Citation Nr: 1315351 Decision Date: 05/09/13 Archive Date: 05/15/13 DOCKET NO. 07-31 360A ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to a higher initial rating for diabetes mellitus, rated as 20 percent disabling. 2. Entitlement to a higher initial rating for hyperalgesic peripheral sensory polyneuropathy of the right lower extremity, evaluated as 20 percent disabling from May 10, 2002, and as 30 percent disabling from February 2, 2012. 3. Entitlement to a higher initial rating for hyperalgesic peripheral sensory polyneuropathy of the left lower extremity, evaluated as 20 percent disabling from May 10, 2002, and as 30 percent disabling from February 2, 2012. 4. Entitlement to a separate compensable rating for upper extremity peripheral neuropathy. 5. Entitlement to a separate compensable rating for diabetic nephropathy. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. Keyvan, Associate Counsel INTRODUCTION The Veteran had active military service from June 1968 to June 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2005 decision by the Department of Veterans Affairs (VA) Appeals Management Center Resource Unit in Bay Pines, Florida, which granted entitlement to service connection for diabetes mellitus and assigned a 20 percent disability evaluation. This matter has since been transferred to the jurisdiction of the Chicago, Illinois, Regional Office. In October 2011, the Board remanded the Veteran's rating claim for further evidentiary development. Specifically, the Board instructed the Agency of Original Jurisdiction (AOJ) to (1) obtain any outstanding treatment records from the VA Medical Center (VAMC) in West Los Angeles, California; and to (2) schedule the Veteran for a VA examination to determine the nature and extent of his service-connected diabetes mellitus as well as any complications arising therefrom. The AOJ did attempt to obtain VA treatment records from the West Los Angeles Healthcare System, and an examination was completed in February 2012. A copy of the VA examination report has been associated with the claims file. The Appeals Management Center (AMC) subsequently readjudicated the claim by way of a July 2012 supplemental statement of the case (SSOC). Additionally, in a July 2012 rating action, the AMC determined that the Veteran's hyperalgesic peripheral sensory polyneuropathy of the right and left lower extremities was secondary to his diabetes mellitus and awarded service connection for both disorders, evaluating each lower extremity as 20 percent disabling from May 10, 2002, and as 30 percent disabling from February 2, 2012. In light of the fact that these disorders are complications arising from the Veteran's service-connected diabetes mellitus, and because the rating criteria for diabetes require that complications be considered, these issues will be addressed below. By the July 2012 rating decision, the AMC also awarded service connection for upper extremity peripheral neuropathy and included it with the diabetes rating. (The issues of entitlement to separate compensable ratings for upper extremity peripheral neuropathy and diabetic nephropathy are addressed in the remand that follows the decision below.) FINDINGS OF FACT 1. The Veteran's service-connected diabetes mellitus requires oral agents, occasional insulin injections and a restricted diet, but does not require regulation of activities. 2. From May 10, 2002, to February 8, 2010, the Veteran's hyperalgesic peripheral sensory polyneuropathy of each lower extremity was manifested by no more than moderate impairment, to include symptoms of pain, numbness, burning and decreased sensation. 3. Since February 8, 2010, the Veteran's hyperalgesic peripheral sensory polyneuropathy of each lower extremity has been productive of severe impairment, to include loss of protective sensation in the feet, deviated interphalangeal joints, and signs of muscle atrophy. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.119, Diagnostic Code 7913 (2012). 2. The criteria for an initial disability rating in excess of 20 percent for hyperalgesic peripheral sensory polyneuropathy of the right lower extremity from May 10, 2002, to February 8, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.124(a), Diagnostic Code 8521 (2012). 3. The criteria for an initial disability rating in excess of 20 percent for hyperalgesic peripheral sensory polyneuropathy of the left lower extremity from May 10, 2002, to February 8, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.124(a), Diagnostic Code 8521 (2012). 4. Effective February 8, 2010, the criteria for an initial assignment of a 30 percent disability rating for hyperalgesic peripheral sensory polyneuropathy of the right lower extremity have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.124(a), Diagnostic Code 8521 (2012). 5. Effective February 8, 2010, the criteria for an initial assignment of a 30 percent disability rating for hyperalgesic peripheral sensory polyneuropathy of the left lower extremity have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.124(a), Diagnostic Code 8521 (2012). 6. The criteria for an initial disability rating in excess of 30 percent for hyperalgesic peripheral sensory polyneuropathy of the right lower extremity on or after February 8, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.124(a), Diagnostic Code 8521 (2012). 7. The criteria for an initial disability rating in excess of 30 percent for hyperalgesic peripheral sensory polyneuropathy of the left lower extremity on or after February 8, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.124(a), Diagnostic Code 8521 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist At the outset, the Board notes the enactment of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). (The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008, during the pendency of the appeal. See 73 Fed. Reg. 23353 -56 (Apr. 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008. The amendments, among other things, removed the notice provision requiring VA to request the Veteran to provide any evidence in the Veteran's possession that pertains to the claim. See 38 C.F.R. § 3.159(b)(1).) The Board finds that all notification and development action needed to render a decision on the claims decided herein has been accomplished. Through notice letters dated in May 2002 and July 2003, the RO notified the Veteran of the information and evidence needed to substantiate his underlying service connection claims. Thereafter, the Veteran was afforded the opportunity to respond. In addition, the Veteran was provided notice concerning the assignment of rating criteria and effective dates via the October 2006 and July 2008 letters. Although the October 2006 and July 2008 letters were not sent prior to initial adjudication of the Veteran's claim, he was subsequently provided adequate notice and was provided several years to respond with additional argument and evidence, which he did. The claims for a higher rating were readjudicated several times, and a statement of the case (SOC) was issued in July 2007, and supplemental statements of the case (SSOCs) were provided to the Veteran in July 2008, July 2009, March 2010, May 2011 and July 2012. A subsequent rating action was also issued in July 2012 addressing the issue of entitlement to separate compensable ratings for peripheral neuropathy. See Prickett v. Nicholson 20 Vet. App. 370 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as by an SOC or SSOC, is sufficient to cure a timing defect). Hence, the Board finds that the Veteran has received notice of the information and evidence needed to substantiate his claims, and has been afforded ample opportunity to submit such information and evidence. The Board also finds that the May 2002 and July 2003 notice letters satisfied the statutory and regulatory requirement that VA notify a claimant what evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). In the letters, the RO notified the Veteran that VA was required to make reasonable efforts to obtain medical records, employment records, or records from other Federal agencies. The RO also requested that the Veteran identify any medical providers from whom he wanted the RO to obtain and consider evidence. Thus, the Board finds that "the appellant [was] provided the content-complying notice to which he [was] entitled." Pelegrini v. Principi, 18 Vet. App. 112, 122 (2004). In addition, the Veteran was given the opportunity to respond following the May 2002 and July 2003 notice letters. In any event, as is the case here, once a veteran disagrees with an initial determination, other provisions apply to the remainder of the adjudication process, particularly those pertaining to the issuance of rating decisions and statements of the case. See 38 U.S.C.A. §§ 5104(a), 7105(d) (West 2002); 38 C.F.R. §§ 3.103(b)(1), 19.29 (2010); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); see also Dunlap v. Nicholson, 21 Vet. App. 112, 119 (2007). Nothing about the evidence or any response to the RO's notification suggests that the case must be re-adjudicated ab initio to satisfy the requirements of the VCAA. The Board also points out that there is no indication that any additional action is needed to comply with the duty to assist in connection with the claims decided herein. The Veteran's service treatment records as well as all identified and available VA medical records pertinent to the years after service are in the claims file and were reviewed by both the AOJ and the Board in connection with the Veteran's current claim. In July 2009, the RO contacted the Social Security Administration (SSA) National Records Center (NRC) and requested any records concerning any claim for disability benefits that may have been filed by the Veteran. An August 2009 response from the SSA indicated that there were no medical records in their office pertaining to the Veteran and either the Veteran did not file for disability benefits, or he filed for disability benefits but no medical records were obtained. Pursuant to the October 2011 Board remand, the AMC attempted to obtain any outstanding VA medical records pertaining to treatment provided for the Veteran's service-connected diabetes mellitus. Several requests were sent to the West Los Angeles VA Medical Center (VAMC) requesting any and all records pertaining to medical care provided to the Veteran at this treatment facility. In a March 2012 response, a representative from the Greater Los Angeles Healthcare System indicated that a review of the West Los Angeles Healthcare System computer data base recovered no treatment or records listed for the Veteran, and a review of the retirement and archived records retrieved no information regarding the Veteran. Based on the foregoing, the Board concludes that VA has done everything reasonably possible to assist the Veteran in obtaining his complete service and post-service treatment records. Moreover, in addition to obtaining all relevant records, the Veteran was also afforded VA examinations in February 2005, August 2009, May 2011 and February 2012. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted below, the Board finds that the VA examinations obtained in this case are adequate as they are predicated on consideration of all of the pertinent evidence of record, to include the statements of the Veteran and reflect that the examiners conducted a full examination of the Veteran, including information necessary to apply the pertinent rating criteria. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination with respect to the issues decided herein has been met. 38 C.F.R. § 3.159(c)(4). Under these circumstances, the Board finds that VA has complied with all duties to notify and assist required by 38 U.S.C.A. §§ 5103(a), 5103A and 38 C.F.R. § 3.159. II. Analysis Disability evaluations are determined by comparing a Veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). The veteran's entire history is reviewed when making disability evaluations. See generally Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where, as in the case of the Veteran's claim, the question for consideration is the propriety of the initial evaluations assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a staged rating are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). If evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. Further, "[w]here there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned." 38 C.F.R. § 4.7 (2012). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2002 & Supp. 2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.3 (2012). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert at 54. A. Diabetes Mellitus The Veteran's diabetes mellitus has been rated 20 percent disabling effective from May 2, 2002. This disorder was evaluated under VA's Schedule for Rating Disabilities, 38 C.F.R. § 4.119, Diagnostic Code (Code) 7913. (As noted in other sections of this decision, complications of diabetes are being addressed separately. An analysis of the effects specifically enumerated in Code 7913 will be undertaken here.) According to Code 7913, a 20 percent evaluation is authorized when the diabetes requires insulin and restricted diet, or oral hypoglycemic agent and restricted diet. A 40 percent evaluation is authorized when the diabetes requires insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities). A 60 percent evaluation is authorized when the diabetes requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions that require 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 for diabetes mellitus requiring 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. 38 C.F.R. § 4.119, Diagnostic Code 7913. The Board has reviewed the evidence of record and finds that the current evaluation of 20 percent under Diagnostic Code 7913 accurately reflects the extent of the severity of the Veteran's diabetes and that a higher rating is not warranted. In order to be entitled to the next higher evaluation of 40 percent under Diagnostic Code 7913, the evidence must show that the Veteran's diabetes requires insulin, a restricted diet, and regulation of his activities. These criteria are conjunctive, meaning all three elements must be met. See Melson v. Derwinski, 1 Vet. App. 334 (June 1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met); compare Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive "or" requirement must be met in order for an increased rating to be assigned). Here, the preponderance of the medical evidence of record does not show the Veteran to have restrictions placed on his activities as a result of his service-connected diabetes mellitus. The Board has reviewed pertinent VA treatment records as well as VA examination reports conducted in February 2005, May 2009, May 2011 and February 2012, all of which address the state of the Veteran's diabetes. The records in totality show that the Veteran has diabetes mellitus which he primarily controls through oral hypoglycemic agents and a restricted diet. A review of the record reflects that the Veteran was diagnosed with diabetes in May 2000, at which time he began to receive counseling and information on the importance of exercise and following a better diet. Subsequent treatment records further reflect the Veteran's continuing education on the importance of exercise and following a healthier diet. See VA treatment records dated in June 2000. A September 2003 VA treatment report issued by the Veteran's clinical dietician instructs the Veteran to follow a 2000 calorie diet that is low in salt and cholesterol. During this treatment visit, it was noted that the Veteran's ability to exercise and participate in physical activities was limited due to his low back pain. During the February 2005 VA examination, the Veteran denied ever having been hospitalized or experiencing any hypoglycemic episodes as a result of his diabetes. It was noted that the Veteran was started on Rosiglitazone (an oral drug) in June 2003. According to the Veteran, he monitored his blood sugar by checking his finger stick levels six to eight times a day after meals, and watching his diet. In particular, the Veteran asserted that he avoided certain dishes such as fried foods. The VA examiner noted that the Veteran's weight had reportedly increased 80 pounds over the past year. While the Veteran complained of blurred vision as a result of his diabetes, the examiner noted that the Veteran had no history of diabetic retinopathy as reflected in the July 2003 VA eye examination. After conducting a physical evaluation of the Veteran and reviewing his laboratory data, the VA examiner noted that while it was difficult to conclusively diagnose the Veteran with type 2 diabetes in the absence of a fasting blood sugar greater than 126 or a non-fasting blood sugar greater than 200, the Veteran's hemoglobin A1C of 7.4 was highly suggestive of glucose intolerance, effectively confirming the diagnosis of type 2 diabetes mellitus. A February 2006 VA treatment note reflects that the Veteran followed an "ADA (American Diabetes Association) style" diet that was low in fat, cholesterol and sodium and high in soluble and insoluble fibers. During a June 2006 VA outpatient visit, the Veteran indicated that he had not exercised on a regular basis since undergoing back surgery in 2004. During a February 2007 clinical visit, the Veteran reported taking 5 milligrams (mg) of glipizide twice a day, and eight mg of topamax and rosigitazone once a day. He also denied any recent episodes of hypoglycemia and stated that he walked a half an hour a day. Subsequent VA treatment records dated from January 2008 to April 2009 reflect that the Veteran was seen on a regular basis for care and treatment of his diabetes. These records indicate that the Veteran continued to take oral medication to monitor his diabetes, and that he was continually educated on the importance of monitoring his blood sugar level, exercising and following a restricted diet. The Veteran was afforded another VA examination in May 2009, at which time he reported a high glucose level but added that he had never been hospitalized as a result of his diabetic condition. According to the Veteran, he initially managed his diabetes by watching his diet, and he now controls his diabetic condition through Metformin, an oral drug. The Veteran denied restricting his activities on account of his diabetes, and added that he does not avoid strenuous activities to prevent experiencing a hypoglycemic reaction. According to the Veteran, he visits his diabetic care provider every three to four months, and has no other symptoms such as visual problems. The examiner further noted that the Veteran complains of peripheral neuropathy of both legs with symptoms such as numbness and tingling that are constant in nature. According to the VA examiner, the Veteran's peripheral neuropathy was at least as likely as not related to his diabetes. The VA examiner further found that the Veteran had no vision problems, and his hypertension was not related to his diabetes, as he had been diagnosed with this prior to his diagnosis of diabetes. At a May 2011 VA examination, the VA examiner noted that the Veteran was currently taking several oral drugs for treatment of his diabetes, and further noted that the Veteran's diabetes was managed through regular insulin injections on a "sliding scale coverage." According to the examiner, the Veteran's physical activities were limited due to the fact that he had recently undergone a right knee arthroplasty, and even prior to the Veteran's arthroplasty, his physical activities had been somewhat limited due to his severe osteoarthritis of the knees. The Veteran did not report any hypoglycemic episodes, and denied a history of any hospitalizations for ketoacidosis, hyperosmolar, hyperglycemic metabolic conditions or profound hypoglycemia. Additionally, the Veteran did not report changes in his glucose level after increased physical activity, and denied changing his activity patterns to avoid hypoglycemic episodes. Upon physical examination, the examiner did not observe any signs of diabetic retinopathy and assessed the Veteran with non-insulin dependent controlled diabetes mellitus, type 2. At a February 2012 VA examination, the same VA examiner who evaluated the Veteran in May 2011, reviewed the Veteran's medical history and noted that the Veteran was currently taking several oral drugs for treatment of his diabetes. According to the VA examiner, the Veteran was not on any insulin treatment. The examiner wrote that the Veteran self-monitors his serum glucose levels and is compliant with a diabetic diet, eating three meals a day without snacks. The examiner further noted that the Veteran's physical activities were limited due to his peripheral polyneuropathy, and became even more restricted after his recent right knee arthroplasty "which had suboptimal results in terms of ambulation." The examiner added that the Veteran's physical activities were limited prior to his arthroplasty due to the severe osteoarthritis in both his knees. The Veteran did not report any hypoglycemic episodes, and denied a history of hospitalizations for ketoacidosis, hyperosmolar, hyperglycemic metabolic conditions or profound hypoglycemia. The Veteran did not report changes in his glucose level after increased physical activity and he did not report to change his activity pattern to avoid hypoglycemic episodes. Based on his review of the records, as well as his evaluation of the Veteran, the examiner assessed the Veteran with non-insulin dependent uncontrolled diabetes mellitus type 2, noting that he has been on oral hypoglycemic treatment since 2000. The Court has held that in order for a Veteran to be entitled to a 40 percent disability rating under Diagnostic Code 7913, the evidence must show that it is medically necessary for him to avoid strenuous occupational and recreational activities. Camacho v. Nicholson, 21 Vet. App. 360 (2007). Medical evidence is required to support the "regulation of activities" criterion of such rating. Id. The Veteran's VA outpatient records and examination reports do not show a regulation of his occupational and recreational activities. Indeed, the medical evidence, as indicated by the VA treatment reports and the February 2005, May 2009, May 2011 and February 2012 VA examination reports, demonstrate that the Veteran was encouraged to exercise and increase his physical activities. While some of the treatment records reflect the Veteran's own assertions that his ability to exercise and move around was limited, the Veteran attributed these limitations to his low back pain and his 2004 back surgery. The Board also acknowledges notations made at the February 2012 examination, wherein the Veteran indicated that his activity was limited due to his peripheral polyneuropathy. While the examiner acknowledged these limitations, he did not advise or recommend that the Veteran limit his recreational and/or occupational activities due to his diabetes mellitus. The examiner further appeared to attribute the majority of the restrictions placed on the Veteran's activities to the Veteran's right knee arthroplasty and his severe osteoarthritis of both knees. Indeed, despite the Veteran's reported statements, none of these records indicates that he was placed on activity restriction because of his diabetes. The general picture presented by the clinical evidence with regard to the Veteran's diabetes mellitus is one that more closely approximates the constellation of symptomatology contemplated in the rating criteria for a 20 percent evaluation on the basis of an non insulin-dependent diabetes with restricted diet. The record reflects that the Veteran requires oral hypoglycemic agents, and a restricted diet to control his diabetes. While the record also reflects the occasional administration of insulin injections on a "sliding scale" basis, the Veteran has continually been assessed with non-insulin dependent diabetes. As noted above, while the Veteran reportedly experiences some limitation in his physical activities due to his peripheral polyneuropathy (which the RO determined to be secondary to his diabetes mellitus), the medical evidence does not show that he has been encouraged and/or instructed to refrain from certain activities as a result of his diabetes mellitus. See February 2005, May 2009, May 2011 and February 2012 VA examination reports. Indeed, at the May 2011 and February 2012 VA examinations, the Veteran denied any changes in his glucose level after increased physical activity, and noted that he did not change his activity pattern to avoid experiencing a hypoglycemic episode. Therefore, the criteria for the assignment of a 40 percent rating have not been met. In addition, the Veteran has not experienced episodes of ketoacidosis or hypoglycemic reactions requiring any hospitalizations or weekly visits to a diabetic care provider. While the record reflects that the Veteran was hospitalized for treatment of his low back and right knee, there is no evidence to show that he has experienced episodes of ketoacidosis or hypoglycemic reactions requiring any hospitalizations or weekly visits to a diabetic care provider. Indeed, the Veteran denied experiencing any such problems at his examinations. Thus, there is no pathology attributable to diabetes mellitus, type 2, which would call for the assignment of an even higher disability rating (i.e., 60 percent, 100 percent), and the Veteran does not appear to so contend. With respect to complications arising from the Veteran's diabetes mellitus, as previously discussed in the Introduction, the February 2012 VA examiner diagnosed the Veteran with hyperalgesic peripheral sensory polyneuropathy, and related this disorder to his diabetes. In the July 2012 rating decision, the AOJ granted separate compensable ratings for peripheral neuropathy of the lower extremities, and further granted service connection for upper extremity peripheral neuropathy. However, the upper extremity peripheral neuropathy has been evaluated as noncompensably disability and combined with the Veteran's already service-connected diabetes mellitus. The evidence is also unclear as to whether the Veteran is entitled to a separate compensable rating for nephropathy that may possibly be connected to his diabetes mellitus. With the exception of these particular issues, based on the evidence of record as it currently stands, the Board does not find that the Veteran exhibits any additional complications arising from his diabetes mellitus that would warrant a separate compensable evaluation. The May 2009 VA examiner did not relate the Veteran's hypertension to his diabetes, noting that he had been diagnosed with this disorder prior to his diabetes. In addition, the August 2009 VA examiner did not relate the Veteran's erectile dysfunction to his diabetes, noting that this condition arose prior to his diabetes mellitus, type 2. Finally, the Veteran's vision, visual acuity and visual system was evaluated in July 2007, and the results were clear for any signs of retinopathy. Further, the Veteran did not report any visual problems at the May 2009 VA examination, and upon evaluating the Veteran's visual system, the May 2011 and February 2012 VA examiner did not identify any signs of diabetic retinopathy. As such, the only complications arising from the Veteran's diabetes are his service-connected hyperalgesic peripheral sensory polyneuropathy of the lower extremities, the merits of which will be addressed in the second part of this decision, and his upper extremity peripheral neuropathy and possible nephropathy, which will be addressed in greater detail in the remand below. (The Board notes that even if the Veteran was granted separate compensable ratings for either of these disorders, he still would not meet the criteria for a rating in excess of 20 percent for his diabetes under the specifically enumerated criteria of Diagnostic Code 7913.) In light of the foregoing evidence, the Board finds that the Veteran has been properly rated for his diabetes mellitus, and there is no basis for assignment of a disability rating in excess of 20 percent. The Board again emphasizes that although the Veteran requires oral agents, insulin and a restricted diet, he is not limited in his activities due to the diabetes. As such, the Veteran meets the criteria for a 20 percent rating under 38 C.F.R. § 4.119, Diagnostic Code 7913. In the absence of regulation of activities, there is simply no basis for a higher rating. Because the evidence in this case is not approximately balanced with respect to the merits of this claim, the benefit-of-the-doubt doctrine does not help the Veteran. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2010); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board therefore finds that no basis exists for the assignment of an initial increased rating in excess of 20 percent for diabetes mellitus, type 2, under Diagnostic Code 7913. Additionally, as the record contains no evidence showing that the Veteran is entitled to a higher rating for his service-connected diabetes mellitus, no staged ratings are appropriate. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Thus, the Board finds that the current 20 percent evaluation is appropriate for the entirety of the rating period. See 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). (There is no indication that the problems experienced by the Veteran are not contemplated by the rating criteria. Therefore, referral for consideration of an extraschedular evaluation is not warranted. 38 C.F.R. § 3.321(b) (2012).) B. Hyperalgesic Peripheral Sensory Polyneuropathy of the Lower Extremities Compensable complications of diabetes are to be evaluated separately unless they are part of the criteria used to support a 100 percent disability evaluation, with noncompensable complications to be considered as part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1) (2012). This requires analysis of the severity of any identified complication of diabetes in order to ascertain whether such complications are compensable. Pursuant to the October 2011 remand, the Veteran was afforded another VA examination in February 2012, specifically to determine whether he had any diabetic complications, to include any neurological abnormalities, that were related to his diabetes mellitus. At the February 2012 VA examination, the examiner diagnosed the Veteran with severe hyperalgesic peripheral sensory polyneuropathy and related said condition to his diabetes. Based on the evidence of record, the AOJ granted service connection for this hyperalgesic peripheral sensory polyneuropathy of the right and left lower extremities and evaluated both extremities as 20 percent disabling prior to February 2, 2012 and 30 percent disabling from February 2, 2012. See July 2012 rating decision. 1. From May 10, 2002, to February 8, 2010 For the period prior to February 2, 2012, the Veteran's hyperalgesic peripheral sensory polyneuropathy of the right and left lower extremities have been separately rated as 20 percent disabling pursuant to the provisions of 38 C.F.R. § 4.124(a), Diagnostic Code 8599-8521. When an unlisted disease, injury, or residual is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" as follows. The first two digits will be selected from that part of the schedule most closely identifying the part or system of the body involved. The last two digits will be "99" for all unlisted conditions. 38 C.F.R. §§ 4.20, 4.27 (2012). Here, the Veteran's disability is not specifically listed in the rating schedule and is therefore rated analogous to a disability in which not only the functions are affected, but the anatomical location and symptoms are closely related. Under Diagnostic Code 8521, a 40 percent rating is available for complete paralysis of the external popliteal nerve (common peroneal) manifested by the following symptomatology: foot drop and slight droop of first phalanges of all toes; cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes. For incomplete paralysis, a 30 percent rating is available for severe impairment; a 20 percent rating is available for moderate impairment; and a 10 percent rating is available for mild impairment. 38 C.F.R. § 4.124a. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to a varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The words "slight," "mild," "moderate" and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. For the reasons that follow, the Board concludes that the Veteran is not entitled to initial evaluations in excess of 20 percent for his hyperalgesic peripheral sensory polyneuropathy of the right and left lower extremities, for the period from May 10, 2002, to February 8, 2010. A review of the evidence reflects that the Veteran presented at the VA Medical Center (VAMC) in East Orange, New Jersey, in April 2000, with complaints of a tingling sensation in both his feet and pain in the posterior thigh of the left leg. Treatment records dated in May 2000 reflect a diagnosis of peripheral neuropathy During an April 2002 VA inpatient visit, the Veteran reported to experience "almost continuous bilateral leg/foot pain assoc[iated] with sensory symptoms" which reportedly began more than two years prior. The Veteran described an initial sensation of tiredness in the right leg, associated with occasional stabbing pains as well as 'burning and tingling' pain in his feet associated with a cold sensation and symptoms of decreased sweating. According to the Veteran, these symptoms were alleviated whenever he walked around, and exacerbated at night, disturbing his sleep on a nightly basis. The Veteran did not report any leg weakness and denied any back and calf pain. Upon physical examination, the Veteran's motor strength was shown to be 5/5 bilaterally, and his heel and toe walk was described as normal. In addition, the Veteran's straight leg raising tests produced normal results, and the reflexes in the lower extremities were shown to be 2+ while his sensory function was decreased to pinprick and intact to vibration. The Veteran underwent an electromyography (EMG) of the lower extremities in June 2002, the results of which were suggestive of peripheral neuropathy. On VA evaluation in February 2005, the Veteran provided his medical history and reported that his peripheral neuropathy manifested three to four years after his discharge from service. When asked to describe his symptoms, the Veteran reported to experience a burning sensation, numbness and pain in his lower extremities. He further reported that these symptoms are alleviated by walking and moving his feet, and aggravated by remaining motionless. According to the Veteran, his foot discomfort had had a significant impact on his life as he was always aware of the pain in his feet and unable to let the sheets touch his feet in bed. The Veteran described his feet as "cold all the time" even in the summertime, and noted that if he ever wakes up in the middle of the night, he is unable to fall back to sleep for two to three hours due to his foot pain. On physical examination, the Veteran's extremities were clear for any signs of clubbing, cyanosis or edema. The Veteran's motor strength was shown to be 5/5 in the upper and lower extremities bilaterally, and his sensation was intact to light touch throughout. The Veteran's gait was described as normal, and the deep tendon reflexes were 1+ at the biceps, absent at the patellae, 1+ at the right ankle and absent at the left ankle. Based on her evaluation of the Veteran, the examiner diagnosed him with peripheral neuropathy. During a July 2007 outpatient consultation, the Veteran complained of worsening burning pain in his lower extremities. Upon neurological evaluation, the Veteran's motor strength was shown to be 5/5 in the lower extremities bilaterally, and the treatment provider observed normal bulk and tone throughout with no signs of cogwheel rigidity, pronator drift, resting, or position or action tremor. With respect to the Veteran's sensory function, the Veteran exhibited "low glove and low stocking sensory loss" to light touch, pinprick and vibration bilaterally. The Veteran's reflexes were shown to be 0 in the patellar and ankle region bilaterally, and the treatment provider attributed the increased intensity of the Veteran's pain to the progression of his diabetic polyneuropathy. In May 2009, the Veteran underwent several vascular studies, the findings of which showed the arterial brachial indices in the superficial femoral, popliteal, and posterior tibial arteries to be normal bilaterally. The right and left toe brachial indices were also shown to be normal and the results of the study revealed a normal ankle-brachial index (ABI). At the May 2009 VA examination, the Veteran complained of peripheral neuropathy in both legs with symptoms such as numbness and tingling that are constant in nature. Upon physical examination, the Veteran had decreased sensation to monofilament and tuning fork vibration at the feet. The examiner assessed him with peripheral neuropathy that is at least as likely as not related to diabetes. A subsequent treatment note, also dated in May 2009, reflects that the Veteran presented at the podiatry clinic "for fitting and dispensing of shoes." Upon being fitted for shoes, the Veteran did not complain of discomfort or pain, nor did he express any new pedal complaints. On neurological evaluation, the Veteran exhibited diminished protective sensation via Semmes Weinstein monofilament. At an August 2009 VA examination, the Veteran described the course of his peripheral neuropathy as progressively bad, and on a scale of one to ten (with one being the least level of pain and ten being the most), he rated his flare-ups at an eight, describing his flare-ups as a burning sensation that occurred at night. According to the Veteran, weight-bearing served to aggravate his condition, while medication helped alleviate it. The Veteran described his peripheral neuropathy as constant in nature, and reported to experience weakness, fatigue and functional loss as a result of his peripheral neuropathy. He also described symptoms of paresthesia, burning and numbness stemming from his neurological condition, and noted that treatment for his peripheral neuropathy, which consists of oral medication and medicated cream, was of limited benefit. On neurological evaluation, the examiner did not observe any signs of pedal edema, but did note positive gross deformities in the second through fourth toes. According to the examiner, the Veteran had full range of motion in his joints, his pulses and reflexes were 2/2 bilaterally, and his strength was 5/5 bilaterally. Results from the bilateral foot examination were also shown to be normal, and the Veteran's gait, stance and coordination were all described as normal, as was the motor status of the peripheral nerves. According to the examiner, the sensory status of the peripheral nerves was abnormal, sensory impairment is distributed to the affected groups of the upper and lower extremities, and the specific nerve involved is localized to the hands and feet bilaterally. The examiner further noted that the Veteran's fine motor control was not affected and there was no muscle wasting or atrophy. In addition, the examiner found that the Veteran's joints were not affected as they demonstrated full range of motion against both strong resistance and gravity. The examiner further observed no pain on motion, and noted that the Veteran's range of motion or function was not limited by pain, fatigue, weakness, or lack of endurance. In November 2009, the Veteran was referred to the Chronic Pain Evaluation Clinic for management of his chronic peripheral neuropathic pain. On a scale of one to ten, the Veteran rated his pain level at a six within the past 24 hours, noting that, on average, his pain level was at a seven, but could reach an eight and be as low as a five. Medication helped reduce the pain from a five to a three. The Veteran claims that the pain interfered with his enjoyment of life, sleep and relationships with other people. The neurological evaluation of the extremities revealed good pulses, and it was noted that the feet were warm and in constant motion. The VA physician did not observe any gross deformity or swelling, and the Veteran's motor strength was shown to be 5/5 bilaterally. The physician did observe some weakness with knee extension on the right, which appeared to be secondary to pain in the right knee, and further noted that the Veteran's reflexes were diminished throughout in the upper extremities, and absent in the knees and Achilles bilaterally. Based on the Veteran's assertions during his VA examinations and treatment visits, he experiences fatigue, pain, a burning sensation, and weakness in his lower extremities - symptoms which affect his relationships with others, as well as his ability to sleep and enjoy life. However, while it is clear that there was pain, weakness and decreased sensation in the Veteran's lower extremities, the record was absent evidence of more significant symptoms. In this regard, the objective medical evidence of record is negative for any signs of muscle wasting or atrophy, and has consistently shown the Veteran's motor strength to be 5/5. In addition, the Veteran's gait, stance and coordination have been described as normal, his pulses have been shown to be good, and he demonstrated full range of motion in his joints at the August 2009 examination. Therefore, the medical evidence suggests a disability that is no more than "moderate," which is precisely the criterion for the assignment of a 20 percent rating under Diagnostic Code 8521. That is, the Veteran's current symptoms are more sensory and do no surpass the "average" or "medium" range and are best described as moderate, thus warranting the 20 percent rating, but no more. The Board finds that the Veteran's symptoms, alone, do not constitute evidence which is sufficient to characterize the peripheral sensory polyneuropathy of the right and left lower extremities as severe for the period from May 10, 2002 to February 8, 2010. Therefore, the Board finds that the criteria for initial ratings in excess of 20 percent for hyperalgesic peripheral sensory polyneuropathy of the right and left lower extremities have not been met. Thus, for the period from May 10, 2002 to February 8, 2010, the Veteran is not eligible for a 30 percent rating under Diagnostic Code 8521, as there is no evidence of severe incomplete paralysis of the right or left lower extremity. 2. On and after February 8, 2010 The Veteran presented at the VAMC again in February 2010 with complaints of burning pain in his feet. On neurological evaluation, the Veteran's muscle tone was described as normal, his muscle bulk was shown to be equal, and his strength was shown to be 5/5 and equal bilaterally. However, the treatment provider noted that the reflexes were "1-0+ bilateral" and the plantar reflexes were "downgoing bilateral." In addition, the Veteran had decreased sensation to pinprick, temperature, vibration, and position sense in the feet and fingers. The Veteran's gait, station and coordination were described as normal, and his distal pulse was palpable. Based on his evaluation of the Veteran, the treatment provider assessed the Veteran with severe peripheral neuropathy. At a May 2011 VA examination, the VA examiner referenced vascular studies that took place in July 2010 and were clear for any evidence of peripheral arterial disease of the lower extremities. However, he noted that the Veteran experienced loss of protective sensation in both forefeet and decreased sensation to pinprick, temperature, vibration, and position sense in the feet and fingers. He also observed "[d]orsally contracted digits 2-5 bilaterally" and "deviation of hallux interphalangeal joint bilaterally." In addition, the examiner found evidence of interossi and plantar muscle atrophy. Pursuant to the October 2011 remand, the Veteran was afforded another VA examination in February 2012, specifically to determine the nature, etiology and extent of any complications arising from his diabetes. Upon physical examination of the lower extremities, the examiner described the Veteran's muscle tone as normal, and noted that his muscle strength was 5/5 bilaterally. The examiner further noted that the Veteran had loss of protective sensation in both forefeet, and decreased sensation to pinprick, temperature, and vibration on propriopception of both feet. The examiner also noted signs of "[d]orsally contracted digits 2-5 bilaterally, deviation of hallux interphalangeal joint bilaterally" and the presence of "[i]nterossi and plantar muscle atrophy." The Veteran's reflexes were shown to be "1-0+ [b]ilaterally" and his plantar movement was described as "downgoing." Based on his review of the claims file and medical literature, as well as his evaluation of the Veteran, the examiner diagnosed the Veteran with severe hyperalgesic peripheral sensory polyneuropathy of the extremities and related this disorder to the Veteran's diabetes. On review of the evidence of record, the Board finds that the disability picture for the Veteran's service-connected hyperalgesic peripheral sensory polyneuropathy of the right and left lower extremities more nearly approximates severe impairment of both extremities, beginning with the neurology consultation note dated on February 8, 2010. However, an initial rating in excess of 30 percent is not warranted at any time because the evidence does not show complete paralysis of the lower extremities with all or most of the symptoms required under Diagnostic Code 8521 noted above. While the May 2011 and February 2012 examination findings revealed signs of deviation in the hallux interphalangeal joint bilaterally, there was no evidence of a foot drop and slight droop of first phalanges of all toes. Therefore, the Board finds that the criteria for separate disability ratings in excess of 30 percent for hyperalgesic peripheral sensory polyneuropathy of the right and left lower extremities have not been met. In reaching this conclusion, the Board acknowledges the Veteran's belief that the symptoms in his lower extremities are more severe than that reflected by the current disability ratings. The Board finds that the Veteran is certainly competent to discuss the severity of his symptomatology. As a lay person, however, the Board gives more weight to the specific objective findings obtained through specialized testing and physical examinations. Such matters require medical expertise to determine. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Thus, the Board finds that the current 30 percent evaluations for the Veteran's service-connected hyperalgesic peripheral sensory polyneuropathy of the right and left lower extremities are appropriate for the period beginning February 8, 2010. In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). As noted above, the very symptoms the Veteran has reported and have been found on examinations are those contemplated by the rating criteria. Therefore, referral for consideration of an extraschedular rating is not warranted. ORDER Entitlement to an initial disability evaluation in excess of 20 percent for diabetes mellitus is denied. Entitlement to an initial disability evaluation in excess of 20 percent for hyperalgesic peripheral sensory polyneuropathy of the right lower extremity for the period from May 10, 2002 to February 8, 2010, is denied. Entitlement to an initial disability evaluation in excess of 20 percent for hyperalgesic peripheral sensory polyneuropathy of the left lower extremity for the period from May 10, 2002 to February 8, 2010, is denied. Entitlement to an initial disability evaluation of 30 percent for hyperalgesic peripheral sensory polyneuropathy of the right lower extremity from February 8, 2010, is granted. Entitlement to an initial disability evaluation of 30 percent for hyperalgesic peripheral sensory polyneuropathy of the left lower extremity from February 8, 2010, is granted. REMAND The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires VA to assist a claimant in obtaining that evidence. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The Board must determine whether the Veteran is entitled to separate compensable ratings for additional complications associated with his diabetes. As previously discussed above, compensable complications of diabetes are to be evaluated separately unless they are part of the criteria used to support a 100 percent disability evaluation, with noncompensable complications to be considered as part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1) (2012). As such, an analysis of the severity of any identified complication of diabetes is required in order to ascertain whether such complications are compensable. The medical evidence of record on file remains unclear as to whether the Veteran has nephropathy as a result of his diabetes. At the May 2009 VA examination, the Veteran did not exhibit any bladder or bowel impairment and findings from his urinalysis were shown to be normal. However, the examiner did identify signs of what appeared to be diabetic kidney disease based on the level of microalbumin in the Veteran's urine, and diagnosed the Veteran with diabetic nephropathy. Diabetic nephropathy is rated pursuant to 38 C.F.R. § 4.115b, Diagnostic Code 7541 (2012). Under that diagnostic code, renal involvement in diabetes mellitus should be rated as renal dysfunction, as follows: A noncompensable evaluation is warranted for evidence of albumin and casts with history of acute nephritis; or, hypertension noncompensable under Diagnostic Code 7101. A 30 percent rating is warranted for constant albumin 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 for 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 is warranted for renal dysfunction with persistent edema and albuminuria with blood urea nitrogen (BUN) 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating is warranted 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%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. See 38 C.F.R. § 4.115a (2012). Subsequent VA examination reports however are absent a diagnosis of nephropathy, and silent as to whether the Veteran has any kidney problems stemming from his diabetes mellitus. While the Veteran denied experiencing any such problems at the August 2009 VA examination, the more recent VA examinations have not addressed the May 2009 diagnosis of diabetic nephropathy; nor have they provided a definite opinion as to whether the Veteran has any such abnormality as a result of his diabetes mellitus. Indeed, the most recent VA examination dated in February 2012 does not comment on the existence or severity of any possible kidney disease stemming from the Veteran's diabetes. In light of the incomplete medical findings, the Board finds that the Veteran should be afforded an additional VA medical examination to determine whether he has any kidney complications as result of his diabetes mellitus. If so, then the nature and severity of this condition should be assessed to determine whether a separate compensable rating for this disability should be awarded. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (the Board is prohibited from exercising its own independent judgment to resolve medical questions). With respect to the Veteran's upper extremity peripheral neuropathy, while the February 2012 VA examiner related the Veteran's hyperalgesic peripheral sensory polyneuropathy to his diabetes mellitus, the examination predominantly focused on how the nerve impairment affects the Veteran's lower extremities rather than his upper extremities. While the Veteran has complained of numbness and pain in his hands and fingertips, the objective medical evidence on file predominantly focuses on the nature of lower extremities and how these symptoms have affected the lower extremities. As such, the record does not provide enough information to assist the Board in understanding the current disability picture with regard to the Veteran's upper extremity peripheral neuropathy. Indeed, the Board is left to question whether the Veteran has peripheral neuropathy in one or both of the upper extremities, and whether the nerve impairment affecting the upper extremities was manifested by symptoms that were mild, moderate or severe in nature, or has resulted in complete paralysis. The duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. See Peters v. Brown, 6 Vet. App. 540, 542 (1994). Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with appropriate VCAA notification as to the information and evidence necessary to support his claims seeking separate compensable ratings for upper extremity peripheral neuropathy and diabetic nephropathy. The notification should provide the Veteran with the statutory and regulatory provisions underlying his claims. 2. Then, schedule the Veteran for a VA examination with a VA endocrinologist to determine the nature and etiology of any kidney disorder present. The claims folder and all records on Virtual VA must be made available to, and reviewed by, the examiner in conjunction with the examination. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed, and all pertinent pathology should be noted in the examination report. The examiner should specifically take into consideration the May 2009 VA examination report reflecting an assessment of diabetic nephropathy. Following a review of the record and an examination of the Veteran, the examiner should specify the nature of any each kidney disability present and provide diagnoses. The examiner should then express an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any kidney disability is related to the Veteran's diabetes mellitus. Any opinion in this regard should be reconciled with the May 2009 VA assessment of diabetic nephropathy. The examiner should provide a complete rationale upon which his or her opinions are based, and must include a discussion of the medical principles as applied to the medical evidence and facts used in establishing his or her opinion. If the examiner determines that he/she cannot provide an opinion without resorting to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). (The AOJ should ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained.) The examiner should also specifically describe the extent of any nephropathy disability. Included in the report should be findings as to the frequency and persistence of any albuminuria (the examiner should discuss whether the albumin levels are constant or recurring); BUN and creatine levels; extent of decrease of function of the kidneys or related organ systems (especially cardiovascular); and symptoms of hypertension. The examiner should also note any lethargy, weakness, anorexia, weight loss, or a limitation of exertion. All pertinent symptomatology and findings should be reported in detail. Any indicated diagnostic tests and studies should be accomplished. 3. After completion of the development sought in paragraph 1 above, schedule the Veteran for a VA examination to determine the current severity of the service-connected peripheral neuropathy of his upper extremities. The claims folder and all records on Virtual VA must be made available to, and reviewed by the examiner in conjunction with the examination. Any indicated evaluations, studies, and tests, must be accomplished and the results must be included in the examination report. The examiner must identify all symptoms that are associated with the Veteran's service-connected peripheral neuropathy of the right and left upper extremities. The examiner should specifically indicate whether the Veteran's peripheral neuropathy of the right and left upper extremities more nearly approximate mild, moderate, or severe nerve impairment. The nerves affected or seemingly affected should be specifically identified and, for each nerve affected, the disability should be described in this manner. Additionally, any functional impairment of the upper extremities deemed to be associated with the Veteran's upper extremity peripheral neuropathy must be identified. In offering any opinion, the examiner should take into consideration all the evidence of record, to include medical records as well as the Veteran's lay statements. All opinions expressed should be accompanied by supporting rationale. 4. Thereafter, adjudicate the claims for separate compensable ratings for upper extremity peripheral neuropathy and diabetic nephropathy. If any benefit sought is denied, provide the Veteran and his representative a supplemental statement of the case. An appropriate period of time should be allowed for response before the case is returned to the Board. No action is required of the Veteran until he is notified; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claims. 38 C.F.R. § 3.655 (2012). The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims remanded by the Board or the Court for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs