Citation Nr: 1310230 Decision Date: 03/26/13 Archive Date: 04/02/13 DOCKET NO. 05-06 402 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for gastroesophageal reflux disease (GERD) and gastroparesis, secondary to service-connected type II diabetes mellitus and related neuropathy. 2. Entitlement to an initial rating in excess of 20 percent for type II diabetes mellitus prior to January 30, 2012. 3. Entitlement to a rating in excess of 60 percent for type II diabetes mellitus from January 30, 2012. 4. Entitlement to an initial separate compensable rating for diabetic retinopathy. 5. Entitlement to an initial compensable rating for diabetic nephropathy prior to November 1, 2005. 6. Entitlement to a rating higher than 30 percent for diabetic nephropathy from November 1, 2005 to January 29, 2012. 7. Entitlement to a rating in excess of 60 percent for diabetic nephropathy from January 30, 2012. 8. Entitlement to an initial rating in excess of 10 percent for left hip strain. 9. Entitlement to an initial rating in excess of 10 percent for right hip strain. 10. Entitlement to an initial rating in excess of 10 percent for left knee strain. 11. Entitlement to an initial rating in excess of 10 percent for right knee strain. ATTORNEY FOR THE BOARD J. Hager, Counsel INTRODUCTION The Veteran served on active duty from January 1966 to September 1969. These matters initially came before the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Atlanta, Georgia, Regional Office (RO) of the Department of Veterans Affairs (VA). In a September 2003 rating decision, the RO granted entitlement to service connection for type II diabetes mellitus with impotence, diabetic retinopathy, and diabetic nephropathy, and assigned a 20 percent disability effective February 7, 2002. The RO also denied entitlement to service connection for GERD with hiatal hernia (claimed as gastroparesis). In a January 2006 decision review officer decision, the RO granted entitlement to service connection for bilateral hip and knee strains, and assigned four separate noncompensable disability ratings effective April 13, 2005. In January 2007, the Board denied the claim of entitlement to an initial separate compensable rating for erectile dysfunction with penile deformity, and remanded the issues of entitlement to service connection for GERD on a direct basis and entitlement to an initial rating in excess of 20 percent for type II diabetes mellitus with diabetic retinopathy and diabetic nephropathy along with the orthopedic initial increased rating claims for further development. In an October 2007 rating decision, the RO granted service connection for post-operative residuals of bilateral cataract surgery with intra-ocular lens, and assigned a 30 percent disability rating effective May 31, 2006. In June 2008, the Board denied entitlement to service connection for GERD on a direct basis and denied entitlement to an initial rating in excess of 20 percent for diabetes mellitus. The Board, however, granted four separate 10 percent disability ratings for bilateral hip and knee strains. The Veteran appealed to the United States Court of Appeals for Veterans Claims (the Court). In a September 2010 memorandum decision, the Court did not disturb the denial of entitlement to service connection for GERD on a direct basis. The Court, however, did remand the issue of entitlement to service connection for GERD, to include gastroparesis, as secondary to service-connected type II diabetes mellitus. The Court also vacated the decision as to the increased rating claims and remanded them to the Board. In the interim, in an August 2010 rating decision, the RO assigned a separate 30 percent disability rating for diabetic nephropathy effective December 23, 2009. In December 2011, the Board remanded to the RO, via the Appeals Management Center (AMC), claims for service connection for GERD and gastroparesis secondary to diabetes, for higher initial ratings for diabetes, diabetic nephropathy, and bilateral hip and knee strain and for a separate compensable rating for diabetic retinopathy. For the reasons stated below, the RO/AMC complied with the Board's December 2011 remand instructions. In September 2012, the RO increased the rating for diabetes to 60 percent effective January 30, 2012, and for diabetic nephropathy to 60 percent effective January 30, 2012. The RO also granted a 30 percent rating for diabetic nephropathy from November 1, 2005. The Board has recharacterized the issues accordingly. In entering this decision, pertinent records in Virtual VA have been reviewed. The issue of entitlement to service connection for GERD and gastroparesis, secondary to diabetes and related neuropathy, 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. Prior to January 30, 2012, the Veteran's diabetes did not require insulin, restricted diet, and regulation of activities. 2. From January 30, 2012, the Veteran's diabetes did not require more than one daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 3. The Veteran's diabetic retinopathy has not caused incapacitating episodes, central visual acuity worse than 20/40 uncorrected distance vision in either eye, or impairment of visual fields or other symptoms warranting a separate compensable rating. 4. Prior to November 1, 2005, the Veteran's diabetic nephropathy did not cause symptoms more nearly approximating albumin constant or recurring with hyaline and granular casts or red blood cells, or transient or slight edema or hypertension at least 10 percent disabling. 5. From November 1, 2005 to January 29, 2012, the Veteran's diabetic nephropathy did not cause symptoms more nearly approximating constant albuminuria with some edema or definite decrease in kidney function or hypertension at least 40 percent disabling. 6. From January 30, 2012, the Veteran's diabetic nephropathy did not cause symptoms more nearly approximating persistent edema and albuminuria with BUN 40 to 80 or creating more than 8 or generalized poor health characterized by lethargy, weakness, anemia, weight loss, or limitation of exertion. 7. Neither hip disability has resulted in limitation of flexion of the thigh to 45 degrees flexion, limitation of extension to 5 degrees, significant limitation of abduction, adduction, or rotation, or ankylosis, flail joint, or impairment of the femur. 8. Neither knee disability has resulted in flexion limited to 45 degrees or extension limited to 10 degrees, or ankylosis, recurrent subluxation or lateral instability, dislocated or removed semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 20 percent for diabetes prior to January 30, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.119, Diagnostic Code (DC) 7913 (2012). 2. The criteria for a rating higher than 60 percent for diabetes from January 30, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.119, DC 7913. 3. The criteria for an initial compensable separate rating for diabetic retinopathy have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.75, 4.84a, DC 6006 (2008); 38 C.F.R. §§ 4.76, 4.79, DC 6006 (2012). 4. The criteria for a compensable rating for diabetic nephropathy prior to November 1, 2005, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.115a, 4.115b, DC 7541. 5. The criteria for a rating higher than 30 percent for diabetic nephropathy from November 1, 2005 to January 29, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.115a, 4.115b, DC 7541. 6. The criteria for a rating higher than 60 percent for diabetic nephropathy from January 30, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.115a, 4.115b, DC 7541. 7. The criteria for an initial rating higher than 10 percent for left hip strain have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5252. 8. The criteria for an initial rating higher than 10 percent for right hip strain have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5252. 9. The criteria for an initial rating higher than 10 percent for left knee strain have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5260. 10. The criteria for an initial rating higher than 10 percent for right knee strain have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Clams Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. As to the claims being decided herein, these are all claims for higher initial ratings that arise from the Veteran's disagreement with ratings assigned in connection with the grant of service connection for these disabilities. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311, 1314-15 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007); VAOPGCPREC 8-2003 (2003). The Court has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as a disability rating) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105 (West 2002). Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). Consequently, further discussion of the VCAA's notification requirements with regard to these claims is unnecessary. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In its December 2011 remand, the Board instructed that the RO/AMC ask the Veteran to identify all relevant treatment records as well as records from a private insurance company, and attempt to obtain records from Piedmont Hospital and the Atlanta VAMC, as well as records relating to the Social Security Administration's (SSA's) disability determination. The RO requested that the Veteran provide the relevant information and authorizations in January and March 2012 letter, and obtained the Veteran's service treatment records (STRs) and all of the identified post-service private and VA treatment records, as well as SSA disability determination records. The RO/AMC thus complied with the Board's December 2011 remand instructions and its duty to assist in this regard. The Board also instructed that the RO/AMC afford the Veteran multiple VA examinations with regard to the severity of his service connected disabilities. For the reasons stated below, the examinations provided were adequate with regard to the claims being decided herein. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The claims for higher initial ratings for diabetes, diabetic retinopathy and nephropathy, and bilateral hip and knee strain are thus ready to be considered on the merits. Analysis Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Fenderson v. West, 12 Vet. App. 119 (1999). As indicated above, the Veteran is in receipt of staged ratings for his diabetes and diabetic nephropathy. See also Hart v. Mansfield, 21 Vet. App. 505 (2007). Diabetes The Veteran is receiving a 20 percent rating for his diabetes under 38 C.F.R. § 4.119, DC 7913. Pursuant to DC 7913, a rating of 20 percent is assigned for diabetes requiring insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet. A 40 percent rating is warranted when the diabetes requires insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted when the diabetes 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. A 100 percent rating is warranted when the diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Note 2 to DC 7913 provides that compensable complications of diabetes are to be separately evaluated unless they are part of the criteria used to support a 100 percent rating, and that noncompensable complications are considered part of the diabetic process under DC 7913. The Veteran has been granted service connection for the following disabilities secondary to his diabetes: diabetic nephropathy, impotence, cataract surgery with intraocular lens implants along with diabetic retinopathy, bilateral shoulder adhesive capsulitis, bilateral hip strain, bilateral knee strain, and hypertension. The definition of "regulation of activities" in the criteria for a 100 percent rating, i.e., "the avoidance of strenuous occupational and recreational activities," applies to the "regulation of activities" criterion for a 40 percent rating under DC 7913. Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). Moreover, because of the successive nature of the rating criteria, such that the evaluation for each higher disability rating includes the criteria of each lower disability rating, each of the three criteria listed in the 40 percent rating must be met in order to warrant such a rating. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). In addition, a 40 percent rating under DC 7913 requires medical evidence that occupational and recreational activities have been restricted by the diabetes. Camacho, 21 Vet. App. at 363-365. On the July 2003 VA examination, the examiner noted that the Veteran had a 21 year history of diabetes mellitus, without a history of ketoacidosis or problems with hypoglycemia. He did have complaints of progressive weight loss, loss of strength, tingling and numbness of his extremities and abnormal sensation and low balance due to lack of feeling in his feet. He also had resulting bladder dysfunction that was partial and intermittent in nature. He had ocular symptoms with cataracts and other eye disorders. He took the medications Glucophage and Glucotrol, each, twice per day. He was able to do all of the activities of daily living without any restrictions. On the November 2005 VA examination, symptoms similar to those described during the 2003 examination report were noted. At this time, the Veteran's medications included Metformin, twice per day, Glucophage twice per day, and daily insulin injections, twice per day. He stated that his diabetes had also affected his eyes, with cataracts and retinopathy and had caused dry skin and erectile dysfunction. The examiner wrote, "The diabetes does not cause any restriction of activities." In his subsequent remarks, the examiner wrote, "The effect of the condition on the claimant's daily activities is limitation of ambulatory capacity due to bilateral hip and knee pain." On the March 2007 VA examination, the Veteran stated that he followed a carbohydrate-restricted diet and that his weight was fairly stable. The examiner wrote that the Veteran exercised by walking his dog around the neighborhood, which was the equivalent of 1-2 miles, and did this 3-4 times per week. In its September 2010 memorandum decision, the Court noted that the Veteran asserted in a March 2008 letter that he never told anyone he "routinely" walked his dog and he had not been able to take extended walks with his dog for several years. The March 2007 VA examiner also wrote, "He did not have any restrictions of activities due to his diabetes." The examiner also indicated that the Veteran did not have any hospitalizations, emergency room visits, hypoglycemic reactions or ketoacidosis. He did have diabetic retinopathy, but no diabetic related skin manifestations. He was treated with insulin in the morning, at lunch and in the evening. There was evidence of peripheral neuropathy and erectile dysfunction, but no bowel, bladder or cardiovascular complications other than hypertension. On the May 2010 VA examination, the examiner reported that the Veteran reported no episodes of diabetic ketoacidosis that required hospitalization, but indicated that he experienced hypoglycemic reactions and required hospital treatment on average 1 time per year including 1 hospitalization in the past year. The Veteran also indicated that he had a ketoacidosis or hypoglycemic reaction within the past year that required 1 hospital stay or visit to a diabetic care provider. The also indicated that he treated diabetes with diet including avoiding refined sugars and carbohydrates, oral medication, and insulin. On the January 2012 VA examination, the examiner indicated in the medical history section that treatment included prescription of oral hypoglycemic agents and insulin more than once per day, that the Veteran did not require regulation of activities as part of medical management of his diabetes, that he visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than 2 times per month, that he did not have any episodes of ketoacidosis or hypoglycemic reactions over the past 12 months, and that he had not had progressive unintentional weight loss or loss of strength attributable to diabetes. The VA examiner indicated that the Veteran reported being hospitalized for a hypoglycemic episode in 2009, that he reported fluctuating blood glucose levels at home, occasional hypoglycemic episodes if he did not eat on time not related to physical activity or strenuous activities and that he had not been physically active due to multiple medical problems. The above evidence reflects that the Veteran required insulin and a restricted diet for treatment of his diabetes but did not require any regulation of his activities such that his disability met the criteria for the 40 percent evaluation. The Board has considered the Veteran's detailed statements regarding the deterioration of his condition as well as his contention that the March 2007 VA examiner's statement that he took extended walks with his dog was inaccurate. Lay witnesses are competent to testify as to their observations, but this testimony must be weighed against the other evidence of record. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). The Board finds the Veteran's statement that he has not been able to take extended walks with his dog for several years to be credible; to this extent, the March 2007 VA examination report is inaccurate. The Board notes, however, that both the November 2005 and March 2007 VA examiners indicated that the diabetes did not cause restriction of activities and the July 2003 VA examiner indicated that the Veteran was able to do all of the activities of daily living without any restrictions. To the extent that these conclusions were based on the Veteran's statements, the Board finds these statements made during the course of VA examinations to be of greater probative weight than those made by the Veteran in connection with his appeal from the denial of greater compensation. See Fed. R. Evid. 803(4) (noting that statements made to physicians for the purposes of diagnosis and treatment are exceptionally trustworthy and not excluded by the hearsay rule because the declarant has a strong motive to tell the truth in order to receive proper care); Rucker v. Brown, 10 Vet. App. 67, 73 (1997) ("[R]ecourse to the [Federal] Rules [of Evidence] is appropriate where they will assist in the articulation of the Board's reasons.")); Pond v. West, 12 Vet. App. 341, 345 (1999); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest may affect the credibility of testimony). To the extent that the VA examiners drew a conclusion of lack of restriction based on the Veteran's statements and their examination of him, and the November 2007 VA examiner also based his conclusion on his review of the claims file, these conclusions are entitled to significant probative weight. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). It is also significant that there is a specific definition of "regulation of activities," i.e., "the avoidance of strenuous occupational and recreational activities," and the Court has held that a 40 percent rating under DC 7913 requires medical evidence that occupational and recreational activities have been restricted by the diabetes. Camacho, 21 Vet. App. at 363-365. The Board's findings above are consistent with the definition of regulation of activities and the requirement of medical evidence to demonstrate such regulation of activities. Moreover, even if the Veteran were competent to testify on this question, the specific findings of trained health care professionals are of greater probative weight than the Veteran's more general lay assertions on this question. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (finding that the Board had cited case law deeming lay evidence categorically incompetent "that has been overturned by this court's precedent"). Although the Veteran has never required regulation of activities for his diabetes, the RO/AMC granted a 60 percent rating effective January 30, 2012, the date of the VA examination on which there was evidence of ketoacidosis or glycemic reactions resulted in multiple hospitalizations or visits to a diabetic care provider within a 12 month period. According to the RO/AMC, it is VA policy to concede regulation of activities in such cases. The Board finds that there is no basis for any higher rating or for an earlier date for the 60 percent rating. Although the Veteran noted a single hospitalization in the previous 12 month period on the May 2010 VA examination, the records of the Veteran's hospitalization from Piedmont healthcare reflect that he was admitted for pneumonia and cardiac arrhythmia following loss of consciousness. Moreover, the above evidence reflects that the Veteran's symptoms have not more nearly approximated the criteria for a 100 percent rating, as it does not reflect that there have been episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider plus progressive loss of weight and strength or compensable complications not separately evaluated. For the foregoing reasons, the preponderance of the evidence is against an initial rating higher than 20 percent prior to January 30, 2012, and a rating higher than 60 percent from that date. Diabetic Retinopathy In October 2007, the RO granted service connection for post-operative bilateral cataract surgery, with intra-ocular lens implants secondary to diabetes. The Veteran submitted private medical evidence indicating that he had cataract surgery with intra-ocular lens implant in May and July 2006. In addition, a March 2007 VA eye examination indicated that the Veteran had moderate diabetic retinopathy and pseudophakia bilaterally, with diminished vision at times and occasional foreign body sensation with mild pain and no significant improvement following cataract surgery. On examination, there was evidence of cataract extraction with intra-ocular lens implants bilaterally, with corrected visual acuity for distance shown as 20/25 bilaterally. The RO assigned a 30 percent rating from the May 2006 date of surgery under 38 C.F.R. § 4.79, DCs 6028-6029. The rating code sheet indicated the disability as post-operative bilateral cataract surgery, with intra-ocular lens implants associated with diabetes, with impotence, diabetic nephropathy and hypertension. Subsequently, separate compensable ratings were granted for diabetic nephropathy and hypertension. This disability is currently listed on the rating code sheet as post-operative bilateral cataract surgery, with intra-ocular lens implants along with diabetic retinopathy associated with diabetes, with impotence. The issue in this regard thus appears to the Board to be whether a separate compensable rating has been warranted for diabetic retinopathy at any point during the appeal period. During the pendency of the appeal, the criteria for rating eye disabilities changed effective December 10, 2008. 73 Fed. Reg. 66,543 (Nov. 10, 2008). As the claim was received prior to that date, the Board will consider whether a separate rating is warranted for diabetic retinopathy under either the former or amended version of the criteria. Under the former version of the regulations, 38 C.F.R. § 4.84a, DC 6006, applied to retinitis and was to be rated, in chronic form, from 10 to 100 percent for impairment of visual acuity or field loss, pain, rest-requirements, or episodic incapacity, combining an additional rating of 10 percent during continuance of active pathology. The minimum rating during active pathology was 10 percent. Under the amended version of the regulations, 38 C.F.R. § 4.79a, DC 6006 is applicable to retinopathy or maculopathy, and is rated under the general rating formula for DCs 6000 through 6009. Under the general rating formula, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. Generally, under both the former and amended version of the criteria, rating based on visual acuity is based on the best corrected distant vision. 38 C.F.R. § 4.75 (2008); 38 C.F.R. § 4.76(b) (2012). In its December 2011 remand, the Board noted that the May 2010 VA examination did not address whether the Veteran's diabetic retinopathy was manifested by incapacitating episodes. However, on review of the claims file, and as noted below, there was an April 2010 VA examination that did address this question. On the July 2003 VA eye examination, both corrected and uncorrected vision was 20/20 in the right eye and 25/25 in the left eye. Examination was essentially normal, with diagnoses of mild to moderate background diabetic retinopathy with no evidence of clinically significant macular edema or proliferative diabetic retinopathy. Cataracts were noted, which were not visually significant and were more likely than not due to diabetes. On the November 2005 VA examination, there was a diagnosis of diabetic retinopathy at least as likely as not a complication of diabetes because the onset of the condition was deemed to be a complication of the diabetes. On the March 2007 VA examination, the Veteran complained of decreased vision in both eyes especially in the mornings, which gradually cleared during the day, as well as trouble reading. He did not notice a significant improvement in vision after cataract surgery and denied diplopia. His May and July 2006 cataract surgeries were noted. Visual acuity was 20/25 with and without correction in the right eye and vision in the left eye was 20/40 uncorrected and 20/25 with correction. After examination, the diagnoses were moderate diabetic retinopathy of both eyes, pseudophakia of both eyes, blepharitis of both eyes, and macroaneurysm of both eyes. On the April 2010 VA eye examination, the Veteran indicated he had no pain, distorted vision, redness, swelling, halos, watering, enlarged images, or floaters. The Veteran indicated he had not had any incapacitating episodes in the previous 12 months due to his eye condition. He did report blurred vision. On examination, best corrected vision was 20/25 in each eye, and uncorrected vision was 20/25 in the right eye and 20/50 in the left eye. After examination, the examiner noted that the Veteran's cataracts were likely related to his diabetes and there was evidence of background diabetic retinopathy in both eyes. The final diagnoses were status post cataract extraction, status post Yag capsulotomies, background diabetic retinopathy of both eyes, pigment epithelial degenerative changes in the right macula, and hyperopia and presbyopia. Eye examination on the May 2010 VA examination was normal. On the January 2012 VA eye examination, diagnoses of background diabetic retinopathy of the left eye and proliferative diabetic retinopathy of the right eye were noted. Uncorrected distance and near vision were 20/40 or better in both eyes. There was no anatomical loss, light perception only, or extremely poor vision or blindness, no corneal irregularity resulting in severe irregular astigmatism, and no diplopia. Slit lamp and external eye examination findings were normal other than the lens, which was PCIOL status post YAG bilaterally. Internal eye exam showed abnormal macula and periphery, with 4 quadrant DBH, diabetic, inactive PDR in the right eye and moderate BDR in the left eye. There was no visual field defect. Cataracts and replacement lenses were noted, with no aphakia or dislocation of the crystalline lens, and no visual acuity or visual impairment was attributable to the cataracts because the surgery was successful. In addition, bilateral retinopathy and maculopathy were noted, with inactive proliferative diabetic retinopathy of the right eye and moderate background diabetic retinopathy of the left eye indicated as the cause of the Veteran's current visual acuity. There was no scarring or disfigurement attributable to any eye condition. Significantly, there were no incapacitating episodes. In his concluding remarks, the examiner noted that the proliferative diabetic retinopathy of the right eye was inactive, and that there was diabetic macular edema of the right eye and moderate non-proliferative diabetic retinopathy of the left eye. The nature and extent of the Veteran's disability was indicated as best corrected visual acuity of 20/30 in the right eye and 20/25 in the left eye, with daytime and night vision limited from diabetic retinopathy. Based on the above evidence, the Veteran is not entitled to a separate compensable rating at any time during the appeal period. The Veteran's central visual acuity was not at any point poor enough (worse than 20/40 corrected distance vision in either eye) to warrant a compensable rating under the Table for Central Visual Acuity Impairment. Moreover, there was no impairment of visual fields or other disorder significant enough to warrant a compensable rating under any potentially applicable diagnostic code under either the former or amended criteria. In addition, while the Veteran is competent to indicate that his vision is blurry, the probative value of the general lay assertions in this regard are outweighed by the specific optometric findings of the trained health care professionals who conducted vision testing throughout the appeal period. The preponderance of the evidence is therefore against a separate compensable rating for diabetic retinopathy. Diabetic Nephropathy In its September 2003, the RO granted service connection for diabetes with impotence and nephropathy and assigned a single 20 percent rating. In an August 2010 rating decision, the RO granted a separate, 30 percent rating for diabetic nephropathy, effective December 23, 2009, which it termed as the date of a claim for increase. In its December 2011 remand, the Board characterized the issues on appeal with regard to this disability as entitlement to an initial separate compensable rating for diabetic nephropathy prior to December 23, 2009 and entitlement to a rating in excess of 30 percent for diabetic nephropathy from that date. In September 2012, the RO/AMC assigned a 30 percent rating from November 1, 2005, the date that the Veteran was granted a separate 10 percent rating for hypertension associated with diabetes, and a 60 percent rating from the January 30, 2012 date of the most recent VA examination. The Board notes that the Veteran timely appealed the initial 20 percent rating assigned for diabetes, which included a determination that nephropathy was to be rated as noncompensable as part of the diabetes. The Board will therefore consider whether the Veteran is entitled to an initial compensable rating prior to November 1, 2005, whether he is entitled to a rating higher than 30 percent from November 1, 2005 to January 29, 2012, and whether he is entitled to a rating higher than 60 percent from January 30, 2012. The Veteran's diabetic nephropathy is rated under 38 C.F.R. § 4.115, DC 7541. That diagnostic code provides that renal involvement in diabetes is rated as renal dysfunction. The criteria applicable to renal dysfunction in 38 C.F.R. § 4.115a indicate that a noncompensable rating is warranted where there is albumin and casts with history of acute nephritis; or, hypertension that is noncompensable under Diagnostic Code 7101. A 30 percent rating is warranted due to albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under Diagnostic Code 7101. A 60 percent rating is warranted where there is constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code 7101. An 80 percent rating requires persistent edema and albuminuria with BUN 40 to 80mg percent; or, creatinine 4 to 8mg percent; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent evaluation is assigned for renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg percent; or, creatinine more than 8mg percent; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. Under 38 C.F.R. § 4.104, DC 7101, a 10 percent rating is warranted for diastolic pressure predominantly 100 or more, or; systolic pressure predominately 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted when diastolic pressure is predominantly 110 or more, or when systolic pressure is predominantly 200 or more. A 40 percent rating requires diastolic pressure of predominantly 120 or more. A 60 percent rating requires diastolic pressure predominantly 130 or more. On the July 2003 VA examination, the examiner indicated that the Veteran's diabetes affected his kidneys resulting in protein in urine, a problem that had existed for 5 years and resulted in complications of weakness and extreme fatigue. The problem was treated with Accupril and the functional impairment was trouble with urination. The examiner indicated that the Veteran suffered from renal problems and there was diabetic nephropathy with objective factors of presence of protein in the urine. Blood pressure readings were 140/80, 143/80, and 150/80. On the November 2005 VA examination, the history section indicated that the diabetes affected the heart resulting high blood pressure, which the Veteran had had for 4 years. The examiner also indicated a history of hypertension for 4 years with medications of Losartan and Potassium. The examiner also indicated that the diabetes affected the kidneys resulting in protein in urine, with the problem having been present for 8 years with no complications. Urinalysis showed the presence of protein, sugar, and hyaline casts, but was absent RBCs and granular casts. There was a diagnosis of diabetic nephropathy at least as likely as not a complication of diabetes. Blood pressure readings were 124/72 and 120/70. On the March 2007 VA examination, urine microalbumin was 17.4. The diagnosis was diabetes with evidence of complications of nephropathy manifested as microalbuminuria of 17.4. The Veteran reported a history of hypertension diagnosed in the 1990s, without current problems with blood pressure. Blood pressure readings were 130/60, 130/62, and 130/80. On the May 2010 VA examination, the Veteran continued to note hypertension and medications, with symptoms of claudication, calf pain at rest, and persistent coldness of the extremities. He also noted a kidney problem of 12 years resulting in protein present, with weakness, extreme fatigue, high blood pressure, and limitation of exertion, but no swelling of the legs or poor appetite. Blood pressure readings were 146/78, 146/78, and 148/60. Urinalysis was absent protein, sugar, RBC, hyaline casts, and granular casts. There was also turbid appearance, trace ketones, and trace protein. The diagnosis was active diabetic nephropathy with subjective factors of complaints of weakness and fatigue and objective factors of abnormal urinalysis, proteinuria, and ketonuria. On the January 2012 VA examination, renal dysfunction was noted, with recurring proteinuria. Urinalysis showed hyaline casts and proteinuria, with protein/creatine ratio of 76.6, BUN readings of 24.2, and Creatine readings of 1.2. The above evidence reflects that the Veteran did not have albumin constant or recurring with hyaline and granular casts or red blood cells, or transient or slight edema or hypertension at least 10 percent disabling prior to November 1, 2005 and is therefore not entitled to an initial separate compensable rating for his diabetic nephropathy prior to that date. In addition, the Veteran did not have symptoms more nearly approximating constant albuminuria with some edema or definite decrease in kidney function or hypertension at least 40 percent disabling between November 1, 2005 and January 29, 2012 and is therefore not entitled to a rating higher than 30 percent during this time period. Moreover, from January 30, 2012, the Veteran has not had symptoms more nearly approximating persistent edema and albuminuria with BUN 40 to 80 or creating more than 8 or generalized poor health characterized by lethargy, weakness, anemia, weight loss, or limitation of exertion. He is therefore not entitled to a rating higher than 60 percent from that date. The Board has considered the Veteran's lay statements regarding his symptoms, but finds that the probative value of his general lay assertions are outweighed by that of the specific test findings of trained health care professionals with regard to the applicable criteria. The preponderance of the evidence thus reflects that no higher rating is warranted for the Veteran's diabetic nephropathy for any time period during the appeal. Knees and Hips The Veteran's knee strains are rated under 38 C.F.R. § 4.71a, DC 5260 and his hip strains are rated under 38 C.F.R. § 4.71a, DC 5252. In its June 2008 decision, the Board assigned separate 10 percent ratings for each knee and hip joint under 38 C.F.R. § 4.71a, DC 5003, which provides for rating of degenerative arthritis. DC 5003 provides that arthritis is to be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joints involved. DC 5003 also provides that when limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is warranted for each joint affected by limitation of motion objectively confirmed by findings such as painful motion. Given that there was noncompensable limitation of motion of each joint, confirmed by painful motion, the Board assigned the separate 10 percent ratings by evaluating each disability as analogous to arthritis. See 38 C.F.R. § 4.20. In its September 2010 memorandum decision, the Court found that the Board erred in not addressing the Veteran's contentions that his knee and hip disabilities had worsened since the then most recent November 2005 VA examination. In its December 2011 remand, the Board instructed the RO/AMC to afford the Veteran a new VA orthopedic examination, and one was provided in January 2012. The Court did not address whether the Veteran was entitled to ratings higher than 10 percent for his disabilities, including prior to the November 2005 VA examination. As the Veteran has not expressed satisfaction with these ratings, the Board will address this issue. See AB v. Brown, 6 Vet. App. 35, 39 (1993) (a veteran is presumed to be seeking the maximum possible rating unless he indicates otherwise). Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a noncompensable rating will be assigned for limitation of flexion of the knee to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the knee to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the knee to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the knee to 15 degrees. Under DC 5261, extension limited to 5 degrees warrants a noncompensable rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. Normal range of motion of the hip is 0 to 125 degrees flexion and 0 to 45 degrees abduction. DC 5252 provides ratings based on limitation of flexion of the thigh. A 10 percent disability rating is for flexion of the thigh that is limited to 45 degrees. A 20 percent rating is for flexion of the thigh that is limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 30 degrees. A 40 percent rating is warranted for flexion limited to 10 degrees. In addition, when evaluating musculoskeletal disabilities based on limitation of motion, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). When considering separate ratings under different diagnostic codes generally, VA must avoid pyramiding, i.e., evaluating the same disability under different diagnostic codes or evaluating the same manifestation under different diagnostic codes. 38 C.F.R. § 4.14. With regard to rating disabilities of the knee, VA's general counsel has issued two opinions indicating that a Veteran who has limitation of motion and instability of the knee may be evaluated separately under separate diagnostic codes provided additional disability is shown. VAOPGCPREC 23-97 (July 1, 1997); VAOGCPREC 9-98 (August 14, 1998). VA's general counsel has also found that separate ratings may be assigned under DCs 5260 and 5261, where there is compensable limitation of flexion and extension. See VAOPGCPREC 9-2004 (2004). On the November 2005 VA examination, range of motion of the knees were 0 to 90 degrees on the right with pain at 90 degrees and 0 to 110 degrees on the left, with pain at 110 degrees. Function of each knee was additionally limited by pain but not fatigue, weakness, lack of endurance and incoordination, but the VA examiner wrote that he was unable to make a determination without resort to speculation as to the degree of additional limitation without resort to speculation. McMurray's and Drawer tests of each knee were normal. Range of motion of the hips were flexion to 110 degrees with pain at 110 degrees bilaterally, extension to 30 degrees out of a normal 30 degrees with pain at 30 degrees bilaterally, adduction to 25 degrees with no pain bilaterally, abduction to 40 degrees out of a normal 45 degrees with pain at 40 degrees bilaterally, external rotation to 50 degrees out of a normal 60 degrees with pain at 50 degrees bilaterally, and internal rotation to 40 degrees our of a normal 40 degrees with pain at 40 degrees bilaterally. Function was additionally limited by pain bilaterally, but the examiner could was unable to determine the additional degree of limitation without resort to speculation. X-rays of each knee and each hip were negative, with no evidence of fracture or other significant bone or soft tissue abnormality. On the May 2010 VA examination, the Veteran complained of weakness, stiffness, giving way, lack of endurance, fatigability, and pain of the knees and hips but indicated he did not experience swelling, heat, redness, locking, deformity, tenderness, drainage, effusion, subluxation, or dislocation. He also indicated that he experienced flare-ups as often as 4 times per day lasting for an hour with a pain level of 7 out of 10. Range of motion of the knees were 0 to 120 degrees with pain at 120 degrees bilaterally. There was no additional limitation of motion on repetitive testing. The examiner also indicated that joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use of either knee. All stability testing of each knee was normal. X-rays of each knee and each hip were negative, with no evidence of fracture or other significant bone or soft tissue abnormality. An August 2010 VA treatment note indicated that there was full range of motion of the extremities. On the January 2012 VA examination, the Veteran indicated that he experienced flare-ups 1-2 times per week lasting about an hour with worsening pain and weakness and difficulty walking. On examination, right knee flexion was 90 degrees with painful motion beginning at 10 degrees. Extension was 0 degrees with painful motion beginning at 0 degrees. Left knee flexion was to 95 degrees with evidence of painful motion at 10 degrees. Left knee extension was 0 degrees with painful motion at 0 degrees. On repetitive motion testing, right knee flexion was to 90 degrees and extension 0 degrees, and left knee flexion was to 95 degrees and extension 0 degrees. There was no additional limitation in range of motion of the knees and lower legs following repetitive use testing, but there was functional loss and/or functional impairment, which was described as less movement than normal and pain on movement bilaterally. There was tenderness or pain on palpation. Muscle strength and joint stability testing were normal, with no evidence of history of recurrent patellar subluxation or dislocation. There were no shin splints, meniscal conditions or surgeries, replacement surgeries, or other pertinent physical findings, complications, conditions, signs, and/or symptoms. The Veteran used a cane occasionally. There was no X-ray evidence of patellar subluxation, no fracture or dislocation, minimal medial tibial spurring, no joint effusion, and there were minimal early degenerative changes in both knees. On the January 2012 VA hip and thigh examination, the Veteran reported flare-ups daily with activity lasting "a couple of hours." Range of motion of the right hip was flexion to 100 degrees, with evidence of painful motion at 10 degrees, extension greater than 5 degrees with evidence of painful motion at 5 degrees. Abduction was not lost beyond 10 degrees, adduction was not limited such that the Veteran could not cross his legs, and rotation was not limited such that the Veteran could not toe out more than 15 degrees. Left hip flexion was to 80 degrees with evidence of painful motion at 10 degrees, extension was greater than 5 degrees with pain at 5 degrees. Abduction was not lost beyond 10 degrees, adduction was not limited such that the Veteran could not cross his legs, and rotation was not limited such that the Veteran could not toe out more than 15 degrees. On repetitive motion testing, right hip flexion was to 100 degrees, extension was 5 degrees or greater, abduction was not lost beyond 10 degrees, adduction was no limited such that the could not cross his legs, and rotation was not limited such that the Veteran could not toe out more than 15 degrees. Left hip flexion was to 80 degrees, extension 5 degrees or greater, abduction was not lost beyond 10 degrees, adduction was not limited such that the Veteran could not cross his legs, and rotation was not limited such that the Veteran could not toe out more than 15 degrees. There was no additional limitation in range of motion of the hip and thigh following repetitive use testing, but there was functional loss, functional impairment, and/or additional limitation of range of motion of the hip and thigh, consisting of less movement than normal and pain on movement. There was tenderness or pain on palpation. Muscle strength testing was normal, there was no ankylosis, no malunion of the femur, flail hip joint, or leg length discrepancy, joint replacement or other surgical procedures, or other pertinent physical findings, complications, conditions, sings and/or symptoms. The Veteran occasionally used a cane. X-rays showed mild degenerative changes bilaterally with slight narrowing of the hip joints and hypertrophic spurring, with remaining osseous structures intact and unremarkable soft tissues. The above evidence reflects that the Veteran is not entitled to a rating higher than 10 percent for either knee or hip at any time during the appeal period under any potentially applicable diagnostic code. Range of motion testing reflected that knee flexion was not limited to 45 degrees and extension was not limited to 10 degrees. Nor was thigh flexion limited to 45 degrees, extension limited to 5 degrees, or abduction, adduction, or rotation significantly limited. In addition, while the Veteran complained of flare-ups, repetitive motion testing did not result in additional limitation warranting any higher rating, and no VA examiner indicated that the degree of additional limitation during flare-ups would result in additional limitation warranting any higher rating. The Board has considered the Veteran's lay statements in this regard, as well as his statements regarding pain and other symptoms, and finds that the above specific findings of trained health care professionals are of greater probative weight than the Veteran's lay assertions regarding limitation of range of motion including the degree of motion lost during flare-ups. Moreover, there was no medical or lay evidence of ankylosis of either knee or hip, impairment of the femur, tibia, or fibula, or flail joint of the hip, recurrent subluxation or lateral instability of the knee, removal or dislocation of semilunar cartilage, or genu recurvatum, warranting a higher or separate rating under any other potentially applicable diagnostic code between 5250 and 5263. For the foregoing reasons, the preponderance of the evidence reflects that the symptoms of the Veteran's bilateral knee and hip strain more nearly approximate the criteria for any higher rating. Extraschedular As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating criteria adequately contemplate the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptoms of the Veteran's disabilities are fully contemplated by the applicable rating criteria. As shown above, the criteria for rating diabetes take account of the fact that there will likely be compensable and noncompensable complications, and, as shown by the analysis above, the complications in this case have been rated under the appropriate diagnostic codes when compensable. With regard to the orthopedic manifestations, the Veteran's symptoms are contemplated by the applicable diagnostic codes including potential symptoms other than limitation of range of motion as well as additional limitation due to flare-ups. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is therefore not required, and referral for consideration of an extraschedular rating for any of the above disabilities is not warranted. Conclusion For the reasons stated above, the preponderance of the evidence is against any higher or separate rating for any of the above disabilities. The benefit-of-the-doubt doctrine is therefore not for application, and the claims for higher ratings must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). ORDER Entitlement to an initial rating in excess of 20 percent for type II diabetes mellitus prior to January 30, 2012 is denied. Entitlement to a rating in excess of 60 percent for type II diabetes mellitus from January 30, 2012 is denied. Entitlement to an initial separate compensable rating for diabetic retinopathy is denied. Entitlement to an initial compensable rating for diabetic nephropathy prior to November 1, 2005 is denied. Entitlement to a rating higher than 30 percent for diabetic nephropathy from November 1, 2005 to January 29, 2012 is denied. Entitlement to a rating in excess of 60 percent for diabetic nephropathy from January 30, 2012 is denied. Entitlement to an initial rating in excess of 10 percent for left hip strain is denied. Entitlement to an initial rating in excess of 10 percent for right hip strain is denied. Entitlement to an initial rating in excess of 10 percent for left knee strain is denied. Entitlement to an initial rating in excess of 10 percent for right knee strain is denied. REMAND In this case the Board denied service connection for GERD on a direct incurrence basis, the Veteran did not contest this decision, and the Court therefore declined to disturb that portion of the Board's decision. Moreover, the Veteran has not argued and the evidence does not reflect that his GERD is related to service. Rather, he contends that his GERD is related to his service-connected diabetes and related neuropathy, and the issue on appeal is therefore so limited. Service connection is warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(b). This latter provision was added as part of an amendment intended conform VA regulations to Allen v. Brown, 7 Vet. App. 439 (1995), and also limited the circumstances in which VA would concede aggravation. See 71 Fed. Reg. 52,744 (Sept. 7, 2006) (codified at 38 C.F.R. § 3.310(b)). As the new regulation, which took effect on October 10, 2006, after the Veteran filed his February 2003 claim, is more restrictive, the former regulation is applicable. The Veteran was granted service connection for diabetes in September 2003, effective February 2002. The Veteran's GERD was first diagnosed in 1997 private treatment records. As noted by the Court, in his February 2003 claim, the Veteran listed gastric problems from neuropathy. In April 2003, one of the Veteran's treating physicians, Dr. "M.G.," at The Doctor's Office filled out a form provided by the RO entitled, "Diabetes Herbicide Presumption," indicated that the Veteran had gastroparesis secondary to his diabetes. Dr. M.G. did not, however, provide any rationale for this opinion. Subsequent VA examiners did not provide an opinion on this question, although the March 2007 VA examiner wrote that a "[g]astric emptying study was negative for evidence of diabetic gastroparesis." As noted by the Court, the presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The diagnoses of gastroparesis and GERD during the pendency of the claim as possibly linked to the Veteran's diabetes therefore warranted consideration. The Board therefore found in its December 2011 remand that a new VA examination was warranted as to the relationship between the Veteran's GERD and his diabetes and related neuropathy. The Board instructed that the examiner indicate whether the Veteran had gastroparesis and, if so, whether it was caused or aggravated by diabetes and any associated neuropathy. The Board also specifically instructed that if the examiner did not diagnose gastroparesis, then he or she should comment on the validity of Dr. M.G.'s April 2003 diagnosis. Finally, the Board instructed that the examiner opine whether the Veteran's GERD was caused or aggravated by his diabetes. The January 2012 that was conducted pursuant to the Board's remand is inadequate for rating purposes for two reasons. First, although the examiner did not diagnose gastroparesis, he did not address whether the Veteran had gastroparesis during the appeal period or address Dr. M.G.'s diagnosis, as specifically instructed by the Board. Second, as to GERD, the January 2012 VA examiner opined that the Veteran's GERD was "less likely as not caused or aggravated by his service-connected diabetes mellitus and any associated neuropathy." The only rationale provided, however, was that he had reviewed a single medical article entitled Diabetic Autonomic Neuropathy of the Gastrointestinal Tract, which stated that GERD may be more common in patient with diabetes and could be caused by autonomic neuropathy related to diabetes, but the LES pressure and relaxation in diabetics was not different in the control group and therefore autonomic neuropathy does not appear to predict the presence of esophageal motor abnormalities. The examiner also reviewed the case with an endocrinologist who stated that although GERD may be common in diabetics, this did not mean there was a proven causational link. What is missing from this rationale is any discussion at all of the application of these or any other medical principles to the facts of this case. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("it is what an examiner learns from the claims file for use in forming the expert opinion-and not just the reading of the file-that matters"). The January 2012 VA examiner did not indicate how what he had learned from the medical article or claims file affected his opinion on the question of a potential relationship between GERD and diabetes in this particular case. An addendum should therefore be sought from the physician who performed the January 2012 VA examination or, if unavailable, a different physician. In addition, when the Board concludes that a private medical examination report is unclear or insufficient in some way, and it reasonably appears that a request for clarification could provide relevant information that is otherwise not in the record and cannot be obtained in some other way, the Board must either seek clarification from the private examiner or the claimant or clearly and adequately explain why such clarification is unnecessary." Savage v. Shinseki, 24 Vet. App. 259 (2011). The RO/AMC should therefore ask Dr. M.G. to explain the reasons for her conclusions in her April 2003 statement. Accordingly, the claim for entitlement to service connection for GERD and gastroparesis, secondary to service-connected type II diabetes mellitus and related neuropathy, is REMANDED for the following action: 1. Send a letter to Dr. M.G. requesting that she explain the reasons for her April 2003 conclusion that the Veteran had gastroparesis secondary to his diabetes. The Veteran's assistance in obtaining this information, including the signing of an appropriate release, should be requested as needed. Any medical evidence or tests that were conducted to lead to the diagnosis should also be requested. All attempts made to obtain this information should be documented in the claims folder. 2. Thereafter, and whether information requested above is received or not, request an addendum from the physician who performed the January 2012 VA examination, or, if unavailable, from a different physician. The claims file must be sent to the physician for review. The physician should first indicate whether the Veteran has had gastroparesis at any time since he filed his February 2003 claim. In answering this question, the physician should specifically address the April 2003 statement of Dr. M.G. that the Veteran had gastroparesis secondary to his diabetes. The physician should also specifically address whether this Veteran's diabetes caused or aggravated his GERD, including explaining how the cited medical article applies to the facts of this particular case. A complete rationale should accompany each opinion provided. 3. Then, review any additional evidence and readjudicate the claim. If any benefit remains denied, issue an appropriate supplemental statement of the case to the Veteran and his representative, and allow an appropriate time for response. Thereafter, return the case to the Board if in order. The Veteran has the right to submit additional evidence and argument on the matter 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. 2011). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs