Citation Nr: 1305863 Decision Date: 02/20/13 Archive Date: 02/27/13 DOCKET NO. 08-08 847 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent prior to May 29, 2012, and in excess of 20 percent thereafter for peripheral neuropathy of the right upper extremity. 2. Entitlement to an evaluation in excess of 10 percent prior to May 29, 2012, and in excess of 20 percent thereafter for peripheral neuropathy of the left upper extremity. 3. Entitlement to an evaluation in excess of 10 percent prior to May 29, 2012, and in excess of 20 percent thereafter for peripheral neuropathy of the right lower extremity. 4. Entitlement to an evaluation in excess of 10 percent prior to May 29, 2012, and in excess of 20 percent thereafter for peripheral neuropathy of the left lower extremity. 5. Entitlement to service connection for a skin condition of the neck and legs, claimed as secondary to chemical herbicide exposure. 6. Entitlement to service connection for testicular cancer, claimed as secondary to chemical herbicides exposure. REPRESENTATION Appellant represented by: John S. Berry, Attorney at Law ATTORNEY FOR THE BOARD C.A. Skow, Counsel INTRODUCTION The Veteran served on active duty from May 1962 to July 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2007 and June 2010 rating decisions of the St. Louis, Missouri, Department of Veterans Affairs (VA) Regional Office (RO). The June 2010 rating decision assigned an initial 10 percent evaluation for peripheral neuropathy of the right upper extremity and the right and left lower extremities effective from November 16, 2009 (date of claim). Thereafter, in August 2012, the RO assigned a 20 percent evaluation for these disorders effective from May 29, 2012 (date of VA examination). As a higher schedular evaluation for these conditions is possible, the issues of entitlement to increased ratings remain before the Board on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). A letter was sent to the Veteran in April 2008 reflects that he had been put on a list of persons wishing to appear before the Travel Board. In May 2008, the Veteran submitted a letter indicating that he never requested this hearing and wished it to be canceled. In September 2009, the Board remanded the claims for service connection for additional evidentiary development. The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal except as to updated VA treatment records, which were considered on the recent adjudication of the claims in August 2012. The Board acknowledges the attorney's report that VA had not issued to the Veteran a Supplemental Statement of the Case (SSOC) following the RO's receipt of a May 2012 VA examination report. However, the claims file reflects that the RO sent to the Veteran an SSOC in August 2012. This correspondence was not returned to VA as undeliverable. There is a presumption of administrative regularity in VA processes, procedures, and mailings allowing the assumption that VA properly discharged its duties and responsibilities. See Ashley v. Derwinski, 2 Vet. App. 62, 64 (1992) (the "presumption of regularity" applies to the official acts of public officers, and in the absence of clear evidence to the contrary, it must be presumed they have properly discharged their official duties); see also Mindenhall v. Brown, 7 Vet. App. 271 (1994). The REMAND portion of the decision below addresses the issues of entitlement to an evaluation in excess of 10 percent prior to May 29, 2012, for peripheral neuropathy of the left upper extremity and in excess of 30 percent thereafter; and service connection for a skin condition and testicular cancer. FINDINGS OF FACT 1. The impairment from peripheral neuropathy of the right upper extremity more nearly approximates mild incomplete paralysis of the radial, median, and ulnar nerves prior to May 29, 2012, and no more than moderate incomplete paralysis thereafter. 2. The impairment from peripheral neuropathy of the right lower extremity more nearly approximates mild incomplete paralysis of the sciatic and femoral nerves prior to May 29, 2012, and no more than moderate incomplete paralysis thereafter. 3. The impairment from peripheral neuropathy of the left lower extremity more nearly approximates mild incomplete paralysis of the sciatic and femoral nerves prior to May 29, 2012, and no more than moderate incomplete paralysis thereafter. CONCLUSIONS OF LAW 1. The criteria for a 20 percent disability rating prior to May 29, 2012, and a 30 percent thereafter, but no more, for right upper extremity peripheral neuropathy are met. 38 U.S.C.A. § 1155 (West 2002) 38 C.F.R. §§ 4.7, 4.124a , Diagnostic Code 8514 (2012). 2. The criteria for a disability rating in excess of 10 percent prior to May 29, 2012, and in excess of 20 percent thereafter for right lower extremity peripheral neuropathy are not met. 38 U.S.C.A. § 1155 (West 2002) 38 C.F.R. §§ 4.7, 4.124a , Diagnostic Code 8520 (2012). 3. The criteria for a disability rating in excess of 10 percent prior to May 29, 2012, and in excess of 20 percent thereafter for left lower extremity peripheral neuropathy are not met. 38 U.S.C.A. § 1155 (West 2002) 38 C.F.R. §§ 4.7, 4.124a , Diagnostic Code 8520 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Although the regulation previously required VA to request that the claimant provide any evidence in the claimant's possession that pertains to the claim, the regulation has been amended to eliminate that requirement for claims pending before VA on or after May 30, 2008. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held the plain language of 38 U.S.C.A. § 5103(a) requires notice to a claimant pursuant to the VCAA be provided "at the time" or "immediately after" VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement articulated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Here, the Veteran's claim arises from his disagreement with the initial disability rating following the grant of service connection for peripheral neuropathy of the upper and lower extremities. It has been held that once service connection is granted, the claim is substantiated and additional notice is not required. Thus any defect in the notice provided to the Veteran is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Nevertheless, by letter dated in December 2009 (prior to the grant of service connection), the Veteran was notified of the evidence necessary to substantiate his claims; the information that he needed to provide; and the information or evidence that VA would attempt to obtain. Additionally, VA provided the Veteran with notice of how VA determines disability evaluations and effective dates. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied. VA further has a duty to assist. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. That is, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d). All relevant records have been obtained and associated the claims file. Furthermore, VA afforded the Veteran VA medical examinations. The Board has reviewed the most recent examination report and finds that it is adequate for rating purposes in that it described the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Neither the Veteran nor his attorney has identified, and the record does not otherwise indicate, the existence of any additional evidence that is necessary for a fair adjudication of the claims. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Accordingly, the Board will address the merits of the claim. II. Evaluation of Peripheral Neuropathy The Veteran seeks increased evaluations for peripheral neuropathy of the right upper extremity, right lower extremity, and left lower extremity. The disorders are evaluated at the 10 percent disability level prior to May 29, 2012, and at the 20 percent disability level thereafter. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. General Legal Criteria Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same ""manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14. The Court has held that a veteran may not be compensated twice for the same symptomatology as "such a result would over compensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Court has acknowledged, however, that when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different Diagnostic Codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). A disability may require re-evaluation in accordance with changes in a veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. For the dominant (major) arm, Diagnostic Code 8514, paralysis of the musculospiral nerve (radial nerve), provides a 20 percent evaluation where there is mild incomplete paralysis; a 30 percent evaluation is provided for moderate incomplete paralysis; and a 50 percent evaluation is provided for severe incomplete paralysis. A 70 percent disability rating requires complete paralysis with drop of the hands and fingers, perpetual flexion of the wrist and fingers, the thumb adducted falling within the line of the outer border of the index finger; inability to extend the hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of the wrist; supination of hand, extension an flexion of elbow weakened, the loss of synergic motion of extensors impairs hand grip; total paralysis of the triceps. 38 C.F.R. § 4.124a, Diagnostic Code 8514. Under Diagnostic Code 8520, paralysis of the sciatic nerve, a 10 percent rating is assigned for mild incomplete paralysis of the sciatic nerve; 20 percent rating is assigned for moderate incomplete paralysis of the sciatic nerve; a 40 percent rating is assigned for moderately severe incomplete paralysis; a 60 percent rating is assigned for severe incomplete paralysis, with marked muscular atrophy; and an 80 percent rating is assigned for complete paralysis of the sciatic nerve; the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. The Board is required to analyze the credibility and probative value of the evidence, account for any evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Daye v. Nicholson, 20 Vet. App. 512, 516 (2006). It is noted that competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In determining whether statements are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). Right Upper Extremity Having carefully reviewed the evidence of record, the Board finds that the evidence warrants a 20 percent evaluation prior to May 29, 2012, and a 30 percent evaluation thereafter. Prior to May 29, 2012, the evidence reflects that the Veteran's right upper extremity peripheral neuropathy was manifested by mild incomplete paralysis of the radial, median, and ulnar nerves. Under Diagnostic Code 8514, a minimum 20 percent evaluation is warranted for mild impairment and a 30 percent evaluation is warranted for moderate impairment. However, neither the lay nor the medical evidence of record more nearly reflects the criteria for the next higher evaluation prior to or after May 29, 2012. 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Code 8514. Report of VA examination dated in June 2010 reflects that the Veteran was diagnosed with peripheral neuropathy of the upper extremities secondary to diabetes mellitus. The Veteran complained of pain and dull ache of the right arm rated as 6 of 10. Sensory examination indicated that the right upper extremity median, radial, and ulnar nerves were involved. There was normal vibration and position sense. There was decreased pain/pinprick and light touch on the dorsum of the hand and finger tips. There were no dysesthesias. Motor examination showed 5/5 active movement against resistance in the right upper extremity. Muscle tone was normal. There was no tremor, or evidence of fasciculations. There was no evidence that any joint function was affected by the nerve disorder. Muscle strength was normal in the right upper extremity. Report of VA examination dated in May 29, 2012 reflects a diagnosis for diabetic peripheral neuropathy of the right upper extremity. The Veteran reported numbness of the right upper extremity. Neurological exam showed normal strength on extension and flexion of the elbow and wrist. Grip and pinch (thumb to index finger) showed 4/5 (less than normal) strength. Reflexes were decreased or absent. Light touch/monofilament testing showed decreased sensation at the inner/outer forearm, and hand/fingers. There was normal position sense, but decreased vibration and cold sensation of the right upper extremity. There was no atrophy. The examiner indicated that the Veteran had incomplete paralysis of moderate severity in the radial nerve and incomplete paralysis of mild severity in the medial and ulnar nerves. The examiner noted that the Veteran's right hand "hurts all the time" and that he has diminished right hand strength. The evidence shows no more than mild impairment prior to May 29, 2012, and no more than moderate impairment from May 29, 2012. Notably, prior to May 29, 2012, impairment was purely sensory; muscle strength and motor examination were normal. By contrast; both sensory and motor abnormalities were found in May 2012, which were characterized by the examiner as moderate in severity. The Veteran is competent to report that his disability is worse than presently evaluated. However, whether a disability has worsened sufficiently to meet the schedular criteria for the assignment of a higher evaluation is a factual determination by the Board based on the Veteran's complaints coupled with the medical evidence. Here, although the Veteran may believe he meets the criteria for the next higher disability rating, his complaints and the medical findings do not meet the schedular requirements for the higher rating. The Board assigns greater probative value to the findings on VA examinations dated in 2010 and 2012 as these were prepared by skill, neutral medical professionals after review of the claims file and evaluation of the Veteran. The Veteran's attorney argues that the Veteran has not been evaluated under the correct Diagnostic Code and suggests that separate disability evaluations are warranted in view of impairment of three different nerves, i.e. radial, ulnar, and medial nerves. The Board disagrees. The Veteran's evaluation under Diagnostic Code 8514 provides him with the highest possible disability rating based on his upper extremity nerve impairment. It is noted that moderate impairment of the radial nerve as shown on the 2012 VA examination is rated at the 30 percent level, whereas mild impairment of the median or ulnar nerves as shown on the same examination warrants only a 10 percent rating. Also, a separation evaluation for each nerve effected is not warranted as this would violate the provisions of 38 C.F.R. § 4.14. The Court has held that a veteran may not be compensated twice for the same symptomatology as "such a result would over compensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. But see Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993) (when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different Diagnostic Codes). In this case, separate and distinct manifestations or symptoms are not shown. The Veteran has pain, numbness, and decreased strength. Also, as there is no joint impairment or muscle injury, a separate rating under the provisions of 38 C.F.R. §§ 4.71a and 4.73 is not warranted. Accordingly, a 20 percent evaluation prior to May 29, 2012, and a 30 percent evaluation thereafter, but not more, is warranted for right upper extremity peripheral neuropathy. There is no basis for additional staging of this disability rating. Fenderson, supra. As the evidence is not in equipoise, there is no doubt to resolve. Gilbert, supra. Lower Extremities A private treatment record dated in August 2008 reflects that the Veteran had complaints of cold, burning sensation in his feet and the feeling his feet were going to sleep. Nerve conduction and EMG studies were abnormal. The impression was sensory peripheral neuropathy. VA treatment notes reflect diabetic neuropathies. In September 2009, there was normal sensory exam of the feet using monofilament. Report of VA examination dated in June 2010 reflects that the Veteran was diagnosed with peripheral neuropathy of the lower extremities secondary to diabetes mellitus. The Veteran complained of a constant burning sensation and numbness in the bilateral toes and pads of the feet rated as 4 of 10. Sensory examination indicated that nerves affected were in the toes and foot pad. There was normal position sense, but decreased vibration, pain/pinprick, and light touch of the toes and pads/soles of feet bilaterally. There were no dysesthesias. Motor examination showed 5/5 active movement against resistance in the lower extremities. Muscle tone was normal bilaterally. There was no gait abnormality, imbalance or tremor, or evidence of fasciculations. There was no evidence that any joint function was affected by the nerve disorder. Gait was described as steady and normal. The Veteran was able move his extremities. There were no color changes, cyanosis, redness, edema, heat, breakdown, or callus formation. Toe nails were yellow, thickened, hypertrophic, and blanched. The Veteran was able to spread his toes without difficulty or limited motion, but he could not distinguish temperature changes and dull versus sharp. Monofilament testing was abnormal. Report of VA examination dated in May 29, 2012 reflects a diagnosis for diabetic peripheral neuropathy of the lower extremities. The Veteran reported constant moderate pain, moderate intermittent ache of the right lower extremity, severe parasthesias/dyesthesias of both lower extremities, and severe numbness of the right lower extremity. Neurological examination showed full strength at the knees and ankles. Ankle reflexes were absent. Light touch/monofilament testing showed decreased sensation at the knee/thigh, ankle/lower leg, and foot/toes. There was decreased position sense of the right lower extremity and absent vibration sensation of both lower extremities. Cold sensation was decreased in both lower extremities. There was no muscle atrophy. There were trophic changes. The examiner indicated that the Veteran had lower extremity incomplete paralysis of the sciatic and femoral nerves of mild severity. Having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against an evaluation in excess of 10 percent prior to May 29, 2012, and in excess of 20 percent thereafter for right and left lower extremity peripheral neuropathy. Prior to May 29, 2012, the evidence reflects that the Veteran's lower extremity peripheral neuropathy was manifested by mild incomplete paralysis of sciatic and femoral nerves; and that, from May 29, 2012, his lower extremity peripheral neuropathy was manifested by no more than moderate incomplete paralysis of the sciatic and femoral nerves. Under Diagnostic Code 8520, a 10 percent evaluation is warranted for mild impairment and a 20 percent evaluation is warranted for moderate impairment. Neither the lay nor the medical evidence of record more nearly reflects the criteria a higher evaluation prior to or after May 29, 2012. 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Code 8520. The evidence shows no more than mild impairment prior to May 29, 2012. Notably, prior to this date, the Veteran had no dysesthesias, normal position sense, and 5/5 muscle strength. There was no gait abnormality or imbalance. From May 29, 2012, the evidence shows no more than moderate impairment. The evidence shows dysesthesias, severe numbness, absent ankle reflexes, decreased light touch and cold sensation, and absent vibration sensation of both lower extremities. Also, position sense of the right lower extremity was diminished. The examiner characterized the severity as mild. While the Veteran is competent to report that his disability is worse than presently evaluated, neither the lay nor the medical evidence shows that the disability more nearly approximates the criteria for a higher evaluation before or after May 29, 2012. Whether a disability has worsened sufficiently to meet the schedular criteria for the assignment of a higher (or separate) evaluation is a factual determination by the Board based on both the Veteran's complaints coupled with the medical evidence. Here, although the Veteran believes he meets the criteria for higher disability ratings, his complaints and the medical findings do not meet the schedular requirements for the higher rating, as explained and discussed above. The Board concludes that the medical evidence, prepared by skilled, neutral medical professionals, is more probative of the degree of disability. Separate evaluations for the sciatic and femoral nerves is not warranted as this would violate the provision of 38 C.F.R. § 4.14. Also, the Board finds that a higher disability evaluation is not warranted under any other potentially applicable provision of the rating schedule. It is noted that impairment of the sciatic and femoral nerves are both rated at the10 and 20 percent disability level for mild and moderate impairment, respectively. Thus a higher rating is not available by changing the Diagnostic Code assigned. 38 C.F.R. § .4.124a, Diagnostic Codes 8520 and 8526. Also, a separate rating based on joint impairment or muscle injury is not warranted. The record show no evidence of that any joints or muscles are affected by the nerve impairment. See 38 C.F.R. §§ 4.71a, 4.73. Accordingly, the claims must be denied. Additional staging of this rating is not warranted. Fenderson, supra. The evidence of record is not in equipoise and, therefore, there is no doubt to resolve. 38 U.S.C.A. § 5107; Gilbert, supra. Extraschedular Consideration The Board has also considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(a). In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the record reflects that the manifestations of the peripheral neuropathy disability are specifically contemplated by the schedular criteria. Accordingly, the Board has concluded that referral of this case for extra-schedular consideration is not in order. Thun v. Peake, 22 Vet. App. 111, 115 (2008). ORDER A 20 percent evaluation prior to May 29, 2012, for peripheral neuropathy of the right upper extremity is granted. A 30 percent from May 29, 2012, for peripheral neuropathy of the right upper extremity is granted. An evaluation in excess of 10 percent prior to May 29, 2012, and in excess of 20 percent thereafter for peripheral neuropathy of the right lower extremity is denied. An evaluation in excess of 10 percent prior to May 29, 2012, and in excess of 20 percent thereafter for peripheral neuropathy of the left lower extremity is denied. REMAND Clarification of Withdrawal of Appeal In December 2012, the Board received from the Veteran's attorney a statement indicating that the "Veteran agrees with the 20 percent rating assigned to his service-connected peripheral neuropathy, left upper extremity, but believes the medical evidence supports [a] higher rating for his peripheral neuropathy of his right upper extremity, and left lower extremity." This statement suggests a withdrawal of the appeal of the claim for increase for peripheral neuropathy of the left upper extremity. However, as the appeal has been staged, action should be taken for clarify whether the claim is withdrawn in regards to the 20 percent evaluation from May 29, 2012, only or both this evaluation and the 10 percent evaluation prior to May 29, 2012 VA's Duty to Assist the Veteran The Veteran seeks service connection for a skin condition and testicular cancer both claimed as secondary to herbicide exposure in service. In September 2009, the Board remanded theses issues for further evidentiary development, to include requesting authorization for release of private medical records and obtaining a VA examination and medical opinion on the Veteran's claimed skin disability. In a May 2010 letter, the RO requested that the Veteran complete an enclosed authorization for release of private treatment records. A second request was made by the RO two weeks later. No response has been received to date in this regard. As remand is necessary for other reasons, the Veteran should again be afforded the opportunity to provide the information necessary so that VA may obtain the outstanding medical records from Carroll County Medical Clinic. In May 2012, a VA skin examination and medical opinion was obtained. The Veteran's attorney argues that the VA examination is inadequate because it was performed during a period of quiescence or inactivity. The Board also finds that the VA medical opinion is inadequate as the medical rationale given bears little relation to the opinion rendered. Specifically, a nurse practitioner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Her rationale was that the disease shown on current examination was not among those afforded presumptive service connection based on herbicide exposure in Vietnam under the law; that there was no indication in the reviewed records of any "chronic ongoing skin conditions that [the] veteran has been seen for;" and that there were no currently shown lesions of scars on the neck, face, or back except for normal seborrhea keratosis lesions on the Veteran's back due to aging and past sun exposure. Also, she opined that the Veteran had dry peeling skin of the right foot that was not related to Agent Orange exposure-no rationale was given. Here, the medical opinion does not support its conclusion with any analysis the Board can consider and weigh against other evidence in the record. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). It is noted that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, remand for another VA examination and medical opinion is necessary. See Stegall v. West, 11 Vet. App. 268 (1998) (a remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders). Additionally, in December 2012, the Board received from the Veteran a statement indicating that missing medical records dated in January 1984 had been located by Dr. Stanley Thawley. VA's duty to assist includes obtaining records in Federal custody and making reasonable efforts to obtain those outstanding medical records not in Federal custody. 38 C.F.R. § 3.159. In light of the information from the Veteran concerning the revelation of pertinent outstanding medical evidence, which appears to be in support of his claims for service connection, remand is necessary so that VA may attempt to obtain these records. Accordingly, the case is REMANDED for the following action: 1. The RO obtain all updated VA treatment records and any other outstanding records pertinent to the Veteran's claims, to include the private medical records relating to the Veteran's hydrocele from Carroll County Medical Clinic referred to in the September 2006 "Authorization and Consent to Release Information" form along with the private treatment records of Dr. Stanley Thawley. These records should be associated with the claims file. All attempts to obtain these records should be documented and associated with the claims file, to include a negative response from any facility unable to provide the requested records. 2. The RO should contact the Veteran and request clarification on whether he seeks to withdraw his appeal of the claim for an evaluation in excess of 10 percent prior to May 29, 2012, and in excess of 30 percent thereafter for peripheral neuropathy of the left upper extremity. 3. The RO should schedule the Veteran for a VA examination by a dermatologist to ascertain whether any currently found skin disorder is related to service or any event of service to include exposure to chemical herbicide agents in service. This disability may have active and inactive stages, thus, it is essential to attempt to schedule the Veteran for an examination of his skin during an active stage. See Ardison v. Brown, 6 Vet. App. 405, 407-08 (1994). The dermatologist should review the claims files along with any pertinent medical records located in the Veteran's Virtual VA file. The dermatologist should render an opinion on the following: (a) Does Veteran currently have any skin condition and, if so, please identify the body areas. (b) If yes, as to each skin condition currently shown, indicate whether it is at least as likely as not (50 percent probability or more) the current skin condition had its onset in service or was incurred in or aggravated by a disease or injury in service. (c) Is any currently shown skin condition at least as likely as not caused by in-service exposure to herbicides or Agent Orange. A complete rationale for any opinions provided. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., that he or she relied upon in reaching his or her conclusion(s). If an opinion cannot be expressed without resort to speculation, the examiner should so indicate and discuss why an opinion is not possible. 4. Then, the RO should also undertake any other development it determines to be warranted. 5. After the development requested above has been completed to the extent possible, the RO should readjudicate the issues on appeal. If the benefit sought on appeal is not granted to the Veteran's satisfaction, he and his attorney should be furnished a Supplemental Statement of the Case and given the requisite opportunity to respond before the claims files are returned to the Board for further appellate action. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs