Citation Nr: 1316476 Decision Date: 05/20/13 Archive Date: 05/29/13 DOCKET NO. 04-02 852 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office and Insurance Center in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to an increased rating for type I diabetes mellitus on an extraschedular basis. 2. Entitlement to a rating in excess of 10 percent for cardiomyopathy prior to May 11, 2010. 3. Entitlement to a rating in excess of 30 percent for cardiomyopathy since May 11, 2010. 4. Entitlement to an initial rating in excess of 20 percent for peripheral neuropathy of the right upper extremity. 5. Entitlement to an initial rating in excess of 20 percent for peripheral neuropathy of the left upper extremity. 6. Entitlement to an effective date earlier than May 11, 2010, for the award of service connection for peripheral neuropathy of the left upper extremity. 7. Entitlement to an effective date earlier than May 11, 2010, for the award of service connection for peripheral neuropathy of the left upper extremity. 8. Entitlement to a total rating based upon individual unemployability due to service connected disabilities (TDIU), prior to June 29, 2005. 9. Whether a separate compensable rating is warranted for erectile dysfunction as a complication of type I diabetes mellitus. 10. Whether a separate compensable rating is warranted for hypertension as a complication of type I diabetes mellitus. 11. Whether a separate compensable rating is warranted for onychomycosis of the bilateral great toes as a complication of type I diabetes mellitus. 12. Whether a separate compensable rating is warranted for seborrhea with folliculitis as a complication of type I diabetes mellitus. 13. Whether a separate compensable rating is warranted for disability attributable to microalbuminuria as a complication of type I diabetes mellitus. 14. Entitlement to an initial rating in excess of 10 percent for diabetic neuropathy of the right lower extremity. 15. Entitlement to an initial rating in excess of 10 percent for diabetic neuropathy of the left lower extremity. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD April Maddox, Counsel INTRODUCTION The Veteran served on active duty from August 1970 to August 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2001 rating decision of the Philadelphia, Pennsylvania, Department of Veterans Affairs (VA) Regional Office and Insurance Center (RO), which (1) denied an increased rating for type I diabetes mellitus; (2) denied a TDIU rating; and (3) granted service connection for bilateral diabetic retinopathy and assigned a noncompensable rating. The Veteran disagreed with the denials and the noncompensable initial rating for his bilateral diabetic retinopathy. The appeal ensued. By rating decision dated in November 2003, the RO granted service connection for cardiomyopathy secondary to the Veteran's diabetes mellitus (assigning a 10 percent disability rating, effective March 19, 2001), granted service connection for diabetic neuropathy of the right lower extremity secondary to the Veteran's diabetes mellitus (assigning a 10 percent disability rating, effective March 19, 2001), and granted service connection for diabetic neuropathy of the left lower extremity secondary to the Veteran's diabetes mellitus (assigning a 10 percent disability rating, effective March 19, 2001). In July 2006, the Board denied the aforementioned claims and the Veteran then appealed the denial to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a June 2007 Joint Motion for Remand, the Court vacated and remanded the Board's July 2006 decision. In September 2007, the Board remanded the claims to the RO for further development. In May 2010, the Board granted a 40 percent rating for type I diabetes mellitus and a TDIU rating, and denied an initial increased (compensable) rating for diabetic retinopathy. The Board also remanded the issues of an increased rating for type I diabetes mellitus on an extraschedular basis, and whether separate compensable ratings were warranted for peripheral neuropathy of the upper extremities, erectile dysfunction, hypertension, onychomycosis of the bilateral great toes and a disability attributable to microalbuminuria, all as complications of type I diabetes mellitus. By rating decision dated in June 2010, the RO effectuated the Board's grant of a 40 percent rating for diabetes and a TDIU rating, both effective June 29, 2005. By rating decision dated in August 2010, the RO continued a 40 percent disability rating for the Veteran's diabetes, increased the disability rating for cardiomyopathy to 30 percent effective May 11, 2010, granted service connection for both peripheral neuropathy of the upper extremities secondary to the Veteran's diabetes mellitus (assigning 20 percent disability ratings for each extremity effective May 11, 2010), and continued a noncompensable rating for the Veteran's diabetic retinopathy. In July 2011, the Board remanded the issues of entitlement to (1) an increased rating for type I diabetes mellitus on an extraschedular basis; (2) a disability rating greater than 10 percent prior to May 11, 2010 and a disability rating greater than 30 percent beginning May 11, 2010 for cardiomyopathy (a complication of the Veteran's diabetes mellitus); and (3) disability ratings greater than 20 percent each for peripheral neuropathy of the upper extremities (a complication of the Veteran's diabetes mellitus), and whether separate compensable ratings were warranted for erectile dysfunction, hypertension, onychomycosis of the bilateral great toes and a disability attributable to microalbuminuria, all as complications of type I diabetes mellitus. With regard to the issues decided below, the Board is satisfied that there has been substantial compliance with the remand directives and the Board may proceed with review. Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that, in addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals VA treatment records dated through September 2012. Notably, the most recent supplemental statement of the case dated in October 2012 reviewed these VA treatment records. The remainder of the documents in the Virtual VA paperless claims file are either duplicative of the evidence in the paper claims file or are not relevant to the issues on appeal. The issues of entitlement to (1) an effective date earlier than July 9, 2008 for the award of service connection for peripheral neuropathy of the right upper extremity; (2) an effective date earlier than July 9, 2008 for the award of service connection for peripheral neuropathy of the left upper extremity; (3) a separate compensable rating for disability attributable to microalbuminuria as a complication of type I diabetes mellitus; (4) an initial rating in excess of 10 percent for diabetic neuropathy of the right lower extremity; (5) an initial rating in excess of 10 percent for diabetic neuropathy of the left lower extremity; and (6) an earlier effective date for the award of a TDIU rating are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's service-connected diabetes mellitus has not had marked interference in his employment or resulted in frequent hospitalizations and the Veteran's symptoms are contemplated by the 40 percent rating. 2. During the September 19, 2002 VA examination the Veteran exhibited an ejection fraction of 48. However, there was no chronic congestive heart failure, or; workload of 3 METs or less, resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with ejection fraction of less than 30 percent. 3. During the May 7, 2003 VA examination, the Veteran exhibited a baseline left ventricular ejection fraction of 52 percent with a peak ejection fraction of 80 percent. During the December 2009 VA diabetes examination an EKG was performed which noted an ejection fraction of 65 percent. There was no evidence of a workload of greater than 5 METs but not greater than 7 METs, resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. 4. During the June 2010 VA examination, an EKG revealed evidence of mild concentric left ventricular hypertrophy. The Veteran's estimated METs were noted as 2-<3 due to his abnormal gait and his use of a cane secondary to his peripheral neuropathy of the lower extremities. There was no evidence of dyspnea, fatigue, angina, dizziness, or syncope. At no point from May 11, 2010 did the Veteran's cardiomyopathy manifest with more than one episode of acute congestive heart failure in the past year, a workload of greater than 2 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 5. The Veteran's erectile dysfunction is currently manifested by loss of erectile ability without any evidence of penis deformity. 6. The Veteran's hypertension is currently manifested by a systolic pressure predominantly greater than 160 but less than 200 and a diastolic pressure of less than 110. 7. The Veteran does not currently have onychomycosis of the bilateral great toes. 8. The Veteran's seborrhea with folliculitis is manifested by a rash on the scalp occupying 30 percent of the Veteran's exposed skin and 10 percent of the Veteran's total skin. There is no evidence that the Veteran's skin disorder affects more than 40 percent of the entire body or more than percent of exposed areas affected. Nor is there evidence of constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. CONCLUSIONS OF LAW 1. The criteria for disability rating greater than 40 percent for type I diabetes mellitus on an extraschedular basis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.120, Diagnostic Code (DC) 7913 (2012). 2. The criteria for an initial disability rating greater than 10 percent for cardiomyopathy prior to September 19, 2002 are not met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.31, 4.104, DC 7020. 3. The criteria for a 60 percent disability rating for cardiomyopathy from September 19, 2002 to May 6, 2003 are met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.31, 4.104, DC 7020. 4. The criteria for a disability rating greater than 10 percent from May 7, 2003 to May 10, 2010 for cardiomyopathy are not met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.31, 4.104, DC 7020. 5. The criteria for a disability rating greater than 30 percent beginning May 11, 2010 for cardiomyopathy are not met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.31, 4.104, DC 7020. 6. The criteria for an initial disability rating greater than 20 percent for peripheral neuropathy of the right upper extremity have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.3, 4.7, 4.124a, DC 8512 (2012). 7. The criteria for an initial disability rating greater than 20 percent for peripheral neuropathy of the left upper extremity have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.3, 4.7, 4.124a, DC 8512. 8. The criteria for a separate compensable disability rating for erectile dysfunction have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.115b, DC 7599-7522 (2012). 9. The criteria for a separate compensable disability rating for hypertension have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, DC 7101 (2012). 10. The criteria for a separate compensable disability rating for onychomycosis of the bilateral great toes have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.118, DC 7805 (prior to October 23, 2008). 11. The criteria for an initial 30 percent disability rating, but no higher, for seborrhea with folliculitis have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.118, DC 7805 (prior to October 23, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS This appeal arises out of the Veteran's claims that his service-connected diabetes mellitus and resulting complications of diabetes are more disabling than currently evaluated. Service treatment records show that the Veteran was diagnosed with type I diabetes mellitus in November 1970. Thereafter, a January 1971 Medical Board report notes that the Veteran was to be discharged from military service due to his diabetes. The Veteran was discharged from military service in August 1971 and filed a claim for service connection for diabetes in September 1971. By rating decision dated in November 1971, the RO granted service connection for type I diabetes mellitus and assigned a 20 percent disability rating, effective August 14, 1971, the day after the Veteran's discharge from military service. In March 2001, the Veteran filed a claim for an increased rating for his service-connected diabetes. He was afforded VA examinations for his diabetes in July and August 2001, which showed a diagnosis of mild nonproliferative diabetic retinopathy. By rating decision dated in October 2001, the RO continued the 20 percent disability rating for the diabetes and granted service connection for diabetic retinopathy, rated noncompensable, effective March 19, 2001. Thereafter, the Veteran perfected an appeal with regard to this decision. By rating decision of November 2003, the RO granted service connection for cardiomyopathy (10 percent disabling), diabetic peripheral neuropathy, right lower extremity (10 percent disabling), and diabetic peripheral neuropathy, left lower extremity (10 percent), all secondary to service-connected type I diabetes mellitus, effective March 19, 2001. In a May 2010 decision, the Board awarded a 40 percent rating for type I diabetes mellitus and a TDIU rating. The following month, the RO effectuated the Board's award of the 40 percent rating for diabetes and a TDIU, both effective June 29, 2005. By rating decision dated in August 2010 the RO continued a 40 percent disability rating for the Veteran's diabetes, increased the disability rating for cardiomyopathy to 30 percent effective May 11, 2010, granted service connection for both peripheral neuropathy of the upper extremities secondary to the Veteran's diabetes mellitus (assigning 20 percent disability ratings for each extremity effective May 11, 2010), and continued a noncompensable rating for the Veteran's diabetic retinopathy. General Legal Criteria Disability ratings are determined by the application of a schedule of ratings, which are based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. The governing regulations provide that the higher of two evaluations will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. A request for an increased rating is to be reviewed in light of the entire relevant medical history. See generally 38 C.F.R. § 4.1; Payton v. Derwinski, 1 Vet. App. 282, 287 (1991). Disabilities may be rated by analogy to a closely related disease where the functions affected and the anatomical location and symptomatology are closely analogous. 38 C.F.R. §§ 4.20, 4.27. When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. 38 C.F.R. § 4.45. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the current appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The effective date of an award based on a claim for increase of compensation "shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor." 38 U.S.C.A. § 5110(a). VA regulations provide that the effective date for increases shall be the "date of receipt of claim or date entitlement arose, whichever is later." 38 C.F.R. § 3.400(o)(1). Under this rule, an effective date for an increased rating may be assigned later than the date of receipt of the claim -- if the evidence shows that the increase in disability actually occurred after the claim was filed -- but never earlier than the date of receipt of the claim. The law provides an exception to this general rule: The effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date. 38 U.S.C.A. § 5110(b)(2). The regulations provide that the effective date shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if claim is received within one year from such date otherwise, date of receipt of claim. 38 C.F.R. § 3.400(o)(2). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of doubt is afforded the claimant. 38 U.S.C.A. § 5107(b). A claim is "a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit." 38 C.F.R. § 3.1(p). A report of examination or hospitalization which meets certain requirements will be accepted as an informal claim for benefits if the report relates to a disability which may establish entitlement. 38 C.F.R. § 3.157(a). Once a formal claim for compensation has been allowed, receipt of a report of examination or hospitalization by uniformed services will be accepted as an informal claim for increased benefits. 38 C.F.R. § 3.157(a), (b). When the following reports relate to examination or treatment of a disability for which service connection has previously been established, the date of outpatient or hospital examination or the date of admission to a VA or uniformed services hospital will be accepted as the date of receipt of claim and the date of a uniformed service examination which is the basis for granting severance pay to a former member of the Armed Forces on the temporary disability retired list will be accepted as the date of receipt of claim. 38 C.F.R. § 3.157(b)(1). Analysis 1. Increased rating for type I diabetes mellitus on an extraschedular basis. As above, the Veteran's type I diabetes mellitus is rated under 38 C.F.R. § 4.120, Diagnostic Code (DC) 7913 as 40 percent disabling. A 40 percent evaluation is warranted for the requirement of insulin, a restricted diet, and regulation of activities. All compensable complications of diabetes are to be evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Any noncompensable complications associated with diabetes mellitus are considered to be part of the diabetic process under DC 7913. 38 C.F.R. § 4.120, DC 7913 at Note (1). In certain circumstances, a claimant may be assigned a higher evaluation on an extraschedular basis. The question of whether such an evaluation may be assigned is a component of a claim for a higher initial or increased evaluation. See Bagwell v. Brown, 9 Vet. App. 337 (1996). Although the Board may not assign an evaluation on an extraschedular basis in the first instance, when the question is raised either by the claimant, or reasonably by the evidence of record, the RO or Board must specifically decide whether to refer the claim to the Director of VA's Compensation and Pension Service under 38 C.F.R. § 3.321 for consideration of the matter. Barringer v. Peake, 22 Vet. App. 242 (2008). The Director is authorized to approve the assignment of an extraschedular evaluation if the claim "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). The Board previously determined that the question of whether the Veteran was entitled to an increased evaluation on an extraschedular basis was raised. It thus referred the claim to the Director of VA's Compensation and Pension Service on an extraschedular basis. In a May 2011 decision, the Director determined that such an evaluation was not assignable because the Veteran's type I diabetes mellitus disability picture was not so exceptional or unusual with related factors such as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular criteria. A review of the record shows that the Veteran was previously employed by the United States Postal Service (USPS) but was terminated in October 2000 due to excessive absences. In a July 2001 claim for a TDIU the Veteran wrote that he last worked for the USPS in December 1998. In his December 2003 substantive appeal the Veteran wrote that in December 1998 the USPS changed the start time of his shift by four hours and that the Veteran could not adapt to this change in schedule due to his service-connected diabetes. Following the Board's award of a 40 percent rating for type I diabetes mellitus and a TDIU rating, the RO effectuated these awards in a June 2010 rating decision and assigned effective dates of June 29, 2005 for both awards. The Board notes that there is no evidence in the claims file of frequent periods of hospitalization for the Veteran's type I diabetes mellitus for the rating period on appeal. Additionally, there is nothing to show that these problems have created marked interference with employment in excess of what is contemplated in a schedular rating so as to render impractical the schedular rating criteria. Rather, the symptoms complained of by the Veteran are those contained specifically in DC 7913-requiring insulin, restricted diet, and regulation of activities. In other words, the Veteran's symptoms are contemplated by the schedular rating criteria. The Board does not doubt that limitation caused by the service-connected diabetes has an adverse impact on employability; however, loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a) and 4.1. 38 C.F.R. § 4.1 specifically states: "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." See also Moyer v. Derwinski, 2 Vet. App. 289 (1992); Van Hoose v. Brown, 4 Vet. App. 361 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Consequently, the Board finds that the assigned schedular rating for the service-connected diabetes mellitus is adequate, and an extraschedular evaluation is not warranted. 2. Increased rating for cardiomyopathy. The Veteran's cardiomyopathy is rated under 38 C.F.R. § 4.104, DC 7020. Under DC 7020, a 10 percent rating is assigned for cardiomyopathy with a workload of greater than 7 METs but not greater than 10 METs, results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication is required. A 30 percent rating is warranted for a workload of greater than 5 METs but not greater than 7 METs, results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. A 60 percent rating contemplates more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs, results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is assigned for chronic congestive heart failure, or; workload of 3 METs or less, results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with ejection fraction of less than 30 percent. Evidence relevant to the severity of the Veteran's cardiomyopathy includes VA examination reports dated in September 2002, May 2003, and June 2010. During the September 2002 VA examination an echocardiogram (EKG) was performed and showed normal chamber sizes, mild reduction in left ventricular systolic function, and no regional wall motion abnormalities. Aortic mitral, tricuspid, and pulmonic valve leaflets were normal. Mild mitral insufficiency was noted. Ejection fraction was given as 48 percent which was noted to be slightly below the lower limits of normal. A stress echo was performed and the Veteran achieved a workload of 8 METs, a peak heart rate of 150 BPM (beats per minute), which was 89 percent of his predicted maximum. He did not have chest pain. The resting EKG was normal. There were no EKG changes with stress. There were no regional wall motion abnormalities at rest or with exercise. There were no rhythm disturbances. The impression was "no evidence of ischemia." During the May 2003 VA examination a dobutamine stress echo was performed. The Veteran's baseline left ventricular ejection fraction was 52 percent with a peak ejection fraction of 80 percent. The resting EKG was normal. The Veteran did not have chest pain. He did not develop significant EKG changes or echo changes with dobutamine stress. There was no significant arrhythmias. The impression was that there was no echo evidence of ischemia. IT was also noted that there was "perhaps slight improvement in baseline LV systolic function since the previous echo." The impression was that the dobutamine stress echo did not suggest significant coronary artery disease. There was borderline left ventricular systolic dysfunction at rest. The thyroid function studies obtained in 2002 were reportedly normal, and the Veteran's iron studies did not suggest hemochromatosis. It was noted that it was at least as likely as not that the Veteran had a mild nonischemic cardiomyopathy which was likely due to the combined effects of the Veteran's diabetes and hypertension. Their relative contributions could not be determined. Therefore, the examiner opined that it was as least as likely as not that the Veteran's mild reduction of ejection fraction was due to his diabetes. The examiner noted that this had not produced clinically significant deterioration of left ventricular contractility, nor had this produced significant functional limitation in terms of the Veteran's ability to exert himself. In that regard, the examiner noted that the Veteran's stress test of August 2002 was notable for a workload of 8 METs and that the study was also negative for ischemia. During the December 2009 VA diabetes examination an EKG was performed which noted an ejection fraction of 65 percent. The impression was normal left ventricular systolic function, no regional wall motion abnormalities, mild concentric left ventricular hypertrophy, no chamber enlargement, trace mitral regurgitation, and trace tricuspid regurgitation. During the June 2010 VA examination an EKG revealed evidence of mild concentric left ventricular hypertrophy. The Veteran's estimated METs were noted as 2-<3 due to his abnormal gait and his use of cane secondary to his peripheral neuropathy of the lower extremities. There was no evidence of dyspnea, fatigue, angina, dizziness, or syncope. There was no evidence of congestive heart failure or pulmonary hypertension. No continuous medication was required for the Veteran's heart disease. The examiner diagnosed cardiomyopathy. The examiner's impression was noted as normal left ventricular systolic function, no regional wall motion abnormalities, no chamber enlargement, trace mitral regurgitation, and trace tricuspid regurgitation. During a February 2011 VA diabetes examination it was noted that, in view of the Veteran's history, he had METs at least greater than 5-7. Heart size was larger than normal and he had an ejection fraction of greater than 50 percent. Based on this evidence, the Board finds that the Veteran's cardiomyopathy warrants a 60 percent rating from the date of the September 19, 2002 VA examination, which showed an ejection fraction of 48 percent (which falls into the 60 percent criteria) until May 6, 2003. At the May 7, 2003 VA examination, it showed baseline left ventricular ejection fraction of 52 percent with a peak ejection fraction of 80 percent, which falls into the 10 percent criteria. Thus, the 60 percent rating criteria were no longer met as of the day of the May 7, 2003 VA examination. Prior to the September 2002 VA examination and from the May 72003 VA examination until May 11, 2010, cardiomyopathy was not manifested by a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. In other words, the evidence prior to September 2002 and between May 2003 to May 2010 do not show clinical findings that warrant a rating in excess of 10 percent for cardiomyopathy. As above, during the May 2003 VA examination the Veteran had a baseline left ventricular ejection fraction of 52 percent with a peak ejection fraction of 80 percent and it was noted that he had METs of 8 in August 2002. During the December 2009 VA diabetes examination an EKG was performed which noted an ejection fraction of 65 percent. Beginning May 11, 2010, when the disability has been rated as 30 percent disabling, the Veteran's cardiomyopathy has not been manifested with more than one episode of acute congestive heart failure in the past year, a workload of greater than 3 METs but not greater than 5 METs, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. While the Veteran's estimated METs were noted as 2-<3 in June 2010, this was due to his abnormal gait and his use of cane secondary to his peripheral neuropathy of the lower extremities. There was no evidence of dyspnea, fatigue, angina, dizziness, or syncope. Also, during a February 2011 VA diabetes examination it was noted that, in view of the Veteran's history, he had METs at least greater than 5-7. Heart size was larger than normal and he had an ejection fraction of greater than 50 percent. The Board has considered other possibly applicable diagnostic codes, specifically supraventricular arrhythmias. 38 C.F.R. § 4.104, DC 7010. The maximum rating under that diagnostic code is 30 percent. As the Veteran is already rated at that level during this time period, the question of whether DC 7010 applies is moot. There are no other potentially applicable diagnostic codes. When weighing the lay and medical evidence of record, the Board finds higher a rating is warranted from September 19, 2002, to May 6, 2003; however, the preponderance of the evidence is against the claim for higher ratings for cardiomyopathy prior to September 18, 2002 between May 7, 2003, to May 10, 2010 (when it was 10 percent) and as of May 11, 2010 . For those periods of time where the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. 3. Increased ratings for peripheral neuropathy of the right and left upper extremities including an earlier effective date for service connection The Veteran's bilateral peripheral neuropathy of the upper extremities has been rated as 20 percent disabling for both the right and left upper extremities under 38 C.F.R. § 4.124a, DC 8512 (each upper extremity has its own evaluation). DC 8512 pertains to paralysis of the lower radicular group. Under DC 8512 a 20 percent rating is assigned when there is mild incomplete paralysis. Moderate incomplete paralysis corresponds to a 30 percent rating for the minor extremity, and 40 percent rating for a major extremity. Severe incomplete paralysis corresponds to a 40 percent rating for the minor extremity, and 50 percent rating for a major extremity. Where there exists complete paralysis, with paralysis of all intrinsic muscles of the hand, and some or all flexors of the wrist or fingers (and substantial loss of use of the hand), a 60 percent rating is warranted for the minor extremity, and 70 percent rating is warranted for a major extremity. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than that associated with complete paralysis. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. For rating purposes, a distinction is made between major (dominant) and minor musculoskeletal groups. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. 38 C.F.R. § 4.69. Here, as the medical evidence shows that the Veteran is right-hand dominant, for rating purposes, his right forearm and wrist are part of his major upper extremity and his left forearm and wrist are part of his minor upper extremity. Evidence relevant to the severity of the Veteran's peripheral neuropathy of the upper extremities includes VA examination reports dated in June 2010, November 2010, and February 2011. During the June 2010 VA examination the Veteran complained of paresthesias and loss of sensation of the upper extremities. Examination findings revealed decreased light touch and vibration sensation in the right upper extremities that included all of the Veteran's fingers. Muscle strength and deep tendon reflexes were normal. The examiner diagnosed bilateral peripheral neuropathy, upper extremities. The impression was that the Veteran developed diabetic-related peripheral neuropathy of the upper extremities and the examiner opined that this condition was due to the complication in relation to the onset of the Veteran's service-connected diabetes. During the November 2010 VA neurological examination, the Veteran complained of numbness, paresthesias, and pain. The type of paresthesias described was tingling, burning, and pins and needles in all extremities. Examination findings revealed decreased light touch in the fingers. With regard to the ulnar, radial, and median nerves of the right and left extremities, vibration, pain/pinprick, and position sense were normal. Also, there was no dysthesia. Muscle strength and deep tendon reflexes were normal. The examiner diagnosed diabetic polyneuropathy. During the February 2011 VA diabetes examination the Veteran had decreased sensation to light touch in all fingers and toes. He reported difficulty holding things and dropping things due to upper extremity peripheral neuropathy. He ambulated with a normal gait. The Veteran reported tingling, burning, and pins and needles in all extremities. Examination findings revealed decreased light touch and vibration sensation in the right upper extremities that included all of the Veteran's fingers. Muscle strength and deep tendon reflexes were normal. The examiner diagnosed bilateral peripheral neuropathy, upper extremities. The impression was that the Veteran developed diabetic-related peripheral neuropathy of the right upper extremities. The examiner opined that the condition was due to the Veteran's complication in relation to the onset of diabetes. Also relevant are private treatment records dated from July 2008 showing impressions of bilateral upper extremity numbness and sensory peripheral neuropathy. Also, a July 2008 nerve study showed sensory peripheral polyneuropathy, left ulnar neuropathy, and mild carpal tunnel syndrome. The Board finds that the preponderance of the evidence is against initial ratings greater than 20 percent for the Veteran's bilateral peripheral neuropathy of the upper extremities. Significantly, on all examinations noted above, muscle strength and deep tendon reflexes were normal. Also, with regard to the ulnar, radial, and median nerves of the right and left extremities, pain/pinprick, and position sense were normal. Also, there was no dysthesia. The Veteran's primary issues with his hands tingling, burning, and pins and needles. The Board finds this symptomatology to be no more than mild. Thus, the Board finds that DC 8512 does not provide a basis for the assignment of initial disability ratings in excess of 20 percent for the Veteran's service-connected peripheral neuropathy of the upper extremities. With regard to DeLuca considerations, because the Veteran's bilateral peripheral neuropathy of the upper extremities is not based on limitation of motion, consideration of the DeLuca factors is not necessary. As for the possibility of an earlier effective date of the grant of service connection for peripheral neuropathy of the right and left upper extremities, as noted above, by rating decision dated in August 2010 the RO granted service connection for both peripheral neuropathy of the upper extremities secondary to the Veteran's diabetes mellitus and assigned 20 percent disability ratings for each extremity effective May 11, 2010. It is evident from the medical evidence of record that the Veteran had peripheral neuropathy of the right and left upper extremities as early as July 9, 2008. As above, a July 9, 2008 private nerve study shows an impression of sensory peripheral polyneuropathy. At that time, the examiner noted that the likely etiology was diabetes. Thus, the evidence establishes that the Veteran had peripheral neuropathy of the right and left upper extremities as early as July 9, 2008 the Board finds that the evidence supports an effective date of July 9, 2008. As for the potential for an effective earlier than July 9, 2008, the Board has remanded this issue to the RO below. 4. Erectile dysfunction as a complication of type I diabetes mellitus Erectile dysfunction disorder is usually rated under 38 C.F.R. § 4.115b, DC 7599-7522. DC 7599 indicates the disability is not listed in the Schedule for Rating Disabilities and it has been rated by analogy under a closely related disease or injury. 38 C.F.R. §§ 4.20, 4.27. Generally, erectile dysfunction is rated by analogy as penis, deformity, with loss of erectile power, evaluated under DC 7522. Under DC 7522, a 20 percent rating is assigned when there is evidence of deformity of the penis with loss of erectile power. In every instance where the schedule does not provide a zero percent evaluation for a DC, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. There is no schedular rating for loss of erectile power alone. In other words, loss of erectile power without penis deformity does not warrant a compensable rating (aside from the special monthly compensation, which has already been granted in this case). 38 C.F.R. § 4.115(b), DC 7522. The first evidence of erectile dysfunction in the claims file is dated in December 2009. It was noted that the Veteran's poorly controlled diabetes led to the development of erectile dysfunction. Specifically, it was noted that the Veteran could not sustain an erection and there was no ejaculation and no treatment. In a July 2001 VA diabetes examination it was noted that both the scrotum and penis were normal. The testes were of normal size, 3.5 centimeters, of normal configuration, and were nontender. Bilaterally, inguinal canals were free of abnormal cough pulsation. The Veteran was afforded a VA genitourinary examination in November 2010. At that time the Veteran reported that he had erectile dysfunction and that vaginal penetration was not possible. There was an absence of ejaculation which was attributed to the Veteran's diabetes. The Veteran reported a history of prostatitis in 2009 and a history of kidney stones in the 1980s. The Veteran declined a genitourinary examination. Given the above evidence, the Board finds that a separate compensable disability rating for the Veteran's erectile dysfunction is not warranted. Significantly, the criteria for a schedular 20 percent rating under DC 7522 is not warranted as there is no evidence of deformity of the penis. The Board has also considered whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period, but finds no evidence for a staged rating in this case. Hart, 21 Vet. App. at 505. Furthermore, a compensable disability rating under DCs 7520, 7521, 7523, or 7524 is not warranted as the veteran has not had any of his penis or testes removed and there is no evidence of deformity. Special monthly compensation may be assigned for erectile dysfunction alone on the theory that it is analogous to the loss of a creative organ and the RO has already assigned special monthly compensation. 5. Hypertension as a complication of type I diabetes mellitus. Hypertension is rated under 38 C.F.R. § 4.104, DC 7101. Under that code, a 10 percent rating will be assigned with diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 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 will be assigned with diastolic pressure which is predominantly 110 or more, or systolic pressure predominantly 200 or more. A 40 percent rating will be assigned with diastolic pressure predominantly 120 or more. A 60 percent rating will be assigned with diastolic pressure predominantly 130 or more. The first evidence of hypertension in the claims file is a July 2002 VA diabetes examination showing an impression of hypertension since at least 1995. It was noted that the Veteran's presenting blood pressure when hospitalized for his initial evaluation of diabetes was borderline and somewhat elevated in an otherwise healthy 20 year old. Evidence relevant to the current level of severity of the Veteran's hypertension includes VA examination reports dated in November 2010 and February 2011. During the November 2010 VA examination the Veteran had blood pressure readings of 152/73, 152/71, and 154/69. During the February 2011 VA examination the Veteran had blood pressure readings of 162/84, 160/76, and 155/76. Given the evidence of record, the Board finds that a separate compensable disability rating for the Veteran's hypertension is not warranted. The available blood pressure readings collectively do not satisfy the criteria for the rating of 10 percent. As above, a 10 percent rating will be assigned with diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 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. None of the readings in November 2010 show a diastolic reading over 100 or a systolic pressure reading over 160 and only one of three readings in February 2011 show a systolic pressure reading over 160. Thus, a compensable disability rating for hypertension is not warranted. 6. Skin disorder as a complication of type I diabetes mellitus. The diagnostic criteria for disorders of the skin are found at 38 C.F.R. § 4.118, DC's 7800-7806. Under DC 7800 disfigurement of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes [including eyelids], ears [auricles], cheeks, lips), or with six or more characteristics of disfigurement will be rated as 80 percent disabling. With visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes [including eyelids], ears [auricles], cheeks, lips), or with four or five characteristics of disfigurement the disability will be rated at 50 percent. With visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes [including eyelids], ears [auricles], cheeks, lips), or with two or three characteristics of disfigurement the disability will be rated at 30 percent. With one characteristic of disfigurement the disability will be rated at 10 percent. 38 C.F.R. § 4.118, DC 7800. The eight characteristics of disfigurement are: skin indurated and inflexible in an area exceeding six square inches; underlying soft tissue missing in an area exceeding six square inches; skin texture abnormal (irregular, atrophic, shiny, scaly, etc) in an area exceeding six square inches; skin hypo or hyperpigmented in an area exceeding six square inches; scar adherent to the underlying tissue; surface contour of scar elevated or depressed on palpation; scar at least one-quarter inch in length; or scar five or more inches in length. 38 C.F.R. § 4.118, DC 7800, Note (1). DC 7801 provides ratings for scars, other than the head, face, or neck, that are deep or that cause limited motion. Scars that are deep or that cause limited motion in an area or areas exceeding 6 square inches (39 sq. cm.) are rated 10 percent disabling. Note (1) to DC 7802 provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note (2) provides that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118. DC 7802 provides ratings for scars, other than the head, face, or neck, that are superficial or that do not cause limited motion. Superficial scars that do not cause limited motion, in an area or areas of 144 square inches (929 sq. cm.) or greater, are rated 10 percent disabling. Note (1) to DC 7802 provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note (2) provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. DC 7803 provides a 10 percent rating for superficial unstable scars. Note (1) to DC 7803 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. DC 7804 provides a 10 percent rating for superficial scars that are painful on examination. Note (1) to DC 7804 provides that a superficial scar is one not associated with underlying soft tissue damage. Note (2) provides that a 10 percent rating will be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable rating. 38 C.F.R. § 4.118. DC 7804 also directs the rater to see 38 C.F.R. § 4.68 (amputation rule). 38 C.F.R. § 4.118. DC 7805 provides that other scars are to be rated on limitation of function of affected part. 38 C.F.R. § 4.118. Under DC 7806 disorders of the skin will be rated as follows: More than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period will result in a 60 percent evaluation. From 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period will result in a 30 percent evaluation. At least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period will result in a 10 percent evaluation. Less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period will result in a non compensable evaluation. 38 C.F.R. § 4.118, DC 7806. The Board notes that on September 23, 2008, VA amended the criteria for evaluating scars. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). The amendments are only effective, however, for claims filed on or after October 23, 2008, although a claimant may request consideration under the amended criteria. In this case, the Veteran submitted his claim in March 2001 and has not requested such consideration. The first evidence of bilateral onychomycosis of the great toes in the claims file is a June 2010 VA diabetes examination showing an impression of onychomycosis of the bilateral great toes. The examiner noted that this was secondary to the Veteran's diabetes. The first evidence of seborrhea with folliculitis is a November 2010 VA skin examination. Evidence relevant to the current level of severity of the Veteran's onychomycosis of the bilateral great toes includes a VA skin examination report dated in November 2010. At that time the examiner noted the Veteran's prior diagnosis of onychomycosis of the bilateral great toes and noted that this was not a known diabetic complication. The examiner also indicated that the Veteran had no complaints regarding the toenails or the skin and an examination of the toenails and feet showed that although his toenails were short, there was no onychomycosis present, nor was there any tinea pedis present. The examiner concluded that there was no complication in the skin and the nails of the feet secondary to diabetes mellitus. Evidence relevant to the current level of severity of the Veteran's seborrhea with folliculitis includes a VA skin examination report dated in November 2010. At that time the examiner noted that the Veteran had been having problems with itching of the scalp since the 1980s which had gradually accelerated and become worse over time, to the point where he had a problem with activation of this itching and burning and drainage of the scalp about ten to twelve months a year. When it was active, it was itching and burning all the time. The treatment consisted of putting alcohol on the affected areas and also Bactine bought over the counter. He had seen a physician about his itching scalp in the past year and was given a Cleocin solution and Nizoral shampoo, neither of which he found helped at all. The scalp problem had been embarrassing for him, and he found that he needed to scratch his scalp in public places and situations. It had been a very negative feature for his social life and romantic life. More recently, the itching had given over occasionally to a burning pain, which had been very intolerable to him. Other than various over-the-counter topicals as he had mentioned, he was not treating his scalp at all. On physical examination there was a diffuse red scaling through the scalp, and there was a perifollicular pustular eruption, much excoriated, with hemorrhagic crusting scattered through the scalp. This could be visualized by pulling the hair apart, as the Veteran had a very good head of hair, so that without close examination, the rash was not disfiguring, but up close it certainly was. The Veteran complained of burning and itching when the scalp palpated. The eruption was severely disfiguring. Photographs were not taken because of the heavy head of hair and the fact that it was not really photographic. The rash occupied 30 percent of the Veteran's exposed skin and 10 percent of the Veteran's total skin. During a February 2011 VA diabetes examination it was noted that there were no diabetic skin abnormalities. Given the evidence of record, the Board finds that a separate compensable disability rating for bilateral onychomycosis of the great toes is not warranted. As above, the November 2010 VA skin examiner found that there was no onychomycosis present on examination and, even if there were, this was not a known complication of diabetes. Also, the February 2011 VA diabetes examiner noted that there were no diabetic skin abnormalities. However, the Board finds that a separate compensable disability rating for seborrhea with folliculitis is warranted. As above, the November 2010 VA skin examiner diagnosed seborrhea with folliculitis and opined that this was secondary to the Veteran's diabetes. Significantly, the examiner noted that the rash on the Veteran's head was severely disfiguring and occupied 30 percent of the Veteran's exposed skin and 10 percent of the Veteran's total skin. While the February 2011 VA diabetes examiner noted that there were no diabetic skin abnormalities, the Board notes that this examination was a general diabetes examination and was not specific to the skin as was the November 2010 examination. As such, the Board gives more weight to the findings in the November 2010 VA skin examination. In order to warrant a 30 percent rating under DC 7806, the evidence must show 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. As above, the November 2010 VA skin examiner indicated that the rash on the Veteran's scalp occupied 30 percent of the Veteran's exposed skin and 10 percent of the Veteran's total skin. As such, a rating of 30 percent for the Veteran's seborrhea with folliculitis is warranted. As for the potential for an even higher rating, the Board finds that there is no evidence that the Veteran's skin disorder affects more than 40 percent of the entire body or more than percent of exposed areas affected. Nor is there evidence of constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 7. Other Considerations The Board also finds that no higher evaluation can be assigned pursuant to any other potentially applicable diagnostic code. Because there are specific diagnostic codes to evaluate the Veteran's diabetes and resulting complications, consideration of other diagnostic codes for evaluating the disability does not appear appropriate. See 38 C.F.R. § 4.20 (permitting evaluation, by analogy, where the rating schedule does not provide a specific diagnostic code to rate the disability). See also Butts v. Brown, 5 Vet. App. 532 (1993). The Board has also considered the statements of the Veteran, his wife, his daughters, and family friends that the Veteran's disabilities are worse. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran and his family and friends are competent to report symptoms because this requires only personal knowledge as it comes to then through their senses. Layno, 6 Vet. App. at 470. However, the Board finds that the more probative evidence concerning the nature and extent of the Veteran's diabetes and resulting complications has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which these disabilities are evaluated. As such, the Board finds these records to be more probative than the statements of the Veteran and his family/friends showing subjective evidence of complaints of increased symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest in the outcome of a proceeding may affect the credibility of testimony). Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). For an increased-compensation claim, section 5103(a) requires, at a minimum, that the Secretary (1) notify the claimant that to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment; (2) provide examples of the types of medical and lay evidence that may be obtained or requested; (3) and further notify the claimant that "should an increase in disability be found, a disability rating will be determined by applying relevant [DC's]," and that the range of disability applied may be between 0% and 100% "based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment." Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 473; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The appellant bears the burden of demonstrating any prejudice from defective notice with respect to the downstream elements. Goodwin v. Peake, 22 Vet. App. 128 (2008). Such notice was not provided in this case. Although the appellant received inadequate notice, the record reflects that the purpose of the notice was not frustrated. Vazquez-Flores, 22 Vet. App. 37, vacated on other grounds sub nom. Vazquez-Flores, 580 F.3d 1270. In a July 2001 letter, the RO stated that to establish entitlement to an increased evaluation for his service-connected diabetes, the evidence must show that his condition had worsened. The letter also explained that the VA was responsible for (1) requesting records from Federal agencies, (2) assisting in obtaining private records or evidence necessary to support his claim, and (3) providing a medical examination. The October 2001 rating decision explained the criteria for the next higher disability rating available for the Veteran's diabetes under the applicable diagnostic code. The November 2003 statement of the case provided the appellant with the applicable regulations relating to disability ratings for his service-connected diabetes, as well as the requirements for an extraschedular rating under 38 C.F.R. § 3.321(b) and stated that, pursuant to 38 C.F.R. § 4.10, disability evaluations center on the ability of the body or system in question to function in daily life, with specific reference to employment. Moreover, the record shows that the appellant was represented by a Veteran's Service Organization and its counsel throughout the adjudication of the claims. Overton v. Nicholson, 20 Vet. App. 427 (2006). Thus, based on the record as a whole, the Board finds that a reasonable person would have understood from the information that VA provided to the appellant what was necessary to substantiate his increased rating claims, and as such, that he had a meaningful opportunity to participate in the adjudication of his claims such that the essential fairness of the adjudication was not affected. VA has obtained service treatment records, assisted the appellant in obtaining evidence, afforded the appellant physical examinations, obtained medical opinions as to the etiology and severity of disabilities, and afforded the appellant the opportunity to give testimony before the Board although he declined to do so. All known and available records relevant to the issues on appeal have been obtained and associated with the appellant's claims file; and the appellant has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. ORDER An increased rating for type I diabetes mellitus on an extraschedular basis is denied. An initial disability rating greater than 10 percent for cardiomyopathy prior to September 19, 2002 is denied. A 60 percent disability rating for cardiomyopathy from September 19, 2002 to May 6, 2003 is granted. A disability rating greater than 10 percent for cardiomyopathy from May 7, 2003 to May 10, 2010 for cardiomyopathy is denied. A disability rating greater than 30 percent beginning May 11, 2010 for cardiomyopathy is denied. An initial disability rating greater than 20 percent for peripheral neuropathy of the right upper extremity is denied. An initial disability rating greater than 20 percent for peripheral neuropathy of the left upper extremity is denied. An effective date of July 9, 2008 for the grant of service connection for peripheral neuropathy of the right upper extremity is warranted, subject to the laws and regulations governing the payment of monetary awards. An effective date of July 9, 2008 for the grant of service connection for peripheral neuropathy of the left upper extremity is warranted, subject to the laws and regulations governing the payment of monetary awards. A separate compensable rating for erectile dysfunction as a complication of type I diabetes mellitus is denied. A separate compensable rating for hypertension as a complication of type I diabetes mellitus is denied. A separate compensable rating for onychomycosis of the bilateral great toes as a complication of type I diabetes mellitus is denied. A separate 30 percent disability rating for seborrhea with folliculitis as a complication of type I diabetes mellitus is granted, subject to the controlling regulations applicable to the payment of monetary awards. REMAND In the July 2011 remand the Board directed the RO to determine whether the Veteran's peripheral neuropathy of the upper extremities was a complication of the Veteran's diabetes prior to May 11, 2010. Unfortunately, the RO did not do this. Given the foregoing, the Board finds that compliance with the July 2011 remand has not been accomplished. Stegall v. West, 11 Vet. App. 268 (1998). As such, the Board finds that this case is not ready for appellate review and must be remanded for further development. Next, in the July 2011 Board remand, the Board took jurisdiction of increased rating claims related to the Veteran's pending appeal for an increased rating for diabetes, pursuant to 38 C.F.R. § 4.120, DC 7913 at Note (1) indicating that all compensable complications of diabetes are to be evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. However, the Board failed to include the issues of entitlement to initial disability ratings greater than 10 percent for diabetic neuropathy of the right and left lower extremities which was granted during the pendency of the Veteran's appeal for an increased rating for his diabetes. On remand, the RO should adjudicate these issues in a supplemental statement of the case. Third, the June 2010 VA diabetes examination report shows an impression of microalbuminuria. The examiner noted that this was secondary to the Veteran's diabetes. Microalbuminuria occurs when the kidney leaks small amounts of albumin into the urine, in other words, when there is an abnormally high permeability for albumin in the renal glomerulus. It is unclear whether the Veteran's microalbuminuria is a disability in and of itself for which VA compensation benefits are payable or whether it is a symptom of his already service-connected diabetes. On remand a medical opinion should be obtained to resolve this question. Lastly, the Veteran has claimed he stopped working for the Post Office in 1998 because of his diabetes. In going through the record in detail, it is clear that there are outstanding relevant records pertaining to the Veteran's employment that have not been secured. For example, in an October 2000 letter from the Post Office, the Postmaster noted that the Veteran had filed a claim with the Department of Labor in the Office of Workers Compensation Program based on an alleged job-related stress. While it appears the claim was denied, the records relied upon in addressing the claim are relevant to the issue of an earlier effective date for the award of a TDIU, as the Veteran claims he stopped working at that time because of the service-connected diabetes. See Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed.Cir.2010) (if there exists a reasonable possibility that records could help the veteran substantiate his claims for benefits, the duty to assist requires VA to obtain the records). Thus, an attempt to obtain these records must be made, and the Veteran is asked to cooperate in this endeavor. Also, in support his claim for a TDIU rating, the Veteran submitted pages from a deposition transcript, where the Veteran's treating physician was asked questions. This deposition was conducted in July 2001. The Veteran submitted page 24, pages 30 - 38, and page 90 (which is the last page). The Board finds that the entire 90 pages of the deposition would be relevant to the issue of whether an earlier effective date is warranted for a TDIU rating. Thus, the Veteran will be asked to submit the entire transcript of the deposition. See 38 C.F.R. § 3.159(c)(1) (2012) (claimant must cooperate fully with reasonable efforts to obtain relevant records from non-Federal agency or department custodians and claimant must authorize release of existing records). Accordingly, the case is REMANDED for the following action: 1. Request records pertaining to the Veteran from The Department of Labor, Office of Workers' Compensation Programs, Division of Federal Employees' Compensation, in connection with his claim for compensation benefits in approximately 1998. All attempts to fulfill this development should be documented in the claims file. If after continued efforts to obtain the records it is concluded that it is reasonably certain they do not exist or further efforts to obtain them would be futile, the AMC must notify the Veteran and his representative and (a) identify the specific records the AMC is unable to obtain; (b) briefly explain the efforts that the AMC made to obtain those records; (c) describe any further action to be taken by the AMC with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 2. The Veteran should provide VA with a copy of the July 2001 deposition transcript that contains all 90 pages. 3. Obtain all outstanding VA treatment records from September 2012 to the present. 4. Obtain a medical opinion as to whether the Veteran's microalbuminuria is a disability in and of itself for which VA compensation benefits are payable or whether it is a symptom of his already service-connected diabetes. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner is not able to provide an opinion, he or she should explain why. Since it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 5. After completion of the foregoing, adjudicate the following issues on the merits: (i) entitlement to an effective date earlier than July 9, 2008, for the award of service connection for peripheral neuropathy of the right upper extremity; (ii) entitlement to an effective date earlier than July 9, 2008, for the award of service connection for peripheral neuropathy of the left upper extremity; (iii) entitlement to initial rating in excess of 10 percent for diabetic neuropathy of the right lower extremity; (iv) entitlement to initial rating in excess of 10 percent for diabetic neuropathy of the left lower extremity; (v) entitlement to a separate compensable rating for a disability attributable to microalbuminuria as a complication of type I diabetes mellitus; and (vi) entitlement to an effective date earlier than June 29, 2005, for the award of a total rating for compensation based upon individual unemployability. If any of the benefits sought on appeal remains denied, the Veteran should be furnished a supplemental statement of the case and afforded a reasonable opportunity to respond. The appellant 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 claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ Alexandra P. Simpson Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs