Citation Nr: 1318104 Decision Date: 06/04/13 Archive Date: 06/11/13 DOCKET NO. 04-22 389 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus type II. 3. Entitlement to service connection for coronary artery disease (CAD), to include as secondary to service-connected diabetes mellitus type II. 4. Entitlement to an initial compensable rating for service connection for bilateral nonproliferative diabetic retinopathy and bilateral clinically significant macular edema. 5. Entitlement to a rating in excess of 10 percent for shell fragment wound residuals, right thigh. 6. Entitlement to a rating in excess of 10 percent for shell fragment wound residuals, left thigh. 7. Entitlement to a rating in excess of 10 percent for left elbow scar, shell fragment wound residuals since May 19, 2003. 8. Entitlement to an initial compensable rating for diabetic nephropathy. 9. Entitlement to a total rating based upon individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Kathy A. Lieberman, Attorney at Law WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD James A. DeFrank, Counsel INTRODUCTION The Veteran served on active duty from February 1968 to March 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions promulgated by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. The Veteran provided testimony at hearings conducted before the personnel at the RO in May 2006 and October 2007. Transcripts from both hearings have been associated with the Veteran's VA claims folder. The record reflects the Veteran submitted a motion to have his case advanced on the docket pursuant to 38 U.S.C.A. § 7107 and 38 C.F.R. § 20.900(c). However, this motion was denied in June 2010. In a September 2010 decision, the Board granted a 10 percent rating for left elbow scar, shell fragment wound residuals, denied a rating in excess of 10 percent for shell fragment wound residuals, right thigh, denied a rating in excess of 10 percent for shell fragment wound residuals, left thigh, and denied a compensable rating for the Veteran's diabetic neuropathy. The September 2010 decision also remanded the Veteran's claims for service connection for an acquired psychiatric disorder to include PTSD, service connection for hypertension, service connection for CAD and entitlement to a TDIU. The Veteran appealed the Board's September 2010 decision to the Court. In an May 2012 Order pursuant to a Joint Motion for Partial Remand (JMPR) filed by the Veteran and the Secretary (parties), the Court vacated and remanded the Board's decision only as to the denial of an evaluation in excess of 10 percent for the left elbow scar, and the claims for higher evaluations for the shell fragment wound residuals, right thigh; shell fragment wound residuals, left thigh; and diabetic neuropathy. Per the September 2010 Board decision, the RO, in a September 2010 rating decision, implemented higher disability rating of 10 percent for left elbow scar, shell fragment wound residuals, effective May 19, 2003. The issues of entitlement to service connection for an acquired psychiatric disorder to include PTSD, entitlement to an initial compensable rating for service connection for bilateral nonproliferative diabetic retinopathy and bilateral clinically significant macular edema, entitlement to a rating in excess of 10 percent for left elbow scar, shell fragment wound residuals since May 19, 2003 and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The evidence of record favors a finding that the Veteran's hypertension has been aggravated by his service-connected diabetes mellitus type II. 2. The Veteran's shell fragment wound residuals of the thighs have not resulted in moderately severe muscle damage/impairment. 3. The Veteran's scar of his shell fragment wound residuals, right thigh is tender to palpation. 4. The Veteran's scar of his shell fragment wound residuals, left thigh is tender to palpation. 5. The competent medical and other evidence of record does not reflect the Veteran's service-connected diabetic nephropathy has resulted in renal dysfunction, to include albumin, is constant or recurring with hyaline and granular casts or red blood cells. CONCLUSIONS OF LAW 1. Hypertension was aggravated by his service-connected diabetes mellitus type II. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. The criteria for a rating in excess of 10 percent for the Veteran's service-connected shell fragment wound residuals, right thigh, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.10, 4.40, 4.45, 4.56, 4.59, 4.73, Diagnostic Code 5314 (2012). 3. The criteria for a rating in excess of 10 percent for the Veteran's service-connected shell fragment wound residuals, left thigh, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.10, 4.40, 4.45, 4.56, 4.59, 4.73, Diagnostic Code 5314 (2012). 4. Resolving all doubt in the Veteran's favor, the criteria for a separate 10 percent disability evaluation for associated scar, shell fragment wound residuals, right thigh, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.118, Diagnostic Code 7804 (2008). 5. Resolving all doubt in the Veteran's favor, the criteria for a separate 10 percent disability evaluation for associated scar, shell fragment wound residuals, left thigh, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.118, Diagnostic Code 7804 (2008). 6. The criteria for an initial compensable rating for the Veteran's service-connected diabetic nephropathy are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.10, 4.115a, 4.115b, Diagnostic Code 7599-7535 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). See also 73 Fed. Reg. 23,353-23,356 (April 30, 2008) (concerning revisions to 38 C.F.R. § 3.159). Given the favorable disposition of the claim for service connection for hypertension, the Board finds that all notification and development actions needed to fairly adjudicate this claim have been accomplished. Regarding the Veteran's claim for an initial compensable rating for diabetic neuropathy, since this claim is the appeal of an initial rating, fully satisfactory notice was delivered after it was adjudicated. However, the RO subsequently readjudicated the claim based on all the evidence in various supplemental statements of the case. The Veteran was able to participate effectively in the processing of his claim. There is no indication in the record or reason to believe that the ultimate decision of the originating agency on the merits of the claim would have been different had complete notice been provided at an earlier time. Regarding the Veteran's increased rating claims, the RO provided notice to the Veteran in a June 2003 letter, prior to the date of the issuance of the appealed September 2003 rating decision. This letter explained what information and evidence was needed to substantiate a claim for an increased rating, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. An April 2008 letter provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). After issuance of the April 2008 letter, and opportunity for the Veteran to respond, the September 2009 supplemental statement of the case (SSOC) reflects readjudication of the claim. Hence, the Veteran is not shown to be prejudiced by the timing of the latter notice. See Mayfield, 20 Vet. App. at 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). VA has also fulfilled its duty to assist in obtaining the identified and available evidence needed to substantiate the claim adjudicated in this decision. The RO has either obtained, or made sufficient efforts to obtain, records corresponding to all treatment for the claimed disorder described by the Veteran. Additionally, he was afforded VA examinations in July 2003, August 2003, November 2004, June 2006, November 2007, December 2008, and April 2009. The Board finds these examination reports to be thorough and consistent with contemporaneous medical records. The examinations in this case are adequate upon which to base a decision with regards to this claim. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (defining adequacy with respect to medical examinations and opinions as those providing sufficient detail so that the Board can perform a fully informed evaluation of the claim). Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). The Board has reviewed all the evidence in the Veteran's claims 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 the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). I. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus type II. Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. In relevant part, 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a 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." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007) In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed.Cir.2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may be granted for a disability that is proximately due to or the result of an established service-connected disability. 38 C.F.R. § 3.310 (2012). This includes disability made chronically worse by service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). In cases of aggravation of a veteran's nonservice-connected disability by a service-connected disability, such veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Id. at 448, see also 38 C.F.R. § 3.322 (2012). The Board notes that 38 C.F.R. § 3.310, the regulation which governs claims for secondary service connection, was amended during the course of the Veteran's claim and appeal. The intended effect of this amendment was to conform VA regulations to the Allen decision. 71 Fed. Reg. 52,744 (Sept. 7, 2006) (codified at 38 C.F.R. § 3.310(b)). However, given the possibility that these changes could potentially be interpreted as substantive, and because the Veteran's claim was pending before the regulatory change was made, the Board will apply the version of 38 C.F.R. § 3.310 that was in effect before the change, which arguably favors the claimant. Accordingly, the Board will evaluate the claimed disabilities, irrespective of any baseline. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Factual Background and Analysis The Veteran contends that his current hypertension was caused or aggravated by his service-connected diabetes mellitus type II disability. The Veteran underwent a VA examination in July 2003. The examiner noted that the Veteran first developed hypertension about 4 or 5 years ago while he was first diagnosed with diabetes type II in 1985. The examiner opined that the Veteran's arterial hypertension was not likely secondary to his diabetes mellitus. The Veteran underwent a VA genitourinary examination in June 2006. The examiner concluded that the Veteran's hypertension was more likely than not due to or the result of the Veteran's diabetes with neuropathy. As a result of these conflicting medical opinions, the Board remanded this issue in September 2010 to obtain a VA opinion on the etiology of the Veteran's hypertension which contained a rationale in support of the opinion. Notably, both the July 2003 and June 2006 examiners did not include rationale for their opinions regarding the etiology of the Veteran's hypertension. Per the September 2010 Board remand, the Veteran underwent a VA examination in September 2011. The examiner noted that the Veteran had hypertension since 1988. The examiner opined that the Veteran's hypertension was not caused by or a result of active military service. However, hypertension was at least as likely as not aggravated by his service-connected diabetes mellitus. In reaching this conclusion, the VA examiner explained that the Veteran had a history of microalbumira in the past but that his last result was within normal limits. The examiner also noted that there was no evidence of renal insufficiency or failure noted. After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for hypertension as secondary to the Veteran's service-connected diabetes mellitus type II is warranted. There are conflicting medical opinions on the question of whether the Veteran's current hypertension is secondary to his service-connected diabetes mellitus type II. The July 2003 VA examiner concluded that the Veteran's current hypertension was was not likely secondary to his diabetes mellitus. However, the June 2006 and September 2011 VA examiners concluded that it was at least as likely as not that the Veteran's hypertension was related to his service-connected diabetes mellitus type II. Notably, while the June 2003 VA examiner addressed service connection for hypertension as secondary to the Veteran's service-connected diabetes mellitus type II disability, unlike the September 2011 VA examiner, he did not address whether the Veteran's service-connected diabetes mellitus type II disability caused or aggravated the Veteran's hypertension disability. The June 2006 VA examiner, while finding that the hypertension was caused by the Veteran's diabetes with nephropathy, offered no rationale in support of that conclusion. Under Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993), the Board must assess the credibility and weight to be attached to medical opinions. Provided these opinions include adequate statements of reasons or bases, the Board may favor one opinion over another. Wray v. Brown, 7 Vet. App. 488 (1995). An assessment or opinion by a health care provider is never conclusive and is not entitled to absolute deference. Rather, the Board must consider the weight to be placed on an opinion depending upon the reasoning employed to support the conclusion and the extent to which the physician reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). In this case, the Board assigns the July 2003 VA examiner's opinions the least evidentiary weight. As noted above, while seemingly a negative opinion, the opinion provided did not address whether the Veteran's service-connected diabetes mellitus type II disability aggravated the Veteran's hypertension. Similarly, the Board affords the June 2006 VA examiner's opinion little weight as the examiner offered no rationale in support of the favorable conclusion. To the contrary, the September 2011 opinion which favors the claim, is based on a review of the claims file and is phrased in a manner that allows the Board to understand the rationale for the opinion and the probability of a relationship between the Veteran's service-connected diabetes mellitus type II disability and his hypertension. Accordingly, the Board finds that the September 2011 VA examiner's opinion is most persuasive as to the matter at hand. In this regard, the Board has considered that the language used by the September 2011 VA examiner was in terms that spoke to aggravation but that the examiner did not express an opinion as to the degree of aggravation. However, as noted above, the Board evaluates the claimed disability irrespective of any baseline. For this reason, and having resolved doubt in favor of the Veteran, the Board finds the Veteran's claim for secondary service connection is adequately supported. 38 C.F.R. § 3.102. Thus, the benefit sought on appeal is granted on a secondary basis. 38 C.F.R. § 3.310. II. Increased Ratings Laws and Regulations The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claims or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claims, in which case, the claims are denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2012). But where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2008). The Board will consider not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. A. Shell fragment wound residuals, right and left thigh. The service-connected shell fragment wound residuals of the right and left thighs have both been evaluated pursuant to 38 C.F.R. § 4.73, Diagnostic Code 5314, which provides evaluations for disability of Muscle Group XIV. Muscle Group XIV includes the muscles involved in extension of the knee, tension of the fascia lata and iliotibial band, acting with Muscle Group XVII in postural support of the body, and acting with the hamstrings in synchronizing the hip and knee. Under this Code, slight muscle damage to this Muscle Group warrants a noncompensable evaluation, moderate muscle damage warrants a 10 percent evaluation, moderately severe damage warrants a 30 percent rating, and severe damage warrants a 40 percent rating. 38 C.F.R. § 4.73, Diagnostic Code 5314. The factors to be considered in evaluating disabilities resulting from muscle injuries are listed in 38 C.F.R. § 4.56. For example, the provision of 38 C.F.R. § 4.56(c) reflects that the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. Information in this regulation provides guidance only and is to be considered with all other factors in the individual case. See Robertson v. Brown, 5 Vet. App. 70 (1993). In addition, under 38 C.F.R. § 4.56(d), disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe. Slight disability of muscles is characterized by simple wound of muscle without debridement or infection. Slight disability of muscle is reflected by history and complaint such as service department records of a superficial wound with brief treatment and return to duty. Healing of slight muscle injuries is followed by good functional results. Slight disability of muscles includes none of the cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. 4.56 (c). Objective findings characteristic of slight muscle disability include minimal scarring, no evidence of fascial defect, atrophy, or impaired tonus, no impairment of function, and no metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56 (d)(1). Moderate disability of muscles is characterized by a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without the explosive effect of a high velocity missile, residuals of debridement, or prolonged infection. History and complaint characteristic of moderate disability of muscle includes service department records or other evidence of in-service treatment for the wound. For a finding of moderate disability of muscle, there should be record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in 38 C.F.R. § 4.56 (c), particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objective findings characteristic of moderate muscle disability include small or linear entrance and (if present) exit scars, indicating a short track of the missile through muscle tissue. For moderate muscle injury, there should be some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2). Moderately severe disability of muscles is characterized by a through and through or deep penetrating wound by a small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. History and complaint characteristic of moderately severe muscle injury includes service department records or other evidence showing hospitalization for a prolonged period for treatment of wound. A showing of moderately severe muscle disability should include a record of consistent complaints of cardinal signs and symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c) and, if present, evidence of inability to keep up with work requirements. Objective findings characteristic of moderately severe muscle disability include entrance and (if present) exit scars indicating the track of the missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side are also indicative of moderately severe muscle disability. Tests of strength and endurance compared with the sound side should demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d) (3). Severe disability of muscles is characterized by a through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. History and complaint characteristic of severe disability of muscle includes service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Objective findings characteristic of severe muscle disability include ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. §4.56(d)(4). In the instant case, the Board finds that the Veteran does not meet or nearly approximate the criteria for a rating in excess of 10 percent for his service-connected shell fragment wound residuals of the right and/or left thighs under Diagnostic Code 5314. With respect to the Veteran's history, the Board acknowledges that there is in-service evidence of muscle injury to the thighs. Specifically, his service treatment records reflect he sustained multiple shell fragment wounds to his thighs and left arm in April 1969, and that he was discharged to duty with a temporary profile in June 1969. However, the service treatment records and other evidence on file does not reflect either thigh sustained deep penetrating wound, nor is there in-service findings of debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. The Board also notes that an April 2009 VA muscles examination found that there was no infection of these muscle injuries prior to healing. With respect to the current impairment, the Board acknowledges that the Veteran has complained of pain in both thighs due to the service-connected shell fragment wound residuals. However, the record does not reflect these complaints have resulted in objective findings of moderately severe muscle damage/impairment of either thigh. For example, the July 2003 VA examination showed that both hips had flexion to 90 degrees, extension to 20 degrees, internal and external rotation to 40 degrees, abduction and adduction to 25 degrees. Normal ranges of hip motion are flexion from zero degrees to 125 degrees; abduction from zero degrees to 45 degrees. 38 C.F.R. § 4.17a, Plate II. Thus, there is limitation of motion of these hips, but not to the extent that would warrant a finding of moderately severe impairment when compared to normal. This conclusion is supported by the fact that these findings would not warrant a rating in excess of 10 percent under Diagnostic Codes 5251 to 5253 which evaluates limitation of motion of the hip. Moreover, the July 2003 VA examiner commented there was no objective evidence of painful motion on all movements of both hips. Further, there was no objective evidence of edema, effusion, instability, weakness, redness, heat, abnormal movement or guarding of movement of both thighs. He was also found to have normal gait cycle. The subsequent November 2004 VA examination found, in part, that both of the Veteran's quadriceps and iliopsoas were 4/5 on muscle strength testing, bilaterally. There was no muscle herniation. Bilateral hip flexion was to 90 degrees, and extension was to 20 degrees bilaterally. There was only mild pain upon motion of both hips bilaterally. There was also moderate tenderness upon palpation at both anterior compartments of the legs. Additionally, it was noted that X-rays conducted in August 2003 showed no evidence of radiopaque foreign bodies of the legs. The most recent VA muscles examination conducted in April 2009 found there was no pain, decreased coordination, increased fatigability, or uncertainty of movement of either thigh. Both thighs did have evidence of weakness, but the record does not reflect this symptom has resulted in objective evidence of moderately severe impairment. Evaluation of the thighs reflects Group 14 muscles had 4/5 strength, while the other thigh muscles (13 and 15) had 5/5 strength. Moreover, there were no residuals of nerve, tendon, or bone damage; nor muscle herniation; nor loss of deep fascia or muscle substance; nor was the motion of any joint limited by muscle disease or injury. Regarding the effect on daily activities, it was found that the shell fragment wound residuals did prevent sports. However, it resulted in only mild impairment of chores, shopping, exercise, recreation, and traveling; and no impairment of feeding, bathing, dressing, toileting, or grooming. In short, despite the Veteran's complaints of pain, the record reflects that his service-connected shell fragment wound residuals have resulted in no more than moderate loss of muscle strength and limitation of motion thereof. Moreover, the record does not demonstrate objective findings characteristic of moderately severe muscle disability as identified by 38 C.F.R. § 4.56. Overall, the evidence did not show more that moderate muscle impairment of Muscle Group XIV. And the criteria for higher rating based on the type of injury, history and complaint, and objective findings, considering functional loss, were not met. Accordingly, the Board finds that the current impairment of these service-connected disabilities is adequately reflected by the current 10 percent rating, and he does not meet or nearly approximate the criteria for a higher rating under Diagnostic Code 5314. While the Veteran does not meet a higher rating under Diagnostic Code 5314, the Board notes that there is evidence that the Veteran has painful and tender scars as a result of his shell fragment wound residuals, right and left thigh. The Board notes that the rating criteria for scars have changed, effective October 2008. However, these amended regulations were specifically effective for applications for benefits received by the VA on or after October 23, 2008. See 73 Fed. Reg. 52710 (October 23, 2008). As the Veteran's claim was filed prior to October 2008, his disability is rated under the old rating criteria for scars. Under Diagnostic Code 7801, the criteria for a 10 percent rating for a scar, other than on the head, face, or neck, were deep or cause limited motion and covered an area exceeding 6 square inches (39 sq. cm.). Under Diagnostic Code 7802, the criteria for a 10 percent rating for a scar, other than on the head, face, or neck, were a superficial and nonlinear and that did not cause limitation of motion and covered an area of 144 square inches (929 sq. cm.). Under Diagnostic Code 7803, the criteria for a 10 percent for a scar were a superficial and unstable scar. A superficial scar was defined as one not associated with underlying soft tissue damage. An unstable scar was defined as one where there is frequent loss of skin over the scar. Under Diagnostic Code 7804, the criteria for a 10 percent were a scar that was superficial and painful on examination. Under Diagnostic Code 7805, a scar could be rated on limitation of function of the affected part. On VA examination in July 2003, the examiner noted that on examination, there was moderate tenderness to palpitation of all scars. The left thigh scar measured 11cm long and 3cm and was vertical shaped. The right thigh scar was 12cm long and 5cm wide and was oblique shaped. There were no adhesions and there was normal texture of the skin. The scars were not unstable and there were no ulceration or breakdown of the skin of the scars. There was no elevation or depression of the surface contours of all scars on palpitation. The scars were superficial. There was no inflammation, edema or keloid formation on the scars but there was loss of color. There were no areas of induration or inflexibility. The scars were mildly cosmetically disfiguring. On VA examination in December 2008, the scar of the right thigh and left thigh were 13cm long and 4cm wide. Both scars were tender to palpation. There was no adherence to underlying tissue, no limitation of motion or loss of function, no underlying soft tissue damage, no skin ulceration or breakdown over the scar, no underlying tissue loss, no elevation of the scar, no depression of the scar and no induration or inflexibility. On a VA muscle examination in April 2009, the examiner noted that the Veteran's scars of his thighs were not tender or painful to touch. While the April 2009 VA examination demonstrated no painful or tender scars of the thighs, the Board finds that there is evidence of tenderness on palpation to both scars as identified by multiple VA examinations. Accordingly, the Board finds that this approximates the criteria for a painful scar on examination under Diagnostic Code 7804, warranting a separate 10 percent rating for each scar. Regarding a rating in excess of 10 percent for each scar, the Board notes that 10 percent is the maximum rating under Diagnostic Code 7804. Additionally, the evidence does not show that the Veteran had scars that covered an area exceeding 6 square inches, Diagnostic Code 7801, or 144 square inches, Diagnostic Code 7802, or were unstable, Diagnostic Code 7803. As for limitation of function under Diagnostic Code 7805, as the Veteran already was rated 10 percent for muscle impairment under Diagnostic Code 5314, a rating under Diagnostic Code 7805 for the same functional loss would be pyramiding, which is not permissible. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994) (separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition). In summary the criteria for separate 10 percent disability ratings for scars associated with the Veteran's service-connected shell fragment wound residuals, right and left thigh, are met. B. Diabetic Nephropathy The Veteran's current diabetic nephropathy is rated by analogy to Diagnostic Code 7599-7535, toxic nephropathy. 38 C.F.R. §§ 4.115a, 4.115b. The RO awarded service connection for this condition as secondary to the Veteran's previously service-connected diabetes mellitus type II. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With injuries and diseases, preference is to be given to the number assigned to the injury or disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27 (2012). The hyphenated diagnostic code in this case indicates that an unlisted genitourinary disorder, under Diagnostic Code 7599, was the service-connected disorder, and nephropathy, under Diagnostic Code 7535, was a residual condition. See Id (unlisted disabilities requiring rating by analogy will be coded by the numbers of the most closely related body part and "99"). The rating criteria for renal dysfunction are found at 38 C.F.R. § 4.115a. Renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, blood urea nitrogen (BUN) more than 80mg% [milligrams per 100 milliliters]; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular, warrants a 100 percent disability rating. Renal dysfunction characterized by persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or a limitation of exertion warrants an 80 percent disability rating. Renal dysfunction with constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code 7101 warrants a 60 percent disability rating. Renal dysfunction where albumin is constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under Diagnostic Code 7101 warrants a 30 percent disability rating. Renal dysfunction with albumin and casts with history of acute nephritis; or, hypertension that is noncompensable under Diagnostic Code 7101 is rated as noncompensable. In this case, the Board acknowledges that there is evidence that the Veteran's has albumin. However, the record does not reflect that the albumin is the result of renal dysfunction, nor that it is constant or recurring with hyaline and graunular casts or red blood cells. For example, the June 2006 VA examination noted that microalbuminuria test was positive, and that present laboratory reports of April 2006 showed microalbuminuria of 59.5 mg/L with hemoglobin A1c of 5.7. There were also findings of albumin on the subsequent November 2007 and December 2008 VA examinations. However, all of these examinations found there was no history of renal dysfunction or renal failure. The December 2008 VA examination also specifically stated that there was normal renal function, and no evidence of renal insufficiency nor kidney failure. The examiner further found that there was previous evidence on prior VA examination of very mild micro-albuminuria, which is consistent with the criteria for a noncompensable (zero percent) rating under Diagnostic Code 7535. Moreover, the examiner stated that these findings were now controlled, and that the Veteran currently had normal values for microalbuminuria on this examination. While the Veteran has hypertension which, as addressed above, the Veteran has been granted service connection for, the Board notes again that Diagnostic Code 7535 requires that the Veteran has renal dysfunction to warrant a compensable rating. In view of the fact the Veteran does not currently experience any renal dysfunction as a result of his service-connected diabetic nephropathy, he is not entitled to a compensable rating under Diagnostic Code 7535. C. Extraschedular Considerations The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b) (1), for exceptional cases where scheduler evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three- step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected shell fragment wound residuals, right thigh; shell fragment wound residuals, left thigh; associated scar for shell fragment wound residuals, right thigh; associated scar for shell fragment wound residuals, left thigh and diabetic nephropathy disabilities is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology for shell fragment wound residuals, right thigh; shell fragment wound residuals, left thigh; associated scar for shell fragment wound residuals, right thigh; associated scar for shell fragment wound residuals, left thigh and diabetic nephropathy. There is no evidence in the medical records of an exceptional or unusual clinical picture. The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b) (1) is not warranted. ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus type II is granted. Entitlement to a rating in excess of 10 percent for shell fragment wound residuals, right thigh is denied. Entitlement to a rating in excess of 10 percent for shell fragment wound residuals, left thigh is denied. A separate 10 percent disability rating for associated scar for shell fragment wound residuals, right thigh is granted, subject to the regulations governing the award of monetary benefits. A separate 10 percent disability rating for associated scar for shell fragment wound residuals, left thigh is granted, subject to the regulations governing the award of monetary benefits. Entitlement to an initial compensable rating for diabetic nephropathy is denied. REMAND The Board finds that more development is necessary prior to final adjudication of the claims remaining on appeal. One of the matters the Board must address is which issue or issues are properly before it at this time. Under the provisions of 38 U.S.C.A. § 7105(a), an appeal to the Board must be initiated by a notice of disagreement and completed by a substantive appeal after a statement of the case is furnished to the veteran. In essence, the following sequence is required: There must be a decision by the RO, the veteran must express timely disagreement with the decision, VA must respond by explaining the basis of the decision to the veteran, and finally the veteran, after receiving adequate notice of the basis of the decision, must complete the process by stating his argument in a timely- filed substantive appeal. See 38 C.F.R. §§ 20.200, 20.201, 20.202, and 20.203. In a January 2013 rating decision, the RO granted service connection for bilateral nonproliferative diabetic retinopathy and bilateral clinically significant macular edema at a noncompensable rating, effective June 7, 2012. In a February 2013 letter, the RO indicated that it had received a written disagreement with the January 18, 2003 rating decision. While the Veteran expressed disagreement with the January 2013 rating decision, it appears that no subsequent statement of the case was ever issued. Under Manlincon v. West, 12 Vet. App. 238, 240 (1999), the Board must instruct the RO that the issue of entitlement to an initial compensable rating for service connection for bilateral nonproliferative diabetic retinopathy and bilateral clinically significant macular edema remains pending in appellate status (see 38 C.F.R. § 3.160(c)) and requires further action. See 38 U.S.C.A. § 7105; 38 C.F.R. § 19.26. In this regard, it is noteworthy that this claim is not before the Board at this time and will only be before the Board if the Veteran files a timely substantive appeal. The Board's actions regarding this issue are taken to fulfill the requirements of the Court in Manlincon. Regarding the issue of entitlement to service connection for CAD, to include as secondary to service-connected diabetes mellitus type II, as noted above, the Board remanded this issue in September 2010 for further development. The January 2010 Board remand essentially requested that the Veteran be afforded a VA examination to evaluate the nature and etiology of his claimed CAD. It was then directed that, if the Veteran's claim was not granted to his satisfaction, the Veteran and his representative should be provided with a supplemental statement of the case (SSOC) and afforded the opportunity to respond thereto before the matter was returned to the Board. No such SSOC was issued with respect to the Veteran's claim for service connection for CAD, to include as secondary to service-connected diabetes mellitus, type II. The Board is obligated by law to ensure that the RO complies with its directives; where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Therefore, in light of the fact that it was expressly requested that an SSOC be issued with respect to this claim following all requested development, and the claims file does not contain any such SSOC following the requested development, the Board finds that VA has not substantially complied with the remand directives. Consequently, a new remand is required to comply with the holding of Stegall. Regarding the issue of entitlement to service connection for an acquired psychiatric disorder to include PTSD, the Board notes that the United States Court of Appeals for Veterans Claims (Court) has held that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). As such, this issue on appeal had been previously characterized to consider all reported and diagnosed psychiatric disabilities in accordance with Clemons. In the September 2010 decision, the Board remanded the issue for further development so that the Veteran could be afforded a VA examination to evaluate the nature and etiology of his claimed PTSD. The examiner was also instructed to express an opinion as to whether it is at least as likely as not that any diagnosed acquired psychiatric disability was incurred or otherwise the result of the Veteran's active service, to include his combat experience therein. Additionally, an opinion was to be expressed as to whether it is at least as likely as not that the psychiatric disorder was caused by or aggravated by the service-connected diabetes mellitus. Pursuant to the Board's remand, the Veteran was afforded an examination in September 2011. The examiner indicated that the Veteran did not have the symptoms that fulfilled the criteria for PTSD. However, the examiner did not address whether any acquired psychiatric disorder was caused or aggravated by a service-connected disability, to include diabetes mellitus. The examination report does not comply with the Board's September 2010 instructions. Again, the United States Court of Appeals for Veterans Claims has held that a remand confers on the veteran, as a matter of law, the right to compliance with the remand orders. Stegall; supra. On remand, the September 2011 VA examiner should amend his examination report in accordance with the Board's September 2010 directives cited herein. Regarding the Veteran's claim for entitlement to a rating in excess of 10 percent for left elbow scar, shell fragment wound residuals since May 19, 2003, as indicated by the Court in its September 2010 Partial Motion for Remand, on VA muscles examination in November 2004, the examiner indicated that the Veteran had injured three muscles in his left forearm which affected the, left biceps, flexor carpi radialis and flex carpi ulnaris muscles. While the Veteran underwent a VA muscles examination in April 2009, the examination only addressed the Veteran's service-connected shell fragment wound residuals of his left and right thighs. Additionally, VA scar examinations have not addressed any muscle damage of the left elbow. Significantly, while the September 2010 Board decision granted a higher disability rating of 10 percent for left elbow scar, shell fragment wound residuals, effective May 19, 2003, the decision did not address Diagnostic Code 5305 (damage to Muscle Group V) in its decision. As noted above, the last VA examination to address the Veteran's muscle damage of his left elbow occurred almost 9 years ago in November 2004. Although a new VA examination is not warranted based merely upon the passage of time [see Palczewski v. Nicholson, 21 Vet. App. 174 (2007)], the Court has held that where a veteran claims that a disability is worse than when originally rated, and the available evidence is too old to adequately evaluate the current state of the condition, the VA must provide a new examination. See Olsen v. Principi, 3 Vet. App. 480, 482 (1992), citing Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). In this context, the Board believes that a medical examinations assessing the current severity of the Veteran's left elbow scar, shell fragment wound residuals disability is necessary to adequately decide this claim. Regarding the Veteran's claim for TDIU, the Board notes that further development and adjudication of the Veteran's claims for service connection for an acquired psychiatric disorder and CAD, the claim for a compensable rating for bilateral nonproliferative diabetic retinopathy and bilateral clinically significant macular edema, and the claim for an increased rating for left elbow scar, shell fragment wound residuals, may provide evidence in support of his claim for TDIU. The Board has therefore concluded that it would be inappropriate at this juncture to enter a final determination on that issue. See Henderson v. West, 12 Vet. App. 11 (1998), citing Harris v. Derwinski, 1 Vet. App. 180 (1991), for the proposition that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any review of the decision on the other claim meaningless and a waste of appellate resources, the claims are inextricably intertwined. Additionally, the Board notes that in a November 2007 letter, a private physician indicated that since 2004, the Veteran was totally and permanently disabled to work because of his diabetes mellitus with diabetic peripheral neuropathy, osteoarthritis in his hips, knees and legs, arterial hypertension and CAD. As a result, an opinion is needed as to whether the Veteran's service-connected disabilities alone, without consideration of his nonservice-connected disabilities, preclude the Veteran from obtaining or maintaining any gainful employment. A VA opinion is required to determine whether the Veteran is unemployable due solely to his service-connected disabilities. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated him for the disabilities on appeal. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. Appropriate efforts must be made to obtain all available VA treatment records. All attempts to procure records should be documented in the file. If the AMC/RO cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran is to be notified of unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit those records for VA review. 2. The RO should issue a statement of the case to the Veteran addressing the matter of entitlement to an initial compensable rating for bilateral nonproliferative diabetic retinopathy and bilateral clinically significant macular edema, including citation to all relevant law and regulation pertinent to this claim. The Veteran must be advised of the time limit for filing a substantive appeal. 38 C.F.R. § 20.302(b). Then, only if the appeal is timely perfected, this issue is to be returned to the Board for further appellate consideration, if otherwise in order. 3. The RO should arrange for the same examiner who conducted the September 2011 examination, if possible, to review the claims folder and determine whether the Veteran's acquired psychiatric disability (diagnosed by the September 2011 examiner as depression and anxiety) whether it is at least as likely as not that this disability was caused by or aggravated by a service-connected disability, to include diabetes mellitus. By aggravation the Board means a permanent increase in the severity of the underlying disability beyond its natural progression. 4. The Veteran should be afforded a VA scar examination in order to obtain a complete description of his service-connected scar, shell fragment wound residuals of the left elbow. The claims folder must be made available to the examiner for review in connection with the examination. In the examination report, the examiner must specifically describe the size, location, and appearance of the service-connected left elbow scar, to include commenting on any symptomatology or functional impairment associated with the scarring. The examiner should also determine the nature and severity of the residuals of his left elbow muscle injuries. If separate neurological and muscle examinations are deemed necessary, they should be scheduled. In the examination report(s), the examiner(s) should delineate all symptoms or pathology attributable to the service-connected scar, shell fragment wound residuals of the left elbow, to include neurological and muscle impairment. The examiner(s) should also assess the severity of each manifestation identified on examination. 5. The claims file should be provided to an appropriate examiner for an opinion regarding the impact of his service-connected disabilities on his employability. The Veteran's claims folder and a copy of this remand must be made available to the examiner for review in conjunction with the opinion. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Based on a review of the evidence contained in the claims file, the examiner is asked to comment on whether it is at least as likely as not that the Veteran is unable to obtain or maintain substantially gainful employment solely as a result of the cumulative effect of his service-connected disabilities. In making this determination, the examiner must consider the Veteran's level of education, experience, and occupational background in determining whether he is unable to obtain or maintain substantially gainful employment in light of the severity of his service-connected disabilities (standing alone). Please note that if the Veteran is found to have some degree of unemployability due to nonservice-connected disabilities, please nevertheless include a clear explanation of the current degree (if none, please explain) of unemployability attributable only to the Veteran's service-connected disabilities. 6. Then, perform any additional development necessary, and then readjudicate the Veteran's claims. If his claims remain denied, he should be provided with a Supplemental Statement of the Case (SSOC). After the Veteran has been given the applicable time to submit additional argument, the claim should be returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims 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). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs