Citation Nr: 1318206 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 09-26 521 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to a rating in excess of 20 percent for diabetes mellitus, type II. 2. Entitlement to an initial rating in excess of 10 percent for right upper extremity peripheral neuropathy. 3. Entitlement to an initial rating in excess of 10 percent for left upper extremity peripheral neuropathy. 4. Entitlement to an initial rating in excess of 10 percent for right lower extremity peripheral neuropathy. 5. Entitlement to an initial rating in excess of 10 percent left lower extremity peripheral neuropathy. 6. Entitlement to a total rating based upon individual unemployability (TDIU) due to service-connected disabilities. 7. Entitlement to service connection for bilateral upper extremity radiculopathy as secondary to diabetes mellitus. 8. Entitlement to service connection for a heart disorder as secondary to diabetes mellitus. 9. Entitlement to service connection for bilateral lower extremity radiculopathy as secondary to diabetes mellitus. 10. Entitlement to service connection for hypertension as secondary to diabetes mellitus. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had active duty service from September 1965 to September 1967. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico which, in pertinent part, granted the Veteran's claims for service connection for bilateral upper extremity and bilateral lower extremity peripheral neuropathy and assigned initial 10 percent rating for each extremity. His claim for an increased rating for diabetes mellitus as well as his claim for TDIU were denied. In addition, his claims for service connection for bilateral upper extremity and bilateral lower extremity radiculopathy, a heart condition and hypertension were denied. The Veteran withdrew his request for a hearing in December 2009. A review of the Virtual VA paperless claims processing system reveals VA treatment records dated through April 2013. A June 2010 supplemental statement of the case (SSOC) considered VA treatment records dated through May 2010. The Veteran's representative waived RO consideration of the VA treatment records dated after May 2010 in April 2013. See 38 C.F.R. § 20.1304(c) (2012). In an October 2012 Informal Hearing Presentation (IHP), the Veteran's representative raised the issue of whether new and material evidence had been received to reopen a claim for service connection for cataracts as secondary to diabetes mellitus. The issues of entitlement to service connection digestive problems, erectile dysfunction and skin changes as secondary to service- connected diabetes mellitus were also raised in the October 2012 IHP. These issues have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them and they are referred to the AOJ for appropriate action. The issues of entitlement to service connection for bilateral lower extremity radiculopathy and hypertension are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. For the entire appellate period, the Veteran's diabetes mellitus was controlled by the use of oral medications and/or insulin and a restricted diet without the regulations of activities or episodes of ketoacidosis or hypoglycemic reactions which required hospitalizations or treatment from a diabetic care provider that occurred at least twice per month. 2. The Veteran is left hand dominant. 3. For the entire appellate period, the Veteran's right upper extremity peripheral neuropathy manifested by subjective complaints of hand numbness as well as objective evidence of reduced or lost reflexes, muscle atrophy in the thenar nerve and reduced or absent sensation without complete paralysis. 4. For the entire appellate period, the Veteran's left upper extremity peripheral neuropathy manifested as subjective complaints of hand numbness as well as objective evidence of reduced or lost deep tendon reflexes, muscle atrophy in the thenar nerve and reduced or absent sensation without complete paralysis. 5. For the entire appellate period, the Veteran's bilateral lower extremity peripheral neuropathy manifested as reduced or absent deep tendon reflexes, reduced or absent sensation with subjective complaints of numbness, cramps and tingling without muscle atrophy or impaired muscle strength. 6. The Veteran's service connected disabilities include diabetes mellitus, rated as 20 percent disabling; right upper extremity peripheral neuropathy, rated as 40 percent disabling; left upper extremity peripheral neuropathy, rated as 50 percent disabling; right and left lower extremity peripheral neuropathy, rated as 20 disabling in each extremity and right and left leg peripheral vascular disease, rated as non-compensably disabling. 7. The Veteran's combined disability rating is 90 percent. 8. For the entire appellate period, the Veteran has been unable to secure and maintain substantially gainful employment as a result of his various service-connected disabilities, including the peripheral neuropathy in his lower extremities. 9. The Veteran does not have a currently diagnosed bilateral upper extremity radiculopathy. 10. The Veteran does not have a currently diagnosed heart disorder. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.10, 4.119, 7913 (2012). 2. The criteria for an initial rating of 40 percent for right upper extremity peripheral neuropathy have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.10, 4.20, 4.27, 4.119, 4.120, 4.123, 4.124a, 8515 (2012). 3. The criteria for an initial rating of 50 percent for left upper extremity peripheral neuropathy have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.10, 4.20, 4.27, 4.119, 4.120, 4.123, 4.124a, 8515 (2012). 4. The criteria for an initial rating of 20 percent right lower extremity peripheral neuropathy have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.10, 4.20, 4.27, 4.120, 4.123, 4.124a, 8520 (2012). 5. The criteria for an initial rating of 20 percent left lower extremity peripheral neuropathy have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.10, 4.20, 4.27, 4.120, 4.123, 4.124a, 8520 (2012). 6. The criteria for a TDIU have been met, effective February 28, 2008. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.341, 4.1, 4.16 (2012). 7. The criteria for service connection for bilateral upper extremity radiculopathy as secondary to diabetes mellitus have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 8. The criteria for service connection for a hear disorder as secondary to diabetes mellitus have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. With respect to the Veteran's inferred claim for TDIU, given the favorable disposition of the action here, which is not prejudicial to the Veteran, the Board need not assess VA's compliance with the VCAA. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92, 57 Fed. Reg. 49,747 (1992). Prior to initial adjudication of the Veteran's claims decided herein, a letter dated in March 2008 fully satisfied the duty to notify provisions as to claims for an increased rating and claims for service connection on a secondary basis. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, at 187. Since the Board has concluded that the preponderance of the evidence is against the claims for service connection for bilateral upper extremity and a heart condition, any questions as to the appropriate disability rating or effective date to be assigned are rendered moot, and no further notice is needed. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board notes that the Veteran was not provided with notice regarding what information was required to substantiate a claim for service connection on a direct basis until the June 2009 statement of the case (SOC). However, the Veteran has actively participated in the adjudication of his claims, and the statements submitted in support of his claims, to include from his accredited representative, have indicated familiarity with the requirements for the benefits sought on appeal. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006) (VA can demonstrate that a notice defect is not prejudicial if it can be demonstrated ... that any defect in notice was cured by actual knowledge on the part of the appellant that certain evidence (i.e., the missing information or evidence needed to substantiate the claim) was required and that the appellant should have provided it.); see also Overton v. Nicholson, 20 Vet. App. 427 (2006). Moreover, the Board notes that the Veteran has not claimed direct service connection with regards to the instant claims. In a claim for an increased rating, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The preadjudication March 2008 letter notified the Veteran that medical or lay evidence could be submitted to substantiate his claims for an increased rating and provided specific examples. This letter stated that such evidence should discuss his disability symptoms from people who have witnessed how they affected him as well as notifying him that he may submit statements from his employers. The remaining elements of Vazquez notice were provided in a January 2009 letter. The timing deficiency with regard to this January 2009 letter was cured by the readjudication of the claim in the June 2010 SSOC. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). In addition, the Veteran has not alleged prejudice with regard to any notice deficiency. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (holding that a party alleging defective notice has the burden of showing how the defective notice was harmful). All the law requires is that the duty to notify is satisfied and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (harmless error). In view of the foregoing, the Board finds that the Veteran was notified and aware of the evidence needed to substantiate his claims, as well as the avenues through which he might obtain such evidence, and of the allocation of responsibilities between himself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. The Board also concludes VA's duty to assist has been satisfied. The evidence of record includes the service treatment records, VA outpatient treatment records, various private treatment records and the VA examination reports. The Veteran was also afforded multiple VA examinations in conjunction with the claims on appeal, including VA examinations conducted in April 2008 and April 2010, to determine the severity of his diabetes mellitus and peripheral neuropathy of the extremities. Neither the Veteran nor his representative has alleged that these VA examinations are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected diabetes mellitus and peripheral neuropathy of the extremities as they include interviews with the Veteran, a review of the record, and full physical examinations, addressing the relevant rating criteria. Moreover, neither the Veteran nor his representative have alleged that his diabetes mellitus and peripheral neuropathy of the extremities has worsened in severity since the April 2010 VA examination. Rather, they argue that the evidence reveals that the Veteran's diabetes mellitus and peripheral neuropathy of the extremities have been more severe than the currently assigned ratings for the duration of the appeal period. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (the passage of time alone, without an allegation of worsening, does not warrant a new examination). Therefore, the Board finds that the examinations of record are adequate to adjudicate the Veteran's claims for an increased rating and no further examination is necessary. Additionally, the Veteran was afforded VA examinations in order to adjudicate his claims for service connection for bilateral upper extremity radiculopathy and a heart condition. In this regard, the Board notes that the April 2008 and April 2010 VA examiners offered etiological opinions as to each claimed disorder and based their conclusions on interviews with the Veteran, a review of the record, and full examinations. Moreover, such opinions offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); 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"). As such, the Board finds that the opinions proffered by the VA examiners are sufficient to assist VA in deciding the instant claims for service connection. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). The Veteran has submitted argument and evidence in support of the appeals. Based on the foregoing, the Board finds that the Veteran has had a meaningful opportunity to participate in the adjudication of his claims such that the essential fairness of the adjudication is not affected. II. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). In instances in which a veteran disagrees with the initial rating, the entire evidentiary record from the time of a veteran's claim for service connection to the present is of importance in determining the proper evaluation of disability, and staged ratings are to be considered in order to reflect the changing level of severity of a disability during this period. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the Veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances 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, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. 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); 38 C.F.R. § 3.102. Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). A. Diabetes Mellitus The Veteran's diabetes mellitus is rated under Diagnostic Code 7913. A 20 percent rating is warranted for diabetes mellitus that requires insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. A 40 percent rating is assigned for diabetes mellitus that requires the use of insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted in cases 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 to a diabetic care provider, plus complications that would not be compensable if separately evaluated. 38 C.F.R. § 4.119, 7913. A 100 percent rating requires 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. Id. "Regulation of activities" has been defined as the situation where a veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,446 (May 7, 1996) (defining "regulation of activities," as used by VA in 7913). Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360 (2007). In addition, a note following the rating criteria indicates that compensable complications from diabetes mellitus are evaluated separately unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are considered part of the diabetic process under 7913. An April 2008 VA diabetes mellitus examination report noted that the Veteran's diabetes mellitus was stable with the use of oral medication and diet. A history of hospitalizations associated with diabetes, hypoglycemic reactions, ketoacidosis, an inability to perform strenuous activities or neurovascular symptoms related to diabetes were denied. Physical examination found a refractive error, status-post cataract surgery, to be present without evidence of diabetic retinopathy. The examiner noted that there was no cardiovascular disease or kidney disease. An April 2010 VA diabetes mellitus examination report noted that the Veteran was using oral hypoglycemic medications to control his diabetes mellitus and that he followed a restricted or special diet. His glycemic control was reported to have been fairly good. Although he also reported episodes of hypoglycemia or ketoacidosis, there were no hospitalizations or visits to a diabetic care provider. These hypoglycemic symptoms, which were reported to include anxiety, hot flashes, blurred vision, sweating and weakness, occurred once or twice per month and were not severe as he managed them by eating something sweet. There was no restriction in the ability to perform strenuous activities. The examiner opined that the Veteran's refractive error was not a complication of diabetes. The remaining VA outpatient treatment records indicated that the Veteran's diabetes mellitus was controlled using a restricted diet and insulin and/or oral hypoglycemic agents. For the entire appellate period, the Veteran's diabetes mellitus required the use of oral medications and/or insulin and a restricted diet. Although he reported episodes of hypoglycemia, these episodes did not require hospitalization or twice monthly visits to a diabetic care provider. The Veteran did not allege, and the clinical evidence did not demonstrate, that there were restrictions of activity due to his diabetes mellitus. In addition, he reported in an April 2010 VA examination that his diabetic complications did not require hospitalizations and that he had no visits to a diabetic care provider and the clinical evidence did not establish such hospitalizations or visits to a diabetic care provider. A rating in excess of 20 percent for diabetes mellitus is therefore not warranted. 38 C.F.R. § 4.119, 7913. In an October IHP, the Veteran's representative argued that a 60 percent rating for the Veteran's diabetes mellitus is warranted as it is controlled with the use of medications and a restricted diet and that his bilateral lower extremity peripheral vascular disease were not in themselves compensable. However, such a rating requires the use of insulin, a restricted diet and the regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice per month visits to a diabetic care provider and such complications that would not be compensable if separately evaluated. As detailed above, the clinical evidence is negative for the use of insulin, the regulation of activities, episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider. See Camacho, supra (holding that where rating criteria are conjunctive, each element of the criteria is needed to meet the requirements for the specified rating). This argument is therefore without merit. The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected diabetes mellitus; however, the Board finds that his symptomatology has been stable throughout the appeal. Therefore, assigning staged ratings for such disability is not warranted. For all the foregoing reasons, the Board finds that a rating in excess of 20 percent for diabetes mellitus is not warranted. The Board has applied the benefit-of-the-doubt doctrine in considering a higher rating, but finds that the preponderance of the evidence is against the assignment of a rating in excess of 20 percent for any period during the course of the appeal. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. B. Peripheral Neuropathy of the Extremities The Veteran's bilateral upper extremity peripheral neuropathy is rated under the diagnostic code for paralysis of the median nerve while his bilateral lower extremity peripheral neuropathy is rated under the diagnostic code for paralysis of the sciatic nerve. Mild incomplete paralysis of the median nerve warrants a 10 percent for either extremity. Moderate incomplete paralysis warrants a 30 percent rating in the major extremity and a 20 percent rating in the minor extremity. Severe incomplete paralysis warrants a 50 percent rating in the major extremity and a 40 percent rating in the minor extremity. 38 C.F.R. § 4.124a, 8515. Complete paralysis of the medial nerve warrants a 70 percent rating for the major extremity and a 60 percent rating in the minor extremity. Complete paralysis occurs where the hand was inclined to the ulnar side, the index and the middle fingers were more extended that normally, there was considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand), pronation was incomplete and defective, there was the absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, the index and middle fingers remained extended, cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm and flexion of wrist was weakened and there was pain with trophic disturbances. Id. With regards to paralysis of the sciatic nerve, ratings of 10 percent, 20 percent and 40 percent are assignable for incomplete paralysis which is mild, moderate or moderately severe in degree, respectively. A 60 percent rating is warranted for severe incomplete paralysis with marked muscle atrophy. Complete paralysis of the sciatic nerve, which is rated as 80 percent disabling, contemplates foot dangling and dropping, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, 8520. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. The Veteran indicated that he was left hand dominant in a September 1955 Report of Medical History (RMH). An April 2008 VA peripheral nerves examination report reflected the Veteran's complaints of numbness, cramps and tingling pain in his lower extremities as well as numbness in his hands that was worse in his digits. Physical examination revealed muscle strength of "5" without motor impairments in the bilateral upper and lower extremities. Sensory examination revealed decreased vibration, pain and light touch as well as normal position sense in all extremities. Detailed reflex examination found bilateral bicep reflex, bilateral triceps reflex and bilateral knee reflex to be 1+ while bilateral brachioradialis reflex and bilateral ankle reflex were zero. Plantar reflex was normal bilaterally. There was no muscle atrophy or abnormal muscle tone or bulk found while gait and balance were normal. Nerve dysfunction and neuralgia were found on examination without paralysis or neuritis. An April 2008 VA diabetes mellitus examination report revealed plaque-like lesions over the tibia and "huge" varicose veins. The bilateral upper extremities were found to have normal temperature and color without trophic changes or ulcers. The bilateral lower extremities were found to have normal temperature and color without hair, dystrophic nails and ulcers. Radial pulses, dorsalis pedis pulses and posterior tibial pulses were found to be normal. Triceps reflex, biceps reflex, brachioradialis reflex, patellar reflex and Achilles reflex were found to be 1+ bilaterally. Physical examination conducted during the April 2010 VA examination revealed that the temperature and color of the bilateral upper extremities were normal without ulcers or tropic changes. The temperature and color in the bilateral lower extremities were found to be normal without trophic changes and ulcers. Radial pulses, dorsalis pedis pulses and posterior tibial pulses were found to be normal. Neurologic examination found decreased vibratory and normal light touch sensation in the bilateral hands while there was decreased light touch and absent vibratory sensation in the bilateral feet. Deep tendon reflexes in the biceps and patellar were found to be 1+ bilaterally while brachioradialis and triceps were found to be 2+ bilaterally. A May 2010 VA peripheral nerves examination report indicated that the Veteran's hand grip was found to be "4/5" bilaterally in the proximal/distal and extensors/flexors while muscle strength was found to be "5/5" in the lower extremities. Vibration and pain were found to be decreased in the bilateral upper and bilateral lower extremities while light touch was found to be absent in the lower extremities and decreased in the upper extremities. Position sense was noted to be normal in all extremities. Biceps reflexes, triceps reflexes, brachioradialis reflexes, knee reflexes were found to be 1+ bilaterally while ankle reflexes were absent bilaterally. There was muscle atrophy in the bilateral thenar (hands). There was no other muscle atrophy, tremors, tics or other abnormal movements found to be present. The examiner noted that there was neuritis and neuralgia without paralysis in the extremities. For the entire appeal period, the Veteran's bilateral upper extremity peripheral neuropathy manifested as subjective complaints of bilateral hand numbness. His grip strength was found to be reduced in May 2010 while deep tendon reflexes were consistently found to be reduced or absent. Sensation was consistently found to be reduced or absent on examination, including the May 2010 VA examination, which found light touch to be absent. In addition, muscle atrophy was found in the thenar nerve (hands) during the May 2010 VA examination. As reduced or a loss of reflexes, muscle atrophy and sensory disturbances have been demonstrated on objective examination, and the Veteran has subjectively claimed hand numbness, a rating for severe incomplete paralysis is warranted for each upper extremity. A higher rating is not warranted as complete paralysis has not been shown by the clinical evidence or alleged by the Veteran. 38 C.F.R. §§ 4.123, 4.124, 8515. With regards to the bilateral lower extremity peripheral neuropathy, for the entire appeal period, the Veteran has subjectively complained of numbness, cramps and tingling. Muscle strength was found to be "5" without atrophy in the April 2008 and May 2010 VA examinations. Sensation examination repeatedly found light touch to be reduced while vibratory was found to be absent in the April 2010 VA examination. Knee reflexes were found to be 1+ in the April 2008 and May 2010 VA examinations while ankle reflexes were found to be absent. In light of the objective evidence of diminished or absent reflexes and decreased or absent sensation, a rating of 20 percent for moderate incomplete paralysis is warranted for each extremity. A rating in excess of 20 percent is not warranted as muscle atrophy was not found or alleged by the Veteran. 38 C.F.R. § 4.124a, 8520. The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected peripheral neuropathy; however, the Board finds that his symptomatology has been stable throughout the appeal. Therefore, assigning staged ratings for such disabilities are not warranted. For all the foregoing reasons, the Board finds that a rating of 40 percent for right upper extremity peripheral neuropathy and a rating of 50 percent for left upper extremity peripheral neuropathy, but no higher, is warranted. In addition, the Board finds that a rating of 20 percent for lower extremity peripheral neuropathy in each extremity, but not higher, is warranted. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. C. Extra-schedular Consideration Additionally, the Board has contemplated whether these matters should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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 extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected diabetes mellitus and peripheral neuropathy of the extremities with the established criteria found in the rating schedule. The Board finds that the Veteran's diabetes mellitus and peripheral neuropathy of the extremities symptomatology is fully addressed by the rating criteria under which such disability is rated. In this regard, all of the Veteran's diabetic and neurology symptomatology are contemplated by the rating criteria, to include those symptoms which are not specifically enumerated. There are no additional symptoms of his diabetes mellitus and peripheral neuropathy of the extremities that are not addressed by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disabilities. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). D. TDIU The Veteran contends that he is unable to work due to his various service-connected disabilities, including the symptomatology associated with his service-connected peripheral neuropathy of the extremities. The Board finds that the preponderance of the evidence favors that position, and hence TDIU is warranted. A veteran may be awarded a TDIU upon a showing that he is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. A total disability rating may be assigned where the schedular rating is less than total when the disabled person is 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, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Consideration may be given to a Veteran's level of education, special training, and previous work experience in arriving at a conclusion but not to his age or the impairment caused by any non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. The term unemployability, as used in VA regulations governing total disability ratings, is synonymous with an inability to secure and follow a substantially gainful occupation. See VAOPGCPREC 75-91 (Dec. 17, 1991). The issue is whether a veteran's service-connected disability or disabilities preclude him from engaging in substantially gainful employment (i.e., work which is more than marginal, that permits the individual to earn a living wage). See Moore v. Derwinski, 1 Vet. App. 356 (1991). In a claim for TDIU, the Board may not reject the claim without producing evidence, as distinguished from mere conjecture, that a veteran's service-connected disability or disabilities do not prevent him from performing work that would produce sufficient income to be other than marginal. Friscia v. Brown, 7 Vet. App. 294 (1995). In determining whether a veteran is entitled to a TDIU, neither his nonservice-connected disabilities nor his age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Court has held that the central inquiry in determining whether a Veteran is entitled to a TDIU is whether service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). The test of individual unemployability is whether a veteran, as a result of his service-connected disabilities alone, is unable to secure or follow any form of substantially gainful occupation which is consistent with his education and occupational experience. 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16. The Veteran's current service-connected disabilities include diabetes mellitus, rated as 20 percent disabling; right upper extremity peripheral neuropathy, rated as 40 percent disabling; left upper extremity peripheral neuropathy, rated as 50 percent disabling; right and left lower extremity peripheral neuropathy, rated as 20 disabling in each extremity and right and left leg peripheral vascular disease, rated as non-compensably disabling. His current combined rating is 90 percent. See 38 C.F.R.§ 4.25. This combined rating satisfies the statutory requirements for TDIU. See 38 C.F.R. § 4.16(a). The Board finds that the evidence supports granting entitlement to a TDIU effective February 28, 2008, the date the claim was filed. The competent evidence persuasively suggests that Veteran's service-connected disabilities precluded him from securing or maintaining substantially gainful employment. The Veteran has reported that he has not been employed since 1974, when he retired as a policeman due to work-related injuries, and the current record does not otherwise suggest employment. On VA examination in April 2010, the examiner found that that the Veteran was not able to tolerate prolonged standing or walking and that he was unable to run due to his peripheral neuropathy condition. The examiner opined that the Veteran was not able to work as a policeman as a result of his service-connected disabilities. Consequently, giving the Veteran the benefit of the doubt and in considering his subjective reports, the Board concludes that the pertinent evidence is at least in equipoise as to whether the Veteran's service-connected disabilities preclude him from obtaining and maintaining a substantially gainful occupation, and therefore entitlement to a TDIU is warranted. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. III. Service Connection 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. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). In a recent decision, the United States Court of Appeals for the Federal Circuit (the Federal Circuit) determined that such an alternative method can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In relevant part, 38 U.S.C.A. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Federal Circuit has held that "[l]ay 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 profession." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence.") Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Certain chronic disabilities such as arteriosclerosis are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. This presumption applies to veterans who have served 90 days or more of active service during a war period or after December 31, 1946. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service connected condition. See 38 C.F.R. § 3.310. Service connection is possible when a service-connected condition has aggravated a claimed condition, but compensation is only payable for the degree of additional disability attributable to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). VA has amended 38 C.F.R. § 3.310 to incorporate the Court's decision in Allen except that VA will not concede aggravation unless there is medical evidence showing the baseline level of the disability before its aggravation by the service connected disability. 38 C.F.R. § 3.310(b). A. Bilateral Upper Extremity Radiculopathy The Veteran contends that he suffers from bilateral upper extremity radiculopathy due to his service-connected diabetes mellitus. The Board notes that although the Veteran has alleged service connection on a secondary basis only, the RO considered service connection on both a direct and secondary basis. VA examinations conducted in June 1974, June 2001, October 2002 and April 2010 were negative for complaints, treatments or diagnoses related to upper extremity radiculopathy. An April 2008 VA peripheral nerves examiner, following an examination and a review of the Veteran's claims file, opined that there was no history or clinical evidence of upper extremity radiculopathy. A March 2013 VA treatment note indicated that there were no radicular signs on physical examination. The remaining post-service VA outpatient treatment records are negative for complaints, findings or diagnoses related to upper extremity radiculopathy. The Board notes that service connection requires evidence that establishes that a Veteran currently has the disability for which service connection is sought. See Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Congress specifically limits service connection for disease or injury to cases where such incidents have resulted in a disability. In this instance, the more competent and probative clinical evidence reflects that the Veteran does not have bilateral upper extremity radiculopathy. The Board must also consider whether, as a layperson, the Veteran is competent to render a diagnosis on this matter. See Jandreau, supra. Lay reports are competent to establish the presence of symptomatology and may provide sufficient support for a claim of service connection. See Layno, supra. However, competence and credibility are different matters. In this regard, whether the Veteran has radiculopathy in the upper extremities and whether it is related to service requires specialized training for a determination as to its causation, and is therefore not the province of lay opinion. The Veteran's assertion that he has upper extremity radiculopathy due to service-connected diabetes mellitus is not probative. In this regard, a skilled clinical professional has greater knowledge. The more probative evidence in this case establishes that the Veteran did not manifest upper extremity radiculopathy. The Board observes that the Veteran has not identified or produced any acceptable evidence, either medical or lay, that tends to show a current disability definitively diagnosed as upper extremity radiculopathy. In this regard, the Board points out that veterans are entitled to VA compensation if they develop a disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty. See 38 U.S.C.A. §§ 1110. In this case, however, there is no definitive or reliable evidence of a disability manifested by upper extremity radiculopathy. The Board thus determines that service connection for upper extremity radiculopathy is not in order. This conclusion is based on clinical findings of record demonstrating that there is no current disability for which service connection, either on a direct or secondary basis, is warranted. Therefore, service connection for upper extremity radiculopathy must be denied. In sum, service connection for upper extremity radiculopathy must be denied on the basis that there is no showing of current disability for VA purposes. In the absence of a current disability, there can be no valid claim. See Brammer, supra. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. B. Heart Disorder The Veteran contends that he suffers from a cardiac disorder due to his service-connected diabetes mellitus. The Board notes that although the Veteran has alleged service connection on a secondary basis only, the RO considered service connection on both a direct and secondary basis. VA examinations conducted in June 1974, June 2001 and October 2002 were negative for complaints, treatments or diagnoses related to a heart disorder. An April 2008 VA cardiac examination report indicated that the Veteran had denied chest pain, dyspnea on exertion and a history of heart disease, including congestive, rheumatic, hypertensive, syphilitic, endocarditis or pericarditis, and the use of continuous medication. While dyspnea on moderate exertion was reported, there had never been a history of syncope, fatigue, angina or dizziness. Physical examination found regular rhythm with heart sounds present in S1 and S2 without murmur, click and pericardial rub. Chest shape/deformity and percussion were normal bilaterally. Breath sounds were clear in the upper and lower lobes. An echocardiogram found the heart size to be normal. The examiner opined that there were no identifiable heart conditions as cardiac symptoms were not demonstrated in the clinical evidence or on objective examination and an echocardiogram was normal. An April 2010 VA diabetes mellitus examination report indicated that the Veteran had denied a history of myocardial infarction, hypertension, heart rhythm disturbance, heart failure, heart disease, angina, dizziness, syncope, fatigue, dyspnea or the use of continuous medication for heart disease. The remaining post-service VA outpatient treatment records are negative for complaints, findings or diagnoses related to any heart disorder. The Board notes that service connection requires evidence that establishes that a Veteran currently has the disability for which service connection is sought. See Rabideau, supra; see also Brammer, supra. Congress specifically limits service connection for disease or injury to cases where such incidents have resulted in a disability. In this instance, the more competent and probative clinical evidence reflects that the Veteran does not have a heart disorder. As previously discussed, the Board must also consider whether, as a layperson, the Veteran is competent to render a diagnosis on this matter. See Jandreau, supra. Lay reports are competent to establish the presence of symptomatology and may provide sufficient support for a claim of service connection. See Layno, supra. However, competence and credibility are different matters. In this regard, whether the Veteran has a heart disorder and whether it is related to service requires specialized training for a determination as to its causation, and is therefore not the province of lay opinion. The Veteran's assertion that he has cardiac disorder due to service-connected diabetes mellitus is not probative. In this regard, a skilled clinical professional has greater knowledge. The more probative evidence in this case establishes that the Veteran did not have a heart disorder. The Board observes that the Veteran has not identified or produced any acceptable evidence, medical or lay, that tends to show a current disability definitively diagnosed as a cardiac disorder. In this regard, the Board points out that veterans are entitled to VA compensation if they develop a disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty. See 38 U.S.C.A. §§ 1110. In this case, however, there is no definitive or reliable evidence of a disability manifested by a heart disorder. The Board thus determines that service connection for a heart disorder not in order. This conclusion is based on clinical findings of record demonstrating that there is no current disability for which service connection is warranted. Therefore, service connection for a cardiac disorder must be denied. In sum, service connection for a heart disorder must be denied on the basis that there is no showing of current disability for VA purposes. In the absence of a current disability, there can be no valid claim. See Brammer, supra. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. ORDER A rating in excess of 20 percent for diabetes mellitus, type II, is denied. An initial rating of 40 percent for right upper extremity peripheral neuropathy is granted, subject to the laws and regulations governing payment of monetary benefits. An initial rating in excess of 50 percent for left upper extremity peripheral neuropathy is granted, subject to the laws and regulations governing payment of monetary benefits. An initial rating of 20 percent for right lower extremity peripheral neuropathy is granted, subject to the laws and regulations governing payment of monetary benefits. An initial rating of 20 percent left lower extremity peripheral neuropathy is granted, subject to the laws and regulations governing payment of monetary benefits. A TDIU due to service-connected disabilities, effective February 28, 2008, is granted, subject to the laws and regulations governing payment of monetary benefits. Service connection for bilateral upper extremity radiculopathy as secondary to diabetes mellitus is denied. Service connection for a heart disorder as secondary to diabetes mellitus is denied. REMAND With respect to the issues of entitlement to service connection for bilateral lower extremity radiculopathy and hypertension remaining on appeal, the Board finds that a remand is necessary in order to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C.A. §§ 5107(a), 5103A; 38 C.F.R. § 3.159(c). VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); Duenas v. Principi, 18 Vet. App. 512 (2004); Robinette v. Brown, 8 Vet. App. 69 (1995); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). For below noted reasons, the Board finds that a VA examination is necessary in order to determine the nature and etiology of the Veteran's claimed bilateral lower extremity radiculopathy and hypertension. The Veteran has claimed to suffer from hypertension and bilateral lower extremity radiculopathy due to his service-connected diabetes mellitus. In April 2008, the VA examiners found that there was no hypertension or bilateral lower extremity radiculopathy demonstrated on physical examination. However, a review of the clinical evidence reveals an assessment of lumbar radiculopathy (i.e. lower extremity radiculopathy) in December 2010 as well as numerous findings of hypertension throughout the course of the appeal. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of the claim, even if the disability resolves prior to the adjudication of the claim). In addition, the Board notes that although the Veteran claimed these disabilities on a secondary basis only, the RO considered these claims for service connection on both a direct and secondary basis. In light of these deficiencies, it is unlikely that the April 2008 VA opinions as to hypertension and bilateral lower extremity radiculopathy would withstand judicial scrutiny. As such, he should be scheduled for a VA examination to determine the nature and etiology of his claimed bilateral lower extremity radiculopathy and hypertension, to include consideration of direct service connection and secondary service connection on the basis of aggravation. Finally, due to the length of time which will elapse on remand, updated VA treatment records dated from April 2013 to the present from the San Juan, Puerto Rico VA Medical Center (VAMC) that are not already associated with the claims file should be obtained for consideration in the Veteran's appeals. Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's updated treatment records from the San Juan VAMC dated from April 2013 to the present that are not already of record. All efforts to obtain these records should be documented in the claims file. If no such records are available, the Veteran should be so informed and also told of the efforts to obtain the records. 2. After obtaining any outstanding records, the Veteran should be afforded an appropriate VA examination to determine the nature and etiology of his claimed hypertension and bilateral lower extremity radiculopathy. All indicated tests and studies should be undertaken. The claims file, including a complete copy of this remand, must be made available for review of the Veteran's pertinent medical history. The examiner is asked to furnish an opinion with respect to the following questions: . (a) Based on the evidence of record, can it be determined with a reasonable degree of medical certainty, that the Veteran has developed hypertension and/or bilateral lower extremity radiculopathy? If so, please specify the diagnosis. The examiner should identify all such disorders that have been present at any time since February 2008. (b) Is it at least as likely as not (50 percent or greater probability) that any such diagnosed hypertension and/or bilateral lower extremity radiculopathy had its onset during the Veteran's period of active duty service from September 1965 to September 1967; or, was any such disorder caused by any incident or event that occurred during his period of service? (c) Is it at least as likely as not that the Veteran's diagnosed hypertension and/or bilateral lower extremity peripheral neuropathy were caused OR aggravated by his service-connected diabetes mellitus? (d) If hypertension is diagnosed, did such manifest to within one year of the Veteran's discharge (i.e., September 1968)? If so, what were the manifestations? The examiner should specifically consider the Veteran's lay statements regarding his hypertension and bilateral lower extremity radiculopathy, to include his contention that it was caused or aggravated by his service-connected diabetes mellitus. The rationale for any opinion offered should be provided. In answering each of the questions posed above, the examiner is advised that the Veteran is competent to report injuries and symptoms, and that his reports must be considered in formulating the requested opinion. If the Veteran's reports are discounted, the examiner should provide a rationale for doing so. A complete rating should be given for each opinion expressed. In this regard, a discussion of the facts and medical principles involved would be considerable assistance to the Board. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence, to include all of the evidence received since the issuance of the June 2010 supplemental statement of the case. If the claims remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This 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). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs