Citation Nr: 1305096 Decision Date: 02/12/13 Archive Date: 02/21/13 DOCKET NO. 10-32 903 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for service connection for peripheral neuropathy of the right lower extremity. 2. Entitlement to service connection for peripheral neuropathy of the right lower extremity on a de novo basis. 3. Whether new and material evidence has been received to reopen a claim for service connection for peripheral neuropathy of the left lower extremity. 4. Entitlement to service connection for peripheral neuropathy of the left lower extremity on a de novo basis. 5. Entitlement to an evaluation in excess of 60 percent for coronary artery disease, status post coronary artery bypass graft, myocardial infarction, ablation therapy and pacemaker implantation. 6. Entitlement to an evaluation in excess of 10 percent for degenerative disc disease of the lumbar spine. 7. Entitlement to an initial evaluation in excess of 10 percent for hypertension. 8. Entitlement to an effective date prior to May 23, 2008, for the initial grant of service connection for diabetes mellitus with erectile dysfunction. 9. Entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Keith D. Snyder, Attorney at Law ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The Veteran had active service from February 1957 to February 1959 and from October 1961 to September 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Winston-Salem, North Carolina, regional office (RO) of the Department of Veterans Affairs (VA). The record shows that entitlement to service connection for peripheral neuropathy of the lower extremities was denied in an April 1994 rating decision. The Veteran did not appeal this decision and it is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 3.105(a) (2012). Upon receipt of the Veteran's current claim the RO noted the previous denials but reopened the claims and denied them on a de novo basis. These claims were then developed and certified to the Board on the de novo basis. A determination on whether a previously denied claim should be reopened is a jurisdictional matter that must be addressed before the Board may consider an underlying claim. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Therefore, regardless of the RO's action, the Board must initially address the question of whether new and material evidence has been presented to reopen the claims of service connection for peripheral neuropathy. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156a (2012). The issues have been characterized accordingly. The Board has reviewed the Veteran's electronic record (Virtual VA) prior to rendering a decision in this case. It does not contain any evidence not already in the claims folder or considered by the RO. FINDINGS OF FACT 1. Entitlement to service connection for peripheral neuropathy of the lower extremities was denied in an April 1994 rating decision; the Veteran did not initiate an appeal of this decision. 2. The Veteran has been awarded entitlement to service connection for diabetes mellitus. 3. Evidence has been received since April 1994 that was not previously submitted, and which purports to show a causal relationship between the Veteran's service-connected diabetes mellitus and his peripheral neuropathy of the right and left legs. 4. Peripheral neuropathy was first diagnosed in 1988, which was approximately three years after the Veteran's discharge from service, and medical records reflect that the Veteran continues to be treated for this disability. 5. The competent medical opinions are in relative equipoise as to whether the Veteran's peripheral neuropathy are the result of his service-connected diabetes mellitus or other causes such as a confirmed vitamin B12 deficiency. 6. The Veteran underwent implantation of a cardiac pacemaker on June 19, 2007. 7. The Veteran does not have congestive heart failure; he is capable of a workload of at least 9 METS, and has an ejection fraction of 50 percent. 8. The rating criteria for supraventricular arrhythmias are not duplicative or overlapping with those for coronary artery disease. 9. The Veteran does not have paroxysmal atrial fibrillation, but does have near permanent atrial fibrillation. 10. The Veteran retains 65 degrees of forward flexion and 235 degrees of combined range of motion without objective evidence of muscle spasm, guarding, or abnormal spinal contour; he does not have increased limitation due to pain, weakness, incoordination or excess fatigue, and he does not have any incapacitating episodes. 11. The Veteran's hypertension is controlled by medication, and there is no evidence of a diastolic reading of 110 or higher or a systolic reading of 200 or higher during the period on appeal. 12. The Veteran's initial claim for service connection for diabetes mellitus was received on May 23, 2008, which is more than one year after discharge from service; there is no indication of a communication from the Veteran prior to May 23, 2008, that expresses a belief that he was entitled to service connection for diabetes mellitus. 13. The Veteran's service-connected disabilities include coronary artery disease, evaluated as 60 percent disabling; diabetes mellitus, evaluated as 20 percent disabling; arthritis of the cervical spine and bilateral knees, evaluated as 10 percent disabling; hiatal hernia, evaluated as 10 percent disabling; hypertension, evaluated as 10 percent disabling; degenerative disc disease of the lumbar spine, evaluated as 10 percent disabling; and gout, the residuals of a inguinal hernia, and an inguinal hernia which are each evaluated as zero percent disabling for a combined evaluation of 80 percent disabling. 14. The Veteran's service-connected disabilities render him medically infeasible for vocational rehabilitation, and unable to be gainfully employed. CONCLUSIONS OF LAW 1. The April 1994 rating decision that denied entitlement to service connection for peripheral neuropathy of the lower extremities is final; but new and material evidence has been submitted to reopen these claims. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 3.105(a), 3.156(a) (2012). 2. Peripheral neuropathy of the right lower extremity was incurred as the result of the Veteran's service-connected diabetes mellitus. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303(a), 3.310(a) (2012). 3. Peripheral neuropathy of the left lower extremity was incurred as the result of the Veteran's service-connected diabetes mellitus. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303(a), 3.310(a) (2012). 4. The criteria for an evaluation in excess of 60 percent for coronary artery disease, status post coronary artery bypass graft, with myocardial infarction, have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.21, 4.104, Code 7005 (2012). 5. The criteria for a separate 10 percent evaluation for the residuals of cardiac pacemaker implantation have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.14, 4.21, 4.104, Codes 7010, 7018 (2012). 6. The criteria for an evaluation in excess of 10 percent for degenerative disc disease of the lumbar spine have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, Code 5243 (2012). 7. The criteria for an initial evaluation in excess of 10 percent for hypertension have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.21, 4.104, Code 7101 (2012). 8. The criteria for an effective date prior to May 23, 2008, for the initial grant of service connection for diabetes mellitus with erectile dysfunction have not been met. 38 C.F.R. §§ 3.155, 3.157(a), 3.400(b)(2)(i) (2012). 9. The criteria for a total rating based on individual unemployability due to service-connected disabilities have been met. 38 C.F.R. §§ 3.340, 4.16(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); C.F.R. § 3.159(b)(1) (2012). Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Pelegrini, the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. The Court has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include (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/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must inform a claimant that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. In this case, the Veteran was provided with a letter in July 2008 that contained all of the notification required by 38 C.F.R. § 3.159, as defined by Dingess and Pelegrini. This letter was provided to the Veteran prior to the initial adjudication of his claims. In addition, the Veteran has been provided additional notification in July 2009 and December 2009. The Board concludes that the duty to notify has been met. The Board further concludes that the duty to assist has also been met. The Veteran's service treatment records have been obtained. Private medical records and VA treatment records have been obtained. He was afforded appropriate VA examinations, and relevant opinions have been obtained from the examiners after a review of the claims folder. There is no indication that there is any relevant evidence outstanding in these claims, and the Board will proceed with consideration of the Veteran's appeal. Furthermore, as the decisions pertaining to service connection for peripheral neuropathy of both the right and left lower extremities and TDIU are favorable to the Veteran, any failure in the duty to notify or to assist was harmless. New and Material Evidence The Veteran contends that he has submitted new and material evidence to reopen his claims of service connection for peripheral neuropathy of the lower extremities. As previously noted, entitlement to service connection for peripheral neuropathy of the lower extremities was denied in an April 1994 rating decision. The Veteran did not appeal this decision after receipt of notice thereof. Therefore, the April 1994 rating decision is final. 38 U.S.C.A. § 7105; 38 C.F.R. § 3.105(a). A Veteran may reopen a finally adjudicated claim by submitting new and material evidence. New evidence is defined as existing evidence not previously submitted to the VA, and material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The evidence considered by the April 1994 rating decision included the Veteran's service treatment records. In addition, there were VA and private medical records dating from 1989 to 1994. The claim was denied on the basis that there was no evidence of neuropathy within one year of discharge from service, and the evidence did not otherwise show service incurrence. The additional evidence submitted since April 1994 includes medical opinions from both VA and private doctors that attribute the Veteran's peripheral neuropathy to diabetes mellitus. The record shows that service connection for diabetes mellitus was established subsequent to the April 1994 rating decision. The Board finds that the evidence submitted since April 1994 is new and material. It is new in that the medical opinions that attribute the Veteran's peripheral neuropathy to his service-connected diabetes mellitus contains information that was not previously considered in April 1994. It is material in that it purports to relate the peripheral neuropathy to the Veteran's service-connected diabetes mellitus and by implication to active service. See 38 C.F.R. § 3.310(a). The lack of evidence relating the Veteran's peripheral neuropathy to active service was a basis for the original denial. Therefore, as there is evidence that is both new and material, his claims for service connection for peripheral neuropathy of the right and left lower extremities is reopened. The Board will proceed to consider these claims on a de novo basis. Service Connection The Veteran contends that he has developed peripheral neuropathy in both legs due to active service. More specifically, he argues that the neuropathy has developed secondary to his service-connected diabetes mellitus. In the alternative, the Veteran believes that his neuropathy is the result of exposure to herbicides such as Agent Orange during his service in Vietnam. Initially, the Board notes that as service connection will be granted for peripheral neuropathy for both lower extremities on bases other than exposure to herbicides in Vietnam, no further discussion of this aspect of the Veteran's contentions is necessary. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage 10 Vet. App. 488, 495-97 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (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. Savage, 10 Vet. App. at 495-96. The record confirms that entitlement to service connection for diabetes mellitus has been established, effective from May 2008. In addition to the laws and regulations pertaining to direct service connection, additional regulations state that a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In this instance, the veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). In a claim for secondary service connection for a diagnosis clearly separate from the service-connected disorder, the veteran must present evidence of a medical nature to support the alleged causal relationship between the service-connected disorder and the disorder for which secondary service connection is sought. See Jones v. Brown, 7 Vet. App. 134 (1994). With regard to the medical evidence, a diagnosis or opinion by a health care professional is not conclusive, and is not entitled to absolute deference. Indeed, the Court has provided guidance for weighing medical evidence. The Court has held, for example, that in meeting our responsibility to weigh the credibility and probative value of the evidence, we may accept one medical opinion and reject others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board recognizes that a lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a 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. Jandreau v. Nicholson, 492 F.3d at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009. A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994); Charles v. Principi, 16 Vet. App 370, 374 (2002). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). The service treatment records are negative for any evidence of peripheral neuropathy. The neurologic portion of the Veteran's June 1985 retirement examination was normal. The Veteran answered "no" to a history of neuritis as well as all other relevant symptomatology on a Report of Medical History he completed as part of his retirement examination. Post-service medical records include a July 1988 electromyogram of the lower extremities that was compatible with a very mild peripheral polyneuropathy. VA treatment records dated August 1989 show that the Veteran presented with several problems, including idiopathic left leg peripheral neuropathy. VA treatment records from February 1992 show that the Veteran reported a history of a burning sensation of both feet for the previous three to four years. Other VA treatment records show that the Veteran continued to be followed for this problem throughout 1992. A March 1993 VA examination for diseases of the arteries and veins includes a history of peripheral neuropathy without identified causes. Significantly, his B12 level was normal. A private April 1993 electromyogram report showed findings in keeping with a motor sensory neuropathy, maximum in the tibial nerves and sural nerve distribution. VA treatment records from April 2004 include a note from the Veteran's primary care provider. The assessments included peripheral neuropathy that was possibly secondary to B12 deficiency, as well as diabetes with neuropathy. An April 2006 VA treatment record notes that the Veteran's medications include vitamin B12. June 2006 VA treatment records state that the Veteran's active problems include an unspecified idiopathic peripheral neuropathy. Private medical records from June 2007 include a problem list of at least ten disabilities. These include diabetes mellitus, B12 deficiency, and peripheral neuropathy. June 2008 VA treatment records indicate that the Veteran has a B12 deficiency, and that he was continuing with B12 shots. June 2009 records note continued treatment for B12 deficiency. The Veteran was afforded a VA examination of his diabetes mellitus in February 2009. The claims folder was not reviewed by the examiner, although the examination report indicates that medical records were reviewed. His medical history included paresthesias and loss of sensation in his feet. At the completion of the examination, the diagnoses included peripheral neuropathy. The examiner opined that this was not a complication of diabetes. The rationale was that the onset of peripheral neuropathy was prior to the onset of diabetes, and due to a known B12 deficiency. The examiner also stated that this condition was not worsened or increased by the Veteran's diabetes. The Veteran was also afforded a VA examination of his peripheral nerves in February 2009. The claims folder was not reviewed, but unspecified medical records were said to have been reviewed. His neuropathy was noted to have begun in 1987 with a gradual onset. The Veteran had reported burning and numbness of the feet prior to the onset of his diabetes, and that he had been diagnosed with a B12 deficiency. At the completion of the examination, the diagnosis was B12 deficiency associated with peripheral neuropathy. The etiology of the problem was a B12 deficiency, and there were significant effects on the Veteran's occupational abilities. A June 2009 private treatment note for the Veteran's diabetes states that the complications included neurological symptoms. A September 2009 letter from M.T., M.D. indicates that the Veteran had been seen for a neurologic consultation. The Veteran had a history of neuropathy since the 1980s. He had served in Vietnam and believed that the neuropathy was from Agent Orange. At the conclusion of the examination, the impression was peripheral neuropathy. The examiner noted that the patient suspected it was due to Agent Orange exposure. The examiner, however, suspected diabetes mellitus as a culprit. There was also questionable lumbar radiculopathy. A private October 2009 electrophysiology report authored by Dr. M.T. includes impressions consistent with peripheral neuropathy and lumbar radiculopathies. It was difficult to tell if there were lumbar radiculopathies due to the presence of the peripheral neuropathy. The Veteran was provided an additional VA examination of his diabetes in December 2009. The Veteran said that diabetes had been diagnosed in 1991, although his records suggested that the actual date was 2001. He had symptoms of peripheral neuropathy that included paresthesias and loss of sensation in his feet. At the conclusion of the examination, the diagnosed medical conditions included neurologic disease. This was bilateral lower extremity peripheral neuropathy. The examiner opined that this was not a complication of diabetes. The rationale was that it was B12 deficiency neuropathy, onset prior to diabetes. VA treatment record dated January 2010 show that the Veteran was examined by his primary care provider. The examination was positive for diabetic neuropathy. The Veteran wished to try a different medication for treatment of the neuropathy as the current medication was not helpful. The Veteran was provided with a VA neurologic consultation in March 2010. He reported many years of burring in the feet, which was attributed to diabetic neuropathy by report of the Veteran. The computerized problem list included vitamin B12 deficiency and diabetes mellitus. Previous nerve conduction studies showed a widespread sensorimotor neuropathy with mixed features. After the physical examination, the diagnoses included peripheral neuropathy. The examiner stated that this was almost certainly due to his diabetes mellitus. After a review of the Veteran's contentions and the medical evidence, the Board finds that evidence both for and against the Veteran's claim that his peripheral neuropathy is the result of his service-connected diabetes mellitus is in relative equipoise. The medical evidence confirms that the Veteran has experienced peripheral neuropathy of the lower extremities. This dates to the late 1980s, with the earliest medical confirmation of peripheral neuropathy dating approximately three years after discharge. Competent medical opinion, however, appears to be split as to whether this peripheral neuropathy is the result of a nonservice-connected B12 deficiency or secondary to his diabetes mellitus. The record confirms that the Veteran has received monthly B12 supplements since at least 2004. In addition, the February 2009 and December 2009 VA examiners opined that this B12 deficiency is the cause of the peripheral neuropathy. They based this opinion on a finding that the peripheral neuropathy developed prior to the diagnosis of diabetes mellitus. A March 1993 VA examination report, however, includes findings of peripheral neuropathy but notes that the B12 levels were normal. Therefore, it appears that the peripheral neuropathy also existed prior to development of the B12 deficiency. Neither of the VA examiners notes the March 1993 examination report. In contrast, VA treatment records from as early as April 2004 have related the peripheral neuropathy at least in part to diabetes mellitus. Both the private physician Dr. M.T. and the March 2010 VA neurologist have opined that the Veteran's peripheral neuropathy is due to his diabetes mellitus. Unfortunately, although the B12 deficiency was at least noted by the VA examiner, neither of these doctors discuss whether this deficiency is significant. As both the opinions in favor of and against the Veteran's claim appear to be flawed, and as there is no indication that one examiner is more highly skilled or trained that the other, the Board finds that the positive and negative opinions are of relatively equal value. It follows that the evidence is in relative equipoise. That being the case, service connection for peripheral neuropathy of the right and left lower extremities is warranted. 38 U.S.C.A. § 5107(b). Increased Evaluations The Veteran contends that the evaluations currently assigned for his service-connected coronary artery disease, degenerative disc disease, and hypertension are each inadequate to reflect the level of impairment that results from these disabilities. The evaluation of service-connected disabilities is based on the average impairment of earning capacity they produce, as determined by considering current symptomatology in the light of appropriate rating criteria. 38 U.S.C.A. § 1155. Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether they are raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In addition, the entire history of the veteran's disability is also considered. Consideration must be given to the ability of the veteran to function under the ordinary conditions of daily life. 38 C.F.R. § 4.10. If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). The Board acknowledges that a claimant may experience multiple degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Board notes that the claim for a higher evaluation for hypertension involves the Veteran's dissatisfaction with the initial rating for this disability assigned following the grant of service connection. The Court has found that there is a distinction between a Veteran's disagreement with the initial rating assigned following a grant of service connection, and the claim for an increased rating for a disability in which entitlement to service connection has previously been established. In instances in which the Veteran disagrees with the initial rating, the entire evidentiary record from the time of the Veteran's claim for service connection to the present is of importance in determining the proper evaluation of disability, and staged ratings are to be considered in order to reflect the changing level of severity of a disability during this period. Fenderson v. West, 12 Vet. App. 119 (1999). Coronary Artery Disease The record shows that entitlement to service connection for coronary artery disease was originally established in a July 1986 rating decision. A 30 percent evaluation was assigned for this disability. It was increased to the current 60 percent evaluation in a June 1993 rating decision, effective from March 1990. The Veteran submitted his claim for an increased evaluation in May 2008. He requested that he be assigned a temporary 100 percent evaluation following the surgical placement of a pacemaker on June 19, 2007. The Veteran also noted that his coronary artery disease had developed additional symptoms such as atrial fibrillation. The May 2009 rating decision on appeal assigned a temporary total rating for the Veteran's coronary artery disease, effective from the June 19, 2007, date of implantation of a pacemaker. This rating decision, however, determined that the 60 percent evaluation would be resumed effective from September 1, 2007. The Veteran submitted a notice of disagreement with this determination and the current appeal ensued. The Veteran's coronary artery disease is currently rated under Diagnostic Code 7005. When there is documented coronary artery disease resulting in a workload of greater than 7 METs but not greater than 10 METs that causes dyspnea, fatigue, angina, dizziness, or syncope, or when continuous medication is required, a 10 percent evaluation is assigned. Coronary artery disease resulting in workload of greater than 5 METs but not greater than 7 METs, with dyspnea, fatigue, angina, dizziness, or syncope; or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray warrants a 30 percent evaluation. More than one episode of acute congestive heart failure in the past year; or workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent requires a 60 percent evaluation. A 100 percent evaluation is warranted for chronic congestive heart failure; or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7005. The rating code for implantable cardiac pacemakers is also for consideration. This code states that a 100 percent evaluation is appropriate for two months following hospital admission for implantation or reimplantation. Thereafter, the Veteran is to be evaluated under the rating codes for supraventricular arrhythmias, ventricular arrhythmias, or atriventricular block. A minimum evaluation of 10 percent is appropriate. 38 C.F.R. § 4.104, Diagnostic Code 7018. A review of the evidence shows that it includes a surgical report dated June 19, 2007, that confirms the Veteran underwent placement of a permanent pacemaker. VA treatment records from September 2007 state that paroxysmal atrial fibrillation was diagnosed. Records dated October 2007 show that the Veteran was feeling dizzy and lightheaded. November 2007 treatment records state that the Veteran was feeling well and not particularly symptomatic. He had experienced almost ten hours of atrial fibrillation on a single day one week earlier but was still felt well on that day. The majority of the atrial fibrillation episodes were less than two minutes in duration. March 2008 VA treatment records indicate that the Veteran had complaints of fatigue and he was found to be in constant atrial afibrillation over the prior three months. He was hospitalized for treatment of this condition and treated with medication for several days. The principle diagnosis was atrial fibrillation. A March 2008 consultation with the VA internal medicine clinic resulted in an assessment of coronary artery disease, symptomatic bradycardia status post pacemaker, and symptomatic atrial fibrillation. He had fatigue and decreased exercise tolerance thought secondary to the atrial fibrillation. May 2008 VA treatment records include a cardiac consultation in which the Veteran was noted to have multiple cardioversions. There had been more than 80 episodes of atrial fibrillation with the longest lasting 28 hours. The Veteran wished to undergo ablation, and the risks of this procedure were discussed. The Veteran was afforded a VA cardiac examination in February 2009. There was no history of congestive heart disease, although hypertensive heart disease had been identified on echocardiogram. Continuous medication was required for his heart disease. He experienced syncope and dizziness monthly, fatigue on a weekly basis, and dyspnea on severe exertion. The Veteran was able to walk one mile daily without complaint. The stress test showed the Veteran was capable of 10 METS. Testing for left ventricular dysfunction was done which showed an ejection fraction of less than 50 percent. The heart size was normal on echocardiogram. VA treatment records dated April 2009 show that the Veteran complained of chest pain after he completed his usual time on the treadmill. He was noted to have low blood pressure at that time. The Veteran underwent an additional VA examination in December 2009. The heart size was normal on echocardiogram. The Veteran had a history of coronary artery disease with myocardial infarction. There was no history of congestive heart failure. There were no significant effects on the Veteran's activities of daily living. He complained of daily fatigue, weekly angina and dizziness, syncope on a monthly basis, and dyspnea on monthly exertion. He could walk a mile in 30 minutes if his back did not bother him. The stress test results were 9 METS. Left ventricular dysfunction testing showed an ejection fraction of 50 percent. The Board finds that the preponderance of the evidence is against the Veteran's claim for an increased evaluation for his coronary artery disease. The rating criteria state that a 100 percent evaluation is awarded if there is chronic congestive heart failure. However, the Veteran does not have a history of congestive heart failure. A load of 3 METS or less that results in dyspnea, fatigue, angina, dizziness or syncope also warrants a 100 percent evaluation, but the February 2009 VA examination found that the Veteran is capable of 10 METS and the December 2009 examination showed that the Veteran tested for 9 METS. Finally, the rating criteria provide for a 100 percent evaluation if there is left ventricular dysfunction with an ejection fraction of less than 30 percent. The February 2009 and December 2009 VA examinations both measured the Veteran's ejection fraction at 50 percent. The evidence demonstrates that the Veteran does not meet the criteria for a 100 percent rating, nor do his symptoms more nearly resemble those of the 100 percent criteria. 38 C.F.R. § 4.104, Code 7005. The rating code for coronary artery disease , however, is not the only one for consideration. The Veteran is also evaluated under the rating code for implantable cardiac pacemakers. The Veteran is no longer entitled to a 100 percent evaluation under this rating code because it has been more than two months following hospital admission for implantation of the device. This rating criterion, however, also provides for a minimum 10 percent evaluation under the rating criteria for supraventricular arrhythmias, ventricular arrhythmias, or atriventricular block. See 38 C.F.R. § 4.104, Code 7018. The Board will examine the rating criteria for each of these disabilities to determine whether there is an appropriate rating code under which to evaluate the Veteran's service-connected pacemaker. The rating criteria for both ventricular arrhythmias and atriventricular blocks include consideration of METS and ejection fractures in more or less the same manner and with the same resulting evaluations as the rating criteria for coronary artery disease. See 38 C.F.R. § 4.104, Codes 7005, 7011, 7015. Therefore, a separate evaluation under either of these rating codes is prohibited. 38 C.F.R. § 4.14. The rating criteria for supraventricular arrhythmias, however, do not address any of the symptomatology that is addressed in the rating criteria for coronary artery disease. These rating criteria state that a 30 percent evaluation is warranted for paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than four episodes per year documented by electrocardiogram or Holter monitor. For permanent atrial fibrillation (lone atrial fibrillation), or, one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by electrocardiogram or Holter monitor, a 10 percent rating is warranted. 38 C.F.R. § 4.104, Code 7010. As none of the symptomatology for supraventricular arrhythmias is duplicative of or overlaps that for coronary artery disease, than a separate evaluation under this rating criteria is warranted. As the evidence is negative for paroxysmal atrial fibrillation, and as the rating criteria for implantable cardiac pacemakers hold that a minimum evaluation of 10 percent should be awarded, the Board finds that the Veteran is entitled to a separate 10 percent evaluation under the rating criteria for implantable cardiac pacemakers and supraventricular arrhythmias. 38 C.F.R. § 4.104, Codes 7010, 7018. See also Esteban v. Brown, 6 Vet. App. 259 (1994). Finally, the Board has considered whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits or to the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2012); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The schedular evaluation in this case is not inadequate. The scheduler criteria adequately describe the Veteran's symptoms for both the coronary artery disease and the residuals of the implantable cardiac pacemaker and supraventricular arrhythmias. The Veteran does not display any cardiac symptoms that are not contemplated by these criteria. Accordingly, referral for consideration of an extra-schedular rating is not warranted. Degenerative Disc Disease The record shows that service connection for low back pain was established in a July 1986 rating decision. A zero percent evaluation was assigned for this disability. The zero percent evaluation remained in effect until it was increased to the current 10 percent evaluation by the May 2009 rating decision on appeal, effective from the May 23, 2008, date of receipt of the Veteran's request for an increase. The Veteran's degenerative disc disease of the lumbar spine is evaluated under the rating criteria for intervertebral disc syndrome. This rating code provides that intervertebral disc syndrome is to be evaluated under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. For intervertebral disc syndrome manifested by incapacitating episodes having a total duration of at least six weeks during the past 12 months, a 60 percent evaluation is warranted; with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, a 40 percent evaluation is warranted; and with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months, a 20 percent evaluation is warranted. Note 1 of that Diagnostic Code provides that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent evaluation is warranted for disability of the thoracolumbar spine when there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted for disability of the thoracolumbar spine when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. An evaluation higher of 30 percent is not warranted under the new criteria unless there is forward flexion of the thoracolumbar spine to 30 degrees or less. An evaluation of 40 or greater requires favorable or unfavorable ankylosis. Unfavorable ankylosis of the entire thoracolumbar spine is evaluated as 50 percent disabling, and unfavorable ankylosis of the entire spine is evaluated as 100 percent disabling. 38 C.F.R. § 4.71a, Code 5243. There are other factors which must be considered in addition to those contained in the applicable rating code. The Board recognizes that the disability of the musculoskeletal system is primarily the inability due to damage or an infection in parts of the system to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. Factors to be considered include pain on movement, weakened movement, excess fatigability, and incoordination. 38 C.F.R. §§ 4.40, 4.45. Functional impairment due to pain must be considered. 38 C.F.R. § 4.59. The Veteran was afforded a VA examination of his back in February 2009. He provided subjective reports of three episodes of flare-ups over the previous year, each of which lasted from one to six weeks and resulted in 75 percent reduction of range of motion. There had been no incapacitating episodes during the past year. The Veteran reported stiffness and spasms, but denied radiation of pain, numbness or tingling, weakness of the extremity and bowel or bladder incontinence. He did not use any assistive devices. The Veteran was able to stand about 30 minutes and walk about one mile. On examination, the curvature of the spine and posture were normal, as was his gait. There was no muscle spasm, tenderness or guarding. The Veteran did not have ankylosis and straight leg raising was negative. Motor function was 5/5 in the lower extremities, and there was no atrophy. Flexion of the thoracolumbar spine was from zero to 65 degrees, with pain at 65 degrees. Extension was to 20 degrees with pain at 20 degrees. Lateral bending to the right and to the left was to 30 degrees with pain at 30 degrees. Rotation to the right and to the left was to 45 degrees with pain at 45 degrees. Repetition of all of the lumbar motions did not result in any additional loss of motion due to pain, weakness, or lack of endurance, although it did result in a broad based gait. X-ray study demonstrated marked narrowing of the lumbosacral interspace, sclerosis at the lumbosacral level, and loss of height of the upper lumbar vertebral bodies. The diagnosis was degenerative disc disease of the lumbar spine. The examiner added that sedentary employment would not be limited by the Veteran's disability, but that physical employment would be limited by his severe neuropathy and his cardiac condition. A private computed tomography scan of the lumbar spine conducted in October 2009 noted a disc protrusion at L2 to L3. Electrodiagnostic testing conducted at this time included an impression of bilateral proximal lumbar radiculopathy. However, the examiner added that it was difficult to tell if there were also lower radiculopathies due to the presence of peripheral neuropathy. The Veteran underwent an additional VA examination of his back in December 2009. His history and complaints were the same as recorded in February 2009. Once again there had been no incapacitating episodes over the previous year. On examination, the curvature of the spine and posture were normal, as was his gait. There was no muscle spasm, tenderness or guarding. The Veteran did not have ankylosis and straight leg raising was negative. Motor function was 5/5 in the lower extremities, and there was no atrophy. The Veteran was unsteady on his feet and he declined the range of motion testing due to fear of falling. There was no obvious limitation to the range of motion of the lumbar spine during dressing and undressing for the examination. The diagnoses were degenerative disc disease and degenerative joint disease of the lumbar spine. The Board finds that the preponderance of the evidence is against an evaluation in excess of 10 percent for the Veteran's degenerative disc disease of the lumbar spine. Initially, the Board notes that both the February 2009 and December 2009 VA examinations stated that the Veteran had not experienced any incapacitating episodes due to his back, and there is no evidence to the contrary. Therefore, it is more favorable to the Veteran to evaluate his disability under the General Rating Formula for Diseases and Injuries of the Spine. A 10 percent evaluation remains warranted under the General Rating Formula because the February 2009 examination demonstrates that the Veteran retains 65 degrees of forward flexion. Flexion must be limited to 60 degrees or less to receive a 20 percent rating. Furthermore, his combined range of motion is 235 degrees, which easily exceeds the 120 degrees that would warrant a 20 percent rating. Finally, although the examinations reported both a normal gait and a wide based gait, the examination was negative for muscle spasm and guarding. There was also no abnormal spinal contour. The criteria for a 20 percent rating have not been met. In reaching this decision, additional limitations due to pain, weakness, fatigue and incoordination have been considered, but these do not result in additional limitations that would meet the criteria for a 20 percent rating. The Veteran did not experience pain on flexion until 65 degrees, and his combined range of motion is not limited to 120 degrees by pain. The February 2009 examination showed that the Veteran did not have any additional limitations due to pain, weakness, or lack of endurance following repetitive motion. The Veteran reports that he experiences a 75 percent reduction in range of motion during flare-ups but this is not confirmed by objective evidence such as the examination. The Board concludes that entitlement to an evaluation in excess of 10 percent for degenerative disc disease of the lumbar spine is not warranted. 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Code 5243. The Board has also considered whether the Veteran is entitled to a separate evaluation for any associated objective neurologic abnormalities that result from his degenerative disc disease. Entitlement to service connection for peripheral neuropathy of both legs has already been established, and the October 2009 private study makes it clear that it is difficult to distinguish between any lumbar radiculopathy and his peripheral neuropathy. Therefore, as the Veteran is already in receipt of compensation for these symptoms, another separate evaluation is prohibited. 38 C.F.R. § 4.14. No other neurologic abnormalities have been demonstrated. Finally, the Board has considered whether the schedular evaluation is inadequate, thus requiring that the RO refer the claim for consideration of an extra-schedular evaluation. The Board finds that it is not. The Veteran does not display any symptoms attributable to his degenerative disc disease that are not already contemplated in the rating criteria. Accordingly, referral for consideration of an extra-schedular rating is not warranted. 38 C.F.R. § 3.321(b)(1). Hypertension Entitlement to service connection for hypertension was granted by the May 2009 rating decision on appeal, effective from the May 28, 2009, date of receipt of the Veteran's claim. An initial evaluation of 10 percent has been assigned. Under the rating criteria, hypertensive vascular disease with diastolic pressure of predominantly 130 or more is evaluated as 60 percent disabling. Diastolic pressure of predominantly 120 or more is evaluated as 40 percent disabling. Diastolic pressure of predominantly 110 or more; or systolic of predominately 200 or more is evaluated as 20 percent disabling. Diastolic pressure of predominantly 100 or more, or systolic pressure predominately 160 or more is evaluated as 10 percent disabling. This is also the minimum evaluation for an individual with a history of diastolic pressure predominately 100 or more that requires continuous medication for control. This regulation further states that hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. The term hypertension means that the diastolic pressure is predominately 90 millimeters or greater, and isolated systolic hypertension means that the systolic blood pressure is predominately 160 millimeters or greater with a diastolic blood pressure of less than 90 millimeters. Hypertension that is due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, is to be evaluated as part of the condition causing it rather than a separate evaluation. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). The Board finds that the preponderance of the evidence is against the Veteran's claim for an increased evaluation for his hypertension. The medical evidence contains numerous blood pressure readings, but they do not demonstrate diastolic pressures of predominately 110 or more or systolic pressures of 200 or more. A March 2008 internal medicine consultation states that the hypertension is under control with medication. His blood pressure was 130/56. The February 2009 VA hypertension examination states that the Veteran's blood pressure runs in the 140's/60's at home. It was 114/50 on examination, with repeat readings of 110/50 and 104/53. VA treatment records contain lists of daily blood pressure readings from March 2009 to May 2009. There is not a single diastolic reading in excess of 110 or a systolic reading in excess of 200, and the average readings were 108/52. A list of daily readings from September 2009 to October 2009 is also negative for a diastolic reading in excess of 110 or a systolic reading over 200, as are daily blood pressure readings recorded from December 2009 through February 2010. The December 2009 VA examination showed the Veteran's blood pressure to be 128/66. Records dated subsequent to February 2010 do not contain any readings showing a single diastolic pressure of 110 or more or a systolic pressure of 200 or more. Therefore, in the absence of even a single diastolic pressure of 110 or more or a systolic pressure of 200 or more, the criteria for a 20 percent rating have not been met, and continuation of the 10 percent rating is warranted. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). The Board has considered whether the schedular evaluation for hypertension is inadequate, but has determined it is not. The Veteran does not display any symptoms attributable to his hypertension that are not already contemplated in the rating criteria, and the evidence indicates this disability is well controlled by medication. Accordingly, referral for consideration of an extra-schedular rating is not warranted. 38 C.F.R. § 3.321(b)(1). Earlier Effective Date The Veteran contends that he is entitled to an effective date prior to May 28, 2008, for a grant of service connection for diabetes mellitus with erectile dysfunction. Entitlement to service connection was initially granted in the May 2009 rating decision on appeal. This decision established an effective date of May 28, 2008. In general, the effective date of an evaluation and award of pension, compensation or dependency and indemnity 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. The effective date for direct service connection is the day following separation from active service or date entitlement arose if the claim is received within one year after separation from service; otherwise, it will be the date of receipt of claim, or date entitlement arose, whichever is the later. 38 C.F.R. § 3.400(b)(2)(i). The record shows that the Veteran's initial claim for service connection for diabetes mellitus was received on May 28, 2008. The Board finds that there is no basis for an effective date prior to that time. A review of the record is completely negative for any communication from the Veteran dated prior to May 28, 2008, that would indicate a belief that he was entitled to service-connected benefits for diabetes mellitus. Therefore, there is no evidence of either a formal or an informal claim before May 28, 2008. 38 C.F.R. § 3.155(a) (2012). Although the evidence includes medical records that indicate that diabetes was diagnosed until 2004, the Board notes that VA medical records can constitute a claim for an increased evaluation or a claim to reopen, but not an initial claim for service connection. 38 C.F.R. § 3.157 (2012). The initial claim that was received on May 28, 2008, is dated well over a year after the Veteran's discharge from service. Therefore, the claim was received more than a year after the Veteran's discharge, and as the May 28, 2008, date of receipt of the claim is after the date of entitlement, then the current effective date of May 28, 2008, is the proper effective date for the Veteran's diabetes mellitus. 38 C.F.R. § 3.400(b)(2)(i). TDIU The Veteran contends that his service-connected disabilities combine to make him unemployable. The VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience by reason of his service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. If the appropriate rating under the pertinent diagnostic code of the rating schedule is less than 100 percent, the issue of unemployability must be determined without regard to the advancing age of the veteran. 38 C.F.R. §§ 3.341(a), 4.19. Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). According to the applicable laws and regulations, a total rating for compensation may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 4.16(a). A total rating, however, based on individual unemployability may still be assigned to a veteran who fails to meet these percentage standards if he or she is unemployable by reason of his or her service-connected disability(ies). 38 C.F.R. § 4.16(b). The Veteran currently has the following service-connected disabilities: coronary artery disease, evaluated as 60 percent disabling; diabetes mellitus, evaluated as 20 percent disabling; arthritis of the cervical spine and bilateral knees, evaluated as 10 percent disabling; hiatal hernia, evaluated as 10 percent disabling; hypertension, evaluated as 10 percent disabling; degenerative disc disease of the lumbar spine, evaluated as 10 percent disabling; and gout, the residuals of a inguinal hernia, and an inguinal hernia which are each evaluated as zero percent disabling. He has a combined evaluation of 80 percent disabling. The Board notes that on the basis of these disabilities, the Veteran meets the schedular criteria for consideration for TDIU. Moreover, this decision has established entitlement to service connection for peripheral neuropathy of each leg and a separate 10 percent evaluation for pacemaker implantation. Even with consideration of the separate 10 percent evaluation, the Veteran's combined evaluation remains at 80 percent. 38 C.F.R. § 4.25. Although there has not yet been an opportunity to assign evaluations for peripheral neuropathy, the Board can still consider the evidence as to how they affect his employability. The Board finds that the Veteran's service-connected disabilities render him unemployable. The record includes a September 2010 memorandum from the Veteran's VA vocational rehabilitation counselor. The counselor notified the Veteran that he was found to be medically infeasible for vocational rehabilitation because of the severity of his service-connected coronary artery disease, diabetes mellitus, degenerative disc disease, and other medical conditions that restrict his work tolerance. The Board observes that in addition to the disabilities named by the counselor, the February 2009 VA examiner stated that the Veteran's peripheral neuropathy is productive of significant effects on his occupational abilities. The Board concludes that the September 2010 determination is highly probative as to whether the Veteran is capable of gainful employment and that it strongly indicates he is not capable. It should be further noted that this assessment was made before service connection was established for peripheral neuropathy, which also affects the Veteran's employability. As the Veteran is unable to be gainfully employed as a result of his service-connected disabilities, entitlement to TDIU is established. ORDER New and material evidence has been received to reopen a claim for service connection for peripheral neuropathy of the right lower extremity; to this extent the appeal is granted. Entitlement to service connection for peripheral neuropathy of the right lower extremity is granted, subject to the laws and regulations governing the award of monetary benefits. New and material evidence has been received to reopen a claim for service connection for peripheral neuropathy of the left lower extremity; to this extent the appeal is granted. Entitlement to service connection for peripheral neuropathy of the left lower extremity is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to an evaluation in excess of 60 percent for coronary artery disease, status post coronary artery bypass graft, and myocardial infarction is denied. Entitlement to a 10 percent evaluation for the residuals of ablation therapy and pacemaker implantation is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to an evaluation in excess of 10 percent for degenerative disc disease of the lumbar spine is denied. Entitlement to an initial evaluation in excess of 10 percent for hypertension is denied. Entitlement to an effective date prior to May 23, 2008, for the initial grant of service connection for diabetes mellitus with erectile dysfunction is denied. Entitlement to a total rating based on individual unemployability due to service-connected disabilities is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs