Citation Nr: 1301547 Decision Date: 01/15/13 Archive Date: 01/23/13 DOCKET NO. 09-40 567 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to a separate compensable disability rating for erectile dysfunction as a result of diabetes mellitus, type II. 2. Entitlement to a disability rating higher than 20 percent for diabetes mellitus, type II. 3. Entitlement to a disability rating higher than 10 percent for peripheral neuropathy of the left leg. 4. Entitlement to a disability rating higher than 10 percent for peripheral neuropathy of the right leg. 5. Entitlement to an effective date earlier than May 30, 2008 for the assignment of separate 20 percent disability ratings for peripheral artery disease in the left leg and in the right leg. 6. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). 7. Entitlement to service connection for hypertension, to include as aggravated by service-connected diabetes mellitus, type II. ATTORNEY FOR THE BOARD Cheryl E. Handy, Associate Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from June 1970 to January 1972, including service in the Republic of Vietnam. This matter is before the Board of Veterans' Appeals (Board) on appeal of rating decisions in February 2009 and August 2010 of the Department of Veterans Affairs (VA) Regional Offices (ROs) in San Juan, Puerto Rico and Phoenix, Arizona, respectively. The Veteran resides in Puerto Rico and jurisdiction rests with the San Juan RO. The Veteran had requested the opportunity to appear at a hearing before the Board, and a hearing was scheduled for October 2011. In a written communication received in October 2011, the Veteran withdrew the request for hearing, but continued his appeals. Therefore, the Board will adjudicate the matter based on the evidence of record. In September 2012, the Veteran applied to have this matter advanced on the Board's docket under 38 U.S.C.A. § 7107(a) and 38 C.F.R. § 20.900(c). This request was denied by a Deputy Vice Chairman of the Board in December 2012 and the Veteran was notified of that decision. The case will be adjudicated in its original docket number order, in compliance with the law. The issues of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and/or major depression, diabetic retinopathy, diabetic nephropathy, diabetic neuropathy of the bilateral upper extremities, and dyslipidemia due to diabetes mellitus, have been raised by the record, but have not been adjudicated by the RO. Therefore, the Board does not have jurisdiction over them, and they are referred to the RO for appropriate action. The issues of entitlement to service connection for hypertension, to include aggravated by diabetes mellitus, entitlement to disability ratings higher than 10 percent for peripheral neuropathy in each leg, and entitlement to TDIU is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's erectile dysfunction is a manifestation of his diabetes mellitus, type II, and is not associated with any deformity of the penis. 2. The Veteran's diabetes mellitus is manifested by the required use of insulin and a restricted diet without regulation of activities. 3. The Veteran's peripheral artery disease in the left and right legs had its onset in 2008 and he filed his claim for a separate disability rating in May 2008. CONCLUSIONS OF LAW 1. The criteria for a separate compensable rating for erectile dysfunction have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.115b, Diagnostic Code 7522 (2012). 2. The criteria for a rating in excess of 20 percent for diabetes mellitus, type II, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). 3. The criteria for an effective date prior to May 30, 2008, for the award of service connection with separate compensable ratings for peripheral artery disease of the left and right legs have not been met. 38 U.S.C.A. §§ 5103A, 5107(b), 5110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.400 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In a claim for increase, the VCAA notice requirements are the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (interpreting 38 U.S.C.A. § 5103(a) as requiring generic claim-specific notice and rejecting Veteran-specific notice as to effect on daily life and as to the assigned or a cross-referenced Diagnostic Code under which the disability is rated). The VCAA notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided pre- and post-adjudication VCAA notice by letters dated in July 2008 and August 2008. The notice included the type of evidence needed to substantiate the claims for increase, namely, evidence that the disabilities had increased in severity and the effect that worsening has on the Veteran's employment. Additionally, the Veteran was notified that VA would obtain VA records and records of other Federal agencies, and that he could submit other records not in the custody of a Federal agency, such as private medical records. The notice included the provisions for the effective date of a claim and for the degree of disability assignable for the claim. As for content of the VCAA notice, the documents complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112 (2004) (to the extent there was pre-adjudication notice); and of Dingess v. Nicholson, 19 Vet. App. 473 (notice of the elements of the claim). To the extent that the VCAA notice came after the initial adjudication, the timing of the notice did not comply with the requirement that the notice must precede the adjudication. The procedural defect was cured as after the RO provided content-complying VCAA notice the claim was readjudicated, as evidenced by the supplemental statement of the case in February 2012. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim. The RO has obtained the Veteran's post-service VA and private treatment records, as well as records relating to his Social Security Disability claim. The Veteran has not identified any additional pertinent records for the RO to obtain on his behalf. The Veteran was afforded a VA examination in September 2008 in relation to the claims currently on appeal. The Board notes that the VA examination report contains sufficiently specific clinical findings and informed discussion of the pertinent history and features of the disability on appeal to provide probative medical evidence adequate for rating purposes. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c)(4). As there is no indication of the existence of additional evidence to substantiate the claim, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claim is required to comply with the duty to assist. Assigning Disability Ratings A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155. 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. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). Here, the evidence indicates that the Veteran's service-connected disabilities have been largely stable throughout the appeals period and there is no basis for assigning staged ratings. Facts On September 2008 VA examination, the examiner noted a diagnosis of diabetes mellitus, type II, in 2004, for which he was taking oral hypoglycemic medication. He was also being treated for hypertension, which was diagnosed in 2004. He was instructed to follow a restricted diet, but there was no restriction on his performance of strenuous physical activities. The examiner noted that the Veteran had peripheral vascular disease in both lower legs, with symptoms of claudication and edema; the condition was due to the Veteran's diabetes. He also complained of erectile dysfunction, for which he was taking an oral medication. On examination, the Veteran's blood pressure was 145/83, 132/72, and 131/80. His lower legs showed loss of hair and decreased dorsalis pedis and posterior tibial pulses, but normal temperature and reflexes. Doppler studies of the lower extremities showed calcified arterial walls but adequate blood flow in both legs. He was employed full time and had lost less than one week of work due to his diabetes in the past year. Possible complications related to diabetes included cardiac disease and peripheral artery disease, although hypertension was not felt to be due to diabetes. At a June 2009 disability evaluation, the Veteran reported a history of diabetes mellitus, type II, arterial hypertension, diabetic neuropathy and diabetic retinopathy since 2004, as well as pain and numbness in both legs beginning in 2008. Physical examination showed adequate pedal pulses, no edema in the extremities, and no motor or sensory deficits. A functional capacity examination noted no limitation on sitting, standing, walking, lifting, carrying or speaking. The evaluator diagnosed diabetes mellitus type II since 2004, uncontrolled arterial hypertension, diabetic neuropathy, and diabetic retinopathy. An August 2009 case analysis for Social Security Disability purposes noted that the Veteran had diabetes with neuropathy, hypertension, and COPD as well as peripheral vascular disease beginning in 2008. A March 2010 decision by the Social Security Administration showed that the Veteran was unable to work since December 30, 2008. The disabilities preventing gainful employment were listed as congestive heart failure, hypertension, coronary artery disease, diabetes mellitus, peripheral diabetic neuropathy, diabetic retinopathy, degenerative joint disease, major depressive disorder, and generalized anxiety disorder. A written statement from the Veteran's primary care physician dated in June 2010 noted that the Veteran is diabetic, on insulin and an oral hypoglycemic medication with poor control, and had numbness and paresthesias in both his upper and lower extremities. He was also taking medication for poorly controlled high blood pressure. The physician noted that these conditions, as well as headaches, blurred vision, episodes of chest pain and heart palpitations, anxiety and depression, he was unable to work or to concentrate on a specific theme or situation. Specific diagnoses were listed as hypertension, diabetes mellitus type II, diabetic neuropathy of both upper and lower limbs, diabetic nephropathy, diabetic retinopathy, dyslipidemia due to diabetes mellitus, peripheral artery disease of the upper and lower limbs, generalized anxiety disorder, major depressive disorder with psychotic features, and post-traumatic stress disorder. The physician certified that the Veteran is 100 percent disabled and cannot work. Analysis Erectile Dysfunction The Veteran reports having erectile dysfunction, which his supported by the medical evidence of record. The evidence shows that the erectile dysfunction is a manifestation of the Veteran's diabetes mellitus, type II, and it is mentioned in the presently assigned 20 percent disability rating for diabetes mellitus. The Veteran asserts that this disability should instead be given a separate compensable rating. There is no medical evidence disassociating this symptom from the Veteran's diabetes mellitus, type II. The criteria for evaluating genitourinary system dysfunctions are contained in 38 C.F.R. § 4.115b. Under Diagnostic Code 7522, erectile dysfunction is rated by analogy, to "penis, deformity, with loss of erectile power." See 38 C.F.R. § 4.20 (2012). That code provides for a 20 percent rating for deformity of the penis with loss of erectile power. While other Diagnostic Codes discuss injuries to the penis or testicles, this is the only one which specifically includes loss of erectile function, and is therefore contains the only rating criteria applicable to this matter. In this case, the diagnosis in effect is erectile dysfunction. There is, however, no evidence of a deformity of the penis, and the Veteran does not contend otherwise. Because the Veteran does not meet the criteria for a compensable evaluation, a noncompensable evaluation - one equivalent to a zero (0) percent rating - is warranted. See 38 C.F.R. § 4.31 (2012). As such, the current rating scheme, which includes erectile dysfunction as a manifestation of the Veteran's diabetes mellitus and incorporates it in the rating assigned to that disability, is not incorrect. Even were a separate disability rating to be assigned for erectile dysfunction, without evidence of penile deformity, a noncompensable rating would be assigned. 38 C.F.R. § 4.115b, Diagnostic Code 7522. Based on the foregoing, the preponderance of the competent evidence is against a finding that the condition is productive of criteria so as to warrant a compensable rating for the erectile dysfunction associated with diabetes mellitus, type II. The record shows that the Veteran has been awarded and is receiving special monthly compensation is provided for erectile dysfunction under 38 U.S.C.A. § 1114, subsection (k) and 38 C.F.R. § 3.350(a), based on loss of use of a creative organ. This represents the maximum level of special monthly compensation provided for loss of use of a creative organ. See 38 U.S.C.A. § 1114, subsection (k); 38 C.F.R. § 3.350(a). A higher level of special monthly compensation is not warranted. Id. Diabetes Mellitus Under Diagnostic Code 7913, diabetes mellitus type II, is evaluated based on the specific symptoms and restrictions associated with the disease which are not separately rated. Where the disease requires management through the use of insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet, it is rated as 20 percent disabling. Where the disease is managed by required doses of insulin, a restricted diet, and regulation of activities, it is rated as 40 percent disabling. Compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under diagnostic code 7913. See 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1) (2012). In this case, the Veteran contends that a higher disability rating is warranted for his service-connected diabetes mellitus. VA records show that a 20 percent rating under the provisions of Diagnostic Code 7913 was established effective from October 2004. In addition, the Veteran has been awarded compensation for the separate disabilities associated with diabetes mellitus including peripheral artery disease in the left and right legs (20 percent each leg) and peripheral neuropathy in the left and right legs (10 percent each leg). The medical evidence, as discussed above, shows that the Veteran's current disability rating of 20 percent for diabetes mellitus, type II, with erectile dysfunction is appropriate. The criteria for a 20 percent rating are the requirement of either insulin injections or oral hypoglycemic medication and restricted diet to control the condition. At the time of the rating decision on appeal here, the Veteran was using diet and oral hypoglycemic medication to control his diabetes, which met the criteria for a 20 percent rating. During the pendency of the appeal, the Veteran's condition has worsened, but only to the point of requiring insulin injections, and it, therefore, still falls within the criteria for a 20 percent disability rating. There is no evidence which suggests a higher rating is warranted. A higher, or 40 percent disability rating, requires a showing of regulation of strenuous activities, as prescribed by a doctor, due to the diabetes mellitus, in addition to the use of diet and insulin or hypoglycemic medication. The definition of "regulation of activities" in the criteria for a 100 percent rating for diabetes mellitus, that is, the "the avoidance of strenuous occupational and recreational activities," also applies to the "regulation of activities" criterion for a 40 percent rating under Code 7913. In addition, the criterion of "regulation of activities" requires medical evidence that occupational and recreational activities have been restricted by the diabetes. Camacho v. Nicholson, 21 Vet. App. 360, 363-65 (2011). There is no evidence to suggest that the Veteran's physicians have instructed him to refrain from strenuous activities due to his diabetes. Therefore, the criteria for a 40 percent disability rating for diabetes mellitus, type II, have not been met. 38 C.F.R. § 4.119 (2012). Extraschedular Rating Although the Board is precluded by regulation from assigning extraschedular ratings under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for a service-connected disability is inadequate. There must be a comparison between the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111 (2008). Here, the rating criteria reasonably describe the Veteran's disability levels and symptomatology related to his diabetes mellitus and associated complications, including peripheral artery disease, neuropathy, and erectile dysfunction. The rating criteria also provide for higher ratings for more severe symptoms. As the disability pictures are contemplated by the Rating Schedule, the assigned schedular ratings are, therefore, adequate. Consequently, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). Assigning Effective Dates Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400. If a claim for disability compensation is received within one year after separation from service, the effective date of entitlement is the day following separation or the date entitlement arose. 38 C.F.R. § 3.400(b)(2). Otherwise, it is the date of receipt of claim or the date entitlement arose, whichever is later. See 38 C.F.R. § 3.400. The effective date of an evaluation and an award of compensation based on a reopened claim is the date of receipt of the new claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400(q)(2). A specific claim in the form prescribed by the VA Secretary must be filed in order for benefits to be paid to any individual under the laws administered by VA. 38 C.F.R. § 3.151. Any communication or action, indicating an intent to apply for VA benefits from a claimant, his duly authorized representative, a Member of Congress or some person acting as next friend of a claimant who is not sui juris may be considered an informal claim. Such informal claim must identify the benefit sought. 38 C.F.R. § 3.155(a). The Veteran seeks an earlier effective date for the award of service connection and a separate disability rating assigned to his peripheral artery disease in the left and right legs. The currently assigned effective date of May 30, 2008, is based on the date the RO received his claim for increased disability rating for diabetes mellitus and related conditions. The Veteran contends that because the peripheral artery disease in his legs is a complication of his diabetes mellitus, type II, and therefore related to his exposure to herbicides in Vietnam, the effective date should be the same as that for his diabetes mellitus itself, namely 2004. The record before the Board is somewhat incomplete, in that the original copy of the claims file was lost in June 2008 and the RO created a secondary file using all the records within the VA computer system, as well as all documents filed after that time. As such, some of the documents submitted by the Veteran, such as the claims of service connection and the claim for increased disability rating, are absent from the file. The Board notes that in this instance, the presumption of regularity, under which it is assumed that government officials "have properly discharged their official duties," applies. See United States v. Chemical Foundation, Inc., 272 U.S. 1, 14-15 (1926). The presumption of regularity in the administrative process may only be rebutted by "clear evidence to the contrary." Schoolman v. West, 12 Vet. App. 307, 310 (1999); Mindenhall v. Brown, 7 Vet. App. 271, 274 (1994). The medical evidence of record shows that the Veteran first reported experiencing pain and numbness in his legs, which was later diagnosed as peripheral artery disease, at some point in 2008. He informed the Social Security Disability evaluator that his peripheral artery problems began in 2008. The September 2008 VA examiner noted such symptoms of peripheral artery disease as claudication and edema, and a Doppler study supported the diagnosis. Despite the large volume of medical records in the claims file, there is no indication of any onset of symptoms or diagnosis of peripheral artery disease until 2008. Under the provisions of 38 C.F.R. § 3.400, the effective date of a disability award is based on the date the claim was filed or the date entitlement arose, whichever is later. In this instance, while the Veteran's underlying disability of diabetes mellitus was diagnosed in 2004 and the claim for that disability was filed in 2004, the evidence shows that peripheral artery disease had its onset in 2008 and the claim was filed in May 2008. Thus, the assigned effective date of May 30, 2008, is appropriate for the award of service connection for peripheral artery disease in the left and right legs as a separate compensable disability. While the specific document seeking inclusion of peripheral artery disease is not contained in the rebuilt file, the February 2009 rating decision lists that as the date of receipt of claim. This date is consistent with the medical evidence showing onset of the condition in 2008, based on September 2008 and June 2009 disability evaluations. The Veteran has not presented clear evidence to suggest that any earlier date is warranted, including any evidence that he had peripheral artery disease at the time any prior claim was filed. As the preponderance of the evidence is against the claim for an effective date earlier than May 30, 2008 for the award of separate disability ratings for peripheral artery disease of the left and the right leg, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). ORDER Entitlement to a separate compensable disability rating for erectile dysfunction as a result of diabetes mellitus, type II, is denied. Entitlement to a disability rating higher than 20 percent for diabetes mellitus, type II, is denied. Entitlement to an effective date earlier than May 30, 2008 for separate 20 percent disability ratings for peripheral artery disease in the right and left legs is denied. REMAND The Veteran seeks service connection for hypertension, which he has asserted is the result of herbicide exposure in Vietnam or was caused or aggravated by his diabetes mellitus, type II. A review of the claims file indicates that a complete analysis of all theories of service connection has not, as yet, been rendered. Specifically, while a VA examiner has stated that the Veteran's hypertension was not caused by his service-connected diabetes mellitus, type II, there is no medical opinion as to whether the service-connected diabetes mellitus, type II, has aggravated the Veteran's hypertension. An examination and opinion on that question is needed. The Veteran also seeks increased disability ratings for his service-connected peripheral neuropathy of the left and right legs, which is currently rated as 10 percent disabling for both the left and the right leg, under Diagnostic Code 8520, with an effective date in February 2010. The August 2010 rating decision on appeal lists findings from a June 2010 VA examination report which is not contained in the claims file. Although the claims file has been rebuilt, this occurred in 2008 and the June 2010 examination should be included in the record. Without this evidence, the Board cannot execute a fully informed and fair adjudication of the Veteran's claim. On remand, a copy of this examination should be located and included in the claims file. If a copy cannot be obtained, a new VA examination should be performed. In addition, the Veteran seeks TDIU benefits based on his assertions that his service-connected disabilities alone are sufficient to render him unable to obtain and maintain reasonably gainful employment. The Board notes that, at present, the Veteran's combined disability rating is 60 percent, and that since all disabilities are related to his diabetes mellitus, type II, resulting from herbicide exposure, the requirements of 38 C.F.R. § 4.16 for a schedular TDIU award are met. In addition, the Veteran is in receipt of Social Security Disability Insurance benefits based on a determination that he is unable to work. However, the Veteran has not been provided a VA examination to determine if the Veteran's diabetes mellitus, type II, and related conditions are alone sufficient to warrant an award of TDIU. Such an examination should be conducted on remand. Notably, the record has raised the issues of entitlement to service connection for additional complications of diabetes, which should be considered in any examination, as should the determination of the claim of service connection for hypertension. Accordingly, the case is REMANDED for the following action: 1. Locate and associate with the claims file a copy of the June 2010 VA examination referenced in the August 2010 rating decision, specifically with regard to the issue of peripheral neuropathy of the legs. If a copy of this report cannot be located or if the Veteran should indicate his condition has worsened since this examination, he should be afforded another examination, to include any additional necessary testing, to determine the current severity of his peripheral neuropathy. The examination referenced in instruction number 3, related to the TDIU claim, would satisfy this requirement, provided that all relevant diagnostic tests are performed and the examiner is asked to specifically address the current severity of this disability. 2. Afford the Veteran an appropriate VA examination to determine whether it is at least as likely as not that his current hypertension is aggravated by his service-connected diabetes mellitus, type II. The examiner should provide the rationale for any opinion(s) rendered. A copy of the claims file should be provided to the examiner for review. 3. After the determination is rendered with respect to the claim of service connection for hypertension, afford the Veteran an appropriate VA examination to determine whether it is at least as likely as not that his current service-connected disabilities, to specifically include diabetes mellitus, type II, peripheral artery disease in both legs, peripheral neuropathy in both legs, and any other complications of diabetes found to exist, such as peripheral neuropathy of the arms, diabetic nephropathy, and diabetic retinopathy, render the Veteran unable to obtain and maintain reasonably gainful employment. The examiner is not to consider the Veteran's age or any disabilities which are not service connected, unless such are conclusively shown to be caused by diabetes mellitus, type II. Any non-service-connected disabilities which are caused by diabetes mellitus, type II, should be specifically identified for action by the RO/AMC upon review of the examination report. The examiner should provide the rationale for any opinion(s) rendered. A copy of the claims file should be provided to the examiner for review. 4. Notify the Veteran that it is his responsibility to report for the examinations and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for the aforementioned examinations, obtain documentation showing that notice scheduling the examinations was sent to the last known address of record, and indicate whether any notice that was sent was returned as undeliverable. 5. On completion of the foregoing, the claim should be adjudicated. If the decision remains adverse to the Veteran, then provide him and his representative a supplemental statement of the case and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claims. See 38 C.F.R. § 3.655 (2012). 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). ______________________________________________ Thomas H. O'Shay Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs