Citation Nr: 1304012 Decision Date: 02/05/13 Archive Date: 02/08/13 DOCKET NO. 10-27 479A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to service connection for right shoulder tendonitis claimed as adhesive capsulitis. 2. Entitlement to service connection for a left shoulder disability claimed as adhesive capsulitis. 3. Entitlement to an evaluation in excess of 40 percent for service-connected diabetes mellitus type I with nephropathy manifested by elevated microalbuminuria and right lower extremity peripheral neuropathy. 4. Entitlement to a separate compensable rating for service-connected nephropathy manifest by elevated microalbuminuria. 5. Entitlement to a separate compensable rating for service-connected peripheral neuropathy of the right lower extremity. 6. Entitlement to an initial evaluation in excess of 10 percent for service-connected peripheral neuropathy of the left lower extremity. REPRESENTATION Appellant represented by: Connecticut Department of Veterans Affairs ATTORNEY FOR THE BOARD S. Keyvan, Associate Counsel INTRODUCTION The Veteran served in the U.S. Army National Guard of Massachusetts from August 1993 to October 2003, with active federal service from August 2001 to April 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the February 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut, which, in pertinent part, denied service connection for right shoulder tendonitis and a left shoulder disability, and further denied a disability evaluation greater than 40 percent for the service-connected diabetes mellitus, type I. In a February 2012 rating action, the Decision Review Officer (DRO) determined that the peripheral neuropathy of the Veteran's left lower extremity was entitled to a separate compensable rating. As the peripheral neuropathy is a complication arising from the Veteran's service-connected diabetes mellitus, it is inextricably intertwined with the claim for an increased evaluation for diabetes mellitus. As such, the claim for entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy of the left lower extremity is also on appeal before the Board. During the pendency of this appeal, the Veteran requested and was scheduled for a local hearing with a Decision Review Officer (DRO) at the Hartford RO in January 2011. A January 2011 Report of General information slip reflects that the Veteran contacted the RO and asked to have his hearing postponed due to a scheduling conflict. The Veteran was thereafter rescheduled for another local hearing before the DRO on August 10, 2011. However, in the August 2011 Informal Conference report, the Veteran withdrew his hearing request, and it was determined that the local DRO hearing would be cancelled. Therefore, no hearing is required prior to consideration of the appeal. The issues of entitlement to separate compensable ratings for the service-connected nephropathy manifest by elevated microalbuminuria and peripheral neuropathy of the right lower extremity, as well as entitlement to an initial increased rating for service-connected peripheral neuropathy of the left lower extremity 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. On March 14, 2012, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran that he wished to withdraw from appellate review his appeal of his claims seeking service connection for right shoulder tendonitis and a left shoulder disability. 2. Throughout the appeal period, the Veteran's diabetes mellitus has been manifested by more than one daily injection of insulin, a restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring weekly visits to a diabetic care provider, plus progressive loss of weight and strength. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal of the claim for service connection for right shoulder tendonitis claimed as adhesive capsulitis, have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 2. The criteria for withdrawal of an appeal of the claim for service connection for a left shoulder disability claimed as adhesive capsulitis, have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 3. Resolving all reasonable doubt in the Veteran's favor, the criteria for a 100 percent evaluation for diabetes mellitus, type I, with nephropathy manifested by elevated microalbuminuria and right lower extremity peripheral neuropathy, have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection for Right Shoulder Tendonitis and Left Shoulder Disability A veteran may withdraw his or her appeal in writing at any time before the Board promulgates a final decision. 38 C.F.R. § 20.204 (2012). When a veteran does so, the withdrawal effectively creates a situation in which an allegation of error of fact or law no longer exists. In such an instance, the Board does not have jurisdiction to review the appeal, and a dismissal is then appropriate. 38 U.S.C.A. § 7105(d) (West 2002); 38 C.F.R. §§ 20.101, 20.202 (2012). In the February 2009 rating action, the RO denied service connection for right shoulder tendonitis and a left shoulder disability. In the January 2010 notice of disagreement (NOD), the Veteran disagreed with the denial of service connection for these claims, and, in the July 2010 substantive appeal, he perfected a timely appeal with respect to these issues. However, prior to certification of the appeal, in the March 2012 Appeal Status Election form, the Veteran expressed his desire to withdraw from appellate review his claims for service connection for right shoulder tendonitis and a left shoulder disability. In view of the Veteran's expressed desire, the Board concludes that further action with regard to his claims for service connection for right shoulder tendonitis and a left shoulder disability, are not appropriate. 38 U.S.C.A. § 7105(d) (West 2002); 38 C.F.R. § 20.204 (2012). The Board does not have jurisdiction over these withdrawn issues and, as such, must dismiss the appeal of these claims. See 38 U.S.C.A. § 7105(d) (West 2002); 38 C.F.R. §§ 20.101, 20.202, 20.204 (2012). II. Increased Rating for Diabetes Mellitus, Type I A. Duties to Notify and Assist On November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, & 5126 (West 2002 & Supp. 2011)). The VCAA imposes obligations on VA in terms of its duty to notify and to assist claimants. The Board has considered the legislation regarding VA's duty to notify and to assist claimants but finds that, given the favorable action taken herein with regard to the issue of entitlement to an increased rating for the service-connected diabetes mellitus, no further discussion of these VCAA requirements is required with respect to this claim. Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92, 57 Fed. Reg. 49,747 (1992). B. Analysis The Veteran contends that he is entitled to a rating in excess of 40 percent for his service-connected diabetes mellitus, type I. For the reasons that follow, the Board concludes that a total schedular rating is warranted. 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). Diagnostic Code 7913 is deemed by the Board to be the most appropriate code, primarily because it pertains specifically to the disability at issue (diabetes mellitus) but also because it provides specific guidance as to how symptoms of this disability are to be evaluated. The Board can identify nothing in the evidence to suggest that another diagnostic code would be more appropriate, and the Veteran has not requested that another diagnostic code should be used. Thus, the Board finds that the Veteran is appropriately rated under Diagnostic Code 7913, with reference to other diagnostic codes as appropriate as required by the criteria set forth therein. Diabetes mellitus requiring insulin, restricted diet, and regulation of activities warrants a 40 percent rating. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). Diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated is assigned a 60 percent disability rating. Diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated, is assigned a 100 percent disability rating. Under Note (1), compensable complications of diabetes are to be evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran's diabetes is most appropriately rated as 100 percent disabling. A brief historical overview reflects that service connection was initially granted for diabetes mellitus, type I, with nephropathy manifested by elevated microalbuminuria and bilateral peripheral neuropathy by way of the July 2007 rating decision, and a 40 percent evaluation was assigned pursuant to 38 C.F.R. § 4.119, Diagnostic Code 7913, effective December 18, 2006. Progress notes issued at the Riverbend Medical Group and dated in May 2005 reflect that the Veteran presented for an evaluation of his diabetes. While the treatment provider observed an improvement in the Veteran's average glucose level, it was noted that the Veteran had had a glucose level of 40 milligrams (mg) per deciliter (dL) earlier that week necessitating a trip to the emergency room. At the May 2007 VA examination, the Veteran provided his medical history and stated that he was first diagnosed with diabetes mellitus, type I, in 2002, six months after his discharge. According to the Veteran, his blood sugars are not well-controlled, and tend to drop throughout the day, becoming worse at night. The Veteran reported to experience blurred vision with high blood sugars, as well as occasional numbness and tingling in his lower extremities. He further stated that his diabetes leaves him feeling wiped out and he visited the emergency room once, and his private physician four to five times the previous year due to episodes of hypoglycemia. The Veteran described his blood sugars as either very low or very high and provided a list of the type of medication and insulin he uses, and the frequency with which he takes his medication and administers insulin injections. With respect to whether there were any restrictions on his activities as a result of his diabetes, the Veteran reported that he is afraid to drive and avoids exercise and strenuous activities, such as hiking, camping, and scuba diving for fear of lowering his blood sugar. When discussing his neurological symptoms, the Veteran reported to experience intermittent numbness, aching, and tingling in the bottom of both feet since 2005. According to the Veteran, the tingling and numbness occurs at the end of the day. The Veteran also reported to have frequent urination with elevated blood sugars, and normal urination with controlled blood sugars. Based on her evaluation of the Veteran, the examiner diagnosed the Veteran with type I diabetes mellitus of five years duration. According to the examiner, the Veteran had fluctuating blood sugar levels and needed to be educated and monitored with regard to the importance of good blood sugar control, diet, exercise and regular follow-up care with his primary care provider. The examiner also diagnosed the Veteran with peripheral neuropathy that is more than likely related to his poorly controlled diabetes mellitus. After reviewing the urinalysis and microalbuminurea results, the examiner acknowledged the Veteran's report of proteinurea and elevated microalbuminurea. The Veteran was afforded another VA examination in May 2008, at which time, it was noted that his blood sugar levels were inadequately controlled. During the evaluation, the Veteran provided his medical history as well as a running list of the type of medication and insulin he uses. According to the Veteran, he experiences hypoglycemic reactions at night that are associated with palpitations and sweats, at least once a week. The Veteran denied any hospitalizations for ketoacidosis or hypoglycemic reactions, but did report to be on a restricted and "[s]elf modified diet." With respect to his activities, the Veteran noted that he tries to limit his driving and no longer participates in camping or hiking trips due to difficulty managing necessary equipment for his diabetes, along with his concerns surrounding possible low blood sugar episodes. The Veteran also reported to visit his diabetic care provider every three to four months. With respect to limitations due to his diabetes, the Veteran denied sudden bursts of energy, and states that he tries to keep a steady even pace as he is "OK" as long as he moves slowly. According to the Veteran, exercise causes a low blood sugar reading while stress causes a high blood sugar reading. The Veteran also reported to experience tingling and pain in his feet. Based on her evaluation of the Veteran, he VA examiner assessed the Veteran with "poorly controlled" diabetes mellitus, type I. VA treatment records dated from February 2008 to February 2009 reflect that the Veteran visited his diabetic care provider on a regular basis for follow-up management and treatment of his diabetes. During a June 2008 treatment visit, the Veteran reported to take 18 units of Lantus in the evenings, and 4 to 6 units of Aspart with meals. The Veteran also reported episodes of overnight hypoglycemia that occur two to three times a week. The VA physician noted that the Veteran did not check his blood sugar regularly and had varied compliance with his insulin regimen. Based on her discussion with, and assessment of the Veteran, the VA physician changed the Veteran's insulin regimen and recommended that he consult with a nutritionist to try and prevent overnight hypoglycemic episodes. She (the VA physician) also provided the Veteran with a glucagon pen for emergency treatment of hypoglycemic episodes. A January 2009 Pharmacy Medication Management note reflects the Veteran's complaints of continuing episodes of hypoglycema over the past few weeks. The Veteran also reported to feel sluggish and tired when his sugar level became too high. The treatment provider reviewed the Veteran's medication and diet regimen as well as the logbook of the finger stick blood sugar levels, and assessed the Veteran with "[u]ncontrolled" diabetes mellitus. It was noted that the Veteran was trying to check his sugar more regularly, but home readings vary dramatically throughout the day. At the January 2010 VA examination, the Veteran reported that his blood sugar level was not adequately controlled, and that he had been visiting his primary care physician and endocrinologist on a regular basis since September 2009. The Veteran further added that he recently experienced a hypoglycemic episode at home, and was hospitalized for an episode of hypoglycemia in December 2008 while visiting his parents in Massachusetts. According to the Veteran, he was following the recommended eating plan set forth by the American Diabetic Association (ADA). With respect to restricting his activities on account of his diabetes, the Veteran explained that he was currently in school, and his class periods are frequently interrupted for a period of ten minutes because he has to check his fingersticks and administer injections of insulin. The Veteran reported to take 25 units of Lantus, an increase from the previously prescribed dosage, and further reported to visit his diabetic care provider on a biweekly basis. Besides interfering with his daily classes, the Veteran also reported that his diabetic condition and inadequately controlled blood sugar level make it difficult for him to study. He denied any visual problems, as well as any cardiac or vascular symptoms. Based on his evaluation of the Veteran, the examiner assessed the Veteran with insulin dependent diabetes mellitus that is currently not adequately controlled and requires closer monitoring and follow up care with his medical care provider. In February 2010, the Veteran was scheduled for a VA examination in connection to his peripheral nephropathy and nephropathy. During the examination, the Veteran reported to experience numbness in his feet that began sometime between 2003 and 2004, as well as a burning sensation in the tips of his toes and fingers. According to the Veteran, he experiences paresthesia and dyesthesia in the bilateral lower extremities after prolonged walking and standing. Upon physical examination, the examiner described the Veteran's gait as normal, and noted that he was able to walk on his heels and toes normally and without assistance. The Veteran's motor strength was shown to be 4-5/5 bilaterally in the lower extremities, and his knee jerk and ankle reflexes were 2+/2+ bilaterally. The Veteran denied any renal dysfunction and reported to void six times during the day, and three to four times at night. The Veteran also reported symptoms of lethargy and weakness. Based on his evaluation of the Veteran, the examiner diagnosed the Veteran with insulin dependent diabetes mellitus, mild nephropathy that is at least as likely as not due to his diabetes mellitus, and possible early neuropathy in the lower extremities. According to the examiner, the Veteran had mild functional impairment due to his peripheral neuropathy VA treatment records dated from February 2010 to June 2010 reflect the Veteran's weekly visits with his health-care provider for treatment and care for his diabetic symptoms. In the June 2010 Diabetology report, it was noted that the Veteran visited his health-care provider on a weekly basis and was making a huge effort to comply with his dietary restrictions. Specifically, the Veteran did not skip his meals, and was making sure to eat protein and check his sugars. Upon reviewing the Veteran's blood glucose day plot data table for the previous week, the treatment provider noted that the average results were linked to a number of hypoglycemic readings. At the end of each treatment visit, the Veteran was provided instructions as to the importance of not skipping meals, exercising, monitoring his fingerstick values, avoiding foods high in salt, and following the appropriate dietary regimen. A July 2011 Outpatient follow up report indicates that the Veteran planned to pursue treatment and management of his diabetic condition at another treatment facility with a private endocrinologist. The Veteran was scheduled for another VA examination in August 2011. During this examination, the VA examiner reviewed the Veteran's medical history and noted that the Veteran managed his diabetes through a restricted diet and prescribed injections of insulin more than once a day. It was further noted that the Veteran regulated his activities in order to manage his diabetic condition. While the Veteran denied experiencing episodes of ketoacidosis or hypoglycemia requiring hospitalizations over the past twelve months, he did report to visit his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions on a weekly basis. According to the examiner, the Veteran has had progressive unintentional weight loss attributable to his diabetes mellitus totaling five percent of his baseline weight as a result of his diabetic condition. The remainder of the examination results focused on the diabetic complications, to include his diabetic peripheral neuropathy and diabetic nephropathy. According to the examiner, both these disorders were recognized complications of the diabetes mellitus. The Veteran reported a worsening in this diabetic neuropathy since his 2008 diagnosis, and described a burning sensation in his feet. Upon physical evaluation, the examiner noted that the Veteran had moderate paresthesias and/or dyesthesias and numbness in his right and left lower extremities. Further examination of the lower extremities revealed 5/5 strength during flexion and extension of the knees and during plantar flexion and dorsiflexion of the ankles. In addition, the Veteran's right and left lower extremity reflexes revealed knee jerk of 2+ and ankle jerk of 2+, and the light touch/monofilament test results revealed normal sensation in the right foot and toes and decreased sensation in the left foot and toes. According to the examiner, the Veteran had diabetic peripheral neuropathy in the lower extremities that manifested as mild incomplete paralysis of the left sciatic nerve. The Veteran stated that his diabetic peripheral neuropathy makes it difficult for him to walk or stand for prolonged periods of time, but he feels he can still work full-time as a radiology technician with reasonable accommodations. With respect to the Veteran's diabetic nephropathy, the examiner noted that the Veteran was diagnosed with diabetic nephropathy in 2005, at which time he was started on the medication lisinopril. The Veteran did not report any renal dysfunction associated with his diabetic nephropathy and further denied any hypertension or heart disease due to his kidney condition. Based on the foregoing, the Board concludes that the preponderance of the evidence shows that the Veteran's diabetes mellitus is manifested by more than one daily injection of insulin, a restricted diet, and regulation of 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. The medical evidence of record clearly shows that the Veteran requires multiple daily injections of insulin and a restricted diet. In addition, the record reflects that the Veteran has had frequent hypoglycemic reactions. A review of the more recent VA treatment records reflect that the Veteran began visiting his primary care physician and endocrinologist on a regular basis to monitor and manage his blood sugar levels, and, upon reviewing the Veteran's logbook, the majority of these treatment providers noted that the Veteran's recorded blood sugar values revealed a number of hypoglycemic readings. In addition, the August 2011 VA examiner reviewed the Veteran's claims file and observed that the Veteran visited his diabetic care provider on a weekly basis for episodes of ketoacidosis or hypoglycemic reactions. Furthermore, in his March 2010 statement, the Veteran asserted to have experienced a number of hypoglycemic episodes which were witnessed by his spouse. With regard to regulation of activities, the Schedule defines this as avoidance of strenuous occupational and recreational activities. 38 C.F.R. § 4.119, Diagnostic Code 7913. The Veteran has stated at several of his VA examinations that he is reluctant to drive in the event of a possible hypoglycemic episode, and avoids exercise and strenuous activities, such as hiking, camping, and scuba diving, because these activities serve to lower his blood sugar levels. The Board finds the Veteran competent to state that he avoids strenuous occupational and recreational activities as a result of his diabetic symptoms. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (nothing that lay testimony is competent to establish observable symptomtology but not competent to establish medical etiology or render medical opinions); Washington v. Nicholson, 21 Vet. App. 191, 195 (2007) (holding that, "[a]s a layperson, an appellant is competent to provide information regarding visible, or otherwise observable, symptoms of disability"). The August 2011 VA examiner noted that the Veteran regulates his activities as part of medical management of his diabetes, and specifically wrote that the Veteran avoids heavy exercise, to include heavy lifting and prolonged running. The Veteran also reported that complications associated with his diabetic condition make it difficult to walk or stand for prolonged periods and in the future he will need reasonable accommodations to work full-time as a radiology technician. Accordingly, the preponderance of the evidence of record shows that the Veteran's diabetes mellitus results in regulation of activities for VA purposes. Finally, the Board emphasizes that the criteria for a 100 percent evaluation includes "either progressive loss of weight and strength or complications that would be compensable if separately evaluated." Here, the August 2011 VA examiner indicated that the Veteran had progressive unintentional weight loss attributable to his diabetes mellitus and noted that the Veteran lost five percent of his baseline weight. While the examiner marked that the Veteran did not have progressive loss of strength attributable to his diabetes mellitus, the Veteran has stated on several occasions that his diabetic condition and fluctuating blood sugar levels leave him feeling "wiped out," tired, sluggish and weak. The Board finds the Veteran to be competent and credible with respect to these assertions. Furthermore, these statements provide evidence suggestive of loss of strength. Based on a longitudinal review of the evidence of record, and resolving reasonable doubt in favor of the Veteran, the Board finds that the preponderance of the evidence shows that the Veteran's diabetes mellitus type I has been manifested by more than one daily injection of insulin, a restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus progressive loss of weight and strength. As such, a 100 percent evaluation is warranted for the Veteran's service-connected diabetic condition. See 38 C.F.R. § 4.119, Diagnostic Code 7913. The issue of whether the Veteran is entitled to separate compensable ratings for his diabetic complications will be addressed further in the Remand section below. The Board has considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulations, an extraschedular disability rating is warranted 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 scheduler standards. 38 C.F.R. § 3.321(b)(1) (2010); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111, 115-116 (2008), the Court set forth a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, as a threshold issue, the Board must determine whether the Veteran's disability picture is contemplated by the rating schedule. If so, the rating schedule is adequate and an extraschedular referral is not necessary. If, however, the Veteran's disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry, that is, whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, then the case must be referred to the VA 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. Here, the evidence of record does not reflect that the Veteran's diabetic condition is so exceptional as to not be contemplated by the rating schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. The rating criteria for the Veteran's service-connected diabetes mellitus contemplate his symptoms, including frequency of insulin injections, restricted diet, and the number of hypoglycemic reactions requiring weekly visits to a diabetic care provider, and there are no symptoms left uncompensated or unaccounted for by the assignment of a schedular rating. As such, the threshold issue under Thun is not met and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. In short, the evidence does not support the proposition that this service-connected disability presents such an exceptional or unusual disability picture as to render impractical the application of the regular scheduler standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2012). Thus, referral of this issue to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. Lastly, the Board has considered whether a claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) should be considered. The Veteran filed a claim for TDIU in February 2010 and this claim was denied in the July 2010 rating decision. The evidence of record since this last rating decision does not show, and the Veteran has not contended, that he is unable to maintain gainful employment as a result of his service-connected diabetes mellitus. In fact, at the August 2011 VA examination the examiner noted that the Veteran was a full-time student, and that his service-connected diabetes mellitus did not impact his ability to work. The Veteran himself commented that he can still work full-time as a radiology technician with reasonable accommodations. Therefore, no further discussion of entitlement to a TDIU is warranted at this time. ORDER The appeal of the issue of entitlement to service connection for right shoulder tendonitis, claimed as adhesive capsulitis, is dismissed. The appeal of the issue of entitlement to service connection for a left shoulder disability, claimed as adhesive capsulitis, is dismissed. A 100 percent rating for diabetes mellitus type I, with nephropathy manifested by elevated microalbuminuria and right lower extremity peripheral neuropathy is granted, subject to the provisions governing the award of monetary benefits. REMAND The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires VA to assist a claimant in obtaining that evidence. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The Board must determine whether the Veteran is entitled to a separate evaluations for complications associated with his diabetes. Compensable complications of diabetes are to be evaluated separately unless they are part of the criteria used to support a 100 percent disability evaluation, with noncompensable complications to be considered as part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1) (2012). This requires analysis of the severity of any identified complication of diabetes in order to ascertain whether such complications are compensable. The evidence of record in the instant case indicates that the Veteran has genitourinary symptoms and peripheral neuropathy due to his diabetes. A review of the record further shows that the Veteran has already been service-connected and separately rated for peripheral neuropathy of his left lower extremity. With respect to the Veteran's genitourinary symptoms, only the predominant area of dysfunction is to be considered for rating purposes to avoid violating the rule against the pyramiding of disabilities. See 38 C.F.R. §§ 4.14, 4.115a (2012). In the instant case, the evidence of record indicates that the Veteran has one genitourinary dysfunction associated with his diabetes mellitus: diabetic nephropathy. Diabetic nephropathy is rated pursuant to 38 C.F.R. § 4.115b, Diagnostic Code 7541 (2012). Under that diagnostic code, renal involvement in diabetes mellitus should be rated as renal dysfunction, as follows: A noncompensable evaluation is warranted for evidence of albumin and casts with history of acute nephritis; or, hypertension noncompensable under Diagnostic Code 7101. A 30 percent rating is warranted for constant albumin or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under Diagnostic Code 7101. A 60 percent rating is warranted for constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code 7101. An 80 percent rating is warranted for renal dysfunction with persistent edema and albuminuria with blood urea nitrogen (BUN) 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent 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. See 38 C.F.R. § 4.115a (2012). In the instant case, the Board finds the medical evidence unclear as to whether a separate compensable evaluation is warranted for the Veteran's diabetic nephropathy based upon renal dysfunction. The medical evidence is absent for any treatment for, or diagnosis of hypertension, and the Veteran denied any signs of renal dysfunction at the February 2010 and August 2011 VA examinations. While the August 2011 examiner did not note any signs of proteinuria, edema, anorexia, weight loss, lethargy, weakness or generalized poor health as a result of renal dysfunction, further review of the urinalysis and diagnostic reports issued at the May 2007 and August 2011 VA examinations do reflect what appear to be fluctuating levels of albumin in the Veteran's blood. Specifically, the May 2007 diagnostic test results reflect an albumin level of 4.5 grams per deciliter (g/dL) and the August 2011 test results reflect an albumin level less than 0.5 g/dL. However, neither VA examiner characterized or described the Veteran's albumin as "constant or recurring" and the Board is unclear as to what constitutes a normal level of albumin as opposed to that which is "constant or recurring." With respect to the peripheral neuropathy of the Veteran's right lower extremity, the February 2010 and August 2011 VA examiners related the Veteran's peripheral neuropathy to his diabetes mellitus, and the August 2011 VA examiner determined that the neuropathy affected the sciatic nerve. Diagnostic Code 8520 governs the evaluation of paralysis of the sciatic nerve. Under that code, an evaluation of 10 percent is for mild incomplete paralysis. A 20 percent rating requires moderate incomplete paralysis, and a 40 percent rating requires moderately severe incomplete paralysis of the sciatic nerve. The next higher evaluation of 60 percent requires severe incomplete paralysis of the sciatic nerve with marked muscular atrophy. An 80 percent evaluation requires complete paralysis of the sciatic nerve, in which the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124(a), Diagnostic Code 8720. After reviewing the more recent medical evidence of record, the Board is again unsure as to whether the peripheral neuropathy of the Veteran's right lower extremity is entitled to a separate compensable rating. While the August 2011 examiner noted that the Veteran had some level of paralysis of the sciatic nerve, and that this resulted in mild incomplete paralysis of the left lower extremity, he did not discuss whether this resulted in complete or incomplete paralysis of the right lower extremity, nor did he characterize the right lower extremity as normal. In light of the incomplete medical findings, the Board finds that the Veteran should be afforded additional VA medical examinations to determine the severity of his nephropathy and neuropathy of the right lower extremity, as well as to determine whether separate compensable ratings for these disabilities should be awarded. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (the Board is prohibited from exercising its own independent judgment to resolve medical questions). Also, as previously discussed above, the Veteran was initially granted service connection for diabetes mellitus, type I with nephropathy manifested by elevated microalbuminuria and bilateral peripheral neuropathy. See July 2007 rating decision. After the August 2011 VA examination, the DRO determined that the peripheral neuropathy of the Veteran's left lower extremity warranted a separate compensable evaluation of 10 percent, effective August 31, 2011. See February 2012 rating action. As it has been over a year since the Veteran's last examination for his left lower extremity peripheral neuropathy and a more detailed examination focusing solely on this condition could provide the Board with greater insight as to the nature, extent and severity of the Veteran's peripheral neuropathy, the Board finds that this claim should also be remanded for another VA examination. The duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. See Peters v. Brown, 6 Vet. App. 540, 542 (1994). Furthermore, the record reflects that the Veteran decided to transition to another private treatment facility for continuing care and treatment of his diabetic condition and the complications arising thereform. Specifically, a July 2011 Outpatient note documented a recent conversation with the Veteran wherein he (the Veteran) indicated that he had been in contact with the Endocrine Practice at another hospital and planned to proceed under their care. However, records pertaining to on-going treatment at this facility have not been associated with the claims file, nor has any attempt been made to obtain the specified treatment records. Under the Veterans Claims Assistance Act of 2000 (VCAA), VA has an obligation to make a reasonable effort to obtain identified private treatment records. See 38 C.F.R. § 3.159(c)(1). As such, the claim must be remanded to attempt to obtain the specified treatment. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with appropriate VCAA notification as to the information and evidence necessary to support his claims seeking separate compensable ratings for nephropathy manifest by elevated microalbuminuria and for peripheral neuropathy of the right lower extremity. The notification should provide the Veteran with the statutory and regulatory provisions underlying his claims. 2. Ask the Veteran to provide the full address for the private treatment facility where he is currently receiving treatment for his diabetes and any associated diabetic complications, as well as the specific dates in which he received treatment there. After acquiring this information, instruct the Veteran to complete a release form authorizing VA to request his private medical records from this treatment center. After securing the appropriate release form from the Veteran, attempt to obtain any private treatment records as well as any other medical records pertinent to the Veteran's claims. If any records are not obtained, inform the Veteran and provide him an opportunity to submit the records. All such available documents should be associated with the Veteran's claims folder. 3. Then, accord the Veteran an appropriate VA examination to determine the current severity of the service-connected peripheral neuropathy of his right and left lower extremities. The claims folder and all records on Virtual VA must be made available to the examiner in conjunction with the examination. A notation to the effect that this review has occurred should be made in the examination report. Any indicated evaluations, studies, and tests, must be accomplished and the results must be included in the examination report. The examiner must identify all symptoms that are associated with the Veteran's service-connected peripheral neuropathy of the right and left lower extremities. The examiner should specifically indicate whether the Veteran's peripheral neuropathy of the right and left lower extremities more nearly approximate mild, moderate, moderately severe, or severe nerve impairment. The nerves affected should be specifically identified and, for each nerve affected, the disability should be described in this manner. It should also be noted whether he has marked muscular atrophy, incomplete paralysis of the sciatic nerve; or complete paralysis of the sciatic nerve (i.e., the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost). Additionally, any marked muscular atrophy or functional impairment of the lower extremities deemed to be associated with the Veteran's service-connected peripheral neuropathy of the right and left lower extremities must be identified. Also, the examiner is requested to provide an opinion as to any impact that the Veteran's peripheral neuropathy of the left lower extremities has on his ability to work. In offering any opinion, the examiner should take into consideration all the evidence of record, to include medical records as well as the Veteran's lay statements. All opinions expressed should be accompanied by supporting rationale. 4. Also, accord the Veteran should also be afforded a VA examination to determine the nature and extent of his service-connected nephropathy. The claims folder and all records on Virtual VA must be made available to the examiner in conjunction with the examination. A notation to the effect that this review has occurred should be made in the examination report. Any indicated evaluations, studies, and tests, must be accomplished and the results must be included in the examination report. The examiner must identify all symptoms that are associated with the Veteran's service-connected nephropathy. The examiner should specifically describe the extent of the Veteran's present disability. Included in his report should be findings as to the frequency and persistence of any albuminuria (the examiner should discuss whether the albumin levels are constant or recurring); BUN and creatine levels; extent of decrease of function of the kidneys or related organ systems (especially cardiovascular); and symptoms of hypertension. The examiner should also note any lethargy, weakness, anorexia, weight loss, or a limitation of exertion. All pertinent symptomatology and findings should be reported in detail. Any indicated diagnostic tests and studies should be accomplished. Also, the examiner is requested to provide an opinion as to any impact that the Veteran's nephropathy has on his ability to work. In offering any opinion, the examiner should take into consideration all the evidence of record, to include medical records as well as the Veteran's lay statements. All opinions expressed should be accompanied by supporting rationale. 5. Thereafter, adjudicate the claims for separate compensable ratings for nephropathy manifest by elevated microalbuminuria and peripheral neuropathy of the right lower extremity. Also, readjudicate the claim for an initial evaluation in excess of 10 percent for service-connected peripheral neuropathy of the left lower extremity. If these issues remains denied, provide the Veteran and his representative a supplemental statement of the case. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matters that 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 remanded by the Board or the United States Court of Appeals for Veterans' Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs