Citation Nr: 1316950 Decision Date: 05/23/13 Archive Date: 05/31/13 DOCKET NO. 09-01 941 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for hypertension, claimed as secondary to service-connected Type 2 Diabetes Mellitus. 2. Entitlement to a rating higher than 20 percent for the Type 2 Diabetes Mellitus with associated retinopathy and a residual scar, status post carotid endarterectomy. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD D. Bredehorst INTRODUCTION The Veteran served on active duty in the military from October 1969 to April 1972 and from April 1974 to January 1992. This appeal to the Board of Veterans' Appeals (Board/BVA) is from February and September 2008, June 2009, and April 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee that, in part, granted a higher 20 percent rating for the Veteran's Type 2 Diabetes Mellitus. The RO also granted separate ratings for other disabilities associated with Type 2 Diabetes Mellitus - namely, for peripheral neuropathy of the lower extremities, with each extremity rated 20-percent disabling effective July 2, 2007, for peripheral neuropathy of the upper extremities, with each extremity rated 10-percent disabling effective November 23, 2007, for diabetic retinopathy rated 0 percent (noncompensable) effective July 2, 2007, and for a scar, status post carotid endarterectomy, also rated 0-percent disabling effective July 2, 2007. As well, in the September 2008 rating decision the RO granted a 0 percent rating for peripheral vascular disease as also associated with the Type 2 Diabetes Mellitus, effective June 24, 2008. The Veteran appealed for an even higher rating for his Type 2 Diabetes Mellitus, which, according to VA regulation, includes all disabilities associated with the diabetes that do not have a separate compensable rating. Therefore, his diabetic retinopathy, scar, and peripheral vascular disease were included in the appeal since each had a noncompensable rating. In support of his claims, the Veteran testified at a videoconference hearing in June 2011 before the undersigned Veterans Law Judge (VLJ) of the Board. During the hearing, the Veteran withdrew his claim for a higher rating for the peripheral vascular disease. See page 17 of the hearing transcript. So that claim was no longer at issue. 38 C.F.R. § 20.204 (2012). In September 2011, the Board remanded the remaining claims for further development and consideration - especially to obtain records from the Social Security Administration (SSA) and VA treatment records dated since November 2010, if concerning evaluation and treatment for these disabilities at issue in this appeal. FINDINGS OF FACT 1. Hypertension was not initially manifested during the Veteran's service or during the first year after conclusion of his service, and a preponderance of the evidence is against finding that it is otherwise related or attributable to his service, including caused or worsened by his service-connected Type 2 Diabetes Mellitus. 2. During the entire course of this appeal, his Type 2 Diabetes Mellitus has required insulin and a restricted diet, but not regulation of activities. 3. His diabetic retinopathy is not manifested by blindness in one eye; at worst, his corrected visual acuity is 20/60 in his right eye and 20/40 in his left eye; and he has not experienced any incapacitating episodes as a result of his diabetic retinopathy. 4. The residual surgical scar, status post carotid endarterectomy, is well healed and not shown to be painful, unstable, or limit function of the affected part. CONCLUSIONS OF LAW 1. The Veteran's hypertension is not due to disease or injury incurred in or aggravated by his active military service, may not be presumed to have been incurred in service, and it is not proximately due to, the result of, or aggravated by his service-connected Type 2 Diabetes Mellitus. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria also are not met for a rating higher than 20 percent for the Type 2 Diabetes Mellitus. 38 U.S.C.A. §§ 1155, 5103 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.84a (2008), 4.118, Diagnostic Code (Code) 6006 (2008), 4.119, Code 7913 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duties to notify and assist claimants with their claims for VA benefits upon receipt of a complete or substantially complete application. The VCAA was codified by statutes at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012), and the implementing VA regulations were codified, as amended, at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). To this end, VA must: (1) inform the claimant of the information and evidence not of record that is necessary to substantiate the claim; (2) inform him of the information and evidence that VA will obtain; and (3) inform him of the information and evidence he is expected to provide. See also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). When the claim is for service connection, the notice should address all five elements of the claim: (1) Veteran status, (2) existence of a disability, (3) relationship between the disability and service, (4) disability rating, and (5) effective date. See Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). The United States Court of Appeals for Veterans Claims (Court/CAVC) held in Pelegrini v. Principi, 18 Vet. App. 112 (2004), that, to the extent possible, the VCAA notice also should be provided to the claimant before an initial unfavorable decision on the claim. Pelegrini at 119-20. If, however, for whatever reason it was not, or the notice provided was inadequate or incomplete, this timing error can be effectively rectified ("cured") by providing any necessary VCAA notice and then readjudicating the claim - such as in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated, rather preserved, and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). VCAA notice errors, even when shown to have occurred, are not presumptively prejudicial, rather, must be judged on a case-by-case basis. And as the pleading party attacking the agency's decision, the Veteran, not VA, has this burden of proof of not only establishing error, but, above and beyond that, showing how it is unduly prejudicial, meaning outcome determinative of the claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Here, June 2007, August 2007, and May 2009 pre-decisional letters provided the Veteran the required notice of the evidence and information necessary to substantiate his claims, the information required of him to enable VA to obtain evidence, and the assistance that VA would provide in obtaining supporting evidence. He also received notice consistent with Dingess as concerning the "downstream" disability rating and effective date elements of his claims, in the event service connection ultimately was granted (if not already). VA also has made reasonable efforts to assist him in obtaining evidence necessary to substantiate his claims. His service treatment records (STRs) are in his claims file, and VA has obtained all pertinent/identified post-service records that could be obtained. He additionally had a videoconference hearing in June 2011 before the undersigned VLJ of the Board. According to 38 C.F.R. § 3.103(c)(2) (2012), it is the responsibility of the presiding VLJ to: 1) explain fully the issues and 2) suggest the submission of evidence that the claimant may have overlooked and that would be advantageous to his position. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that the presiding VLJ's duties under section 3.103(c)(2) are twofold. First, the hearing officer must explain fully the issues still outstanding that are relevant and material to substantiating the claim by explicitly identifying them for the claimant. Id., at 496. Second, the presiding VLJ must suggest that a claimant submit evidence on an issue material to substantiating the claim when such evidence is missing from the record or when the testimony at the hearing raises an issue for which there is no evidence in the record. Id., at 496-97. Here, the undersigned presiding VLJ identified the issues on appeal and during the course of the hearing engaged in a discussion regarding evidence that would be especially relevant to the claims - such as nexus evidence suggesting a correlation between the Veteran's hypertension and his military service, including secondarily by linking it to his already service-connected Type 2 Diabetes Mellitus either by showing the diabetes caused or aggravated the hypertension. As well, there was discussion concerning the type of evidence needed to show his diabetes deserves a higher rating. Moreover, he did not raise any new issues pertaining to these claims during the course of his hearing. See Bryant, 23 Vet. App. at 497-98. Thus, the Board finds that the presiding VLJ's two-fold duty to inform the Veteran of the outstanding issues relevant and material to the claims and to suggest the submission of evidence that was missing or may have been overlooked was satisfied. See id. at 496-97. The Veteran has not alleged there was any deficiency in the conducting of that hearing, including in relation to the presiding VLJ's duties under section 3.103(c)(2). See Bryant, 23 Vet. App. at 497-98. Moreover, even assuming for the sake of argument there was such a deficiency, the Board finds that it did not prejudice his claims. In Bryant, 23 Vet. App. at 498-99, the Court held that although the hearing officer did not explicitly lay out the material issues of medical nexus and current disability, the purpose of 38 C.F.R. § 3.103(c)(2) nonetheless had been fulfilled because the record reflected that these issues were developed by VA, and there was no indication the appellant had any additional information to submit. Given the additional development of these claims by the RO or Appeals Management Center (AMC) as a result of the Board remanding them in September 2011, the Board finds that any deficiency in the June 2011 videoconference hearing was non-prejudicial. See id. This is especially true recognizing the Veteran has evidenced his actual knowledge of the type of evidence and information needed to substantiate his claims, including in his responses to the questions posed to him during his hearing. Actual knowledge is established by statements or actions by the claimant or the claimant's representative demonstrating an awareness of what is necessary to substantiate the claim. Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007). The additional development of these claims directed by the Board's September 2011 remand was completed and all evidence, including constructively of record, has been obtained. Since records from the SSA and ongoing VA treatment records were obtained, there was compliance with these remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (A Veteran is entitled to compliance with remand directives, and the Board itself commits error, as a matter of law, in failing to ensure compliance). But see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); and Dyment v. West, 13 Vet. App. 141, 146-4 (1999) (indicating situations when it is acceptable to have "substantial", even if not "exact" or "total", compliance with remand directives). The Board therefore is proceeding with the adjudication of these claims. Service Connection Legal Criteria and Analysis Service connection is granted for disability resulting from a disease contracted or an injury sustained in the line of duty during active military service or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). Establishing entitlement to service connection on a direct-incurrence basis requires competent and credible evidence showing: (1) the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of his claim; (2) in-service incurrence or aggravation of a relevant disease or an injury; and, (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may be granted for a disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Certain diseases, including hypertension, are considered chronic, per se, and therefore will be presumed to have been incurred in service if manifested to a compensable degree (generally meaning to at least 10-percent disabling) within one year following separation from service. This presumption, however, is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). But if chronicity of disease or injury in service is not shown, or if it is legitimately questionable, then a showing of continuity of symptomatology following service is required to support the claim. 38 C.F.R. § 3.303(b). Establishing continuity of symptomatology under 38 C.F.R. § 3.303(b) is an alternative method of satisfying the second and third Shedden requirements to show chronicity (permanency) of disease or injury in service to, in turn, link current disability to service. See also Clyburn v. West, 12 Vet. App. 296, 302 (1999). That is, these second and third elements can be satisfied under 38 C.F.R. § 3.303(b) by competent and credible evidence demonstrating: (1) the condition was observed ("noted") during service; (2) symptoms of that condition continued after service; and, (3) the current condition is related to those continuing symptoms. The United States Court of Appeals for the Federal Circuit (Federal Circuit Court), however, recently held that continuity of symptomatology only can be used to establish this required linkage between the current condition and service if the condition is one of those explicitly recognized as "chronic" under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Hypertension, as mentioned, is among the conditions listed in this VA regulation as chronic, per se. Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) and (b) (2012). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Medical evidence is generally, although, as mentioned, not always, required to associate the claimed condition with a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Velez v. West, 11 Vet. App. 148, 158 (1998); and McQueen v. West, 13 Vet. App. 237 (1999). So service connection may be established either by showing direct service incurrence or aggravation, or by using applicable presumptions, if available, or by showing the condition claimed is secondarily related to service, again, meaning either caused or permanently worsened by a service-connected disability. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is "credible", or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 (2007) (Observing that once evidence is determined to be competent, the Board must additionally determine whether it is also credible). Only if the evidence is both competent and credible does it ultimately have probative value. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("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) (Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In ascertaining the competency of lay evidence, the Courts generally have held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found competent with regards to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). On the other hand, laypersons equally have been found not competent in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger VA's duty to seek a medical opinion on the issue). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). Competent medical evidence, as opposed to lay evidence, is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza at 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see also Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). As fact finder, when considering whether lay evidence is satisfactory, the Board may not only consider internal inconsistency of statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, but also the Veteran's demeanor when testifying at a hearing when he has testified. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). See, too, Macarubbo v. Gober, 10 Vet. App. 388 (1997) (similarly holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). In ultimately rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons or bases 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). To this end, the Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the Federal Circuit Court, citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id., at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court similarly has declared that, in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). The standard of proof to be applied in decisions on claims for Veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). In deciding these claims, the Board has reviewed all of the evidence in the Veteran's claims file, both his physical claims file and electronic ("Virtual VA") file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by him or obtained on his behalf be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran has contended that his hypertension began in service, although it was not monitored and he resultantly was not treated for it, such as with medication. See his May 2010 notice of disagreement (NOD). He also has contended that his hypertension alternatively is related to his service-connected diabetes mellitus. See his April 2009 claim. So his claim for hypertension is predicated on the notions that it was directly, if not presumptively, incurred during his service or that it is secondarily related to his service, meaning caused or aggravated by a service-connected disability, namely, his Type 2 Diabetes Mellitus. When deciding a claim for service connection, the Board must consider all potential bases of entitlement - so direct, presumptive and secondary. Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). VA has a duty to address all arguments put forth by a claimant and/or theories under which entitlement to benefits sought may be awarded. See Robinson v. Mansfield, 21 Vet. App. 545, 552 (2008) (noting that the Board is required to consider all issues raised either by the claimant or reasonably by the evidence of record), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009); Buckley v. West, 12 Vet. App. 76, 83 (1998) (noting that where the RO and the Board have failed to address an argument reasonably raised by a claimant in support of a claim over which the Court has jurisdiction by virtue of an NOD satisfying Veterans Judicial Review Act (VJRA) § 402, the Court will remand the claim with directions that the Board address the particular argument(s) in support thereof). Regarding direct service connection, the Veteran's STRs do not show he had hypertension while in the military, meaning persistently elevated blood pressure. For VA compensation purposes, hypertension is defined as diastolic blood pressure that is predominantly 90 millimeters (mm.) or greater, and isolated systolic hypertension is defined as systolic blood pressure that is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. To support a diagnosis of hypertension the blood pressure readings must be taken two or more times on at least three different days. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). Here, though, none of the blood pressure reading taken during service met the criteria for a diagnosis of hypertension and none of the records in service contain a diagnosis of hypertension. Hence, the record shows that hypertension was not first manifested during service. The Veteran's first period of service ended in April 1972, and his second period of service ended in January 1992. Post-service treatment records dated in June 2001, September 2001, August 2002, December 2003, and December 2004 also contain blood pressure readings within normal limits and indicate there was no history of hypertension and that it was not an active problem. Since hypertension was not shown or diagnosed in service or manifested to the required compensable degree of at least 10-percent disabling in the first post-service year, following either period of service, service connection for hypertension on the premise that it was directly or presumptively incurred in service and has persisted as a chronic disease under 38 U.S.C.A. § 1112 and 38 C.F.R. § 3.309(a) since is not established. The earliest mention or diagnosis of hypertension is shown to have been made in April 2005, after and as a result of which the Veteran was placed on medication. That was some 13 years after the conclusion of his second period of service, with no mention in the interim of even so much as a subjective complaint. This tends to refute any notion that he had experienced hypertension or its consequent effects since his military service. In the appropriate circumstance, such as here, the Board may consider the absence of any indication of a relevant medical complaint until so relatively long after service as one factor, just not the only or sole factor, in determining whether a disease or an injury in service resulted in chronic or persistent residual disability. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). See, too, Mense v. Derwinski, 1 Vet. App. 354 (1991) (holding that VA did not err in denying service connection when the Veteran had failed to provide evidence demonstrating continuity of symptomatology since service and had failed to account for the lengthy time period following his service during which there was no clinical documentation of the claimed disorder). Consider also that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which, as mentioned, is an alternative means of linking the condition now claimed to service, although applying to hypertension since it is a condition listed in § 3.309(a) as "chronic", nonetheless does not apply in this particular instance inasmuch as there was no indication or notation of hypertension during the Veteran's service. In other words, this notion of continuity of symptomatology only applies when a condition was first "noted" in service, which did not occur here. While, at least during one point in the appeals process, the Veteran has asserted that his hypertension was directly related to his service, there simply is no competent and credible evidence of record suggesting there exists the required nexus between his military service and the eventual development of hypertension. He testified in June 2011 to the fact that he had asked doctors what had caused his hypertension, and even according to him all he was ever told was that "it just happens". See page 14 of the hearing transcript. He does not assert continuity of symptomatology since his service and, in fact, to the contrary, he testified that his hypertension did not first occur until the 1990s or early 2000, so did not develop until years after he had retired from the Coast Guard. See page 12 of the hearing transcript. Thus, in the absence of competent and credible evidence directly relating his hypertension to his military service, including by indicating it began during his service or presumptively establishing incurrence by showing its initial manifestation within a year of his discharge from service, the preponderance of the evidence is against this claim on direct and presumptive bases. This being the case, the benefit-of-the-doubt doctrine is inapplicable, and this claim resultantly must be denied on the theories that his hypertension is either directly or presumptively related to his service. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. See also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Since, however, he also has asserted his hypertension is related to his Type 2 Diabetes Mellitus, his claim also must be considered on the alternative basis of secondary service connection. As already alluded to, the legal requirements for a successful secondary-service-connection claim are: (1) evidence confirming the Veteran has the claimed condition; (2) evidence of a service-connected disability; and (3) competent and credible evidence of a nexus between the two. Two opinions are required for secondary-service-connection claims: 1. Is the claimed disorder "caused by" or "due to" the service-connected disability? AND 2. Is the claimed disorder "aggravated by" the service-connected disability (Allen Aggravation)? Evidence of baseline disability is necessary to establish entitlement to service connection for aggravation of a nonservice-connected condition by a service-connection condition (regulatory change effective from September 2006). An opinion that something "is not related to" or "is not due to" does not answer the question of aggravation. Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310(b). Here, service connection for Type 2 Diabetes Mellitus was established in a November 1992 rating decision, and the record indicates hypertension was first diagnosed more recently in April 2005. However, the third requirement to establish entitlement to service connection on a secondary basis, which is nexus evidence linking the claimed disability to the service-connected disability, is not met in this instance. The Veteran had a VA compensation examination in February 2009 during which the examiner reviewed the claims file and obtained a history of these conditions. While confirming the Veteran had hypertension, that VA examiner concluded it was not a complication of the Veteran's Type 2 Diabetes Mellitus since the two disorders were diagnosed at the same time. But since, as mentioned, the record shows that hypertension was diagnosed many years after service, and even many years after service connection was granted for the Type 2 Diabetes Mellitus, so many years after VA had acknowledged the existence of the diabetes, the opinion has no probative value because it was based on an inaccurate factual predicate. See Black v. Brown, 5 Vet. App. 177 (1993); Swann v. Brown, 5 Vet. App. 229 (1993); and Reonal v. Brown, 5 Vet. App. 458 (1993). The Veteran resultantly was also provided another VA examination in September 2010 to again determine whether there was any relationship or correlation between his diabetes and hypertension. The claims file was reviewed and the examiner obtained a history from the Veteran in which he reported that he had developed and been treated for high blood pressure sometime around 1992. The examiner observed this conflicted with what is in the record. After a review of the record and examination of the Veteran, the examiner stated that she could not resolve the issue without resorting to mere speculation due to a September 2007 record that contains a medical history of "HTN, DIABETES X 21YEARS". In Jones v. Shinseki, 23 Vet. App. 382 (2010), the Court held that, in order to rely upon a statement that an opinion cannot be provided without resorting to mere speculation, it must be clear that the procurable and assembled data was fully considered and the basis for the opinion must be provided by the examiner or apparent upon a review of the record. The Court in Jones also acknowledged there are instances where a definitive opinion cannot be provided because required information is missing or can no longer be obtained or current medical knowledge yields multiple possible etiologies with none more likely than not the cause of the claimed disability. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (noting the Board need not obtain further medical evidence where the medical evidence "indicates that determining the cause is speculative"). Here, since the examination report reflects that all of the evidence was reviewed and a rationale was provided, the opinion is not considered inadequate so as to require another opinion. However, when an opinion, such as this one, is inconclusive as to the origin of a disorder, it generally cannot be employed as suggestive of a link between the disorder and the Veteran's military service - including, as is being alleged here, by way of a service-connected disability. See Warren v. Brown, 6 Vet. App. 4, 6 (1993); Sklar v. Brown, 5 Vet. App. 104, 145-6 (1993). These types of opinions also cannot be used to rule out this purported correlation, either. Ultimately, noncommittal opinions like this amount to "nonevidence," neither for nor against the claim, because service connection may not be based on speculation or remote possibility. See generally Bloom v. West, 12 Vet. App. 185 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). See also 38 C.F.R. § 3.102 (when considering application of the benefit-of-the-doubt doctrine, reasonable doubt is one within the range of probability, as distinguished from pure speculation or remote possibility). More recent case law, however, suggests that caution must be exercised when referring to medical reports and opinions as "nonevidence" and that, instead, the probative value or weight (competency and credibility) of the evidence should be assessed. Notably for instance, in Hogan v. Peake, 544 F.3d 1295 (Fed. Cir. 2008), the Federal Circuit Court indicated a determination regarding service connection requires consideration of all pertinent medical and lay evidence, including medical opinions that do not state definitively when a particular disorder or condition began; therefore, classifying a medical opinion as "non-evidence" is "troubling." In Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009), the Federal Circuit Court more recently held that an examiner's statement, which recites the inability to come to an opinion, provides neither positive nor negative support for service connection; therefore, it is not pertinent evidence regarding service connection. The remainder of the report, however, must be considered as evidence of whether the disability was incurred in service or, here, is secondary to a service-connected disability. Because, here, there is no probative evidence suggesting the Veteran's hypertension is related to his Type 2 Diabetes Mellitus, again, meaning caused or aggravated by this service-connected disability, only instead evidence that at best is inconclusive on this critical point, he has not shown the required correlation between these two conditions to warrant the granting of secondary service connection. As the preponderance of the evidence is against the claim on direct, presumptive, and secondary bases, the benefit-of-the-doubt doctrine does not apply, and his claim of entitlement to service connection for hypertension resultantly must be denied. Increased Rating Legal Criteria and Analysis Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt material to the determination is resolved in the Veteran's favor. 38 C.F.R. § 4.3. The degrees of disability specified are considered adequate to compensate him for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of a Veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation in that the rating is "staged". See Hart v. Mansfield, 21 Vet. App. 505 (2007) (concerning established ratings); and Fenderson v. West, 12 Vet. App. 119 (1999) (pertaining to initial ratings). The Veteran's Type 2 Diabetes Mellitus is rated as 20-disabling under Diagnostic Code 7913. Under this code, a 10 percent rating requires a restricted diet only; a 20 percent rating requires insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet; a 40 percent rating requires insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities); a 60 percent rating requires insulin, a restricted diet, and the regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated; and a 100 percent rating requires more than one daily injection of insulin, a restricted diet, and the regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Note (1) to Code 7913 provides that compensable complications of diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent rating (under Code 7913). Noncompensable complications are considered part of the diabetic process under Code 7913. 38 C.F.R. § 4.119. After reviewing all of the relevant evidence in this case, the Board finds that a preponderance of this evidence is against the Veteran's claim for a rating higher than 20 percent for his service-connected Type 2 Diabetes Mellitus, and this is true for the entire rating period at issue, which includes consideration of the noncompensable complications of diabetic retinopathy and a scar. As already alluded to, service connection for the Type 2 Diabetes Mellitus was established in a November 1992 rating decision based on evidence showing the Veteran had this disability in service and that it was controlled by dieting. The current 20 percent rating was assigned based on additional evidence showing the required use of insulin to treat the diabetes. See the February 2008 rating decision. The Veteran's appeal is for an even higher rating. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993) (It is presumed a Veteran is seeking the highest possible rating for a disability absent express indication to the contrary). Private treatment records in 2006 mention insulin, but there was no indication of whether regulation of activity also was required. See July 2006 private treatment records. VA treatment records indicate his medication was increased in February 2007 and that he was to be rechecked in 2 to 3 months. During a May 2007 follow-up, he reported that his glucose had improved after eliminating some types of foods from his diet. His reported levels of 70 to 135 in the morning and 100 to110 in the afternoon and evening. He denied having hypoglycemia as long as he ate "on time". In July 2007, he reported that home glucose levels varied from 130 to 170 in the morning and decreased approximately once a week to the 50s at night. After eating something sweet it improved, but then his glucose level would be 300 in the morning. In September 2007, he was interested in switching his medication to insulin after retiring from his job. He reported having continued hypoglycemia during the day and at night at least 3 to 4 times a week and that it woke him up at night. A January 2008 record shows he began using insulin and the following month he reported that his glucose levels were essentially controlled at his current insulin levels and he denied having any hypoglycemic episodes. In March 2008, he reported that his glucose varied at home from the 100's to 240's in the a.m. and occasionally dropped to 48 to 50 during the middle of the night. During these night-time episodes he awoke and ate to resolve his hypoglycemia. His diabetes was considered uncontrolled at the time. A June 2008 VA consultation request notes he reported walking one mile 2 to 3 times a week and not always sticking to his diet. He also had occasional hypoglycemic episodes. During his June 2008 VA compensation examination, it was noted that he was taking insulin more than once a day and oral medication to manage his diabetes. There was no history of hospitalization because of the disability, but he did have episodes of hypoglycemic reactions or ketoacidosis that did not require hospitalization. He also reported being restricted in his ability to perform strenuous activities, as he reported becoming hypoglycemic on exertion. The effects on usual daily activities due to the disability were mild regarding chores, moderate regarding exercise, travel, and driving, and prevented sports. During his more recent February 2009 VA compensation examination, it was noted that he continued to take insulin more than once a day and oral medication, the side effect of which was hypoglycemia that did not require hospitalization. These episodes required visits with a diabetic care provider that were on a monthly basis or less. He continued to report being restricted in his ability to perform strenuous activities since his blood sugar dropped with exertion. He also carried glucose tablets. As far as his usual daily activities, the disability mildly affected his driving and had a moderate impact on chores, shopping, and exercise. The examiner commented that the Veteran's VA medication report showed he had good control of blood sugars and that he recently had taken a trip to Dollywood Park in Tennessee. The evaluating physician commented that an opinion could not be provided without resorting to speculation as to whether the Veteran was required to regulate his activities due to his diabetes mellitus. The examiner observed the Veteran had reported the need to regulate his activities since 2008, but the VA report shows the diabetes was under good control. There was no documented hospitalization for hypoglycemia, but the Veteran still insisted that his blood sugar dropped on exertion. In a November 2008 statement, the Veteran argued that he met all of the criteria for a higher 60 percent rating - except for the number of doctor's visits. A November 2008 lay statement from C. D. indicates he had seen the Veteran doing routine work activities when his blood sugar suddenly dropped. He recalled one incident in particular when the Veteran bent over while they worked on a car and he became disoriented and dropped his tools. Upon standing, he almost passed out, staggered, and fell against the car. He was shaking and sweating, and he stated that his blood sugar likely was low. After eating it took approximately 30 to 45 minutes for him to recover. In a November 2008 statement from the Veteran's wife, she recalled how he awoke shaking during the night 2 to 3 times a week with low blood sugars. During the summer she was afraid for him to mow the lawn because his blood sugar would drop. During walks in the park he had to stop and take glucose tablets to keep his sugar level up. A March 2009 VA treatment record shows the Veteran reported his blood sugar ranged from 36 (symptomatic) to 239, and that his fasting level in the morning was usually 101-156. A May 2009 VA record indicates he was unable to complete an examination pending control of his blood sugars. His diabetes mellitus was not considered to be at goal. A January 2011 VA treatment record shows some of his laboratory test results were worse since he was last tested in August 2010. As a result, some of his medication was changed and he was advised to lose weight, increase exercises, and diet to control his diabetes mellitus. The following month he reported he was doing better and that his diabetes mellitus was well controlled. He was reminded to lose weight, increase exercises, and diet to reach his HgbA1C goal. In June 2011, he testified that he was taking Insulin twice a day and Metformin, and that he had "maxed out the required dose or the maximum dose allowable". He also stated that his Insulin dose had doubled since 2010. He also used diet to control his diabetes. See pages 5 and 6 of the hearing transcript. He said he felt his blood sugar drop on his way to the hearing and that he had to eat a piece of candy to maintain his blood sugar levels. This could happen whether he was active or just watching television. He also testified that he had to regulate his activities because his blood sugars dropped whenever he was physical. See pages 7 and 8 of the hearing transcript. He experienced a significant drop approximately biweekly. See page 9 of the hearing transcript. To show entitlement to the next higher rating of 40 percent, the Court has held that all of the criteria must be met given the clearly conjunctive structure of the language used in Code 7913. See Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007); see also Tatum v. Shinseki, 23 Vet. App. 152, 155-56 (2009) (comparing the successive nature of Diagnostic Code 7913 for diabetes mellitus with the non-successive Diagnostic Code 7903 for hypothyroidism). Additionally, medical evidence is required to support the "regulation of activities" criterion. See Camacho, 21 Vet. App. at 364. "Regulation of activities" has been defined as a situation in which the Veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,446 (May 7, 1996) (defining "regulation of activities," as used by VA in Diagnostic Code 7913). In this particular case at hand, however, the only regulation of activity shown has been self-imposed by the Veteran himself in response to his reported sudden drop in his glucose levels upon exertion. But only a regulation of activity medically prescribed or advised can satisfy the third requirement of DC 7913 for a 40 percent rating. As shown by the record, there have been occasions when he has been medically advised to increase (rather than decrease) his level of exercise, so to do more instead of less activity, hence, there is no suggestion he has been instructed to regulate or avoid strenuous activity on the whole. Although the June 2008 VA compensation examiner noted in the medical history portion of the report that the Veteran was restricted in his ability to perform strenuous activity due to episodes of hypoglycemia on exertion, that was based on information the Veteran had provided, himself, not instead on the advice or recommendation of a doctor. The Veteran has reported on several occasions that his activities were restricted. But, again, while this was indicated in the medical history reported by the evaluating physicians, it apparently was merely them recounting what the Veteran had told them, without them also prescribing or advising him to actually regulate his activities to an extent contemplated by DC 7913 and the holdings in Camacho. Cf. Leshore v. Brown, 8 Vet. App. 406, 409 (1995) (holding that evidence that is simply information recorded by a medical examiner, unenhanced by any additional medical comment by the examiner, does not constitute the competent evidence needed to support a claim). The February 2009 VA compensation examiner also reported the same history regarding strenuous activity, but even with the claims file available to review an opinion could not be provided without resorting to mere speculation. The examiner's reasoning reflected a review of the record and essentially was based on the inability to reconcile treatment records indicating adequate control of the diabetes versus the Veteran's self-reported hypoglycemic reactions on exertion. The examiner nonetheless provided adequate information to allow the Board to rely on the report, even though the opinion ultimately was inconclusive concerning this. See Jones, supra. Thus, absent the required medical evidence showing the Veteran has to regulate his activities because of his diabetes, the criteria are not met for a higher 40 percent or even greater rating since the rating criteria for each progressive level of impairment (40, 60, and 100 percent) contains this requirement, even aside from others. Since the current 20 percent rating also includes consideration of the noncompensable ratings for the associated diabetic retinopathy and scar, these additional ratings also are being addressed. Service connection for diabetic retinopathy was established in the February 2008 rating decision and considered noncompensable since the criteria for a compensable rating were not met. The criteria for rating eye disabilities are set forth in 38 C.F.R. § 4.79, which were revised and amended effective December 10, 2008. See 73 Fed. Reg. 66543 (Nov. 10, 2008). Since the Veteran's claim was filed in February 2007 and the new criteria are only applicable to claims filed on or after December 10, 2008 only the old criteria as set forth under 38 C.F.R. § 3.84a (2008) are applicable in this case. A November 2011 VA treatment record shows he has cataracts in each eye; however, only his bilateral visual acuity is shown to be associated with diabetic retinopathy, which will be rated by analogy under 38 C.F.R. § 4.84a, Code 6006 for retinitis. Such diseases are to be rated from 10 to 100 percent disabling based upon impaired visual acuity or loss of field of vision, pain, rest-requirements, or episodic incapacity, combining an additional rating of 10 percent during continuance of active pathology. A minimum rating of 10 percent is to be assigned during active pathology. 38 C.F.R. § 4.84, Codes 6000-6009 (2008). The overall loss of acuteness or "sharpness" of vision is determined by applying the criteria set forth at 38 C.F.R. § 4.84a. In making this assessment, the best distant vision obtainable after best correction with glasses will serve as the basis of the rating, except in cases of keratoconus, where contact lenses are medically required. 38 C.F.R. § 4.75. Specifically, under 38 C.F.R. § 4.84a, Codes 6061 through 6079 provide a chart wherein the visual acuity in one eye is compared to the visual acuity in the other eye to achieve the bilateral rating. 38 C.F.R. § 4.84a, Codes 6061-6079, Table V (2008). These criteria provide that the impairment of central visual acuity is to be evaluated from noncompensable to 100 percent based upon the degree of the resulting impairment of visual acuity. Id. The percentage evaluation will be found from Table V by intersecting the horizontal row appropriate for the Snellen index for one eye and the vertical column appropriate to the Snellen index of the other eye. 38 C.F.R. § 4.83a (2008). A September 2007 VA eye retinal note indicates the Veteran was seen for follow-up. Visual acuity was initially noted in the right eye to be 20/50 and 20/40. Visual acuity in the left eye was 20/30-1 and 20/niph. These findings were distant vision with his then current glasses. An addendum corrected the visual acuity initially reported and notes visual acuity in the right eye was 20/40 PH 20/30 and left eye 20/25-2. Again, this was distant vision with glasses. During his December 2007 VA compensation examination the Veteran complained of decreased night vision while driving; there were no other ocular visual complaints. It was noted that he had proliferative diabetic retinopathy in both eyes secondary to diabetes mellitus and that he had undergone extensive PRP (panretinal photocoagulation) laser treatment in both eyes. His best corrected visual acuity at distance was 20/25-2 in the right eye and 20/20- in the left eye. The papillary examination did not demonstrate an AD, and the pupils were equally reactive 3 mm in the dark to 2 mm in the light in each eye. The external eye examination was unremarkable and he demonstrated full motility in both eyes. The eye lids and lashes were normal, the sclera and conjunctiva were white, the cornea were clear, the anterior chamber was deep and quiet, and the iris was flat with no rubeosis iritis identified. There was trace nuclear sclerotic cataracts in both eyes. The dilated fundus examination a cup-to-disc ration of 0.3 in both eyes. There was moderate vessel attenuation and a few microaneurysms in the macula, bilaterally. The peripheral examination demonstrated dense PRP at 360 degrees in both eyes. No neovascularization is identified. The examiner opined that the Veteran's retinal changes were consistent with diabetic retinopathy. During his July 2008 VA examination for diabetes mellitus, the Veteran reported a history of intermittent blurred vision related to his diabetes. A VA treatment record shows he was seen in November 2010 for DME (diabetic macular edema) and that he had last been seen one year earlier. He complained of flashes of light in each eye for the past 9 months without increased floaters or veils, bilaterally. He also complained a gritty right eye, increased night glare, and blurred vision at a distance in each eye while driving. His past ocular history was negative for glaucoma, but he did have cataracts in each eye. His past Rx was 20/60+1 in the right eye and 20/40 in the left eye. The current findings were 20/60 in the right eye and 20/20- in the left eye. The assessment was a history of PDR (proliferative diabetic retinopathy) in each eye and mild NPDR (nonproliferative diabetic retinopathy) left eye on the current examination; DES (Dry eye syndrome) in each eye; mild cataracts in each eye. When these findings of the best corrected visual acuity on examinations are applied to Table V they correspond to noncompensable ratings. There also is no evidence of loss of field of vision, pain, a rest requirement, incapacitating episodes, or active pathology. Thus, there is no basis upon which to provide a separate compensable rating for the diabetic retinopathy. Regarding the scar, the February 2008 rating decision also conceded the Veteran had a residual scar for right carotid stenosis status post carotid endarterectomy that was secondary to his service-connected Type 2 Diabetes Mellitus. A noncompensable rating was assigned for this scar. During the course of the appeal the criteria for rating scars also were revised. These regulatory changes only apply to applications received by VA on or after October 23, 2008, or if the Veteran requests review under the clarified criteria. See 73 Fed. Reg. 54708 (Sept. 23, 2008). As neither situation applies in this case, the 2008 changes are inapplicable to this claim, and consideration of the claim under the applicable criteria for claims filed prior to October 23, 2008 is appropriate. Prior to October 23, 2008, the regulations provided a 10 percent evaluation for scars, other than the head, face, or neck, which are superficial and that do not cause limited motion with an area or areas of 144 square inches (929 sq. cm) or greater. 38 C.F.R. § 4.118, Code 7802 (2007). A superficial scar is one not associated with underlying soft tissue damage. Id. at note (2). A 10 percent evaluation is assigned for superficial, unstable scars. 38 C.F.R. § 4.118, Code 7803 (2007). An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. at note (1). A 10 percent evaluation is assigned for superficial scars, painful on examination. 38 C.F.R. § 4.118, Code 7804 (2007). Other scars are rated on limitation of function of the affected part. 38 C.F.R. § 4.118, Code 7805 (2007). In every instance where the schedule does not provide a zero percent rating for a diagnostic code, a zero percent rating shall be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. During the December 2007 VA compensation examination, it was noted the Veteran's surgical scar was well healed. There is no evidence of the scar being symptomatic - such as painful on examination (to touch or palpation or pressure), unstable, or showing it limits functioning of the affected part according to the VA examination report or in any of the VA treatment records. None of the Veteran's statements during the course of the appeal have included any complaints regarding the scar. Therefore, the Board finds there is no basis upon which to assign a compensable rating. Since, for these reasons and bases, a preponderance of the evidence is against a higher rating for the diabetes mellitus and associated retinopathy and scar, the benefit-of-the-doubt doctrine is inapplicable and this claim must be denied. Extra-schedular Consideration The question of an extra-schedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). And although the Board may not assign an extra-schedular rating in the first instance, it must specifically adjudicate whether to refer a case for extra-schedular evaluation when the issue either is raised by the claimant or reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The Board has considered whether an extra-schedular disability rating is warranted under 38 C.F.R. § 3.321(b)(1) (2012), which requires a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. In this case, however, there is no evidence suggesting the applicable diagnostic codes do not contemplate the level of occupational and functional impairment shown. The service-connected diabetes mellitus rating criteria reasonably describe the Veteran's disability level and symptomatology. They account for his medication regimen (insulin), as well as his dietary restrictions. His primary complaint regarding his diabetes mellitus is having episodes in which his blood sugar drops (hypoglycemia), causing what he surmises is a need to regulate his activities, but this has not been shown to cause additional impairment so as to render the schedular criteria impractical. The schedular criteria apply absent this special circumstance. Furthermore, his vision complaints are mild and his corrected visual acuity is good so a separate rating is not warranted. There also are no complaints associated with his surgical scar. Accordingly, referral for extra-schedular consideration is unwarranted. See Thun v. Peake, 22 Vet. App. 111 (2008). ORDER The claim of entitlement to service connection for hypertension is denied. The claim for a rating higher than 20 percent for the Type 2 Diabetes Mellitus also is denied. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs