Citation Nr: 1310024 Decision Date: 03/25/13 Archive Date: 04/02/13 DOCKET NO. 04-29 457 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to an increased (compensable) rating for status-post hemorrhoidectomy. 2. Entitlement to an increased (compensable) rating for diabetes mellitus, currently evaluated as noncompensable (0 percent disabling) prior to May 28, 2011, and as 10 percent disabling thereafter. 3. Entitlement to a separate initial compensable rating for peripheral neuropathy of the right lower extremity prior to May 28, 2011, and a rating in excess of 10 percent after that date. 4. Entitlement to a separate initial compensable rating for peripheral neuropathy of the left lower extremity prior to May 28, 2011, and a rating in excess of 10 percent after that date. 5. Entitlement to an initial compensable rating for erectile dysfunction. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran had active duty service from September 1955 to August 1975. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2003 rating decision rendered by the Togus, Maine Regional Office (RO) of the Department of Veterans Affairs (VA) which denied the Veteran's claims for a compensable rating for diabetes mellitus, and for status-post hemorrhoidectomy. The Veteran appealed the issues of entitlement to increased ratings, and in April 2007, and April 2011, the Board remanded the claims for additional development. A May 2012 rating action then increased the rating for diabetes mellitus to 10 percent, effective from May 28, 2011, assigned 10 percent ratings for right and left lower extremity peripheral neuropathy from that date, and assigned a noncompensable rating for erectile dysfunction from October 13, 2004. All of these ratings were assigned during the Veteran's appeal of his rating for diabetes and are therefore additional matters for current appellate review. Jurisdiction over this matter was transferred to the Baltimore, Maryland RO immediately after the issuance of the May 2003 rating decision. In January 2013, the Veteran was afforded a hearing at the Central Office before the undersigned Acting Veterans Law Judge who is rendering the determination in this claim and was designated by the Chairman of the Board to conduct that hearing, pursuant to 38 U.S.C.A. § 7102(b) (West 2002). As noted in the Board's April 2011 Remand, the issues of entitlement to service connection for a thyroid disorder, a prostate disorder and a cardiac disorder to include ischemic heart disease were raised by the Veteran in a [July] 2007 statement, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). The Veteran also raised a claim for service connection for obstructive sleep apnea and "skin problems" in a November 2001 letter. The Board does not have jurisdiction over these claims and they are again referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran's service-connected status-post hemorrhoidectomy is productive of internal hemorrhoids that frequently prolapse without evident reduction which is consistent with a finding of irreducible, large, or thrombotic hemorrhoids with excessive redundant tissue and evidencing frequent recurrences; while there is periodic bleeding, persistent bleeding with secondary anemia or fissures is not shown. 2. Prior to May 28, 2011, the Veteran is shown to have had diabetes mellitus that was manageable by restricted diet only. 3. At no time during the time frame on appeal has the Veteran been shown to have diabetes mellitus that is productive of the need for insulin, or an oral hypoglycemic agent. 4. The medical evidence of record shows that the Veteran's right lower extremity peripheral neuropathy is manifested by mild incomplete paralysis throughout the entire period on appeal. 5. The medical evidence of record shows that the Veteran's left lower extremity peripheral neuropathy is manifested by mild incomplete paralysis throughout the entire period on appeal. 6. The record reflects that although the Veteran is reportedly on oral medication for erectile dysfunction and has recently received implants, no deformity has been shown. CONCLUSIONS OF LAW 1. The criteria for a 10 percent, but not greater, rating for service-connected status-post hemorrhoidectomy have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.114, Diagnostic Code 7336 (2012). 2. Prior to May 28, 2011, the criteria for a 10 percent, but not greater, rating for diabetes mellitus have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.119, Diagnostic Code 7913 (2012). 3. The criteria for a rating in excess of 10 percent for diabetes mellitus have not been met at any time during the time frame on appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.119, Diagnostic Code 7913 (2012). 4. The criteria for separate initial compensable ratings for peripheral neuropathy of the right and left lower extremities have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.124a, Diagnostic Code 8625 (2012). 5. The criteria for separate ratings in excess of 10 percent for peripheral neuropathy of the right and left lower extremities have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.124a, Diagnostic Code 8625 (2012). 6. The criteria for a separate initial compensable rating for erectile dysfunction have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.115b, Diagnostic Code 7522 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Ratings The Veteran asserts that he is entitled to increased ratings for his service-connected status-post hemorrhoidectomy, and diabetes mellitus, type 2. The Board initially notes that during his hearing, held in January 2013, it was noted that a May 2012 rating decision "may not have yet been promulgated." It was noted that this rating decision showed that the Veteran's evaluation for diabetes had been increased to 10 percent, that the Veteran had been assigned two separate ratings for peripheral neuropathy of the bilateral lower extremities, that service connection had been granted for erectile dysfunction, and that special monthly compensation had been granted based on loss of use of a creative organ. It was indicated that the Veteran had never received the May 2012 rating decision, and it was agreed that the record would be held open 30 days for this matter to be resolved by the Veteran and his representative. No relevant argument, statements, or other information was subsequently received from either the Veteran or his representative as to the May 2012 rating decision, and it therefore appears that there are no unresolved issues as to this rating decision. Disability evaluations are determined by comparing the veteran's present symptomatology with the criteria set forth in the VA's Schedule for Ratings Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § Part 4. 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. A. Status-post hemorrhoidectomy The Veteran asserts that he is entitled to a compensable rating for his status-post hemorrhoidectomy. During his hearing, held in January 2012, he testified that he had symptoms that included bleeding and pain. He argued, in part, that he had been given a colonoscopy a few years before which showed that he had internal hemorrhoids. With regard to the history of the disability in issue, see 38 C.F.R. § 4.1 (2012), the Veteran's service treatment reports include examination reports, dated in February 1966 and May 1971, which note one or two small external hemorrhoids. A "report of medical history" accompanying the May1971 report indicates that his hemorrhoids had been removed. See also June 1975 separation examination report (noting a history of drained and removed hemorrhoids in 1971). As for the post service medical evidence, a December 1975 VA examination report includes a diagnosis of status post hemorrhoidectomy. Tri Care reports include a May 2000 report which notes a history of hemorrhoid resection "unknown internal/external" 10 years ago. In May 1976, the RO granted service connection for status-post hemorrhoidectomy and assigned a 0 percent rating. There was no appeal, and the RO's decision became final. See 38 U.S.C.A. § 7105(c) (West 2002 & Supp. 2011). In March 2002, the Veteran filed a claim for an increased (compensable) rating. In May 2003, the RO denied the claim. The Veteran has appealed. The Veteran's disability has been evaluated as noncompensable under 38 C.F.R. § 4.114, DC 7336. Under 38 C.F.R. § 4.114 , DC 7336, which pertains to both internal and external hemorrhoids, a 0 percent (noncompensable) evaluation is warranted for mild or moderate hemorrhoids. A 10 percent evaluation is warranted for irreducible, large, or thrombotic hemorrhoids with excessive redundant tissue and evidencing frequent recurrences. 38 C.F.R. § 4.114. Id. Tri Care reports, dated in March 2002, show that the Veteran was noted to have bright red rectal bleeding, and that he underwent a colonoscopy. The impression notes diminutive sigmoid polyp, and internal hemorrhoids. A May 2003 report also notes internal hemorrhoids. A VA examination report, dated in March 2003, shows that the Veteran reported recurrent anal bleeding. On examination, there were no external hemorrhoids. The relevant diagnosis noted recurrent anal bleeding, with no external hemorrhoids on examination. VA progress notes, dated in 2007, contain "problem lists" noting "internal hemorrhoids without mention of complication." A VA examination of the rectum and anus, dated in June 2011, shows that the Veteran's claims file had not been reviewed, but that his medical records had been reviewed. The Veteran reported a history of rectal bleeding during service, a hemorrhoidectomy in 1980, and that he had been on Colase bid (twice daily) since then. He stated that if he watches his diet and is not constipated, he does not have a problem. He stated that his last episode of pain and bleeding had been eight months before. The report notes the following: there was an occasional history of rectal bleeding. The Veteran reported anal itching, diarrhea, pain, and difficulty passing stool. He denied swelling, tenesmus, and burning. There was a history of occasional bleeding hemorrhoids. On examination, hemorrhoids were not present. The diagnosis was hemorrhoids, no visible external hemorrhoids, and it notes that a colonoscopy in 2007 confirms internal hemorrhoid, minimal bleeding and pain, last event in early 2010. There were no significant effects on usual occupation, or on usual daily activities. The Board finds that the criteria for a 10 percent rating have been met during the entire time frame on appeal. The medical evidence dated during the time period in issue, i.e., since March 2001, see 38 C.F.R. § 3.400(o)(2) (2012), shows that the Veteran has been noted to have internal hemorrhoids and to have bleeding. In addition, he has credibly testified that his disability has been demonstrated by frequently prolapsing hemorrhoids without evident reduction which the Board finds to be consistent with a finding of irreducible, large, or thrombotic hemorrhoids with excessive redundant tissue and evidencing frequent recurrences. However, while there is evidence of periodic bleeding, there is no evidence of persistent bleeding with anemia or fissures. Accordingly, the Board finds that the evidence supports entitlement to a 10 percent rating but is against a rating of 20 percent. B. Diabetes Mellitus, Type 2 The Veteran asserts that he is entitled to a compensable rating for his diabetes mellitus, type 2. During his hearing, held in January 2012, he testified that he was told upon separation from service that he required a restricted diet for control of his symptoms. He denied every using medication, or insulin. However, he later stated that he had been put on medication at one point, but that this had been discontinued and that he adhered to exercise and diet. With regard to the history of the disability in issue, see 38 C.F.R. § 4.1, the Veteran's service treatment reports show that in August 1975, he was evaluated for diabetes mellitus. As for the post-service medical evidence, a December 1975 VA examination report shows that the Veteran reported that he had been told that he had "chemical diabetes," i.e., abnormal glucose tolerance. The diagnosis was "no diabetes found this examination." However, in May 1976, the RO granted service connection for adult-onset diabetes mellitus and assigned a 0 percent rating. Thus, the Veteran has clearly been service-connected for this disability. Therefore, the only question that remains is whether his symptoms meet the requirement for an increased rating. In March 2002, the Veteran filed a claim for an increased rating. In May 2003, the RO denied the claim. The Veteran appealed, and in May 2012, the Appeals Management Center (AMC) granted the claim, to the extent that it assigned a 10 percent rating, with an effective date of May 28, 2011. Since this increase did not constitute a full grant of the benefits sought, the increased rating issue remains in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). The Veteran's diabetes mellitus is currently evaluated pursuant to 38 C.F.R. § 4.119, Diagnostic Code (DC) 7913. Under those criteria, a 10 percent rating is assigned if the condition is manageable by restricted diet only. A 20 percent rating is warranted for diabetes mellitus requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. Id. "Successive" rating criteria, such as Diagnostic Code 7913 for diabetes mellitus, is where the evaluation for each higher disability rating includes the criteria of each lower disability rating, such that if a component is not met at any one level, the Veteran can only be rated at the level that does not require the missing component. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). For example, the diagnostic code for diabetes mellitus (DC 7913) is successive because each higher evaluation requires the elements of the lower evaluation: the 10 percent evaluation requires a restricted diet; the 20 percent evaluation requires a restricted diet and insulin or oral hypoglycemic agent, the 40 percent evaluation requires insulin, restricted diet, and regulation of activities; and so forth. Camacho v. Nicholson, 21 Vet. App. 360 (2007). 1. Prior to May 28, 2011 The relevant medical evidence is summarized as follows: VA progress notes show the following: the Veteran's blood tests were normal, except for cholesterol (October 2001); the Veteran had dietary restrictions due to cholesterol (January 2002); the Veteran did not have "insulin-requiring diabetes" (February 2002); and the Veteran denied a history of diabetes mellitus (April 2002). A VA diabetes mellitus examination report, dated in September 2002, shows that the Veteran reported that he had been told that he had diabetes mellitus upon discharge from service, and that no treatment was suggested other than diet. It was noted that he had apparently never been treated for diabetes mellitus. A VA diabetes mellitus examination report, dated in March 2003, shows that the examiner noted a previous history of a normal blood sugar test, and an inability to confirm diabetes mellitus. There was no relevant diagnosis. A November 2009 VA hypertension examination report shows that the Veteran's glucose was within normal limits; there was no relevant diagnosis. The Board finds that the Veteran's diabetes is entitled to a 10 percent, but not greater, rating. More specifically, the Veteran is clearly service connected for this disorder and while the evidence that the Veteran was placed on restricted diet in 2001 was reportedly associated with high cholesterol, a history was reported by the Veteran of restricted diet arising out of his diabetes, and this was further credibly testified to by the Veteran at his hearing before the Board. Therefore, the Board will give the Veteran the benefit of the doubt, and find that he is entitled to a 10 percent, but not greater, rating for his diabetes for the period prior to May 28, 2011. 2. A Rating in Excess of 10 Percent before and after May 28, 2011 The only additional relevant medical evidence dated during the time period in issue is a VA diabetes mellitus examination report, dated in May 2011, which indicates that the Veteran was examined on May 28, 2011. The VA examination report shows that the examiner stated that the Veteran's claims file had been reviewed. The Veteran reported a history of diabetes mellitus, and that he was "no longer on oral medication and controls his blood glucose through diet and exercise alone." The oral medication was not identified as a hypoglycemic agent and there is no medical evidence that supports a finding that the Veteran was ever prescribed such an agent. His last HgA1c (glycosylated hemoglobin) (on November 5, 2010) was noted to reveal "excellent" blood glucose control (5.5 percent). His current treatment was noted to be "diet alone." The report notes that there was no history of diabetes-related hospitalization, or surgery. The relevant diagnosis was diet-controlled diabetes mellitus. The Board finds that the Veteran's claim for rating in excess of 10 percent must be denied with respect to the entire time frame on appeal. There is no medical evidence that supports the conclusion that the oral medication that the Veteran was taking was a hypoglycemic agent, and at the Veteran's May 2011 VA examination, he reported that he controlled his blood glucose through "diet and exercise alone." In addition, during his hearing, held in January 2012, he indicated that he was not using insulin, or medication. There is simply no medical evidence to show that the Veteran requires insulin, or an oral hypoglycemic agent. The Board therefore finds that the evidence is insufficient to show that the Veteran has diabetes mellitus requiring insulin and restricted diet, or an oral hypoglycemic agent and restricted diet, that the preponderance of the evidence is against the claim for a rating in excess of 10 percent, and that the claim for a rating in excess of 10 percent for diabetes must be denied. C. Right and Left Lower Extremity Peripheral Neuropathy VA examination in May 2011 revealed that the examiner reviewed the Veteran's claims folder in conjunction with this examination. The examiner rendered a diagnosis of mild bilateral lower extremity peripheral neuropathy, and indicated that the nerves affected were the peroneal, sural, tibial, and calcaneal nerves. The examiner noted decreased vibration in the right and left plantar aspect of the feet and toes, and dysesthesias located in the plantar aspect of the feet and toes. The examiner also noted that the Veteran had neuritis and that he reported bilateral foot pain and burning after being on his feet for prolonged periods of time. At the Veteran's recent hearing before the Board the Veteran recognized that he was granted separate ratings of 10 percent for the burning and tingling sensation he reported at the time of VA examination on May 28, 2011. He believed that he may have had these symptoms prior to that date, but not as pronounced. Under Diagnostic Code 8525, incomplete paralysis of the tibial nerve warrants a 10 percent rating when it is mild or moderate in degree. A 20 percent rating is warranted for incomplete paralysis which is severe in degree. With respect to diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis for a particular 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. 38 C.F.R. § 4.124a (2012). A 30 percent rating is assigned for complete paralysis that is demonstrated by paralysis of all muscles of the sole of the foot, frequently with painful paralysis of a causalgic nature, inability to flex the toes, weakened abduction, and impairment of plantar flexion. Based on the findings associated with the Veteran's peripheral neuropathy and the examiner's opinion that the Veteran has neuritis, the Board agrees that Diagnostic Code 8625, which applies to neuritis under Diagnostic Code 8525, is the most appropriate code for rating the Veteran's symptoms of burning and tingling in the plantar aspect of his feet and toes. The Board further agrees with the RO's decision to assign 10 percent ratings for the Veteran's right and left lower extremity peripheral neuropathy based on the results of the May 2011 VA peripheral nerves examination. The Board does not, however, find that there is sufficient evidence to warrant a 10 percent rating prior to May 28, 2011. At the time of the Veteran's hearing before the Board, the Veteran himself was unclear as to the frequency of his radiculopathy prior to May 28, 2011, and there is no evidence that it had necessitated treatment or complaints to his treating physician's prior to this date. Consequently, the Board finds that there is no basis to find that a 10 percent rating should be assigned earlier than May 28, 2011. Moreover, with respect to the issue of entitlement to a ratings in excess of 10 percent for the Veteran's lower extremity peripheral neuropathy, a higher rating for severe neuritis is not warranted because there is no medical evidence of record that characterizes the Veteran's bilateral lower extremity symptoms as greater than mild in degree. The May 28, 2011, VA report specifically diagnosed the peripheral neuropathy as mild, which the Board finds to be consistent with the fact that current symptoms are limited to decreased sensory loss and impairment. Accordingly, ratings in excess of 10 percent for the Veteran's right and left lower extremity peripheral neuropathy are not warranted. D. Erectile Dysfunction At the Veteran's May 28, 2011, VA peripheral nerves examination, it was noted that the Veteran suffered from erectile dysfunction but with oral medication was apparently able to achieve vaginal penetration about 50 percent of the time. At the time of his hearing before the Board, while the Veteran also noted that he had been recently provided with implants, he did not indicate that this surgical procedure left him with any deformity. As was noted previously, the Veteran has been assigned a noncompensable rating for erectile dysfunction effective from the date of his claim for service connection for this disorder. Under 38 C.F.R. § 4.115b, Diagnostic Code 7522, a 20 percent evaluation is awarded for penis deformity with loss of erectile power. As no penis deformity has been shown, the Board finds that the Veteran is not entitlement to a separate award of service connection for erectile dysfunction under Diagnostic Code 7522. In addition, while special monthly compensation may also be awarded for the loss of use of a creative organ under 38 U.S.C.A. § 1114(k) and 38 C.F.R. § 3.350 (2012), the record reflects that the Veteran has already been awarded this benefit and thus, this regulation also does not provide a basis for an increased rating for the Veteran's erectile dysfunction. Consequently, the Board finds that a preponderance of the evidence is against entitlement to an increased rating for the Veteran's additionally service-connected erectile dysfunction. E. Extraschedular Consideration Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Schedule is sufficient. 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008); Fisher v. Principi, 4 Vet. App. 57 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria under the Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Schedule, and the assigned schedular evaluation is adequate, and no referral is required. When service-connected disability affects employment in ways not contemplated by the rating schedule, § 3.321(b)(1) is applicable. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disability ratings for status-post hemorrhoidectomy, diabetes mellitus, right and left lower extremity peripheral neuropathy, and erectile dysfunction, inadequate. The Veteran's status-post hemorrhoidectomy, diabetes mellitus, peripheral neuropathy, and erectile dysfunction are evaluated under diagnostic codes the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. As noted above, the Veteran's status-post hemorrhoidectomy is manifested by frequently prolapsing internal hemorrhoids without evident reduction, his diabetes mellitus is manifested by symptoms requiring a restricted diet, his lower extremity peripheral neuropathy is manifested by mild symptoms of sensory impairment, and his erectile dysfunction is manifested by symptoms that require medication and have resulted in the use of implants but not deformity. When comparing the disability picture as to these disabilities with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the disability ratings assigned herein for these disorders. Ratings in excess of the ratings assigned herein are provided for certain manifestations of the disorders, but the medical evidence reflects that those manifestations are not present in this case. The criteria for the ratings assigned herein for the Veteran's disorders more than reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently schedular evaluations assigned herein are adequate and no referral is required. See VAOGCPREC 06-96, 61 Fed. Reg. 66749 (1996); see also 38 C.F.R. § 4.119, Diagnostic Code 7913. The Board would like to also point out that while some of these service-connected disorders would cause some functional impact on the Veteran's occupation prior to his retirement (security guard), there is no evidence and the Veteran has not contended that any of these disorders preclude him from engaging in or maintaining gainful employment. Consequently, the Board does not find that the record has raised an implied claim for a total disability rating based on individual unemployability pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). F. Conclusion In deciding the Veteran's increased rating claims, the Board has considered the determination in Hart v. Mansfield, 21 Vet. App. 505 (2007) and Fenderson v. West, 12 Vet. App. 119 (1999), 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 the Veteran's status post hemorrhoidectomy, diabetes mellitus, peripheral neuropathy, or erectile dysfunction should be increased for any other separate period based on the facts found during the whole appeal period. The evidence of record from the day the Veteran filed the claims to the present supports the conclusion that the Veteran is not entitled to additional increased compensation during any time within the appeal period. In reaching these decisions, the Board considered the doctrine of reasonable doubt, however, with the exception of the increased rating for status post hemorrhoidectomy and the staged rating for diabetes, the medical evidence, as discussed in detail above, provides a decided preponderance of evidence against the claims. As the preponderance of the evidence is otherwise against the appellant's claims, the doctrine of reasonable doubt is not for application and the appeal must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). II. The Veterans Claims Assistance Act of 2000 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 & Supp. 2011); 38 C.F.R. § 3.159 (2012). In April 2002, and June 2007, the Veteran was issued VCAA notices in association with his claims. The RO has 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 records relevant to the issues on appeal have been obtained and are associated with the Veteran's claims file. The RO has obtained the Veteran's service treatment reports, and VA and non-VA medical records, to include Tri-Care records. The Veteran has been afforded VA examinations. In April 2011, the Board remanded these claims. The Board directed that the Veteran be afforded examinations for both of his claims, and in May and June of 2011, this was done. The reports of these examinations show that the examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate physical examinations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. In this regard, to the extent that the June 2011 VA examination was not based on a review of the Veteran's claims file, such a review is not required in every case. See VAOPGCPREC 20-95, 61 Fed. Reg. 10 ,064 (1996). This is an increased rating claim, the purpose of which is to obtain current findings. The examiner stated that the Veteran's medical records were reviewed. This examination report shows that the examiner recorded the Veteran's relevant history and current complaints, performed an examination, and provided all necessary findings. The Board therefore concludes that these examination reports are adequate for purposes of rendering decisions in the instant appeal. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Given the foregoing, the Board finds that there has been substantial compliance with its April 2011 remand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to a veteran are to be avoided). The Board concludes, therefore, that decisions on the merits at this time do not violate the VCAA, nor prejudice the Veteran 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). ORDER A 10 percent, but not greater, rating for status-post hemorrhoidectomy is granted, subject to the statutes and regulations governing the payment of monetary benefits. Prior to May 28, 2011, a 10 percent, but not greater, rating for service-connected diabetes mellitus, type 2, is granted, subject to the statutes and regulations governing the payment of monetary benefits. A rating in excess of 10 percent for service-connected diabetes mellitus, type 2, is denied. A separate initial compensable rating for right lower extremity peripheral neuropathy is denied. A separate initial compensable rating for left lower extremity peripheral neuropathy is denied. A separate rating in excess of 10 percent for right lower extremity peripheral neuropathy is denied. A separate rating in excess of 10 percent for left lower extremity peripheral neuropathy is denied. A separate initial compensable rating for erectile dysfunction is denied. ______________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs