Citation Nr: 1318386 Decision Date: 06/06/13 Archive Date: 06/11/13 DOCKET NO. 08-04 753 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an increased disability rating for diabetes mellitus, currently rated as 20 percent disabling. 2. Entitlement to an increased disability rating for peripheral neuropathy of the right lower extremity, currently rated as 10 percent disabling. 3. Entitlement to an increased disability rating for peripheral neuropathy of the left lower extremity, currently rated as 10 percent disabling. 4. Entitlement to a compensable disability rating for erectile dysfunction. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD D.S. Lee, Counsel INTRODUCTION The Veteran served on active duty from December 1965 through September 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. A timely Notice of Disagreement (NOD) was received from the Veteran in September 2007. After a Statement of the Case was issued in January 2008, the Veteran perfected his appeal in February 2008, via VA Form 9 substantive appeal. The issues of entitlement to increased disability ratings for peripheral neuropathies of the lower extremities, currently rated as 10 percent disabling for each lower extremity, 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. For all periods relevant to this appeal, the Veteran's diabetes mellitus required treatment by insulin, oral glycemic medication, and adherence to a restricted diet; but did not require restriction of any activities and was not manifested by ketoacidosis or hypoglycemic reactions that required hospitalization or treatment with a diabetic care provider at least twice a month. 2. For all periods relevant to this appeal, the Veteran has experienced loss of erectile power. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for diabetes mellitus, type II are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2 4.3, 4.7, 4.119, Diagnostic Code 7913 (2012). 2. The criteria for a 20 percent disability rating, and no more, for erectile dysfunction have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2 4.3, 4.7, 4.115b, Diagnostic Code 7522 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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 & Supp. 2010) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice 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. VA's notice requirements apply to all five elements of a service-connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. Such notice should be provided to a claimant before the initial unfavorable decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). A March 2007 pre-rating letter provided the Veteran with notice of the information and evidence needed to substantiate his claims for increased disability ratings for his service-connected diabetes mellitus, associated peripheral neuropathies of the lower extremities, and erectile dysfunction. Consistent with Dingess, this letter included notice of the process by which VA assigns disability evaluations and effective dates. Subsequently, the Veteran's claims for higher disability ratings were adjudicated in the RO's August 2007 rating decision. Thus, because the VCAA notice in this case was legally sufficient, VA's duty to notify in this case has been satisfied. In addition, VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the Veteran's claims. His service treatment records, claims submissions, identified and relevant private treatment records, and VA treatment records have been obtained and associated with the record. VA examinations of his diabetes mellitus and associated neuropathies and erectile dysfunction were conducted in May 2007, July 2008, December 2009, and November 2012. Moreover, VA has not received any additional evidence since the November 2008 examination which indicates that the service-connected disabilities have changed such as to warrant the scheduling of a new VA examination to reassess their symptoms and severity. Hence, these examinations, along with the other evidence of record, are fully adequate for the purpose of determining the extent of the Veteran's disabilities in light of the applicable diagnostic criteria. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. I. Increased Disability Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations applies, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Moreover, staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. 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). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in the veteran's favor. 38 C.F.R. §§ 3.102, 4.3. Once the evidence is assembled, the Board is responsible for determining whether the preponderance of the evidence is against the claim. If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). A. Diabetes Mellitus, Type II In this case, the Veteran's claim for an increased disability rating in excess of 20 percent for diabetes mellitus, type II, was received by VA in March 2007. In his claims submissions, the Veteran simply asserts generally that he is entitled to a higher disability rating for his diabetes mellitus. The Veteran's diabetes mellitus, type II has been rated in accordance with 38 C.F.R. § 4.120, Diagnostic Code 7913, which provides specific rating criteria for diabetes mellitus. Under those criteria, a 20 percent disability rating is assigned for diabetes mellitus that has required insulin and a restricted diet, or; has required oral hypoglycemic agent and a restricted diet. A 40 percent disability rating is warranted for diabetes mellitus that has required insulin, restricted diet, and regulation of activities. A 60 percent disability rating is awarded where diabetes mellitus has required 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. A maximum schedular 100 percent disability rating is assigned where diabetes mellitus has required 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. 38 C.F.R. § 4.119, Diagnostic Code 7913. Note (1) to Diagnostic Code 7913 provides that compensable complications of diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent disability rating under Diagnostic Code 7913. Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119. Mindful of the foregoing, the Board notes again that separate disability ratings are already in effect for the Veteran for peripheral neuropathies of the lower extremities and erectile dysfunction. Upon careful and thorough review and consideration of the evidence of record, the Board finds that a disability rating in excess of 20 percent for the Veteran's diabetes mellitus, type II, is not warranted in this case. The evidence shows that the Veteran received medical treatment for poorly controlled diabetes mellitus, has required treatment via restricted diabetic diet and insulin taken twice per day, and has demonstrated some weight loss. Nonetheless, there is simply no evidence in the record that he has been required to regulate any of his activities due to his diabetes mellitus; nor is there evidence that he has required any hospitalization or has required treatment at least twice a month for episodes of ketoacidosis or hypoglycemic reactions. In relation to the foregoing, the Board notes that VA treatment records dated from March 2006 through January 2013 show that the Veteran has been followed on a regular basis for poorly controlled diabetes mellitus. VA treatment records from April 2007 show that he was referred to a dietician. Records from May 2007 show that the Veteran was being treated via insulin known as Humalin and oral hypoglycemic agents such as Glyburide. Subsequent VA treatment records show ongoing management of poorly controlled diabetes marked by poor compliance on the part of the Veteran with dietary restrictions and prescribed medications. In January 2013, the Veteran's weight was noted as being 170 pounds. These records show that the Veteran continued to take insulin twice per day. However, there is no indication in the VA treatment records of any restriction of activities, ketoacidosis, hypoglycemia, or complications associated with diabetes, other than the aforementioned peripheral neuropathies and erectile dysfunction. Concurrent with the VA treatment noted above, the Veteran underwent four separate VA examinations of his diabetes mellitus. The first such examination was performed in May 2007. At that time, the Veteran denied having any prior history of hospitalization for ketoacidosis or hypoglycemia; however, reported that he did have three incidences of hypoglycemia in the past month. As noted above, however, this is not documented in the treatment records in the claims file. The Veteran also denied any prior history of eye retinopathy or hypertension. Notably, he explicitly denied being physically restricted from any activities. The Veteran stated that he was managing his diabetes with restricted diet and oral medications including Avandia, Metformin, and Glyburide. A physical examination at that time revealed blood pressure readings of 136/64, 138/64, 128/70 mmHg. Cardiovascular examination was grossly normal. Physical examination of the extremities was also grossly normal. During a July 2008 VA examination, the Veteran reported that he was initially diagnosed with diabetes mellitus in 2000 and that he was experiencing symptoms such as polydipsia, weight loss, constipation, and polyuria at that time. He stated that his blood sugar was currently being controlled by insulin and that he was following a 2000 calorie diet. Again, he denied any history of hospitalization or any ketoacidosis or hypoglycemic reactions, weight gain or loss, or associated vision problems. Although he reported difficulty with standing and walking due to symptoms in his legs (which are discussed more fully in the following section), he continued deny experiencing any actual restriction of his activities. The Veteran also denied other complications such as hematuria, incontinence, renal stones, dysuria, anorexia, weight loss, weakness, lethargy, or abnormal renal function. A physical examination performed during the July 2008 VA examination revealed essentially normal findings. Laboratory tests revealed elevated glucose levels. The examiner confirmed previous diagnoses of insulin-dependent diabetes mellitus, type II with associated peripheral neuropathies of the lower extremities; and erectile dysfunction. Other diagnoses of coronary artery bypass; depression; tobacco abuse; hypercholesterolemia; hypothyroidism; gastroesophageal reflux disease; chronic obstructive pulmonary disease; allergic rhinitis; and polyposis of the colon were also rendered, however, these disorders were apparently not related to the Veteran's diabetes, peripheral neuropathies, or erectile dysfunction. During a December 2009 VA examination performed to determine the Veteran's current employability, the Veteran continued to deny having any prior hospitalizations or treatment for ketoacidosis or hypoglycemia. He stated that he was following a diabetic diet and denied having any weight loss or gain. Overall, he stated that the main restriction associated with his diabetes were symptoms associated with his neuropathies. He continued to report that he was taking insulin twice per day. Physical examination revealed the Veteran's weight was 194 pounds. He was able to walk with a normal gait and posture. Cardiovascular examination was normal and did not indicate the presence of peripheral edema or active varicosities. Other findings from the physical examination were also within normal limits. In November 2012, the Veteran was afforded another VA examination of his diabetes mellitus. At that time, he reported that he was still taking an oral hypoglycemic and insulin administered twice per day. Once again the Veteran denied being required to regulate his activities due to his diabetes. He also denied experiencing any weight loss or gain, loss of strength, or episodes of ketoacidosis and/or hypoglycemia requiring treatment twice or more per month. He also continued to deny any history of hospitalization. Once again, laboratory testing revealed the presence of elevated glucose levels; however, no abnormal physical findings were apparently observed. In summation, the evidence in the record shows that the Veteran's diabetes mellitus, type II, has required treatment through insulin administered twice daily and a prescribed diabetic diet. As noted above, the Veteran's weight during his December 2009 VA examination was 194 pounds, compared with his weight of 170 pounds, as noted during his January 2013 VA treatment. Accordingly, the evidence appears to indicate that the Veteran lost approximately 24 pounds over the period from December 2009 through January 2013. Nonetheless, there is no evidence in the record that the Veteran has been required at any time to restrict his activities. Although the Veteran reported having three episodes of hypoglycemic reactions in the month preceding his May 2007 VA examination, he has expressly and repeatedly denied any history of hospitalization and there is no evidence that he required visits with a diabetic care provider at least twice a month. Other evidence pertaining to the state of the diabetes mellitus, type II do not reflect any episodes of ketoacidosis or hypoglycemia. In view of the foregoing evidence, the Veteran's diabetes mellitus, type II, does not meet the criteria for a disability rating higher than 20 percent. 38 C.F.R. § 4.119, Diagnostic Code 7913. The Board has also considered the provisions under 38 C.F.R. § 3.321(b)(1), which govern the assignment of extra-schedular disability ratings. However, in this case, the record does not show that the severity of the Veteran's diabetes mellitus is so exceptional or unusual such as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (2012). The threshold factor for extra-schedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, 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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and, no extra-schedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular rating does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extra-schedular regulation (38 C.F.R. § 3.321(b)(1) ) as "governing norms"(which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show that the Veteran's diabetes mellitus presents an exceptional disability picture that renders inadequate the available schedular ratings. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. As discussed above, there are higher ratings available under the applicable diagnostic code; however, the Veteran's diabetes mellitus is not productive of the manifestations required for a higher disability rating. As such, it cannot be said that the available schedular ratings for the Veteran's diabetes mellitus are inadequate. The Board also observes that, even if the available schedular evaluation for the disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." As noted previously, the record does not show, and in fact the Veteran has expressly denied, that the Veteran has required frequent hospitalizations for his diabetes mellitus. Further, there is nothing in the record to indicate that the Veteran's diabetes mellitus, acting alone, causes impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Based on the foregoing, the Board finds that the requirements for an extra-schedular evaluation for the Veteran's service-connected diabetes mellitus, under the provisions of 38 C.F.R. § 3.321(b)(1), have not been met. Thun, 22 Vet. App. 111; Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). The Board has also considered whether "staged" disability ratings are warranted by the evidence. The symptomatology shown upon examination and treatment, however, has been essentially consistent and fully contemplated by the assigned disability rating. As such, there is no basis for staged disability ratings in connection with the Veteran's diabetes mellitus. For the foregoing reasons, the Board concludes that the record does not support the assignment of a disability rating in excess of 20 percent for diabetes mellitus, type II. To that extent, this appeal is denied. 38 C.F.R. §§ 4.3, 4.7. B. Erectile Dysfunction The Veteran's claim for a compensable disability rating was also received by VA in March 2007. In his claims submissions, the Veteran does not allege any specific symptoms or manifestations in support of his claim, but asserts generally that he is entitled to a higher disability rating. The Veteran's erectile dysfunction has been rated pursuant to the criteria under 38 C.F.R. § 4.115b, Diagnostic Code 7522. This criteria provides a 20 percent disability rating for all disabilities marked by deformity of the penis with loss of erectile power. As noted in a footnote accompanying this criteria, such disabilities are subject to review for entitlement to special monthly compensation under 38 C.F.R. § 3.350. The Board notes, however, that special monthly compensation due to loss of use of a creative organ was already awarded, effective April 26, 2004, by a January 2005 rating decision. Although the Veteran has not urged the application of any other specific rating criteria for his erectile dysfunction, the Board has also considered the potential application of the other provisions of 38 C.F.R., Parts 3 and 4. Schafrath, 1 Vet. App. 589. In doing so, the Board notes that no other rating criteria are applicable in this case, given the manifestations and symptoms shown by the evidence in this case. In this case, the post-service treatment records, which include VA treatment records from June 2006 through January 2013, private psychiatric treatment records from Dr. D.B. dated July 2008, and private hospital records from Paris Regional Medical Center dated September 2010, do not reflect any treatment pertinent to the Veteran's erectile dysfunction. VA examinations performed in May 2007, July 2008, December 2009, and November 2012 reflect consistent complaints by the Veteran of difficulty in achieving an erection, decreased libido, and general infrequency of sexual activity. During his May 2007 VA examination, the Veteran reported that he was experiencing erectile dysfunction for the past two years and that he was unable to have sexual intercourse. During his July 2008 VA examination, the Veteran continued to report that he was most recently able to have sexual intercourse a year before the examination. During his November 2012 VA examination, he denied any history of orchiectomy, voiding dysfunction, urinary tract or kidney infections, or retrograde ejaculation; however, continued to report erectile dysfunction that prevented him from achieving erection. Overall, he reported normal anatomy of the penis and declined a physical examination of the genitalia and testicles. The examiner continued to confirm previous diagnoses of erectile dysfunction. The foregoing evidence shows that the Veteran has experienced erectile dysfunction marked by continuous loss of erectile power manifested by difficulty in achieving an erection and engaging in sexual intercourse. Under the circumstance, the Board finds that the Veteran's symptoms from his erectile dysfunction more nearly approximate those contemplated by the higher, 20 percent rating, pursuant to Diagnostic Code 7522. An increase to 20 percent is therefore warranted. The Board has also considered whether an extra-schedular disability rating is warranted for the Veteran's erectile dysfunction pursuant to 38 C.F.R. § 3.321(b)(1). However, under similar analysis as that undertaken above in connection with the Veteran's diabetes mellitus, the Board finds that the record does not show that the Veteran's erectile dysfunction presents an exceptional disability picture that renders inadequate the available schedular ratings. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Board also observes that, even if the available schedular evaluation for the disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." In that regard, there is no evidence that the Veteran has required any hospitalization for his erectile dysfunction. Further, there is no evidence that the Veteran's erectile dysfunction impacts his employment in any way. See Van Hoose, 4 Vet. App. at 363. Under the foregoing analysis, the Board finds that the requirements for an extra-schedular evaluation for the Veteran's erectile dysfunction, under the provisions of 38 C.F.R. § 3.321(b)(1), have not been met. Thun, 22 Vet. App. 111; Bagwell, 9 Vet. App. 337; Shipwash, 8 Vet. App. 218. Again, the Board has also considered whether "staged" disability ratings are warranted for the Veteran's erectile dysfunction. The symptomatology shown upon examination and treatment, however, has been essentially consistent and fully contemplated by the assigned disability rating. As such, there is no basis for staged disability ratings. Under the foregoing analysis, the Veteran is entitled to a 20 percent disability rating, and no more, for erectile dysfunction. To that extent, this appeal is granted. 38 C.F.R. §§ 4.3, 4.7. ORDER Entitlement to an increased disability rating for diabetes mellitus, currently rated as 20 percent disabling, is denied. Entitlement to a 20 percent disability rating for erectile dysfunction is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND In November 2012, the Veteran was afforded a VA examination for the service-connected peripheral neuropathies in his bilateral lower extremities. During the examination, the Veteran reported the existence of paresthesias and numbness in his feet. A neurological examination conducted as part of a general physical examination apparently revealed normal neurological findings which included the full strength of the bilateral knees and ankles, normal deep tendon reflexes, intact sensation to light touch and vibration, and the absence of muscle atrophy. Although the examiner noted that nerve conduction studies were ordered, and that results from such testing would be forwarded when available, the results from the nerve conduction studies performed that day are not contained in the record, nor are the examiner's interpretations of the data from such testing. In view of the foregoing, VA must undertake efforts to associate with the claims file the results from the nerve conduction tests performed in conjunction with the November 2012 VA examination. Thereafter, the claims file should be provided to the same VA examiner who performed the November 2012 examination, and she must be asked to provide an interpretation of the November 2012 nerve conduction test results and a new opinion as to the current severity of the peripheral neuropathies in the Veteran's bilateral lower extremities. If the same VA examiner who performed the November 2012 examination is unavailable, or, she determines that the opinion sought cannot be provided without a re-examination of the Veteran, then the Veteran should be arranged to undergo a new VA examination to determine the current severity of the peripheral neuropathies in his bilateral lower extremities. 38 C.F.R. § 3.159(c)(4). Prior to requesting the opinion requested above, and in order to insure that the most complete and up-to-date evidence has been associated with the claims file, the Veteran should also be asked to identify any other private or VA treatment providers who have rendered treatment for the peripheral neuropathies in his lower extremities since January 2013. VA must then make efforts to obtain any treatment records that are identified by the Veteran. 38 C.F.R. § 3.159. Accordingly, the case is REMANDED for the following action: 1. A letter should be sent to the Veteran explaining, in terms of 38 U.S.C.A. §§ 5103 and 5103A, the need for additional evidence regarding his claims for increased disability ratings for peripheral neuropathies of the bilateral lower extremities, currently rated as 10 percent disabling in each lower extremity. This letter must inform the Veteran about the information and evidence that is necessary to substantiate his claims, and also, must provide notification of both the type of evidence that VA will seek to obtain and the type of evidence that is expected to be furnished by the Veteran. The letter must also notify the Veteran that VA is undertaking efforts to obtain a copy of the results from nerve conduction studies performed during his November 2012 VA examination and to obtain an addendum report from the VA examiner as to the current severity of the peripheral neuropathies in his lower extremities. The Veteran should be advised that it remains his responsibility to report for the scheduled VA examinations and to cooperate with the development of his claim; failure to report without good cause may result in denial of his claim. The Veteran should also be provided a VA 21-4142 release form, and be requested to identify on the release the name(s) and address(es) of any private or VA medical providers who have provided treatment for the peripheral neuropathies in his bilateral lower extremities since January 2013. 2. Make efforts to obtain a copy of the results from the nerve conduction tests performed in conjunction with the Veteran's November 2012 VA examination, as well as any records of any treatment identified by the Veteran. Any records obtained as a result of such efforts should be associated with the claims file. If such efforts yield negative results, a notation to that effect should be inserted in the file. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow the Veteran the opportunity to obtain and submit those records for VA review. 3. After the above development has been completed to the extent possible, the claims file should be forwarded to the same VA examiner who performed the November 2012 VA examination. The examiner should review the entire claims file, to include the nerve conduction test results from the November 2012 examination, provide an interpretation of the nerve conduction test data, and provide an opinion as to the severity of the peripheral neuropathies in the Veteran's bilateral lower extremities. The examiner's opinion and conclusions should be expressed in a typewritten addendum report. A complete rationale for all expressed opinion, which includes citation to any relevant facts, evidence, or medical principles, must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, she should expressly indicate this and provide a supporting rationale as to what additional information is necessary and why the opinion sought cannot be given without resorting to speculation. If the same VA examiner who performed the November 2012 VA examination is unavailable, or, she determines that the opinion sought cannot be provided without re-examination of the Veteran, then the Veteran should be arranged to undergo a new VA examination for the opinion requested above. All tests and studies deemed necessary by the examiner should be performed. A report of the new examination should be prepared and associated with the Veteran's VA claims file. A complete rationale which includes citation to any relevant facts, evidence, or medical principles must be provided for all opinions rendered. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to what additional information is necessary and why the opinion sought cannot be given without resorting to speculation. 4. If a new VA examination is necessary, and the Veteran fails to report to the scheduled examination, the RO must obtain and associate with the claims file a copy of any notice(s) of the dates and times of the examinations sent to the Veteran by the pertinent VA medical facility. 5. After completion of the above development, the issues of entitlement to increased disability ratings for peripheral neuropathies of the bilateral lower extremities, currently rated as 10 percent disabling in each lower extremity, should be readjudicated. If the determination remains adverse to the Veteran, he and his representative should be furnished with a supplemental SOC and be given an opportunity to respond. 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). ______________________________________________ Bethany L. Buck Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs