Citation Nr: 1317047 Decision Date: 05/24/13 Archive Date: 05/31/13 DOCKET NO. 08-13 103A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for respiratory disability, to include chronic obstructive pulmonary disease (COPD). 2. Entitlement to service connection for a skin condition to include psoriasis, claimed as due to exposure to herbicides. 3. Entitlement to service connection for renal disability, to include chronic renal insufficiency, to include as secondary to the service-connected diabetes mellitus. 4. Entitlement to service connection for hypertension, to include as secondary to the service-connected diabetes mellitus or as due to exposure to herbicides. 5. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as secondary to the service-connected diabetes mellitus. 6. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to the service-connected diabetes mellitus. 7. Entitlement to service connection for erectile dysfunction, to include as secondary to the service-connected diabetes mellitus. 8. Entitlement to a rating in excess of 50 percent for the service-connected major depressive disorder. 9. Entitlement to increased rating for the service-connected diabetes mellitus, rated as 20 percent disabling prior to January 27, 2012. 10. Entitlement to increased rating for the service-connected diabetes mellitus, currently evaluated as 10 percent disabling from that date. 11. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. 12. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance of another person or by reason of being housebound. 13. Entitlement to a temporary total evaluation because of hospital treatment in excess of 21 days. 14. Entitlement to a temporary total evaluation for convalescence. REPRESENTATION Appellant represented by: John R. Worman, Attorney ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from May 1969 to November 1971, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions issued in September 2007, August 2008 and September 2009 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran's respiratory and renal disability claims have been recharacterized as set forth on the title page in light of Clemons v. Shinseki, 23Vet. App. 1 (2009). In his substantive appeal the Veteran requested a hearing before a Member of the Board, and a videoconference hearing was duly scheduled in March 2013. Prior to the hearing the Veteran submitted a request in writing that his hearing be cancelled and that the appeal be adjudicated based on the existing record. The appeal from the August 2008 rating decision originally also included the issues of entitlement to service connection for peripheral neuropathy of the right and left lower extremities, but the RO recently issued a rating decision in March 2012 that granted service connection for these two disabilities. As the RO's action represents a complete grant of the benefits claimed those issues are no longer on appeal. In September 2012 the Veteran's representative submitted additional evidence to the Board in the form of private medical and professional opinions addressing the severity of the Veteran's psychiatric disability and the impairment of that disability on the Veteran's employability. The additional evidence was accompanied by a waiver of initial RO jurisdiction. The Board has accepted this additional evidence for inclusion into the record on appeal. See 38 C.F.R. § 20.800 (2012). The Veteran had a VA eye examination in January 2012 in which the examiner found trace nuclear sclerosis cataracts in both eyes that may be caused either by aging or by the Veteran's diabetes mellitus. The question of entitlement to separate compensation for cataracts has not been adjudicated by the RO and is accordingly referred to the RO for appropriate action. The Veteran's respiratory disability, renal disability, hypertension, erectile dysfunction and SMC for aid and attendance claims are addressed in the Remand that follows the Order section of the Decision below. FINDINGS OF FACT 1. The Veteran does not have a skin condition, to include psoriasis, which is etiologically related to service, to include as due to exposure to herbicides. 2. The Veteran does not have peripheral neuropathy of the left or right upper extremities that is etiologically related to service or that is caused or permanently worsened by his service-connected disabilities, to include diabetes mellitus. 3. The Veteran does not have erectile dysfunction that is etiologically related to service or that is caused or permanently worsened by his service-connected disabilities, to include diabetes mellitus. 4. The disability picture associated with MDD most closely approximates occupational and social impairment with reduced reliability and productivity, but not with deficiencies in most areas. 5. Prior to January 27, 2012, the Veteran's diabetes mellitus did not require insulin and regulation of activities 6. In a March 2012 rating decision, the RO reduced the evaluation of the Veteran's diabetes mellitus from 20 percent to 10 percent without considering the provisions of 38 C.F.R. § 3.344; the 20 percent evaluation had been in effort for more than 5 years. 7. The Veteran's diabetes mellitus does not currently require insulin and regulation of activities. 8. The Veteran's service-connected disabilities, alone, render him unable to obtain and maintain gainful employment consistent with his education, training and work experience. 9. The Veteran has not required hospital treatment or observation for a service-connected disability in excess of 21 days. 10. The Veteran has not required a period of convalescence for a service-connected disability for at least one month. CONCLUSIONS OF LAW 1. A skin condition was not incurred in or aggravated by service. U.S.C.A. §§ 1101, 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. Peripheral neuropathy of the right upper extremities was not incurred in or aggravated by service or proximately due to or aggravated by a service-connected disability. U.S.C.A. §§ 1101, 1110, 1112 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 3. Peripheral neuropathy of the left upper extremities was not incurred in or aggravated by service or proximately due to or aggravated by a service-connected disability. U.S.C.A. §§ 1101, 1110, 1112 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 4. The criteria for a rating in excess of 50 percent for major depressive disorder are not met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.130, Diagnostic Code 9434 (2012). 5. The criteria for a rating higher than 20 percent for diabetes mellitus prior to January 27, 2012, are not met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.119, Diagnostic Code 7913 (2012). 6. The RO's March 2012 reduction of the disability rating for the Veteran's diabetes mellitus from 20 percent to 10 percent, without compliance with the requirements set forth in 38 C.F.R. § 3.344 (2012), renders the reduction void ab initio. Kitchens v. Brown, 7 Vet. App. 320 (1995). 7. Restoration of the 20 percent disability rating assigned for the Veteran's diabetes mellitus is warranted. 38 U.S.C.A. §§ 1155, 7104 (West 2002); 38 C.F.R. §§ 3.344(a) and (b) (2012). 8. The criteria for a rating higher than 20 percent for diabetes mellitus are not met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.119, Diagnostic Code 7913 (2012). 9. The criteria for a TDIU are met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). 10. The criteria for a temporary total evaluation due to hospital treatment in excess of 21 days are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.29 (2012). 11. The criteria for a temporary total evaluation due to treatment for convalescence are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.30 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Before addressing the merits of the Veteran's claims on appeal, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The VA is required to assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The VA is required to notify a claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, the VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, the VA will attempt to obtain on behalf of the claimant. In addition, the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant be provided "at the time" of, or "immediately after," the VA's receipt of a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). Complete notification in this case was provided to the Veteran prior to the rating decisions on appeal, in that he was timely notified of the elements to show entitlement to service connection on a direct and secondary basis, entitlement to increased rating for service-connected disability, entitlement to TDIU and entitlement to temporary total ratings. In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing an error is harmful or prejudicial normally falls upon the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The RO also provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The Veteran's service treatment records and service personnel records are associated with the claims file, as are post-service treatment records from those VA and private medical providers the Veteran has identified as having records potentially relevant to adjudication of the issues on appeal. The Veteran's Social Security Administration (SSA) disability records have also been obtained. The Veteran was scheduled for a hearing before the Board, per his request, but he cancelled his request in writing. The Veteran has also been afforded appropriate VA examinations, which are adequate to evaluate the disabilities on appeal. Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. See Mayfield, 499 F.3d 1317. Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. Service Connection Claims Applicable Legal Principles Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Service connection may also be granted for disability that is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability is also compensable under 38 C.F.R. § 3.310, which provides that any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service- connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity due to the natural progress of the disease from the current level. A veteran who, during active military, naval or air service served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent unless there is affirmative evidence to establish the veteran was not exposed to an herbicide agent during such service. The last date on which the veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. Service in the Republic of Vietnam includes service in the waters offshore or service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). The Secretary of Veterans Affairs has determined there is no presumptive positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also Notice, 61 Fed. Reg. 41, 442-449 and 61 Fed. Reg. 57, 586-89 (1996); Notice, 64 Fed. Reg. 59, 232-243 (Nov. 2, 1999). The availability of presumptive service connection for a disability based on exposure to herbicides does not preclude a veteran from establishing service connection with proof of direct causation. Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). To prevail on the issue of secondary service causation, the record must generally show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Evidentiary considerations In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (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. Davidson, 581 F.3d 1313, 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). 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. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, id. 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 United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) 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). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. 498, 511. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Service connection for a skin condition The Veteran submitted a Statement in Support of Claim in September 2007 asserting he had a skin condition due to exposure to herbicides in Vietnam. The Veteran served in Vietnam, and has been granted service connection for diabetes mellitus and for coronary artery disease based on presumption of exposure to herbicides. Service connection may be granted for chloracne as presumptive to herbicides. See 38 C.F.R. § 3.309(e). The Veteran is not shown to have chloracne, and there is no other skin condition for which service connection may be granted as presumptive to herbicide exposure. However, the Veteran may establish entitlement to service connection under Combee if he can show he has a skin condition, however diagnosed, due to herbicide exposure. STRs show no indication of a skin condition in service. His separation physical examination shows clinical evaluation of the skin as normal. The Veteran presented to Tru-Med walk-in clinic in December 1990 complaining of a skin abnormality on the abdomen. The clinical impression was ringworm. The Veteran had a VA examination in June 1997 in which he reported a history "for years" of chronic hives, associated with an allergy to shellfish and with periods of nervousness; the hives were manifested by welts that were red and itchy. The examination report is silent in regard to any currently observed abnormality of the skin, and no skin disorder was diagnosed. A VA psychiatry initial assessment in June 1999 notes reported medical history of chronic hives. VA clinical examinations of the skin in January 2002 and August 2002 found no active disease. In March 2005 the Veteran's VA medication list included a topical ointment to apply three times per day for "dry skin." The prescription was renewed intermittently thereafter. The Veteran had a VA diabetes examination in November 2005 in which he reported some skin rash over the left lower extremity (LLE). Examination showed some nonspecific rash over the LLE that looked like some kind of ringworm and could have been diabetic-related, although the examiner was uncertain. The Veteran had a VA dermatology consult in March 2006 for transient rash on the lower extremities described as consistent with statis dermatitis. The Veteran had a VA examination in January 2012. The examiner indicated by checkmark that the Veteran did not have a skin condition as a complication of diabetes. Review of the file shows the Veteran did not have a skin disorder in service. Since service he had been treated intermittently for skin complaints variously described as ringworm (tinea), psoriasis and statis dermatitis, but there is no medical evidence whatsoever attributing such skin disorders to herbicide exposure or any other incident of service. Accordingly, there is no basis on which to award service connection on a direct basis. The Board has considered whether the November 2005 examination shows entitlement to service connection for a skin disorder secondary to herbicides. However, the examination report is vague as to both the nature of the condition ("some kind of ringworm") and the association ("I am not sure; it can also be diabetic-related"). Medical opinions expressed in speculative language do not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79, 85 (stating that a speculative medical opinion as to causation cannot establish a medical nexus to service). In this regard, the Board notes that a medical opinion is speculative when it uses equivocal language such as "could" or "might" without any other rationale or supporting data. See, e.g., Hood v. Shinseki, 23 Vet. App. 295, 298-99 (2009); Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009) (noting that doctor's statement that the Veteran's brain tumor "may well be" connected to Agent Orange exposure was speculative). Further, the Board finds that the possibility voiced by the November 2005 VA examiner is outweighed by the opinion offered by the January 2012 VA examiner, who specifically indicated that the Veteran does not have a skin disorder related to his diabetes mellitus. Based on the evidence and analysis above, the Board finds that the Veteran does not have a skin condition that is due to or aggravated by service. Accordingly, the criteria for service connection are not met and the claim must be denied. Because the preponderance of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. Peripheral neuropathy of the right and left upper extremities STRs show the Veteran had an injury to the right hand in 1970 due to receiving glass fragments related to falling while carrying a bottle. He subsequently had an infection of the right hand in 1971 secondary to surgery. He was treated in 1971 for recurrent dislocations of the left arm, both in 1971. His separation physical examination shows clinical evaluation of the upper extremities as normal. The Veteran presented to the Family Care Center of Arlington in September 1996 complaining of numbness in both arms. The clinical impression was carpal tunnel syndrome (CTS). The Veteran had a VA neurological examination in June 1997 in which he reported a 15-year history of intermittent numbness in both arms. Neurological examination showed the cranial nerves to be intact; there was no obvious muscle atrophy or weakness, deep tendon reflexes were physiologic and there was no obvious sensory deficit. The examiner's diagnoses do not mention any neurological disorder associated with the upper extremities. The Veteran had a non-VA nerve conduction velocity (NCV) study of the upper extremities in May 1998, performed due to his complaint of pain and discomfort in both hands. The Veteran was described as a 205-pound male with negative history of diabetes. The impression after NCV was bilateral CTS, greater on the right than left. A June 1998 treatment report from Jacksonville Orthopedic Institute shows an impression of bilateral CTS. The Veteran had a VA diabetes examination in November 2005 in which he reported some numbness and tingling in the hands without pain or paresthesia. Neurological examination showed the cranial nerves to be intact and motor strength 4+ to 5+ in all extremities. The examination report is silent in regard to diabetic neuropathy of the upper extremities. The Veteran also had a diabetes examination in August 2007 in which neurological examination was normal. The examiner stated the Veteran had no complications attributable to diabetes. The Veteran had a VA examination in August 2008, performed by a physician who reviewed the claims file. The Veteran reported having had CTS surgery in 1998; since then he had bilateral wrist pain and numbness in the right hand. Neurologic examination showed the cranial nerves to be grossly intact. Sensory examination was normal in the left upper extremity (LUE) but decreased in the right upper extremity (RUE). The examiner diagnosed peripheral neuropathy of the right hand. The examiner stated an opinion that the peripheral neuropathy of the right hand was not caused by or a result of diabetes, because the peripheral neuropathy had its onset prior to the diagnosis of diabetes. The Veteran had a VA examination in January 2012, performed by an examiner who reviewed the claims file and the VA CPRS file. The examiner indicated that the Veteran had peripheral neuropathy of the bilateral lower extremities that was likely due to diabetes, but the Veteran had no peripheral neuropathy of the upper extremities on examination. The evidence of record shows the Veteran had CTS diagnosed in 1998; by his report at the time of a 15-year history his disorder began in approximately 1983. Thus, onset of CTS-related symptoms was more than 20 years after discharge from service. The Veteran has not asserted, and the medical evidence of record does not suggest, that he developed CTS as a result of any injury in service. Accordingly, service connection for CTS is not for consideration. Turning to the question of diabetic neuropathy, the VA examinations in August 2007, August 2008 and January 2012 were unable to find any neuropathy of the LUE on examination. The examiner in August 2008 found neuropathy in the RUE (the other two examiners did not find neuropathy in the RUE) but stated an opinion that such neuropathy was not due to diabetes because the symptoms pre-dated diagnosis of diabetes. These opinions are not contradicted by any other medical evidence of record. By submitting a claim for service connection for peripheral neuropathy of the RUE and LUE the Veteran was expressing his own belief that the claimed disability is somehow related to service. The Veteran is competent as a layperson to report the onset and severity of symptoms such as numbness and tingling, but the etiology of a neuropathy that apparently began some time after service is a medical question of such complexity that it is beyond the competence of a layperson, particular in the presence of multiple risk factors. Kahana, 24 Vet. App. 428. It is the province of trained health care professionals to enter conclusions that require medical expertise, such as opinions as to diagnosis and causation. Jones v. Brown, 7 Vet. App. 134, 137 (1994). In this case the competent and uncontroverted medical opinion of record shows the Veteran does not have diabetic neuropathy of the RUE or LUE. Accordingly, the criteria for service connection are not met and the claims must be denied. Because the preponderance of the evidence is against the claims the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. Evaluation of Disabilities The rating decision on appeal issued in September 2007 denied service connection for renal insufficiency and also continued the current ratings for major depressive disorder (50 percent) and diabetes mellitus (20 percent). The Veteran appealed all three issues, and the RO issued a Statement of the Case (SOC) addressing all three issues in May 2008. The Veteran's substantive appeal, received later in May 2008, appealed only the issue of service connection for renal insufficiency. Accordingly, the rating issues were dropped from the Veteran's appeal. Thereafter, a rating decision in September 2009 denied entitlement to a TDIU, and the Veteran appealed. The RO issued an SOC in March 2012 in which the issues of evaluation of major depressive disorder and diabetes mellitus were added to the issues on appeal as being inextricably intertwined with the TDIU issue. Thus, the rating issues arise from the February 2009 claim for TDIU. Applicable legal principles Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. In any claim for higher ratings, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities herein decided. The Board has found nothing in the historical record that would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations that would warrant an exposition of remote clinical histories and findings pertaining to the disabilities. The claim for TDIU, which is the basis for these rating issues, was received in February 2009. The Board will consider evidence of symptoms from February 2008, one year prior to submission of the claim. 38 C.F.R. § 3.400. Evaluation of major depressive disorder When determining the appropriate disability evaluation to assign, VA's "primary consideration" is the Veteran's symptoms. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Major depressive disorder is rated under the criteria of 38 C.F.R. § 4.130 (schedule of ratings - mental disorders), diagnostic code 9434 (major depressive disorder). In relevant part, the rating criteria are as follows. A rating of 50 percent is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A rating of 70 percent is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A rating of 100 percent is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behaviour; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. A VA mental health clinic (MHC) treatment note in March 2008 shows the Veteran reported contending with daily panic attacks. The Veteran's attention and concentration were poor, and most of his activities of daily living were managed by his wife. During interview the Veteran was alert and oriented, with adequate cognition for conversation. Speech and thought process were at baseline, with very little spontaneity. The Veteran's wife had to bring up all of the issues. There were no delusions or perceptual disturbances. The Veteran's mood had been depressed and dysthymic. Affect was blunted-to-flat. There was no suicidal or homicidal ideation or plan. Insight was adequate and judgment was good. Current assessment was PTSD with associated depression. The psychiatrist did not note a current global assessment of functioning (GAF). As noted above, the Veteran had protracted inpatient treatment in May-June 2008 for respiratory and renal problems, including sepsis. Thereafter, a VA MHC note dated in July 2008 shows the Veteran complained he was not doing well because of all his ongoing medical problems. The Veteran's memory and attention was poor, and his wife basically provided the pertinent information and dates. The Veteran was alert and oriented but his speech was slow and non-spontaneous and his though processes were slow. There were no delusions or perceptual disturbances. Mood was depressed and affect was listless. There was no suicidal or homicidal ideation, plans or intent. Insight was adequate and judgment was good. Assessment was PTSD and major depression; again the psychiatrist did not assign a GAF. A VA MHC note in November 2008 states the Veteran reported that he was doing about the same overall as in his previous visit, as he continued to wax-and-wane with PTSD and depressive symptoms. The Veteran complained of sleep disturbance as his medications were adjusted. His wife complained of his poor attention and recent memory; the Veteran remained totally dependent on his wife for his daily activities and medications. Clinical observations were consistent with previous visits. A VA MHC note in April 2009 states the Veteran's PTSD and depression were being managed with high doses of medication, but the Veteran's wife complained that the medication was not effective in addressing the Veteran's irritability and poor memory. During interview the Veteran was alert and oriented times four, with adequate cognition for conversation. Speech and thought processes were baseline for the Veteran as he was not spontaneous and would only answer in short sentences. There were no delusions or perceptual disturbances. Mood was depressed/dysthymic and affect was restricted-to-blunted. The Veteran denied suicidal or homicidal ideation, plan or intent. Insight was adequate and judgment was good. A VA MHC note in August 2009 shows the Veteran reported doing about the same as in the last visit, although his wife believed that his changed medications had been reasonably effective in managing the Veteran's anger and irritability. The Veteran's sleep remained disturbed. Clinical observations were grossly consistent with previous visits. The file contains a December 2009 letter from the Veteran's attending VA psychiatrist stating the Veteran was being treated with high doses of two medications for his problems with sleep and nightmares; he was on two other medications for depression and panic attacks. The Veteran would need lifelong treatment because his condition was chronic, with constant waxing and waning of symptoms. Due to the severity and vacillating nature of his illness the Veteran was not expected to be gainfully employed or in the future. The Veteran's GAF scores had averaged in the 45 range for several years and sometimes as low as 41. The Veteran had a VA mental disorders examination in January 2012, performed by a psychologist. The Veteran stated he had a "pretty good" marriage and that he had a close relationship with his children and grandchildren. The Veteran had one neighbor friend, but admitted he had no close friends prior to service. The Veteran recounted taking four prescribed medication, with some resulting improvement in sleep but no other benefit. The Veteran denied side effects from the medication. He denied receiving current counseling. The Veteran endorsed mild anxiety attacks 2-3 times per week, mild-to-moderate depressed mood daily and frequent anger/irritability. The Veteran reported sleep of about 4 hours per night. There were no signs of mania, hypomania or psychosis. The Veteran did not endorse obsessive thoughts or compulsive behavior. When asked about panic attacks, the Veteran stated he had dreams and would wake up in the middle of the night. On examination the Veteran missed the correct date by six days. He was alert and oriented times four. The Veteran recalled 3 out of 3 items immediately and 2 out of 3 items after a few minutes; there was no sign of remote memory impairment. The examiner stated the Veteran's disorder most closely approximated the schedular criteria for the 50 percent rating. Of the symptoms cited by the psychiatric schedular rating criteria, the examiner stated that only three were applicable (depressed mood, anxiety and chronic sleep impairment); the other symptoms (panic attacks, memory loss, etc.) were absent. The examiner recorded a diagnosis of MDD (the examiner did not enter a second diagnosis) and assigned a current GAF of 60. Finally, the Veteran was examined in September 2012 by Dr. Albert Fink, a psychologist who reviewed the VA claims file. The Veteran reported he avoided events that brought memories of his military experiences. The Veteran reported great trouble sleeping, with flashbacks and nightmares common; he was frequently exhausted in the morning. The Veteran reported having little energy or motivation and studiously avoiding social activities, preferring to stay at home. The Veteran had no particular hobbies or special interests. Throughout the telephone interview the Veteran was hesitant and mildly agitated. There was no evidence of unusual thought process. The Veteran had no difficulty with proverb interpretation. The Veteran's judgment/insight responses were adequate and memory (immediate, recent and remote) was intact. The Veteran had good command of basic information facts. Dr. Fink stated that the Veteran's symptoms since 1999, as reflected in the record and in current examination, have been as follows: recurrent and distressing recollections of the event, including images, thoughts or perceptions; recurrent distressing dreams of the event; efforts to avoid activities, places or people that arouse recollections of the event; markedly diminished interest or participation in significant activities; reduced socialization; restricted range of affect; difficulty falling or staying asleep; irritability or outbursts of anger; exaggerated startle response; panic attacks; anxiety; poor concentration; and, alcohol dependence. Dr. Fink stated that this array of symptoms and the functional effects are consistent with primary diagnosis of PTSD, assignment of GAF of 45 and rating of social and occupational impairment appropriate to the 70 percent schedular rate (deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood). Dr. Fink also described at length why he felt the VA examination in January 2012 was internally inconsistent and lacking in credibility and validity. The Board finds on review of the evidence above that the Veteran's service-connected psychiatric disorder most closely approximates the criteria for the currently-assigned 50 percent rating. In that regard, the Veteran has demonstrated only one of the symptoms associated with the higher 70 percent rating; i.e., difficulty in adapting to stressful circumstances including work or a worklike setting. See Vazquez-Claudio v. Shinseki. All the other symptoms cited for the higher rating (suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; and, inability to establish and maintain effective relationships) are disproved by the record. Id. The Board acknowledges the opinion of Dr. Fink that the Veteran's disability picture approximated deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. However, Dr. Fink asserted no deficiencies in the Veteran's family relations, he found no evidence of unusual thought process and he found the Veteran's judgment to be "adequate." Thus, Dr. Fink's examination showed deficiencies only in work and mood ("school" is not applicable in this case), which does not approximate "most areas" as Dr. Fink asserted in his summary. The Board also notes that the Veteran's attending VA psychiatrist shows the Veteran's disability to be significantly more severe than does the VA examiner in January 2012, as manifested by the examiner's assignment of GAF of 60 versus the attending psychiatrist's GAF of 41-45. However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Reviewing the documentation associated with the Veteran's attending VA psychiatrist, in the form of his treatment notes and his December 2009 letter, the Board finds ample evidence of symptoms associated with the current 50 percent rating including panic attacks more than once a week, difficulty in understanding complex commands, impairment of short- and long-term memory, impaired judgment; impaired abstract thinking; disturbances of motivation and mood and difficulty in establishing and maintaining effective social relationships. However, as in the case of Dr. Fink, the only deficiencies shown by the VA attending psychiatrist were in work and mood; all the other symptoms associated with the 70 percent rating are conspicuous by their absence. Based on the evidence above, the Board finds that the disability picture associated with the Veteran's service-connected psychiatric disorder more closely approximates the schedular criteria for the 50 percent rating. Because the criteria for the higher 70 percent rating were not shown during any distinct period, "staged ratings" are not applicable. Hart, 21 Vet. App. 505. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria contemplate the Veteran's disability on appeal, as he has described no functional impairments that are not specifically incorporated in the schedular criteria. The rating criteria are therefore adequate to evaluate the Veteran's psychiatric disability, and referral for consideration of extraschedular rating is not warranted. Finally, the United States Court of Appeals for Veterans Claims (Court) recently held that a request for a total rating based on individual unemployability (TDIU), whether expressly raised by a claimant or reasonably raised by the record, is an attempt to obtain an appropriate rating for disability or disabilities, and is part of a claim for increased compensation. See Rice v. Shinseki, 22 Vet. App. 447 (2009), citing Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009). Entitlement to TDIU is separately addressed below. Evaluation of diabetes mellitus Diabetes mellitus is rated under the criteria of 38 C.F.R. § 4.119 (schedule of ratings - endocrine system), diagnostic code 7913 (diabetes mellitus). The rating criteria are as follows. A rating of 10 percent is assigned for diabetes mellitus manageable with restricted diet only. A rating of 20 percent is assigned for diabetes mellitus requiring insulin and restricted diet; or, oral hypoglycemic agent and restricted diet. A rating of 40 percent is assigned for diabetes mellitus requiring insulin, restricted diet and regulation of activities. A rating of 60 percent is assigned or diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits a diabetic care provider, plus complications that would not be compensable if separately evaluated. A rating of 100 percent is assigned for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Note (1) to DC 7913 states to evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100 percent evaluation; noncompensable complications are considered part of the diabetic process. Note (2) states when diabetes mellitus has been conclusively diagnosed, do not request a glucose test just for rating purposes. As of February 2008 the Veteran's diabetes mellitus was not shown to be treated with oral hypoglycemic agents or insulin. The Veteran's VA active medications list as of May 2008 shows he received glucose test-strips to test his blood sugar levels three times per week; there is no indication of prescribed insulin or hypoglycemics. A VA examination for aid and attendance, performed in March 2008, characterizes the Veteran's disease as non-insulin dependent diabetes mellitus (NIDDM). The Veteran was treated at Memorial Hospital of Jacksonville in May 2008 for right middle lobe pneumonia and respiratory insufficiency. During inpatient treatment he developed hyperglycemia and a diabetes consult ensured. The consultant noted the Veteran had a 3-4 year history of diabetes but did not appear to have been on medication. He was placed on a regimen of insulin during inpatient treatment. The assessment was diabetes mellitus, under control. Insulin was discontinued in June 2008. A VA podiatry note dated in December 2008 characterizes the Veteran's disease as NIDDM. The Veteran's VA treatment records and medication lists between December 2008 and January 2012 are silent in regard to prescription for insulin or hypoglycemic or visits to a diabetic care provider. The Veteran had a VA examination on January 27, 2012, performed by an examiner who reviewed the claims file and the CPRS file. The examiner noted the Veteran's diabetes was not currently managed by medication and did not require regulation of activities. Frequency of visits to a diabetic care provider was not recorded. During the past 12 months the Veteran had no episodes of ketoacidosis or hypoglycemia requiring hospitalization. The Veteran had no unintended weight loss or loss of strength due to diabetes. The Veteran was noted to have diabetes-associated peripheral neuropathy (of the lower extremities) but no other recognized complications. The examiner stated the diabetes did not impact the Veteran's ability to work because his symptoms were well-controlled without medication, so sedentary or physical employment was not precluded. As a consequence of the VA examination above the RO reduced the rating for diabetes mellitus from 20 percent to 10 percent effective from January 27, 2012, the date of the examination showing improvement. Addressing the period prior to January 27, 2012, a rating higher than the currently-assigned 20 percent requires insulin, restricted diet and regulation of activities. The Veteran clearly did not require insulin before or after his inpatient treatment in June 2008. During that inpatient treatment he received insulin, but there is no indication he required regulation of activities due to his diabetes during that period. Accordingly, a rating higher than 20 percent is not warranted. Where a reduction in the evaluation of a service-connected disability or employability status is considered warranted, and the reduction would result in the reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons; the beneficiary must be notified at his or her last address of record of the action contemplated and furnished detailed reasons therefor and must be given 60 days for the presentation of new evidence to show that compensation should be continued at the present level. 38 C.F.R. § 3.105(e). Although 38 C.F.R. § 3.105(e) does not apply if the rating reduction does not reduce the veteran's compensation; see VAOPGCPREC 71-91. The rating decision in March 2012 that reduced the compensation for diabetes mellitus concurrently granted service connection for peripheral neuropathy of the RLE and LLE, each rated as 10 percent disabling. Accordingly, the rating decision did not result in reducing the Veteran's compensation. The circumstances under which a disability rating may be reduced are specifically limited and carefully circumscribed, however, by regulations promulgated by the Secretary of VA. See Dofflemeyer v. Derwinski, 2 Vet. App. 277, 280 (1992). In reducing the disability rating of the Veteran's diabetes mellitus to 10 percent, the RO neither cited to nor discussed 38 C.F.R. § 3.344, the pertinent regulation in effect at that time governing the reduction of a disability rating of a disability that was in effect for five or more years, rendering the reduction void ab initio. In this regard, the Board observes that, in Brown v. Brown, 5 Vet. App. 413, 419 (1993), the Court held that 38 C.F.R. § 3.344(a) contains four distinct criteria, each of which must be satisfied, before the reduction of a disability rating that has been in effect for at least five years can be effectuated. In that case, the Court explained why none of the four criteria identified in the regulation were complied with. In doing so, the Court termed "cursory" VA's conclusion that the examination upon which the reduction was predicated was "full and complete." The Court held that the reduction was void ab initio, reversed the Board's decision, and remanded the matter for the reinstatement of the prior evaluation. Thereafter, in Kitchens v. Brown, 7 Vet. App. 320 (1995), the Court noted that, in affirming the RO's action in reducing a rating that had been effective for more than five years, the Board failed to discuss the applicability of 38 C.F.R. § 3.344(a) or (b). In addition, the Court concluded that the criteria were not satisfied. The Court held, "Where, as here, the Court finds that VA has reduced a Veteran's rating without observing applicable laws and regulation, such a rating is void ab initio and the Court will set it aside as not in accordance with the law." Id. at 325. Thereafter, in Hayes v. Brown, 9 Vet. App. 67 (1996), the Court indicated that, although the Board "recognized that a more thorough examination was required under 38 C.F.R. § 3.344(a)," in its decision, the Board "simply omitted" that requirement of the regulation. Citing Kitchens, the Court reversed the Board's decision and ordered that the rating be reinstated because the reduction was accomplished without compliance with the applicable laws and regulations. Id. at 73. In Greyzck v. West, 12 Vet. App. 288 (1999), the Court observed that the regulatory language in 38 C.F.R. § 3.344(a) had not changed since its adoption in February 1961 and, citing Brown and Kitchens, declared that it had consistently held that where VA reduces a disability rating without complying with applicable VA regulations, the reduction is void ab initio. Id. at 292. In reaching this conclusion, the Board acknowledges that, as noted above, where the evaluation of a disability is reduced, but the amount of compensation is not reduced because of a simultaneous increase in the evaluation of one or more other disabilities, section 3.105(e) does not apply. See Stelzel v. Mansfield, 508 F.3d 1345, 1349 (Fed. Cir. 2007) (holding that VA was not obligated to provide a Veteran with sixty days notice before making a disability ratings decision effective if the decision did not reduce the overall compensation paid to the Veteran); see also VAOPGCPREC 71-91 (Nov. 7, 1991) (where the evaluation of a specific disability is reduced, but the amount of compensation is not reduced because of a simultaneous increase in the evaluation of one or more other disabilities, section 3.105(e) does not apply). Here, however, the RO also failed to comply with the substantive provisions of 38 C.F.R. § 3.344 for a disability rating in effect for more than five years. Thus, the Board reiterates that the reduction is void ab initio. Kitchens; Brown. From January 27, 2012, the VA examiner established that the Veteran did not require insulin or hypoglycemics and did not require regulation of activities. Accordingly, his diabetes is manageable by restricted diet alone, and the criteria for a rating higher than 20 percent are not met. The Veteran has not asserted by lay evidence that he has required medications other than those cited above, or that he has required medical intervention for his diabetes such as hospitalization for hypoglycemic episodes or frequent visits to a diabetic caregiver. Accordingly, the lay evidence provided by the Veteran, in which he generally argues that he should have a higher rating, does not show the schedular criteria for higher rating were met. The Board finds there is no distinct period during the course of the appeal warranting "staged" higher rating. Hart, 21 Vet. App. 505. The Board finds that the rating criteria contemplate the Veteran's disability on appeal, as he has described no functional impairments that are not specifically incorporated in the schedular criteria. The rating criteria are therefore adequate to evaluate the Veteran's diabetes mellitus, and referral for consideration of extraschedular rating is not warranted. Thun, 22 Vet. App. 111. Entitlement to TDIU It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate, "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340(a)(1), 4.15. A TDIU may be assigned, if the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability it is ratable at 60 percent or more, and that if there are two or more such disabilities at least one is ratable at 40 percent or more and the combined rating is 70 percent or more. 38 C.F.R. § 4.16(a). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to a TDIU is based on an individual's particular circumstances." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, in adjudicating a TDIU claim, VA must take into account the individual Veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering Veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering Veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering Veteran's master's degree in education and his part-time work as a tutor). The Veteran is service-connected for the following disabilities: MDD, rated as 50 percent disabling; diabetes mellitus, rated as 20 percent disabling; coronary artery disease, rated as 10 percent disabling; and, peripheral neuropathy of the right and left lower extremities, each rated as 10 percent disabling. He also has service connection for scars status post bypass surgery, rated as noncompensable. This combined rating for service-connected disabilities is 70 percent. He accordingly meets the schedular threshold for consideration of TDIU under 38 C.F.R. § 4.16(a). A decision by the Social Security Administration (SSA) dated in January 2003 granted disability benefits effective from July 2002 due to osteoarthritis (primary diagnosis) and obesity (secondary diagnosis). The file contains a December 2009 letter from the Veteran's attending VA psychiatrist stating the Veteran would need lifelong treatment because his condition was chronic, with constant waxing and waning of symptoms. Due to the severity and vacillating nature of his illness the Veteran was not expected to be gainfully employed or in the future. The Veteran was therefore deemed unemployable to his service-connected conditions. The Veteran had a VA mental disorders examination in January 2012, during which he reported having most recently worked 12-15 years previously; he stopped working due to surgery on the right knee, two heart attacks and an arthritic back condition. The examiner stated the Veteran's symptoms associated with the diagnosed MDD were not severe enough to prevent him from either obtaining or maintaining gainful employment. The examiner noted that the Veteran stated he had been unable to work due to a medical condition, not psychiatric symptoms. The Veteran was examined in September 2012 by Dr. Albert Fink, a psychologist who reviewed the VA claims file. The Veteran stated he had stopped working 11 years previously due to increased medical and psychological problems, and that although his medical problems did not preclude him for less strenuous work he had increasing difficulty with concentration, follow-through, attitude and ability to stay focused. The Veteran found he had problems dealing with people and was easily irritated, moody and often angry. Dr. Fink stated the Veteran's cognitive and affective difficulties would cause occupational impairment in the following areas: understanding more than the simplest instructions; concentration; persistence; short-term memory; independent decision-making; follow-through; motivation; energy levels; stress management; teamwork; and, responsiveness to supervision. Dr. Fink stated the Veteran was likely to require considerable structure and oversight and would have difficulty with environments that are more than minimally stressful, with the overall profile suggesting the likelihood of decompensation under such circumstances. Finally, the file contains a letter dated in September 2012 from Dr. Stephanie Barnes, a vocational consultant. Dr. Barnes reviewed the Veteran's VA claims file and the psychological examination by Dr. Fink cited above. The Veteran was noted to have a 9th grade education and a 26-year history of work experience as an auto body repairman until 2001, at which time he left work due to physical problems and associated emotional problems. The Veteran's emotional problems intensified after he ceased working. Dr. Barnes stated the Veteran had physical issues with diabetes, neuropathy, coronary artery disease and PTSD that prevent him from sustaining employment. Dr. Barnes stated an opinion, based on her review of the medical records in total, that the Veteran could not work in a competitive setting and had not been able to do so for several years due to the worsening of his emotional issues. She noted the Veteran had problems with stress tolerance, concentration, interacting with others and meeting the productivity requirements of even simple work tasks in a full-time setting. On review of the evidence above, the Board finds the Veteran is precluded by his service-connected mental and physical disabilities from obtaining and maintaining gainful employment. Thus, the Board has found the criteria for a TDIU are met. The benefit of the doubt has been resolved in the Veteran's favor. Entitlement to temporary total evaluation Applicable legal principles Service-connected disabilities requiring hospital treatment or observation A total disability rating (100 percent) will be assigned without regard to other provisions of the rating schedule when it is established that a service-connected disability has required hospital treatment in a Department of Veterans Affairs or an approved hospital for a period in excess of 21 days or hospital observation at Department of Veterans Affairs expense for a service-connected disability for a period in excess of 21 days. 38 C.F.R. § 4.29. Subject to the provisions of paragraphs (d), (e), and (f) of this section this increased rating will be effective the first day of continuous hospitalization and will be terminated effective the last day of the month of hospital discharge (regular discharge or release to non-bed care) or effective the last day of the month of termination of treatment or observation for the service-connected disability. 38 C.F.R. § 4.29(a). Notwithstanding that hospital admission was for disability not connected with service, if during such hospitalization, hospital treatment for a service-connected disability is instituted and continued for a period in excess of 21 days, the increase to a total rating will be granted from the first day of such treatment. If service connection for the disability under treatment is granted after hospital admission, the rating will be from the first day of hospitalization if otherwise in order. 38 C.F.R. § 4.29(b). The assignment of a total disability rating on the basis of hospital treatment or observation will not preclude the assignment of a total disability rating otherwise in order under other provisions of the rating schedule, and consideration will be given to the propriety of such a rating in all instances and to the propriety of its continuance after discharge. Particular attention, with a view to proper rating under the rating schedule, is to be given to the claims of veterans discharged from hospital, regardless of length of hospitalization, with indications on the final summary of expected confinement to bed or house, or to inability to work with requirement of frequent care of physician or nurse at home. 38 C.F.R. § 4.29(c). On these total ratings, Department of Veterans Affairs regulations governing effective dates for increased benefits will control. 38 C.F.R. § 4.29(d). The total hospital rating if convalescence is required may be continued for periods of 1, 2, or 3 months in addition to the period provided in paragraph (a) of this section. 38 C.F.R. § 4.29(e). Extension of periods of 1, 2 or 3 months beyond the initial 3 months may be made upon approval of the Veterans Service Center Manager. 38 C.F.R. § 4.29(f). Meritorious claims of veterans who are discharged from the hospital with less than the required number of days but need post-hospital care and a prolonged period of convalescence will be referred to the Director, Compensation and Pension Service, under § 3.321(b)(1) of this chapter. 38 C.F.R. § 4.29(g). Convalescent ratings A total disability rating (100 percent) will also be assigned without regard to other provisions of the rating schedule when it is established by report at hospital discharge (regular discharge or release to non-bed care) or outpatient release that entitlement is warranted under paragraph (a) (1), (2) or (3) of this section effective the date of hospital admission or outpatient treatment and continuing for a period of 1, 2, or 3months from the first day of the month following such hospital discharge or outpatient release. Such total rating will be followed by appropriate schedular evaluations. When the evidence is inadequate to assign a schedular evaluation, a physical examination will be scheduled and considered prior to the termination of a total rating. 38 C.F.R. § 4.30. Total ratings will be assigned under this section if treatment of a service-connected disability resulted in: (1) surgery necessitating at least one month of convalescence; (2) surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited; or, (3) immobilization by cast, without surgery, of one major joint or more. The total rating will be followed by an open rating reflecting the appropriate schedular evaluation; where the evidence is inadequate to assign the schedular evaluation, a physical examination will be scheduled prior to the end of the total rating period. 38 C.F.R. § 4.30(a). A total rating under this section will require full justification on the rating sheet and may be extended. 38 C.F.R. § 4.30(b). Evidence and analysis The Veteran bases his claim on inpatient treatment provided by Memorial Hospital of Jacksonville during the period May 3, 2008, to June 12, 2008. Upon discharge from Memorial Hospital he was immediately transferred to Specialty Hospital until July 9, 2008. The treatment records from Memorial Hospital and Specialty Hospital are associated with the claims file. Review of those records show the Veteran was initially admitted for respiratory symptoms suspicious of pneumonia, and during treatment for such respiratory disorder he developed complications including renal disease and sepsis. After he was stabilized at Memorial Hospital the Veteran was transferred to Specialty Hospital for the purpose of weaning him off his ventilator. After inpatient treatment at Specialty Hospital he was discharged to the care of a homecare provider. Careful review of the treatment records from Memorial Hospital and Specialty Hospital does not show the Veteran was admitted or treated for a service-connected condition. Essentially, he was admitted for nonservice-connected respiratory problems and required protracted treatment due to nonservice-connected renal problems. The Veteran's service-connected diabetes mellitus is not shown to have complicated his treatment to any degree, in that records show he was simply placed on insulin during inpatient treatment and remained stable. His other service-connected disabilities are not cited as complicating factors during inpatient treatment or subsequent convalescence. In sum, the file shows the Veteran had inpatient treatment for more than 21 days in May-July 2008, and that he required a period of home care convalescence thereafter. However, as such treatment was not caused by or aggravated by a service-connected disability, temporary total compensation is not warranted. ORDER Service connection for a skin condition, to include psoriasis, is denied. Service connection for peripheral neuropathy of the right upper extremity is denied. Service connection for peripheral neuropathy of the left upper extremity is denied. A rating in excess of 50 percent for major depressive disorder is denied. A rating in excess of 20 percent for diabetes mellitus prior to January 27, 2012, is denied. Subject to the law and regulations governing payment of monetary benefits, effective January 27, 2012, the Veteran's 20 percent disability rating for diabetes mellitus, is restored. A rating in excess of 20 percent for diabetes mellitus is denied. A TDIU is granted, subject to the criteria applicable to the payment of monetary benefits. A temporary total evaluation because of hospital treatment in excess of 21 days is denied. A temporary total evaluation for convalescence is denied. REMAND In a March 2011 rating decision, the RO granted service connection for coronary artery disease. In light of this determination, the Board finds that a medical opinion is necessary to adjudicate the Veteran's claims of service connection for respiratory disability, renal disability, hypertension and erectile dysfunction. As such, these issues must be remanded. The Board also finds additional development is required before the issue of entitlement to SMC for aid and attendance can be adjudicated. The file contains letters from the Veteran's sister-in-law, Ms. CM, and the Veteran's neighbor Mr. DM, both received in November 2010 and both stating the Veteran had progressively become unable to care for himself without the assistance of his wife. Similarly, VA psychiatric treatment records state the Veteran essentially depended on his wife to answer questions and to manage their affairs. The Veteran had a VA examination for aid and attendance in March 2008. The examiner noted current significant diagnoses of non-insulin dependent diabetes mellitus (NIDDM) with peripheral vascular disease (PVD), chronic kidney disease, hypertension (HTN), sleep apnea, morbid obesity, hyperlipidemia and degenerative joint disease (DJD) of the left hip. The examiner was asked to circle "yes" or "no" to questions relating to the patient's ability and to explain each in detail. The examiner stated the Veteran had partial or complete loss of use of the lower extremities and explained that this impairment was due to arthritis and obesity. The examiner also stated that the Veteran was currently not able to dress himself, to bathe and attend to hygiene without assistance, to leave home without assistance, to live on his own, to protect himself from the daily environmental hazards of ordinary life, to manage his own funds or manage his own medications, but he did not explain what disabilities rendered the Veteran unable to do these things. Similarly, the examiner circled "yes" to the question as to whether there were other pertinent facts that would show the claimant's need for aid and attendance, but did not indicate what those facts were. The March 2008 examination report appears to indicate that the Veteran was at the time in need of aid and attendance of another person, but the report does not show if such need was due to service-connected disabilities versus nonservice-connected disabilities. Because the examination was inadequate, additional examination is required. Since the March 2008 examination report cited above the Veteran has been service-connected for additional disabilities; i.e., coronary artery disease and diabetic neuropathy of the bilateral lower extremities. These disabilities were not considered in March 2008 and should be considered on re-examination. Accordingly, the case is REMANDED to the RO via the Appeals Management Center (AMC) for the following action: 1. Associate, physically or electronically, any pertinent, outstanding records with the claims folder. 2. The Veteran should be afforded an appropriate VA examination to determine the nature, extent, onset and etiology of respiratory disability, renal disability, hypertension and erectile dysfunction found to be present. The claims folder should be made available to and reviewed by the examiner. All indicated studies should be performed and all findings should be reported in detail. The examiner must state whether it is at least as likely as not that the Veteran has respiratory disability, renal disability, hypertension and erectile dysfunction that is related to or had its onset in service. Thereafter, the examiner must also opine as to whether it is at least as likely as not that the Veteran has a respiratory disability, renal disability, hypertension and erectile dysfunction that was caused or aggravated by his service-connected diabetes mellitus, coronary artery disease, or the aggregate impact of those conditions. The rationale for all opinions expressed should be provided in a legible report. 3. Afford the Veteran a VA examination to determine whether the Veteran's service-connected disabilities cause him to be housebound or in need of regular aid and attendance of another person. The examiner should indicate the underlying disability or disabilities causing each specific impairment of function noted. The examiner should also state an opinion as to whether any of these functional impairments, alone or in combination, render the Veteran housebound or in need or regular aid and attendance of another person. 4. Then readjudicate the appeal. If the benefits sought on appeal remain denied, furnish to the Veteran and his representative a supplemental statement of the case and afford them the requisite opportunity to respond. Thereafter, if indicated, the case should be returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. 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). The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs