Citation Nr: 1300778 Decision Date: 01/09/13 Archive Date: 01/16/13 DOCKET NO. 09-20 670 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Whether severance of service connection for prostatitis was proper. 2. Entitlement to service connection for a heart condition, including hypertension (HTN), to include as secondary to service-connected diabetes mellitus (DM). 3. Entitlement to service connection for a kidney condition, including diabetic nephropathy, to include as secondary to service-connected DM. 4. Entitlement to service connection for decreased visual acuity, including diabetic retinopathy, to include as secondary to service-connected DM. 5. Entitlement to service connection for liver disease, to include as secondary to service-connected DM. 6. Entitlement to a disability rating in excess of 20 for service-connected DM. 7. Entitlement to an initial disability rating in excess of 10 for service-connected peripheral neuropathy of the right upper extremity. 8. Entitlement to an initial disability rating in excess of 10 for service-connected peripheral neuropathy of the left upper extremity. 9. Entitlement to an initial disability rating in excess of 10 for a service-connected depressive disorder. 10. Entitlement to an initial compensable disability rating for service-connected erectile dysfunction. 11. Entitlement to service connection for a right leg scar. 12. Entitlement to a total rating based on individual unemployability (TDIU) due to service-connected disabilities. ATTORNEY FOR THE BOARD L. J. Wells-Green, Counsel INTRODUCTION The Veteran served on active duty from November 1964 to October 1966. This matter comes to the Board of Veterans' Appeals (Board) on appeal from December 2008, August 2009, December 2009 and March 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. The issues of entitlement to service connection for a bilateral eye disability, to include diabetic retinopathy, a right leg scar and for TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The grant of service connection for chronic prostatitis as secondary to service-connected DM was not clearly and unmistakably erroneous. 2. Any currently diagnosed heart condition, to include HTN, did not have its onset in service or within one year thereafter and has not been etiologically linked to the Veteran's service, any incident therein, or to a service-connected disability. 3. Objective evidence of a current kidney condition, to include diabetic nephropathy, is not shown. 4. Objective evidence of current liver disease is not shown. 5. During the pendency of his appeal, the Veteran's DM is manifested by daily use of oral medication and a restricted diet, without evidence of a need for regulation of activities, episodes of ketoacidosis or hypoglycemic reactions. 6. During the pendency of his appeal, the Veteran's peripheral neuropathy of the right upper extremity is no more than mildly disabling. 7. During the pendency of his appeal, the Veteran's peripheral neuropathy of the left upper extremity is no more than mildly disabling. 8. During the pendency of his appeal, the Veteran's depressive disorder is manifest by complaints of sleep disturbance, depressed mood and social isolation resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 9. The Veteran's service-connected depressive disorder does not cause more than occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. 10. During the pendency of his appeal, there is no evidence of any deformity of the Veteran's penis or loss of any part of the penis. CONCLUSIONS OF LAW 1. As severance of service connection for chronic prostatitis was not in accordance with law, service connection is restored effective December 1, 2009. 38 U.S.C.A. §§ 1110, 5109 (West 2002); 38 C.F.R. §§ 3.105, 3.303, 3.304, 3.306, 3.309, 3.310 (2012). 2. A heart condition, to include HTN, was not incurred in active military service; and cannot be presumed to have been incurred therein; and is not a result of service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 3. A kidney condition, to include nephropathy, was not incurred in active military service; and cannot be presumed to have been incurred therein; and is not a result of service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 4. Liver disease was not incurred in active military service; and is not a result of service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 5. The criteria for a disability rating in excess of 20 percent for DM are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7913 (2012). 6. The criteria for an initial disability rating in excess of 10 percent for peripheral neuropathy of the right upper extremity have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.123, 4.124, 4.124a; Diagnostic Code 8515 (2012). 7. The criteria for an initial disability rating in excess of 10 percent for peripheral neuropathy of the left upper extremity have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.123, 4.124, 4.124a; Diagnostic Code 8515 (2012). 8. The criteria for a disability rating in excess of 10 percent for depressive disorder have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.1-4.7, 4.21, 4.130, Diagnostic Code 9434 (2012). 9. The criteria for a compensable disability rating for erectile dysfunction have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.20, 4.31, Diagnostic Codes 7520, 7521, 7522 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties To Notify And Assist The provisions of 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012) set out VA's duty to notify and assist Veteran's with claims for benefits. VA's notice requirements were satisfied in September 2008, February 2009 and March 2010 letters. With respect to the duty to assist, VA has secured or attempted to secure all relevant documentation to the extent possible. The Veteran's available service treatment records, private treatment records, as well as VA evaluations and treatment records are of record. The Veteran's written contentions regarding the circumstances of his disabilities are also of record, and these records were reviewed by both the RO and the Board in connection with the Veteran's claims. VA examinations with respect to the issues on appeal were obtained in March 2007, October 2008, March 2009, April 2009, November 2009, March 2010 and October 2011. 38 C.F.R. § 3.159(c)(4). The examination reports in aggregate are adequate as they are predicated on examinations of the Veteran and either provided opinions as to whether the Veteran had current disabilities, and if so, the etiology of any diagnosed disabilities with rationale or fully addressed the rating criteria relevant to evaluating the Veteran's service-connected disabilities. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations regarding the issues decided herein has been met, and there remains no issue as to the substantial completeness of the Veteran's claims. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002); 38 C.F.R §§ 3.102, 3.159, 3.326(a) (2012). Analysis Severance of Service Connection for Prostatitis Once service connection has been granted, it can be severed only where the evidence establishes that the grant is clearly and unmistakably erroneous (the burden being on the Government). 38 C.F.R. § 3.105. A review of the record shows that in a May 2008 rating action, service connection was granted for the Veteran's chronic prostatitis on the basis that it was aggravated by his service-connected DM. Thereafter, a June 2009 rating action proposed to sever service connection on the basis that he does not have chronic prostatitis and it is not a disability presumed to be due to exposure to Agent Orange. An August 2009 rating decision severed service connection for chronic prostatitis, effective from December 1, 2009. At the time of the May 2008 rating decision, private treatment records indicate that the Veteran had a history of chronic prostatitis as early as March 2007 and underwent treatment for diagnosed chronic prostatitis in April 2008. The rating decision indicates that a March 25, 2008 medical certificate from the Veteran's private treating physician shows that his chronic prostatitis had been aggravated by his service-connected DM. Unfortunately, the March 2008 medical certificate is no longer of record. However, following receipt of this 2008 medical certificate and the private treatment records, the RO granted service connection for chronic prostatitis on the basis that it was aggravated by his service-connected DM. In both April 2009 and November 2009, the Veteran underwent VA genitourinary examinations. During both examinations, the examiners, while noting the history of chronic prostatitis, determined that he did not currently have prostatitis. With the Veteran's consistent report of a history of chronic prostatitis; together with his private treating physician's medical certificate indicating that his chronic prostatitis was aggravated by his service-connected DM, it is not untenable to have concluded service connection was warranted. As indicated above, in order to sever service connection, it must be found that the original decision was clearly and unmistakably erroneous. With the favorable medical opinion in the record, and objective evidence of chronic prostatitis such a conclusion is not possible. Moreover, the April 2009 and November 2009 VA examiners merely determined that the Veteran did not have prostatitis at the time of the examinations and did not opine regarding whether he had chronic prostatitis. Accordingly, the Board finds that severance of service connection was not proper and service connection is restored effective the date of severance, December 1, 2009. Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). The second and third elements may be established by showing continuity of symptomatology. Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson, 581 F. 3d at 1316; Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007) (Holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). In addition to the above-cited statutes and regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, supra. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, the Board, when considering whether lay evidence is satisfactory, the Board may properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). A Heart Condition to Include HTN After carefully considering all of the evidence of record under the laws and regulations as set forth above, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a heart condition, to include HTN. Initially, the Veteran's service treatment records show no relevant complaints, findings, treatment or diagnosis in service. His October 1966 separation examination report shows his blood pressure was 122/74. VA and private treatment records, dating from September 1979, show a blood pressure reading of 140/80 during a September 1979 VA compensation examination with a normal cardiovascular examination, almost 13 years after his discharge. An August 2006 VA treatment record indicates he was on medication for elevated blood pressure and a diagnosis of uncontrolled HTN. Consequently, as HTN was not demonstrated during the first post service year, a grant of service connection on a presumptive basis is not warranted. Moreover, after reviewing the Veteran's claims files including his service treatment records, a VA physician in March 2007 and October 2008 reports, opined that since the Veteran's HTN diagnosis pre-dated the onset of his DM, it could not be a complication of his DM. The examiner further opined that as there was no diagnosis of diabetic renal disease, his HTN was not caused or aggravated by his DM. Likewise, there is no objective evidence linking the Veteran's HTN to his service-connected DM. In this respect, although a private physician noted that DM can cause damage to the heart in a January 2010 letter, the examiner did not etiologically link the Veteran's HTN to his service, any incident therein or any service-connected disability. Rather the physician stated that the Veteran should be evaluated to "rule out the possibility" that his HTN is related to his DM. Although the Veteran believes that his diagnosed HTN is the result of his service, the Board finds that the service and post-service treatment records and the March 2007 and October 2008 VA physician's opinion to be more probative and credible than the Veteran's current assertions. Although he is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the Veteran is not competent to provide evidence as to more complex medical questions as in this case. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The Board finds that the Veteran is not competent to offer lay evidence regarding the etiology of his HTN and that his statements alone are not sufficient to establish a nexus to service. By contrast, the VA physician who conducted the March 2007 and October 2008 examinations, based her opinion on a review of the Veteran's claims files and provided rationale for her opinion. Therefore, the Board finds that there is no competent evidence that indicates the Veteran's HTN had its onset in service, within one-year of his discharge from service or is etiologically related to his service, any incident therein, or to his service-connected DM. The most probative evidence of record establishes that the Veteran's current HTN is not attributable to his service, did not manifest within one year of his separation from service and was not proximately due to or aggravated by his service-connected DM. Therefore, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a heart condition, to include HTN. 38 U.S.C.A. § 5107(b). A Kidney Condition, Including Nephropathy The Veteran contends that he has a kidney condition as a result of his service-connected DM. After carefully considering all of the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for diabetic nephropathy or any other kidney condition. Initially, service treatment records fail to show any relevant complaints, findings, treatment or diagnoses. Although the October 1966 discharge examination report shows that clinical evaluation of the Veteran's genitourinary system was abnormal for acute gonorrhea, there was no evidence of any renal disability. Post-service VA and private treatment records repeatedly indicate no relevant complaints, findings, treatment or diagnoses. Indeed, during the March 2007 and October 2008 VA DM examinations, the examiners specifically determined that there was no evidence of diabetic nephropathy. Although the Veteran believes that he has a kidney condition secondary to his service-connected DM, the Board finds that the post-service VA and private treatment records, as well as the VA DM examination reports to be competent and persuasive in showing that the Veteran does not currently have a kidney condition. The Veteran is not competent to provide medical evidence concerning the diagnosis of a kidney condition and the evidence fails to show that he currently has any such disability. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. §§ 1110, 1131; see Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997)(holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the Veteran currently has the disabilities for which benefits are being claimed. While the Board has considered the Veteran's contentions, the objective evidence of record fails to show any diagnosed diabetic nephropathy or any other kidney condition or identifiable underlying disabilities with regard to this claim. Thus, the preponderance of the evidence of record does not establish that the Veteran currently has a kidney condition, to include diabetic nephropathy. Liver Disease Likewise, after carefully considering all of the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for liver disease as there is no evidence of a current disability. Initially, his service treatment records fail to show he was ever diagnosed or treated for any liver condition in service. Although the Veteran believes that he has liver disease secondary to his service-connected DM, VA and private treatment records, dated as early as September 1979, show no relevant complaints, findings, treatment or diagnoses. He is not competent to provide medical evidence concerning the diagnosis of a liver condition, and the evidence fails to show that he currently has any such disability. While the Board has considered the Veteran's contentions, the objective evidence of record fails to show any diagnosed diabetic liver condition or identifiable underlying disabilities with regard to this claim. Thus, the preponderance of the evidence of record does not establish that the Veteran currently has liver disease, and service connection is not warranted. Increased Disability Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the "present level" of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where VA's adjudication of an increased rating claim is lengthy, a claimant may experience multiple distinct degrees of disability that would result in different levels of compensation from the time the increased rating claim was filed until a final decision on that claim is made. Thus, VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending. Hart v. Mansfield, 21 Vet. App. 505 (2007). Similarly where a veteran appeals the initial rating assigned for a disability at the time that service connection for that disability is granted, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous . . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. DM The Veteran's service-connected DM is currently rated as 20 percent disabling under the provisions of 38 C.F.R. § 4.119, Diagnostic Code 7913. Pursuant to Diagnostic Code 7913, a 20 percent evaluation is warranted for DM that requires insulin and a restricted diet or an oral hypoglycemic agent and restricted diet. The next higher 40 percent evaluation requires insulin, a restricted diet, and regulation of activities. A 60 percent under this code requires insulin, a 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. A maximum rating of 100 percent is warranted when the disability requires more than one daily injection of insulin, a 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. In addition, a note following the rating criteria indicates that compensable complications from DM are evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. However, noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. "Regulation of activities" has been defined as the situation where the Veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,446 (May 7, 1996)(defining "regulation of activities," as used by VA in Diagnostic Code 7913). Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360 (2007). After a careful review of the record, the Board finds that the preponderance of the evidence is against a disability rating in excess of 20 percent under the rating criteria. The medical evidence of record shows that, during the pendency of his appeal, a combination of oral medications and a restricted diet have controlled the Veteran's DM. Private and VA treatment records further show that he is seen intermittently for routine maintenance of his condition. Moreover, the October 2008 VA examination report specifically noted that there was no history of ketoacidosis or hypoglycemia, hospitalization or restriction of activities due to the Veteran's DM. The Board finds that the preponderance of the evidence of record does not show that the Veteran's DM required restriction or regulation of his activities as defined in Diagnostic Code 7913 at any time during the pendency of this appeal. The VA and private treatment records show the Veteran's DM is well controlled with oral medications and a restrictive diet. For the reasons set forth above, the Board concludes that the most probative evidence fails to establish that the Veteran's DM has required regulation of his activities, as contemplated by the rating criteria. In light of the foregoing, an initial disability rating in excess of 20 percent under Diagnostic Code 7913 for the Veteran's DM is not warranted. Peripheral Neuropathy Diseases of the peripheral nerves are rated under 38 C.F.R. § 4.124a. The Veteran's peripheral neuropathy of the upper extremities is rated as separate 10 percent disability ratings pursuant to the provisions of 38 C.F.R. § 4.124a, Diagnostic Code 8515 that governs the evaluation of paralysis of the median nerve. Under this Code, a 10 percent rating is assigned when there is mild incomplete paralysis of the median nerve on either the major (dominant) side or the minor (nondominant) side. Moderate incomplete paralysis warrants a 30 percent rating on the dominant side and a 20 percent rating on the nondominant side. Severe incomplete paralysis warrants a 50 percent rating on the major side and 40 percent rating on the minor side, respectively. In a general note for rating diseases of the peripheral nerves, it is clarified that the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The next higher evaluations of 70 and 60 percent for the major and minor sides respectively, require complete paralysis of the median nerve, in which the hand inclines to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. After carefully reviewing the evidence of record, the Board finds that the preponderance of the evidence is against separate disability ratings in excess of 10 percent, under the applicable rating criteria. Despite the Veteran's subjective complaints of numbness and tingling in both his hands, the objective neurological testing during the March 2009 VA examination showed only decreased sensation to light touch, vibration and pain in both extremities, assessed by the examiner as mild sensory neuropathy. Subsequent VA treatment records repeatedly indicate on routine examination that the Veteran had no complaints and that there was no gross motor and sensory deficit. There is no objective evidence of record indicating that the Veteran's bilateral peripheral neuropathy of the upper extremities is more than mild at any time during the pendency of his claims. Therefore, the Board finds that the criteria for separate disability ratings in excess of 10 percent for bilateral peripheral neuropathy of the right and left upper extremities have not been met. Depressive Disorder The Veteran's service-connected depressive disorder is currently rated as 10 percent disabling under 38 C.F.R. § 4.130, Diagnostic Code 9434. Under this code, a 10 percent rating is assigned when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. In a January 2010 letter, a private physician opined that the Veteran had a depressed mood with changes in his sleep pattern as a consequence of his DM and lifestyle changes. At that time he had markedly decreased interest and pleasure in most of his usual activities, was fatigued or had low energy nearly every day and problems with concentration. However, VA and private treatment records, dating over the course of many years show no treatment for any diagnosed psychiatric disability. In March 2010, the Veteran underwent a VA psychological examination. At that time he complained of sexual dysfunction, sleeping difficulty due to leg pain, crying spells and irritability. He indicated that he maintained good family relations and had no difficulties in the degree and quality of his social relationships. He had no history of violence or suicide attempts. He was not seeking treatment for his depressive disorder at that time. Mental status examination revealed the Veteran was clean in appearance and cooperative. His psychomotor activity was unremarkable and his affect was normal. He looked sad when talking about his medical conditions, but he was alert, oriented to person, time and place. His attention was intact and his thought content was unremarkable. There was no evidence of hallucinations or delusions and his judgment and insight were not impaired. There was no evidence of obsessive/ritualistic behavior, panic attacks, or of homicidal or suicidal thoughts. The Veteran had good impulse control. His remote and recent memory was normal, although his immediate memory was mildly impaired. The examiner noted that the Veteran was retired as a result of eligibility by age or duration of employment. The diagnosis was depressive disorder. The examiner opined that the Veteran's depressive disorder symptoms did not cause occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks, or reduced reliability and productivity. In October 2011 the Veteran again underwent a VA psychological examination. He reported that he had a one-time appointment with a private psychiatrist who had diagnosed PTSD. He complained of sexual dysfunction, sleeping difficulties due to pain, crying spells, and irritability due to physical conditions. He had been married to his second wife for 14 years and described his relationship with his 3 adult children as "good." He reported that he had no friends and did not socialize even with his siblings. On examination, the Veteran was clean. His psychomotor activity was unremarkable. He was alert, oriented to person, time and place. His attention was intact and his thought content was unremarkable. There was no evidence of hallucinations or delusions and his judgment and insight were not impaired. There was no evidence of obsessive/ritualistic behavior, panic attacks, or of homicidal or suicidal thoughts. The Veteran was cooperative, friendly, relaxed, and attentive; he was able to do serial sevens; spell a word forward and backward; and understood the outcome of behavior. He likewise could perform the activities of daily living, knew the amount of his benefit payment, the amount of his monthly bills, and the examiner judged the Veteran could prudently handle payments, and personally handle money and pay bills. The Veteran had good impulse control. The examiner determined that the Veteran did not meet the diagnostic criteria for PTSD. The diagnosis was depressive disorder, with mild PTSD symptoms. The examiner noted that the Veteran had no history of having sought psychiatric treatment and opined that his depressive disorder would improve if he sought treatment. After considering the totality of the record, the Board finds the evidence fails to support a 30 percent disability rating for the Veteran's depressive disorder. During the pendency of his appeal, the Veteran's depressive disorder was manifested by recurrent sleep disturbance, depressed mood, and evidence of social isolation, the effects from which are contemplated in a 10 percent evaluation. The Veteran reported a good relationship with his wife and children, there is no evidence to show anxiety, suspiciousness, or panic attacks, and any social isolation appears to be a consequence of physical limitations. The Veteran has not sought any treatment for his condition, and a VA examiner specifically concluded the consequences of symptoms contemplated for a 30 percent evaluation were not present. In reaching this conclusion, the Board takes note of the GAF scores. The March 2010 examination shows the Veteran was assessed with a GAF score of 70, the October 2011 examination shows a GAF of 60. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). GAF scores ranging between 51 and 60 indicate moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 61 and 70 reflect mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships. An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See 38 C.F.R. § 4.126 (2009); see also VAOPGCPREC 10-95 (Mar. 31, 1995) (cited at 60 Fed. Reg. 43,186 (Aug. 18, 1995)). The March 2010 examiner assessed the Veteran with a GAF score indicating no more than mild symptoms, consistent with a 10 percent rating. The October 2011 examiner assessed a GAF score indicating moderate symptoms or impairment in social, occupational or school functioning. However, the symptoms set out in the report are not consistent with this level of impairment, as contemplated by the rating schedule. The symptoms described more nearly approximate a 10 percent rating, as the examiner noted the Veteran was cooperative, friendly, relaxed, and attentive; he was able to do serial sevens; spell a word forward and backward; and understood the outcome of behavior. He likewise could perform the activities of daily living, knew the amount of his benefit payment, the amount of his monthly bills, and the examiner judged the Veteran could prudently handle payments, and personally handle money and pay bills. Erectile Dysfunction The Veteran's service-connected erectile dysfunction is currently rated as noncompensable under Diagnostic Code 7522. 38 C.F.R. § 4.115b. Under Diagnostic Code 7522, where the penis has a deformity with loss of erectile power, a 20 percent disability will be assigned. Diagnostic Code 7521 also provides a 20 percent disability rating for removal of the glans of the penis. Diagnostic Code 7520 provides a 30 percent disability rating if there is removal of half or more of the penis. 38 C.F.R. § 4.115b. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The Veteran has also been granted special monthly compensation under 38 U.S.C.A. § 1114(k) and 38 C.F.R. § 3.350(a) for his erectile dysfunction. After considering the totality of the record, the Board finds the preponderance of the evidence is against the Veteran's claim for a compensable initial disability rating for his service-connected erectile dysfunction. Although his erectile dysfunction has been progressively unresponsive to medication, the evidence does not indicate that any portion of the penis or the glans of the penis has been removed. Moreover, there is no indication that there is any deformity of the penis. In fact, April 2009 and November 2009 VA genitourinary examination reports specifically note that the Veteran's genitalia were normal. Consequently, the Board finds that the Veteran does not have a deformity of the penis and does not meet the criteria for a compensable evaluation under Diagnostic Codes 7520, 7521 and 7522. Accordingly, the claim for a compensable initial disability rating for erectile dysfunction must be denied. Conclusion In reaching these determinations, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1) and the Court's decision in Thun v. Peake, 22 Vet. App. 111 (2008). 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 claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant'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. The evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for service-connected DM, peripheral neuropathy of the upper extremities, depressive disorder and erectile dysfunction are inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned ratings with the established criteria found in the rating schedule shows that the rating criteria reasonably describes the Veteran's disability levels and symptomatology. As discussed above, there are higher ratings available under the diagnostic codes for each of the above-mentioned disabilities, but the Veteran's disabilities are not productive of such manifestations as a result of his service-connected disabilities. Therefore, it cannot be said that the available schedular evaluations are inadequate. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluations for the Veteran's service-connected disabilities under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, supra. ORDER The severance of service connection for chronic prostatitis was improper, and restoration of service connection, effective December 1, 2009, is granted. Service connection for a heart condition, to include HTN, is denied. Service connection for a kidney condition, to include diabetic nephropathy, is denied. Service connection for liver disease is denied. Entitlement to a disability rating in excess of 20 percent for DM is denied. Entitlement to an initial disability rating in excess of 10 percent for peripheral neuropathy of the right upper extremity is denied. Entitlement to an initial disability rating in excess of 10 percent for peripheral neuropathy of the left upper extremity is denied. Entitlement to disability rating in excess of 10 percent for service-connected depressive disorder is denied. Entitlement to a compensable disability rating for erectile dysfunction is denied. REMAND Initially, the Board notes that a March 2007 rating decision denied service connection for a right leg scar. In October 2007, along with new claims for service connection for chronic prostatitis and erectile dysfunction, the Veteran submitted what the Board construes as a notice of disagreement (NOD) with the denial of service connection for a right leg scar as it is clear that this was the Veteran's intention. See 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.201 (2011); see also Gallegos v. Gober, 14 Vet. App. 50 (2000) (VA should liberally interpret a written communication which may constitute an NOD under the law.), rev'd sub nom Gallegos v. Principi, 283 F. 3d 1309 (Fed. Cir. 2002) (the language of 38 C.F.R. § 20.201 properly implemented 38 U.S.C. § 7105, and assuming that the [claimant] desired appellate review, meeting the requirement of § 20.201 was not an onerous task). See also Gallegos v. Principi, 16 Vet. App. 551 (2003) (per curiam). The Veteran has not been furnished a statement of the case that addresses this issue. Therefore, the Board is required to remand the issue to the RO for issuance of a proper statement of the case. See Manlicon v. West, 12 Vet. App. 238 (1999). With regard to the Veteran's claim for service connection for a bilateral eye disability, to include diabetic retinopathy, although March 2007 and October 2008 VA examination reports show diagnoses of refractive error and bilateral cataracts, with no evidence of active retinal diabetic changes, and numerous subsequent VA treatment records indicate no evidence of visual changes, a June 2010 VA treatment record specifically notes that he was assessed with diabetic retinopathy and would start treatment. However, there are no subsequent findings or diagnoses associated with diabetic retinopathy. The Board therefore finds that the Veteran should be provided another VA examination to determine whether he currently has diabetic retinopathy. Regarding the TDIU claim, the Veteran should be provided a more current examination to assess whether his service-connected disabilities alone render him unemployable. Finally, the Board notes that the Veteran's most recent VA treatment records are dated in February 2011. Copies of any available VA records subsequent to August 2008 need to be obtained and incorporated in the claims files. Accordingly, the case is REMANDED for the following action: 1. The RO should furnish the Veteran a Statement of the Case with respect to the issue of entitlement to service connection for a right leg scar. The RO should return this issue to the Board only if the Veteran files a timely substantive appeal. 2. Physically or electronically associate any pertinent, outstanding VA records dated after February 2011, with the claims folders. 3. Provide the Veteran with an appropriate VA examination to determine the current nature and etiology of any bilateral eye disability found to be present. All necessary studies or tests should be accomplished. The examiner should review the evidence in the claims folders, and acknowledge such review in the examination report. Based on the medical findings and a review of the claims folders, the examiner is requested to offer an opinion as to whether it is at least as likely as not that any eye disability, to include diabetic retinopathy, if present, is causally related to or aggravated by the Veteran's diagnosed DM. A complete rationale for all findings and conclusions should be included in the report. 4. Schedule the Veteran for an appropriate VA examination to evaluate the effect of all of his service-connected disabilities (DM, peripheral neuropathy of the upper and lower extremities, depressive disorder, chronic prostatitis [and potentially an eye disability and right leg scar]) jointly on the Veteran's employability. The examiner is requested to opine whether it is at least as likely as not that the Veteran's service-connected disabilities, without consideration of his non-service-connected disabilities, render him unable to secure or follow a substantially gainful occupation. 5. After conducting any additional development deemed necessary, VA should readjudicate the issues of entitlement to service connection for a bilateral eye disability, including diabetic retinopathy, to include as secondary to service-connected DM, and TDIU, considering all the evidence of record. If the benefits requested on appeal are not granted to the Veteran's satisfaction, the Veteran should be furnished a supplemental statement of the case and be provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if in order. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs