10 percent rating is also warranted when the Veteran has a history of a diastolic pressure of 100 or more and requires continuous medication for control. A 20 percent rating is warranted for hypertension, manifested by a diastolic pressure of predominantly 110 or more and a systolic pressure of 200 or more. A 40 percent rating is warranted for hypertension, manifested by a diastolic pressure of predominantly 120 or more. Staged ratings are currently in effect for the Veteran's prostatitis: the disability has been rated as 10 percent disabling prior to June 17, 2009, and 40 percent thereafter. Even so, VA must consider all the evidence of record to determine when an ascertainable increase occurred in the rated disability. See Hazan v. Gober, 10 Vet. App. 511 (1997); see also Swanson v. West, 12 Vet. App. 442 (1999). The Veteran was afforded a VA genitourinary examination in April 2009. Pertinently, he complained of urinary symptoms, to include urgency, hesitancy/difficulty starting stream, weak or intermittent stream, dribbling, straining to urinate, daytime voiding intervals less than one hour, and three voiding per night. He denied dysuria, hematuria, urine retention, urethral discharge, urinary leakage, recurrent urinary tract infections, obstructed voiding, urinary tract stones, renal dysfunction, acute nephritis, and hydronephrosis. Upon physical examination, the VA examiner reported normal bladder, anus and rectal walls, urethra, and perineal sensation as well as no abdominal or flank tenderness. Further, examination of the Veteran's prostate was normal. A VA treatment record dated June 2009 documents the Veteran's treatment for his prostatitis. In particular, the Veteran complained of increased urinary frequency, nocturia, occasional incontinence, and weak, dribbling urine stream. He also reported burning once or twice a month and the tip of the penis, but otherwise no dysuria, hematuria, or drainage. The examining physician noted that a rectal examination revealed perineal skin tags and enlarged, smooth, nontender prostate. The Veteran was provided a VA genitourinary DBQ in August 2011. He continued his complaints of urinary symptoms, to include hesitancy, slow stream, dribbling, and increased frequency of urination. Notably, he reported daytime voiding intervals less than one hour and nighttime awakening to void two times. He also reported that he must wear a diaper which he changes twice a day. He used medication for treatment of his prostatitis. He reported that his voiding dysfunction did not require use of an appliance. The examiner indicated no history of recurrent symptomatic urinary tract or kidney infections. An abnormal prostate was noted upon examination. Based on the evidence of record, the Board finds that a 40 percent disability rating is warranted for the Veteran's prostatitis prior to June 17, 2009. As discussed above, a 40 percent disability rating is warranted for urinary frequency when the evidence shows daytime viding intervals less than one hour. Crucially, the April 2009 VA examination report documented such. There is no evidence to the contrary. However, the Board finds that a disability rating in excess of 40 percent for the Veteran's prostatitis is not warranted during any period on appeal. In this regard, the competent and probative evidence does not show that the Veteran requires the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. As such, an increased rating is not warranted for voiding dysfunction. With regard to urinary frequency, the Veteran is currently assigned the maximum disability rating. Further, the maximum disability rating for obstructed voiding and urinary tract infection is 30 percent. Finally, the competent and probative evidence of record does not indicate that the Veteran's prostatitis is manifested by renal dysfunction. The absence of such was specifically noted in the April 2009 and August 2011 VA examination reports, and there is no evidence to the contrary. Accordingly, the Board finds that a 40 percent disability rating is warranted for the Veteran's prostatitis prior to June 17, 2009, and a disability rating in excess of 40 percent is not warranted during any period under consideration. Extraschedular consideration In evaluating the severity of his service-connected right hand disability and prostatitis, the Board also has considered whether the Veteran is entitled to a greater level of compensation for the disabilities at issue on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected disabilities on appeal are inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities, with the established criteria shows that the rating criteria reasonably describe the level and symptomatology thereof. The criteria specifically provide for evaluation of the disability based upon impairment of the right hand and genitourinary system, and they practicably represent the average impairment in earning capacity resulting from the Veteran's service-connected disabilities. See 38 C.F.R. § 4.1. ORDER New and material evidence having been received, the claim of entitlement to service connection for diabetes mellitus, type II, is reopened; to this extent only, the appeal is granted. Entitlement to an initial 10 percent rating for service-connected residuals of injury to the right hand is granted prior to August 17, 2011, subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to an initial evaluation in excess of 10 percent for service-connected residuals of injury to the right hand is denied. Entitlement to a 40 percent rating for service-connected prostatitis is granted prior to June 17, 2009, subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to an evaluation in excess of 40 percent for service-connected prostatitis is denied. REMAND Higher evaluation for hypertensive heart disease The Veteran's disability due to hypertensive heart disease has been assigned a 60 percent rating effective since November 12, 2008 under a general set of criteria applicable to diseases of the heart found at 38 C.F.R. § 4.104, Diagnostic Code 7007 (for rating hypertensive heart disease) Under Diagnostic Code 7007, a 60 percent is warranted where there has been more than one episode of acute congestive heart failure in the past year; or a workload of greater than three METs but not greater than five 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. A 100 percent rating is assigned when the Veteran manifests chronic congestive heart failure, or; workload of three METs or less that results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7007. In this case, the competent and probative evidence of record is unclear as to whether the Veteran currently suffers from chronic congestive heart failure, which as noted above, warrants a 100 percent disability rating under Diagnostic Code 7007. In this regard, the Board observes that April 2009 and August 2011 VA examination reports specifically note that the Veteran does not evidence chronic congestive heart failure. However, an Ischemic Heart Disease DBQ dated February 2011 indicates a diagnosis of chronic congestive heart failure. Crucially, neither the April 2009 or August 2011 VA examiner nor the examining physician who provided the February 2011 Ischemic Heart Disease DBQ stated a rationale as to their finding with respect to whether or not the Veteran currently suffers from congestive heart failure. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) [the failure of the health care provider to provide a basis for his/her opinion goes to the weight or credibility of the evidence]. In light of the foregoing, the Board finds that an examination and medical nexus opinion must be obtained which addresses whether the Veteran currently suffers from such. See Charles v. Principi, 16 Vet. App. 370 (2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 C.F.R. § 3.159(c)(4) (2012) [a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient medical evidence to decide the claim]. Service connection for diabetes mellitus and left hand disability The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.326(a) (2012). The VCAA requires that VA must provide notice that informs the claimant (1) of the information and evidence not of record that is necessary to substantiate the claim, (2) of the information and evidence that VA will seek to provide, and (3) of the information and evidence that the claimant is expected to provide. Furthermore, VA must "also request that the claimant provide any evidence in the claimant's possession that pertains to the claim." 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1). In this case, the Board finds that a VA medical opinion is necessary with respect to the Veteran's claims of entitlement to service connection for diabetes mellitus, type II, and a left hand disability prior to further appellate consideration. 38 C.F.R. § 3.159(c)(4). In particular, the Veteran contends that his diabetes mellitus, type II, is related to his service-connected hypertension, and that his left hand disability is related to a fall caused by the hypertension. See statements from the Veteran dated January and June 2008. Pertinently, none of the medical records currently associated with the Veteran's VA claims folder offer an opinion as to a possible causal relationship between the Veteran's diabetes mellitus or his left hand disability and the service-connected hypertension. In light of the foregoing, the Board finds that an examination and medical nexus opinion must be obtained which addresses whether the Veteran's diabetes mellitus and left hand disability are related to the service-connected hypertension. See Charles v. Principi, 16 Vet. App. 370 (2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 C.F.R. § 3.159(c)(4) (2012) [a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient medical evidence to decide the claim]. Accordingly, the case is REMANDED for the following action: 1. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of the claims remanded herein. Based on the Veteran's response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. All attempts to secure this evidence must be documented in the claims folder by the RO. If, after making reasonable efforts to obtain named records the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; and (c) describe any further action to be taken by the RO with respect to the claim. The Veteran must then be given an opportunity to respond. 2. The RO should thereafter schedule the Veteran for a VA cardiovascular examination to determine the current severity of his service-connected hypertensive heart disease. The examiner must review the Veteran's claims file and must explain the complete rationale for all opinions expressed and conclusions reached. The examiner should specifically note whether the Veteran's hypertensive heart disease is manifested by one of the following: a. 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; b. More than one episode of acute congestive heart failure in the past year, or; workload of greater 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; c. Workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray; or d. Workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. All tests and studies deemed necessary by the examiner should be performed. A complete rationale for any opinion expressed shall be provided. With regard to whether or not the Veteran suffers from chronic congestive heart failure, the examiner should specifically discuss the rationale for their finding and address the February 2011 Ischemic Heart Disease DBQ which indicates a diagnosis of chronic congestive heart failure. The report of the examination should be associated with the Veteran's VA claims folder. 3. Thereafter, schedule the Veteran for a VA examination(s) to determine the etiology of his diabetes mellitus, type II, and left hand disability. The examiner(s) must review the Veteran's claims file and must explain the complete rationale for all opinions expressed and conclusions reached. After examining the Veteran, reviewing his pertinent medical history and any competent lay statements regarding observable symptomatology, the examiner(s) should then respond to the following questions: a. Is it at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran's diagnosed diabetes mellitus, type II, is either (1) caused or (2) aggravated (i.e. permanently worsen beyond the normal progression of the disability) by the Veteran's service-connected hypertension? If the examiner finds that the diabetes mellitus is aggravated by the service-connected hypertension, then he/she should quantify the degree of aggravation, if possible. b. Does the Veteran currently suffer from a left hand disability? c. If a left hand disability is identified, is it at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran's diagnosed left hand disability is either (1) caused or (2) aggravated (i.e. permanently worsen beyond the normal progression of the disability) by the Veteran's service-connected hypertension? If the examiner finds that the left hand disability is aggravated by the service-connected hypertension, then he/she should quantify the degree of aggravation, if possible. All tests and studies deemed necessary by the examiner should be performed. A complete rationale for any opinion expressed shall be provided. The report of the examinations should be associated with the Veteran's VA claims folder. 4. After undertaking any additional development deemed by it to be appropriate, the RO should then readjudicate the Veteran's claims. If the benefits sought on appeal remain denied, the Veteran and his representative should be provided a supplemental statement of the case and given an appropriate opportunity to respond. Thereafter, the case should be returned to the Board for further consideration, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. See 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. 2011). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs