Citation Nr: 1306609 Decision Date: 02/26/13 Archive Date: 03/01/13 DOCKET NO. 06-35 458 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial evaluation in excess of 20 percent for diabetes mellitus, type II, with cataracts. 2. Entitlement to an initial evaluation in excess of 10 percent for arteriosclerotic heart disease for the period prior to September 13, 2011, and in excess of 60 percent thereafter. 3. Whether a separate compensable disability rating is warranted for diabetic cataracts. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD H. Hoeft, Counsel INTRODUCTION The Veteran served on active duty service from August 1961 to July 1967. This matter comes before the Board of Veterans' Appeals (Board) initially on appeal from a May 2005 rating decision in which the RO, in pertinent part, granted service connection for diabetes mellitus, type II, and for arteriosclerotic heart disease associated with diabetes mellitus, type II, and assigned initial 20 percent and 10 percent ratings, respectively, effective October 8, 2004. The Veteran perfected appeals to the initial disability ratings assigned. See September 2005 Notice of Disagreement; September 2006 Statement of the Case; and September 2006 VA Form 9. The Veteran testified during a Travel Board hearing before the undersigned Veterans Law Judge at the RO in December 2007; a transcript of that proceeding has been associated with the claims file. These claims were previously before the Board in March 2008 and in August 2008, at which time they were remanded for further development. In December 2012, the RO granted an increased evaluation of 60 percent, effective September 13, 2011, for arteriosclerotic heart disease. This increase during the appeal did not constitute a full grant of the benefit sought. Therefore, the Veteran's claim for an increased evaluation for heart disease remains on appeal. See AB v. Brown, 6 Vet. App. 35, 39 (1993). Additionally, the Board notes that the appeal originally encompassed a claim for service connection for abdominal aortic aneurysm (AAA), as secondary to the service-connected heart condition. Service connection for AAA was granted in an October 2012 rating decision, and therefore, the claim is no longer in appellate status. The Veteran's service-connected diabetes mellitus has been characterized as including cataracts which is rated at the noncompensable level. The rating criteria for diabetes mellitus provides for service connection for complications of the disease. If the complications are noncompensable, they are to be considered part of the process under Diagnostic Code 7913. 38 C.F.R. § 4.119 (2012). In the instant case, service connection includes cataracts. This disability requires further development in order to determine if it is entitled to a separate compensable disability rating apart from the current rating for diabetes mellitus. The issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) has been raised by the record, as reflected on the first page of the present decision. The Board notes that the Veteran currently meets the schedular requirements for a TDIU, and pursuant to the holding in Rice v. Shinseki, 22 Vet. App. 447 (2009), which finds that a TDIU claim is part of an increased rating claim when such claim is reasonably raised by the record, the Board will address the issue of entitlement to a TDIU in this decision. Lastly, the Board notes that, in addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. The issue of entitlement to service connection for erectile dysfunction as secondary to service-connected abdominal aortic aneurysm has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issues of entitlement to a TDIU rating, and entitlement to a separate compensable disability rating for diabetic cataracts is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's service-connected diabetes mellitus, type II has required oral medication and/or insulin, and a restricted diet throughout the appeals period. The Veteran has not required the regulation of activities due to his diabetes mellitus, nor has he experienced any episodes of ketoacidosis and/or hypoglycemic reactions requiring hospitalization at any time during the appeals period. 2. Prior to September 13, 2011, the Veteran's service-connected arteriosclerotic heart disease is not shown to have been productive of a workload of 7 METs or less that results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 3. As of September 13, 2011, the Veteran's service-connected arteriosclerotic heart disease is not shown to have been productive of chronic congestive heart failure, a 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. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial disability evaluation in excess of 20 percent for diabetes mellitus, type II, have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.7, 4.76, 4.79, 4.119, Diagnostic Code 7913 (2012). 2. Prior to September 13, 2011, the criteria for an initial evaluation in excess of 10 percent for service-connected arteriosclerotic heart disease have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.104, Diagnostic Code 7005 (2012). 3. As September 13, 2011, the criteria for an evaluation in excess of 60 percent for service-connected arteriosclerotic heart disease have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.104, Diagnostic Code 7005 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist With regard to the claims for increased initial evaluations for arteriosclerotic heart disease, and diabetes mellitus, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The notification obligation in this case was accomplished by way of letters from the RO to the Veteran dated in October 2004, April 2008, and August 2011. Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). These claims involve initial evaluations, and the Court in Dingess held that in such cases section 5103(a) notice is not required, because the purpose that the notice was intended to serve has been fulfilled. The RO also provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. It appears that all known and available service treatment reports, and post- service treatment reports, have been obtained and are associated with the Veteran's claims files. The RO has obtained the Veteran's VA and non-VA medical evidence, and SSA records. The Veteran has been afforded multiple VA examinations. The issues on appeal involve the severity of the Veteran's symptoms, the examiners stated that the Veteran's CPRS files were reviewed, and the purpose of the examinations was to assess the current severity of the Veteran's conditions. See 38 C.F.R. § 3.327 (2012). The Board finds that the examination reports are adequate for purposes of this decision. The Board concludes, therefore, that decisions on the merits at this time do not violate the VCAA, nor prejudice the appellant under Bernard v. Brown, 4 Vet. App. 384 (1993). Based on the foregoing, the Board finds that the Veteran has not been prejudiced by a failure of VA in its duty to assist, and that any violation of the duty to assist could be no more than harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Higher Initial Evaluations Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). The Veteran's claims for higher ratings for diabetes mellitus, type II, and arteriosclerotic heart disease are original claims that were placed in appellate status by a NOD expressing disagreement with an initial rating award. As such, separate ratings can be assigned for separate periods of time based on the facts found--a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). Diabetes Mellitus The Veteran's diabetes mellitus has been evaluated as 20 percent disabling (effective October 8, 2004) under Diagnostic Code 7913. He contends a higher rating is warranted. Under Diagnostic Code 7913, a 20 percent evaluation contemplates diabetes mellitus requiring insulin and a restricted diet, or an oral hypoglycemic agent and a restricted diet. A 40 percent evaluation is warranted for the requirement of insulin, a restricted diet, and regulation of activities. A 60 percent evaluation is for consideration where the disorder requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. Finally, a 100 percent evaluation is assigned when the diabetes mellitus requires more than one daily injection of insulin, (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). Note (1) to Diagnostic Code 7913 directs adjudicators to evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under this diagnostic code. Note (2) provides that, when diabetes mellitus has been conclusively diagnosed, a glucose tolerance is not necessary solely for rating purposes. 38 C.F.R. § 4.119, Diagnostic Code 7913. The Court has held that the conjunctive "and" used in Diagnostic Code 7913 for the criteria for both the 40 percent and 60 percent disability ratings requires that all criteria must be met to establish those ratings. See Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007); see also Tatum v. Shinseki 23 Vet. App. 152, 155-56 (2009). Moreover, medical evidence is required to support a finding of regulation of activities. Camacho, 21 Vet. App. at 364. With respect to the pertinent medical evidence, the Veteran underwent a general VA examination in January 2005 and reported a history of impaired glucose intolerance dating back to 1991. He was place on Amaryl in 1999. He denied having any ketoacidosis, hypoglycemic episodes, and/or hospitalizations relating to his diabetes. Notably, he denied being on a restricted diet. Currently, he stated that he was on Glucotrol (10 mgs/daily), and that he visited his diabetic care provider once every 6 months. The pertinent diagnosis was non-insulin dependent diabetes with mild to moderate impairment. The Veteran testified before the undersigned in December 2007 concerning his diabetic condition. At that time, he denied experiencing any neuropathy/tingling in his lower extremities; he also denied problems with his eyes and/or vision. He stated that current treatment consisted of medication and diet, but no restrictions on his physical activities. The Veteran underwent a VA diabetes examination in September 2009. The examination report indicated that the Veteran was taking Glipizide for his diabetes at that time; he denied taking insulin. He also denied diabetes-related hospitalizations and episodes of ketoacidosis. When asked about his diet, the Veteran responded that he did not eat sweets, and that his weight had been stable. He stated that he worked around the house and cut grass, but did not walk much for exercise. No restriction of activities was reported. The pertinent diagnosis was diabetes mellitus, type II, fair control with oral hypoglycemic agent, and no evidence of neuropathy or nephropathy. It was noted that the Veteran did not undergo an eye screening. VA treatment records dated from 2009 to 2011 reflect continued treatment for diabetes, which was primarily controlled by a restricted diet, oral medications and/or insulin. See, e.g., VA Treatment Records dated in November 2009; June 2010; May 2011. The Board notes that the Veteran started taking insulin in May 2011 due to Metforim (oral medication) intolerance. The treatment records also reflect that the Veteran was encouraged to follow a restricted diet and to exercise daily. See, e.g., VA Treatment Records, May 2010 and November 2009. There is no indication in the treatment records that any restriction of activities was necessary. Finally, the Veteran underwent a VA diabetes examination/defined benefits questionnaire (DBQ) in September 2011. The DBQ report indicated that the Veteran's diabetes was treated with the following: a restricted diet; oral hypoglycemic medications; and insulin injections. The report expressly noted that a regulation of activities was not required. In addition, the Veteran was noted to visit his diabetic care provider less than 2 times per month. There had been no hospitalizations and/or episodes of ketoacidosis in the past 12 months. The report indicated there was no evidence of diabetic neuropathy, nephropathy, or retinopathy. Rather, the only related diabetic complication listed was cataracts (note: this disability is addressed in the REMAND portion of this decision below). In addition, the DBQ report indicated that the Veteran's peripheral vascular disease was aggravated by (or secondary to) the service-connected diabetes mellitus. Accordingly, the Board notes that service connection for peripheral vascular disease of the right and left lower extremities was granted in an October 2012 rating decision and separate 20 percent disability evaluations were assigned, effective September 13, 2011. In sum, the evidence outlined above shows that the Veteran takes oral hypoglycemic agents and/or insulin (as of May 2011) and must adhere to a restricted diet for control of his diabetes. However, a 40 percent under DC 7913 rating requires additional factors of insulin and regulation of activities. There is no evidence that at any time during the appeal period the Veteran has been required to regulate his activities due his diabetes mellitus. In fact, the evidence shows that the Veteran has been encouraged to exercise and incorporate physical activity into his treatment plan, if anything. Moreover, not even the Veteran, himself, has asserted that his diabetes requires a regulation of activities as evidenced by his hearing testimony. The Board therefore finds that the preponderance of the evidence shows that criteria for an initial evaluation in excess of 20 percent under DC 7913 have not been met. Therefore the claim must be denied. The Board also notes that ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year, or twice-a-month visits to a diabetic care provider, have not been shown. See DC 7913 (criteria for a 60 percent rating). Arteriosclerotic Heart Disease The Veteran's arteriosclerotic heart disease/coronary artery disease has been evaluated as 10 percent disabling prior to September 13, 2011, and 60 percent disabling thereafter, under Diagnostic Code 7005. He contends a higher evaluation is warranted. Under Diagnostic Code 7005 (arteriosclerotic heart disease/coronary artery disease), a 10 percent rating is assigned for a workload of greater than 7 MET's but not greater than 10 METs which results in dyspnea, fatigue, angina, dizziness, or syncope, or continuous medication required. A 30 percent rating is assigned for a workload of greater than 5 MET's but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. Id. A 60 percent rating contemplates 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 which results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent to 50 percent. Id. A 100 percent rating is warranted for coronary artery disease resulting in chronic congestive heart failure; or, workload of 3 METS or less results in dyspnea, fatigue, angina, dizziness, or syncope; or, there is left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. One MET (metabolic equivalent) is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). Entitlement to an evaluation in excess of 10 percent prior to September 13, 2011 With regard to the overall history of the disability in issue, see 38 C.F.R. § 4.1 (2012), private treatment records reflect that the Veteran underwent a left heart catherization with stent and temporary pacemaker placement due to an acute inferior myocardial infarction in March 2004. No surgical or post-surgical complications were noted; however, the treating physician did indicate that the Veteran still had significant residual three vessel coronary artery disease and was in need of bypass surgery. The Veteran was discharged in stable condition on a medical regimen including aspirin, Plavix, folic acid, Lopressor, Monopril, and Lipitor. See, generally, Singing River Hospital System/Ocean Springs Hospital Records. The Veteran subsequently underwent a VA general examination in January 2005, at which time the examiner opined that the Veteran's diagnosed arteriosclerotic heart disease was secondary to his service-connected diabetes. Subjectively, the Veteran reported tightness in his chest at least once or twice per week, along with fatigue and shortness of breath and dyspnea on exertion. He denied dizziness, diaphoresis, or radiation of symptoms. He reported one syncopal episode at the time of his March 2004 heart attack. Current medications included metoprolol, nitroglycerin spray, aspirin, and lisinopril. He was not being followed by a cardiologist. He reported that he did not exercise, but performed light duty work within his home. Objectively, the cardiovascular examination revealed a regular heart rate and rhythm. The examiner confirmed a diagnosis of arteriosclerotic heart disease with moderate impairment secondary to chest pain and fatigue. An echocardiogram was scheduled for February 2005, however, the Veteran did not appear due to hospitalization for an abdominal aortic aneurysm repair. The Veteran underwent an echocardiogram in August 2005 which showed patent aorto to bi-common iliac arteries graft. A January 2005 VA cardiovascular stress test was positive for chest pain, but revealed no ECG changes, a normal left ventricle, normal right ventricle, normal perfusion, normal wall motion, and a resting ejection fraction of 60 percent. Based on the evidence outlined above, the Board finds that the criteria for an initial 30 percent evaluation have not been met. There is no competent evidence to show that the Veteran had a workload of 5 METs but not greater than 7 METs, or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. See Diagnostic Code 7005. Accordingly, the preponderance of the evidence is against the claim for an initial evaluation in excess of 10 percent prior to September 13, 2011, and the claim must be denied. Entitlement to an evaluation in excess of 60 percent as of September 13, 2011 The Veteran underwent a VA heart examination in September 2009. At that time, an echocardiogram revealed normal left ventricle size, wall thickness, wall motion, systolic function, diastolic relaxation, and an ejection fraction of 62 percent. There was trace pulmonic insufficiency and mild mitral regurgitation. A nuclear stress was ordered in order to provide METS, but the Veteran declined the test. Objective cardiac examination was normal. The pertinent diagnosis was coronary artery disease, with previous myocardial infarction, post-stent. Next, a September 2011 VA chest x-ray indicated normal cardiac size and no active congestive heart disease or heart failure. The Veteran underwent a VA heart examination/DBQ in September 2011. At that time, the examination report indicated that continuous medication was required for control of the Veteran's heart condition. There was no evidence of cardiac hypertrophy and no evidence of cardiac dilation. There was no evidence of congestive heart failure. A contemporaneous EKG was positive for sinus bradycardia. An exercise stress test revealed the presence of dyspnea and fatigue at 3 to 5 METs (which was consistent with activities such as yard work, mowing the lawn, and brisk walking). The examiner attributed 70 percent of the METs level limitation to the service-connected heart condition, and 30 percent of the limitation to diabetes. Based on the evidence outlined above, the Board finds that, as of September 13, 2011, a rating in excess of 60 percent is not warranted under Diagnostic Code 7005. There is no competent evidence to show that the Veteran has chronic congestive heart failure, or that he has an ejection fraction of 30 percent or less. 38 C.F.R. § 4.104, Diagnostic Code 7005. In fact, the Veteran's ejection fraction was 62 percent upon VA examination in September 2009, and the September 2011 VA examiner expressly found that congestive heart failure was not present. With regard to METS levels, to the extent that the September 2011 VA examination report notes that the Veteran's activity levels qualify him at METs range of 3 to 5, this indicates the possibility of a METS level 3, which would meet the criteria for a 100 percent rating. However, it also indicates a METS level as high as 5, which is two METS levels above those criteria. In summary, when viewed in the context of contemporaneous medical evidence, the Board finds that the evidence is insufficient to show that the Veteran has chronic congestive heart failure, a workload of 3 METS or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or that he has an ejection fraction of 30 percent or less. Accordingly, as of September 13, 2011, the criteria for an evaluation in excess of 60 percent under Diagnostic Code 7005 are not shown to have been met, and the claim must be denied. Conclusion The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where scheduler evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulations, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular scheduler standards. See 38 C.F.R. § 3.321(b)(1) (2012); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111, 115-116 (2008), the Court set forth a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, as a threshold issue, the Board must determine whether the Veteran's disability picture is contemplated by the rating schedule. If so, the rating schedule is adequate and an extraschedular referral is not necessary. If, however, the Veteran's disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry, that is, whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With regard to the Veteran's service-connected disabilities, the evidence of record does not reflect that the Veteran's disability picture is so exceptional as to not be contemplated by the rating schedules. In essence, there is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. The rating criteria for the Veteran's arteriosclerotic heart disease, and diabetes mellitus, fully contemplate his symptoms, and there are no symptoms left uncompensated or unaccounted for by the assignment of the respective schedular ratings. In particular, the Veteran's subjective and objective symptoms of his diabetes mellitus are contemplated in the rating criteria and are allowed for in his 20 percent rating. There is a very specific criterion to meet, specifically regulation of activities, to justify any higher rating under Diagnostic Code 7911. The evidence clearly demonstrates that no regulation of activities is required. Likewise, the symptoms of the Veteran's arteriosclerotic heart disease are contemplated in the rating criteria and are allowed for in his assigned 10 percent (prior to September 13, 2011) and 60 percent (as of September 13, 2011) ratings. There is also very specific criterion to meet to justify higher ratings under Diagnostic Code 7005 and as explained above, the Veteran's heart-related symptoms did not approximate the criteria for the next-higher evaluations. As such, the threshold issue under Thun is not met and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. In short, the evidence does not support the proposition that the Veteran's service-connected disabilities present such an exceptional or unusual disability picture as to render impractical the application of the regular scheduler standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1). Thus, referral of this issue to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. In deciding the Veteran's claims, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119, 126 (1999) and Hart v. Mansfield, 21 Vet. App. 505 (2007), and whether the Veteran is entitled to increased evaluations for separate periods based on the facts found during the appeal period. The Board does not find evidence that either of the Veteran's evaluations should be increased for any separate period based on the facts found during the whole appeal period. The evidence of record supports the conclusion that the Veteran is not entitled to additional increased compensation during any time within the appeal period. The Board therefore finds that the evidence does not show that the Veteran had a worsening of either of the disabilities in issue at any distinct time during the appeal period, such that an increased initial evaluation is warranted. As the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). ORDER Entitlement to an initial evaluation in excess of 20 percent for diabetes mellitus, type II, is denied. Prior to September 13, 2011, an initial evaluation in excess of 10 percent for service-connected arteriosclerotic heart disease is denied. As of September 13, 2011, an evaluation in excess of 60 percent for service-connected arteriosclerotic heart disease, is denied. REMAND Cataracts As noted in the Introduction, the Veteran is service connected for diabetes mellitus. He is also service connected for cataracts, which has been determined to be a complication of his service-connected diabetes mellitus. See September 2011 VA Diabetes Examination; see also December 2012 Rating Decision Granting Service Connection. This disability is currently evaluated as part of the Veteran's diabetes mellitus disability rating because it has not yet been determined to rise to a compensable disability level on its own. The Board makes no finding to change that status at this time. Pursuant to the September 2011 VA diabetes examination findings, the RO scheduled the Veteran for a VA eye examination in order to determine the nature and severity of the diagnosed cataract disability. However, a notation in the claims file from the Central Alabama VA Healthcare System indicates that the Veteran had "refused" to have an examination at their location. See November 2012 RO Letter. A November 2012 letter from the RO to the Veteran requested that the Veteran confirm whether he wished to have an examination or not. In a letter received by the Board in November 2012 (and dated and signed in November 2012), the Veteran responded that he did not "refuse the eye examination," but rather he received notice of the scheduled examination one day after the appointment date. He stated that he wanted to go forward with a VA examination. He also noted that he was due to have eye surgery in January (2013). In light of the Veteran's statements regarding the lack of timely notice of the scheduled eye examination; the likelihood of outstanding private treatment records relating to the eye disability; and further considering that the Veteran has not been afforded a comprehensive VA eye examination in association with his diabetic cataracts, the Board finds that the Veteran should be scheduled for such an examination in order to determine whether a separate compensable disability rating is warranted for diabetic cataracts. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). See also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one). TDIU VA will grant a total disability evaluation 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 or her education and occupational experience, by reason of service-connected disability or disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. If there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16(a). For those veterans who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a), total disability ratings for compensation may nevertheless be assigned when it is found that the service-connected disabilities are sufficient to produce unemployability; such cases should be referred to the Director, VA Compensation and Pension Service, for extraschedular consideration. 38 C.F.R. § 4.16(b). The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529(1993). Neither non-service-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). For a veteran to prevail on a claim based on unemployability, it is necessary that the record reflect some factor which places the claimant in a different position than other veterans with the same disability rating. The sole fact that a claimant is unemployed or has difficulty obtaining employment because of economic circumstances is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. See Van Hoose, supra. As noted, consideration may not be given to the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. In this case, the Veteran is currently service connected for arteriosclerotic heart disease, rated as 60 percent disabling; diabetes mellitus, rated as 20 percent disabling; peripheral neuropathy of the left lower extremity, rated as 20 percent disabling; peripheral neuropathy of the right lower extremity, rated as 20 percent disabling; surgical scars, rated as 0 percent disabling; and abdominal aortic aneurysm, rated as 0 percent disabling; and cataracts, rated as 0 percent disabling. His combined rating is 80 percent. Therefore, the Veteran meets the schedular requirements for a TDIU, as he has one disability rating of at least 40 percent or higher and sufficient additional disability ratings to warrant a combined rating of 70 percent for his service-connected disabilities. The Veteran has indicated that he has not worked full-time since 2004 and that he is presently unemployable. See, e.g., January 2005 VA General Examination. Given that he meets the threshold percentage requirements for a TDIU, additional development should be conducted to determine whether he is unemployable as a result of his service-connected disabilities. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a letter which describes the evidence necessary to substantiate a claim for TDIU, including the Veteran's duties to substantiate the record, and VA's duties. Allow for a reasonable period to respond. 2. Send the Veteran a letter requesting him to identify any pertinent VA or private treatment records reflecting treatment for diabetic-related cataracts and to furnish the appropriate release forms for any private treatment records, to include any treatment or surgery in January 2013. Then, request these records and associate such records with the claims file. All efforts to obtain these records must be fully documented and associated with the claims file, including any negative responses. If these records cannot be obtained, the Veteran should be notified of this fact and a copy of such notification associated with the claims file. 3. Thereafter, the Veteran should be scheduled for a VA eye examination to address the symptoms and severity of the service-connected diabetic cataracts. The examiner should review the claims folder and note such review in the examination report. The examination must encompass visual acuity and field vision testing and must address all eye symptoms. The claims file should be furnished to the examiner for his or her review. The results of visual field testing must be recorded on a standard Goldmann chart, and the Goldmann chart must be included with the examination report. The Veteran's subjective complaints should be addressed, and all opinions must be supported by a complete rationale. 4. Then, determine whether the Veteran is entitled to a TDIU. If deemed necessary, schedule the Veteran for the appropriate VA examination(s) to determine whether it is at least as likely as not (i.e., to at least a 50/50 degree of probability) that he is unemployable as a result of his service-connected disabilities; or whether being unemployable as a result of his service-connected disabilities is unlikely (i.e. less than a 50/50 degree of probability). Note: As used above, the term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. The claims file, to include a copy of this Remand, must be reviewed in conjunction with the examination. All relevant information of record should be considered. Any opinion provided should include discussion of specific evidence of record. If any question cannot be answered without resorting to pure speculation, the examiner must provide a complete explanation why those questions cannot be answered. 5. After undertaking any additional development which it deems necessary, the RO should then readjudicate the Veteran's claims. If the benefits sought on appeal remain denied, the RO should provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. The case should then be returned to the Board for further consideration, if otherwise in order. The appellant 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). ______________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs