Citation Nr: 1318523 Decision Date: 06/06/13 Archive Date: 06/11/13 DOCKET NO. 05-29 658 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent prior to November 2, 2012, and in excess of 20 percent thereafter for peripheral neuropathy of the right lower extremity. 2. Entitlement to an initial rating in excess of 10 percent prior to November 2, 2012, and in excess of 20 percent thereafter for peripheral neuropathy of the left lower extremity. 3. Entitlement to an initial compensable rating prior to November 2, 2012, and in excess of 30 percent thereafter for peripheral neuropathy of the right upper extremity. 4. Entitlement to an initial compensable rating prior to November 2, 2012, and in excess of 20 percent thereafter for peripheral neuropathy of the left upper extremity. 5. Entitlement to an initial rating in excess of 10 percent for arteriosclerotic heart disease. 6. Entitlement to service connection for partial loss of vision, to include as secondary to service-connected diabetes mellitus, type II. 7. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus, type II. 8. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). ATTORNEY FOR THE BOARD Kristi L. Gunn, Counsel INTRODUCTION The Veteran served on active duty from December 1965 to December 1967. This matter comes to the Board of Veterans' Appeals (Board) on appeal from January 2005 and July 2005 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. During the pendency of the appeal, a February 2013 rating decision increased the Veteran's disability ratings for the following disabilities: peripheral neuropathy of the right upper extremity, 30 percent disabling; peripheral neuropathy of the left upper extremity, 20 percent disabling; peripheral neuropathy of the right lower extremity, 20 percent disabling; and peripheral neuropathy of the left lower extremity, 20 percent disabling, all effective November 2, 2012. Applicable law mandates that when a Veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). In August 2008 and September 2012, the Board remanded the claims for additional development and adjudicative action. The case has been returned to the Board for further appellate review. A review of the Virtual VA paperless claims processing system reflects that additional records have been added to the present appeal. These records include VA medical records. A supplemental statement of the case (SSOC) was issued in February 2013, which addressed this additional evidence. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of entitlement to service connection for partial loss of vision, to include as secondary to service-connected diabetes mellitus, type II; entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus, type II; entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU); and entitlement to an initial rating in excess of 10 percent for arteriosclerotic heart disease 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. Prior to November 2, 2012, the Veteran's service-connected peripheral neuropathy of the right and left lower extremities were manifested by numbness, tingling, weakness, and decreased sensation, which more nearly approximates mild incomplete paralysis of the sciatic nerve and/or common peroneal nerves. 2. As of November 2, 2012, the Veteran's service-connected peripheral neuropathy of the right and left lower extremities were manifested by numbness, tingling, weakness, and decreased sensation, which more nearly approximates moderate incomplete paralysis of the common peroneal nerve. 3. Prior to November 2, 2012, the Veteran's service-connected peripheral neuropathy of the right and left upper extremities were manifested by numbness, tingling, weakness, and decreased sensation, which more nearly approximates mild incomplete paralysis of the median nerve. 4. As of November 2, 2012, the Veteran's service-connected peripheral neuropathy of the right and left upper extremities were manifested by numbness, tingling, weakness, and decreased sensation, which more nearly approximates moderate incomplete paralysis of the median nerve. CONCLUSIONS OF LAW 1. Prior to November 2, 2012, the criteria for an initial rating in excess of 10 percent for peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.124a, Diagnostic Codes (DCs) 8520, 8521, 8522, 8599 (2012). 2. As of November 2, 2012, the criteria for an initial rating in excess of 20 percent for peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.124a, Diagnostic Code (DC) 8520, 8521, 8522 (2012). 3. Prior to November 2, 2012, the criteria for an initial rating in excess of 10 percent for peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.124a, Diagnostic Codes (DCs) 8520, 8521, 8522, 8599 (2012). 4. As of November 2, 2012, the criteria for an initial rating in excess of 20 percent for peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.124a, Diagnostic Code (DC) 8520, 8521, 8522 (2012). 5. Prior to November 2, 2012, the criteria for an initial 10 percent rating for peripheral neuropathy of the right upper extremity have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.124a, Diagnostic Codes (DCs) 8515, 8516, 8517, 8599 (2012). 6. As of November 2, 2012, the criteria for an initial rating in excess of 30 percent for peripheral neuropathy of the right upper extremity have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.124a, Diagnostic Code (DC) 8515, 8516, 8517 (2012). 7. Prior to November 2, 2012, the criteria for an initial 10 percent rating for peripheral neuropathy of the left upper extremity have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.124a, Diagnostic Codes (DCs) 8515, 8516, 8517, 8599 (2012). 8. As of November 2, 2012, the criteria for an initial rating in excess of 20 percent for peripheral neuropathy of the left upper extremity have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.124a, Diagnostic Code (DC) 8515, 8516, 8517 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). 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 or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from 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. 38 C.F.R. § 3.159(b). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159 (b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, the Veteran is challenging the initial evaluation assigned following the grants of service connection. In Dingess, the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided in September 2004 before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. In any event, the Veteran was provided with adequate notice by letters dated in September 2004 and April 2006, and the claims were readjudicated in a February 2013 supplemental statement of the case. Regarding the duty to assist, VA's duty under the VCAA includes helping the claimant to obtain service treatment records and other pertinent records, as well as providing an examination or obtaining a medical opinion when such is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). In this case, the RO has obtained the Veteran's service treatment records, private treatment records, and VA outpatient treatment records. In accordance with the Board's remand directives, records from the Social Security Administration (SSA) were obtained as well as updated VA outpatient treatment records. The Veteran has not identified any other outstanding records that he wanted VA to obtain or that he felt were relevant to the present claims. Thus, VA has discharged its duty to assist in obtaining relevant records on the Veteran's behalf. See 38 C.F.R. § 3.159(c). The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a), 3.327 (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the veteran's disability, a new VA examination must be conducted. See 38 C.F.R. § 3.327(a); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, in accordance with the Board's remand directives, VA examinations for the service-connected peripheral neuropathy of the bilateral upper and lower extremities were performed in October 2009 and November 2012. The Board finds that the VA examination reports are adequate for the purpose of rendering decisions on these claims. Specifically, the examiners reviewed the Veteran's medical history, conducted examinations of the Veteran, documented the clinical findings, specifically identified the paralysis of the nerves involved, and provided rationales for all opinions stated which are grounded in and consistent with the evidence of record and the examiner's clinical findings. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding that an examination is adequate when it is based on consideration of the claimant's medical history and describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). The Veteran has not stated and there is no other evidence indicating that there has been a material change in the severity of his service-connected peripheral neuropathy of the bilateral upper and lower extremities since he was last examined by VA in November 2012. See 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See VAOPGCPREC 11-95 (April 7, 1995). Accordingly, VA's duty to assist with respect to obtaining a VA examination or opinion is satisfied. See 38 C.F.R. §§ 3.159(c)(4); 3.326(a); McLendon, 20 Vet. App. at 83; Barr, 21 Vet. App. at 312. In sum, VA's duty to notify and assist has been satisfied, the Veteran has had ample opportunity to participate in the development of his claims, and there is no indication of any prejudicial error. See Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004). Further, as shown in the above discussion, there has been substantial compliance with all of the Board's remand directives pertaining to the service-connected peripheral neuropathy of the bilateral upper and lower extremities. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to insure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999). II. Increased Ratings The Veteran was initially granted service connection for peripheral neuropathy of the bilateral upper and lower extremities in a January 2005 rating decision. He was assigned 10 percent disability evaluations for his peripheral neuropathy of the right and left lower extremities and 0 percent disability evaluations for his peripheral neuropathy of the right and left upper extremities, all effective December 14, 2004. In a February 2013 rating decision, the RO increased the Veteran's service-connected disability evaluations to 30 percent disabling for peripheral neuropathy of the right upper extremity and 20 percent disabling for peripheral neuropathy of the left lower, right lower, and left upper extremities, all effective November 2, 2012. The Veteran disagrees with the rating assignments and contends that higher ratings are warranted. Disability ratings are based on the average impairment of earning capacity resulting from a disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. An evaluation of the level of disability present includes consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. §§ 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). In Fenderson v. West, 12 Vet. App 119 (1999), the Court emphasized the distinction between a new claim for an increased evaluation of a service-connected disability and a case, such as this one, in which the Veteran expresses dissatisfaction with the assignment of an initial disability evaluation where the disability in question has just been recognized as service-connected. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim-a practice known as "staged rating." The Veteran bears the burden of presenting and supporting his claim for benefits. 38 U.S.C.A. § 5107(a). In its evaluation, the Board considers all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. Id. Under the anti-pyramiding provision of 38 C.F.R. § 4.14, the evaluation of the "same disability" or the "same manifestation" under various diagnoses is to be avoided. The United States Court of Veterans Appeals (Court) held, in Esteban v. Brown, 6 Vet. App. 259 (1994), that for purposes of determining whether the appellant is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of, or overlapping with, the symptomatology of the other conditions. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). The Board notes that VA may consider other analogous rating criteria if warranted under the facts and circumstances of a case. See 38 C.F.R. § 4.20 (stating that when an unlisted condition is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous). Specifically, evaluation of a service-connected disability in accordance with schedular criteria that closely pertain to an analogous disease in terms of functions affected, anatomical localization, and symptomatology, is permitted. Id. The Board has reviewed all of the evidence in the Veteran's claims file, including his VA outpatient treatment records, SSA records, private treatment records, VA examination reports, and statements submitted in support of his claim. In this regard, the Board notes that, although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, all of the extensive evidence of record. Indeed, it has been held that while the Board must review the entire record, it need not discuss each piece of evidence in rendering a decision. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007); Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board's analysis will focus specifically on the evidence that is needed to substantiate the Veteran's claims for increased ratings for his service-connected peripheral neuropathy of the bilateral upper and lower extremities. In November 2004, the Veteran was afforded a VA examination for his service-connected peripheral neuropathy of the bilateral upper and lower extremities. The Veteran complained of numbness in his arms from the elbows downward and in both feet nightly or upon awakening. He also reported mild weakness in both hands and overall, indicated that the symptoms have gradually progressed now to occurring nightly. The Veteran also admitted to the occasional tingling sensation in his whole body and while the symptoms reported bother him at night, he stated that they do not wake him from his sleep or cause major limitations when performing daily routine activities. Upon physical examination testing, the VA examiner noted that the Veteran's tone was adequate in all extremities. Active range of motion was within normal limits and strength testing was 5/5 in all muscles proximally and distally. Deep tendon reflexes were +2 in biceps, brachioradialis, patellar and Achilles bilaterally with no corticospinal signs. Sensory testing revealed decreased sensation to pinprick and light touch distally in the lower extremities, but was adequate in the upper extremities. Vibration decreased distally as compared with proximally in the upper and lower extremities, and there was no atrophy in the extremities. Overall, the VA examiner noted that examination testing revealed symmetrical findings without evidence of atrophy, and function was not additionally limited by pain, fatigue, weakness, or lack of endurance. The VA examiner diagnosed the Veteran with mostly sensory peripheral neuropathy with electrodiagnostic testing showing mild motor axonal peripheral neuropathy. Private treatment records in the claims folder show muscle strength of 4/5 with atrophy. See November 2004 Social Security Administration (SSA) Physician's Assessment; Dr. Nazario September 2004 Assessment. On the Veteran's SSA Adult Function Report, completed February 2005, he asserted that his lower extremity numbness caused him to slip. In October 2009, the Veteran underwent his second VA examination for his service-connected peripheral neuropathy of the bilateral upper and lower extremities. The Veteran complained of weakness and numbness associated with his upper extremities. He admitted to dropping things with his hands and that his symptoms have progressively worsened over time. Upon physical examination testing, the VA examiner noted that there was no atrophy present, no abnormal muscle tone or bulk, and no tremors, tics, or other abnormal movements. Both his gait and balance were normal, and there was no function of any joint affected by the nerve disorder. Motor testing showed that muscle strength was 5/5 and there was no motor function impairment. Sensory testing reflected decreased vibration, pain, and light touch. The VA examiner indicated that the location of the abnormality was distally, position sense was normal, and the affected nerve was peripheral. Reflex examination testing was normal for bilateral bicep reflexes, bilateral tricep reflexes, bilateral brachioradialis reflexes, bilateral finger jerk, bilateral abdominal reflexes, bilateral knee reflexes, bilateral ankle reflexes, and bilateral plantar flexion. The VA examiner noted that the Veteran's service-connected bilateral peripheral neuropathy mildly affected chores, shopping, exercising, sports, and traveling; and had no effect on recreation, feeding, bathing, dressing, toileting, and grooming. The Veteran was diagnosed with mild diabetic peripheral neuropathy of the sensory type in the upper and lower extremities without functional deficit or impairment that could interfere with employability. The Veteran was afforded his third VA examination for his service-connected peripheral neuropathy of the bilateral upper and lower extremities in November 2012. The Veteran complained of constant pain occurring moderately in the bilateral upper and lower extremities, intermittent pain occurring moderately in the bilateral upper and lower extremities, moderate paresthesias and/or dysesthesias in the bilateral upper and lower extremities, and moderate numbness in the bilateral upper and lower extremities. Muscle strength testing revealed normal strength (5/5) for bilateral elbow flexion, bilateral elbow extension, bilateral wrist flexion, bilateral wrist extension, bilateral grip, bilateral pinch (thumb to index finger), bilateral knee extension, bilateral ankle plantar flexion, and bilateral ankle dorsiflexion. There was no muscle atrophy present, and deep tendon reflexes were normal (2+) for bilateral biceps, bilateral triceps, bilateral brachioradialis, bilateral knees, and bilateral ankles. Sensation testing for light touch was decreased for the bilateral shoulder area (C5), bilateral inner/outer forearm (C6/T1), bilateral hand/fingers (C6-8), bilateral upper anterior thigh (L2), bilateral thigh/knee (L3/4), bilateral lower leg/ankle (L4/L5/S1), and bilateral foot/toes (L5). The VA examiner indicated that the Veteran's gait was normal, Phalen's sign was positive on the right and left, and Tinel's sign was positive on the right and left. The VA examiner also noted trophic changes in his feet due to his service-connected peripheral neuropathy of the bilateral upper and lower extremities. There was no paralysis of the radial nerve bilaterally (musculospiral nerve), musculocutaneous nerve, circumflex nerve, long thoracic nerve, upper radicular group (5th and 6th cervicals), middle radicular group, lower radicular group, sciatic nerve, anterior tibial (deep peroneal) nerve, internal popliteal (tibial) nerve, posterior tibial nerve, anterior crural (femoral), nerve, left obturator nerve, external cutaneous nerve of the thigh bilaterally, or the ilio-inguinal nerve bilaterally. There was moderate incomplete paralysis of the right side median nerve, moderate incomplete paralysis of the left side median nerve, moderate incomplete paralysis of the right side ulnar nerve, moderate incomplete paralysis of the left side ulnar nerve, moderate incomplete paralysis of the external popliteal (common peroneal) nerve of the right side, moderate incomplete paralysis of the external popliteal (common peroneal) nerve of the left side, moderate incomplete paralysis of the musculocutaneous (superficial peroneal) nerve of the right side, and moderate incomplete paralysis of the musculocutaneous (superficial peroneal) nerve of the left side. The VA examiner indicated that no assistive devices were used by the Veteran because he has a normal mode of locomotion, and there was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The VA examiner diagnosed the Veteran with peripheral neuropathy in the upper and lower extremities. A. Peripheral Neuropathy of the Right and Left Lower Extremities Prior to November 2, 2012 Prior to November 2, 2012, the Veteran has been assigned 10 percent disabling evaluations for his service-connected peripheral neuropathy of the right and left lower extremities pursuant to 38 C.F.R. § 4.12a, DCs 8599-8520 and 8599-8522 (2012), respectively. When a particular disability is not listed among the diagnostic codes, a code ending in "99" is used; the first two numbers are selected from the portion of the schedule most approximating a Veteran's symptoms. 38 C.F.R. § 4.27. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. 38 C.F.R. § 4.27. In this case, DC 8599 refers to peripheral neuropathy of the lower extremities, while the more specific DC 8520 refers to paralysis of the sciatic nerve and DC 8522 refers to the musculocutaneous nerve (superficial peroneal). 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 percent 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. Under DC 8520, complete paralysis of the sciatic nerve warrants an 80 percent rating. Incomplete paralysis is assigned ratings of 10 to 60 percent, depending on the severity of the claimant's symptoms. A 60 percent rating is assigned for severe incomplete paralysis with marked muscular muscle atrophy. A 40 percent rating is appropriate for moderately severe incomplete paralysis. Moderate incomplete paralysis warrants a 20 percent rating, and a 10 percent rating is assigned for mild incomplete paralysis. The Board finds that consideration of DC 8521 is also appropriate, as abnormal findings concerning the common peroneal nerve were noted on VA examination in November 2012. Under DC 8521, complete paralysis of the external popliteal nerve; foot drop and slight droop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes warrants a 40 percent rating. Incomplete paralysis is assigned ratings of 10 to 30 percent depending on the severity of the claimant's symptoms. A 30 percent rating is assigned for severe incomplete paralysis of the external popliteal nerve. A 20 percent rating is assigned for moderate incomplete paralysis of the external popliteal nerve. A 10 percent rating is assigned for mild incomplete paralysis of the external popliteal nerve. Under DC 8522, complete paralysis of the superficial peroneal nerve; eversion of the foot weakened warrants a 30 percent rating. Incomplete paralysis is assigned ratings of 0 to 20 percent depending on the severity of the claimant's symptoms. A 20 percent rating is assigned for severe incomplete paralysis of the superficial peroneal nerve. A 10 percent rating is assigned for moderate incomplete paralysis of the superficial peroneal nerve. A 0 percent rating is assigned for mild incomplete paralysis of the superficial peroneal nerve. 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. Applying the facts in this case to the criteria set forth above, the Board concludes that the criteria for increased ratings in excess of 10 percent for the Veteran's bilateral lower extremities, prior to November 2, 2012, have not been met. The Board finds that the involvement of the Veteran's nerves of the lower extremities was at worst mild, causing numbness, tingling, and pain down his bilateral lower extremities. This is most evident by the November 2004 VA examiner's diagnosis of mostly sensory peripheral neuropathy, and the October 2009 VA examiner's assessment of mild diabetic peripheral neuropathy of the sensory type in the lower extremities without functional deficit. In November 2004, the VA examiner noted that examination testing revealed symmetrical findings without evidence of atrophy. Likewise, upon physical examination testing in October 2009 the VA examiner noted that there was no atrophy present. Strength was 5/5 on both examinations. While private treatment records showed muscle strength of 4/5 with atrophy in 2004, this finding appears to have been incidental and is not consistent with the findings of both the 2004 and 2009 VA examinations. More importantly, electrodiagnostic testing in November 2004 showed only mild motor axonal peripheral neuropathy. The next higher rating under DC 8520 requires moderate incomplete paralysis of the sciatic nerve, under DC 8521 requires moderate incomplete paralysis of the common peroneal nerve, and under DC 8522 requires severe incomplete paralysis of the superficial peroneal nerve. In view of the foregoing, the Board finds no evidence that would warrant higher ratings or demonstrate more than a mild degree of incomplete paralysis of the sciatic, common peroneal, and/or superficial peroneal nerves. As such, ratings in excess of 10 percent for the Veteran's service-connected peripheral neuropathy of the right and left lower extremities are not warranted. The Veteran is competent to report his symptoms, and the Board does not doubt the sincerity of the Veteran's belief that his service-connected peripheral neuropathy of the right and left lower extremities have worsened. However, the objective clinical findings do not support his assertions for the reasons stated above. As the preponderance of the evidence is against the Veteran's claims for increased ratings for his service-connected peripheral neuropathy of the right and left lower extremities, prior to November 2, 2012, the benefit-of-the-doubt doctrine is not for application, and increased ratings must be denied. See 38 U.S.C.A. § 5107(b; Gilbert, 1 Vet. App. at 55. As of November 2, 2012 As of November 2, 2012, the Veteran has been assigned 20 percent disabling evaluations for his service-connected peripheral neuropathy of the right and lower extremities pursuant to 38 C.F.R. § 4.12a, DC 8521. The Board finds that consideration of DC 8522 is also appropriate, as abnormal findings concerning the superficial peroneal nerve were noted on VA examination in November 2012. Based upon the evidence of record, the Board finds that increased ratings in excess of 20 percent are not warranted for the Veteran's service-connected peripheral neuropathy of the right and lower extremities, as of November 2, 2012. In this respect, the Board notes that the neurological findings on clinical testing are not shown to more closely approximate a severe incomplete paralysis of the common peroneal nerve or complete paralysis of the superficial peroneal nerve. Based on results from the November 2012 VA examination, there has been no evidence of atrophy or loss of tone in the muscles, loss of muscle strength, significantly decreased motor function or sensory loss, or complete paralysis. Further, the November 2012 VA examiner described the Veteran's peripheral neuropathy involving the common and superficial peroneal nerves as causing moderate incomplete paralysis of the right and left sides. In addition, the sciatic nerves were noted to be normal on VA examination in November 2012. As such, increased ratings in excess of 20 percent disabling are not warranted for the Veteran's service-connected peripheral neuropathy of the right and left lower extremities, as of November 2, 2012, under DC 8520, 8521, or 8522. The Board notes that the November 2012 VA examiner noted that the Veteran demonstrated moderate incomplete paralysis of the superficial peroneal nerve of the left lower extremity (DC 8522) and moderate incomplete paralysis of the common peroneal nerve (DC 8521). The Board acknowledges this finding, but points that separate ratings under each of these diagnostic codes (DCs 8521 and 8522) would entail compensating the Veteran twice for the same symptoms. See 38 C.F.R. § 4.14. Under the anti-pyramiding provision of 38 C.F.R. § 4.14, the evaluation of the "same disability" or the "same manifestation" under various diagnoses is to be avoided. The Court held, in Esteban v. Brown, 6 Vet. App. 259 (1994), that for purposes of determining whether the appellant is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of, or overlapping with, the symptomatology of the other conditions. The Veteran is competent to report his symptoms, and the Board does not doubt the sincerity of the Veteran's belief that his service-connected peripheral neuropathy of the right and left lower extremities, as of November 2, 2012, have worsened. However, the objective clinical findings do not support his assertions for the reasons stated above. As the preponderance of the evidence is against the Veteran's claims for increased ratings in excess of 20 percent for his service-connected peripheral neuropathy of the right and left lower extremities, as of November 2, 2012, the benefit-of-the-doubt doctrine is not for application, and increased ratings must be denied. See 38 U.S.C.A. § 5107(b; Gilbert, 1 Vet. App. at 55. B. Peripheral Neuropathy of the Right and Left Upper Extremities Prior to November 2, 2012 Prior to November 2, 2012, the Veteran has been assigned noncompensable (0 percent) disability evaluations for his service-connected peripheral neuropathy of the right and left upper extremities pursuant to 38 C.F.R. § 4.12a, DCs 8599-8517. As mentioned previously, DC 8599 refers to peripheral neuropathy of the upper extremities, while the more specific DC 8517 refers to paralysis of the musculocutaneous nerve. Under DC 8517, a noncompensable evaluation is prescribed for mild incomplete paralysis of the musculocutaneous nerve of both the major and minor extremities. Moderate incomplete paralysis of the musculocutaneous nerve warrants a 10 percent evaluation for both the major and minor extremities. Severe incomplete paralysis of the musculocutaneous nerve warrants a 20 percent evaluation for both the major and minor extremities. Complete paralysis which involves weakness but not loss of flexion of elbow and supination of forearm warrants a 20 percent rating for minor extremities and 30 percent rating for major extremities. As impairment of the median and ulnar nerves was demonstrated on VA examination in November 2012, consideration of DCs 8515 and 8516 is also appropriate. Under DC 8515, for rating paralysis of the median nerve, mild incomplete paralysis of the median nerve in the major or minor extremity warrants a 10 percent rating. For the major extremity, moderate incomplete paralysis warrants a 30 percent rating and severe incomplete paralysis warrants a 50 percent rating. For the minor extremity, moderate incomplete paralysis warrants a 20 percent rating and severe incomplete paralysis warrants a 40 percent rating. Complete paralysis with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand), pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended, cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm, flexion of wrist weakened, and pain with trophic disturbances warrants a maximum 70 percent rating in the major extremity and a 60 percent rating in the minor extremity. 38 C.F.R. § 4.124a. DC 8516 provides the rating criteria for paralysis of the ulnar nerve. Under this diagnostic criteria, mild incomplete paralysis warrants a 10 percent rating; moderate incomplete paralysis warrants a rating of 20 percent; severe incomplete paralysis warrants a 30 percent rating; and a maximum evaluation of 50 percent is warranted for complete paralysis of the ulnar nerve, which is defined as being manifested by the 'griffin claw' deformity due to flexor contraction of the ring and little fingers, very marked atrophy in the dorsal interspace and thenar and hypothenar eminences; loss of extension of the ring and little fingers, inability to spread the fingers (or reverse), inability to adduct the thumb; and weakened flexion of the wrist. As the Veteran is right-handed (dominant), the major ratings apply to the right extremities and the minor ratings apply to the left extremities. The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a, DC 8517 (2012). When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. Id. Applying the facts in this case to the criteria set forth above, the Board concludes that the criteria for 10 percent ratings, but not higher, for the Veteran's bilateral upper extremities, prior to November 2, 2012, have been met. In November 2004, vibration was decreased distally as compared with proximally in the upper extremities. The VA examiner diagnosed the Veteran with mostly sensory peripheral neuropathy with electrodiagnostic testing showing mild motor axonal peripheral neuropathy. In October 2009, sensory testing reflected decreased vibration, pain, and light touch. The Veteran was diagnosed with mild diabetic peripheral neuropathy of the sensory type in the upper extremities. In view of the foregoing, the Board finds that mild incomplete paralysis of the median nerves was demonstrated prior to November 2, 2012. Therefore, 10 percent ratings for the right and left upper extremities are warranted under DC 8515. However, moderate incomplete paralysis of the median nerves was nor demonstrated prior to November 2, 2012. This is most evident by the November 2004 VA examiner's diagnosis of mostly sensory peripheral neuropathy, and the October 2009 VA examiner's assessment of mild diabetic peripheral neuropathy of the sensory type without functional deficit. In November 2004, the VA examiner noted that examination testing revealed symmetrical findings without evidence of atrophy. Likewise, upon physical examination testing in October 2009 the VA examiner noted that there was no atrophy present. Strength was 5/5 on both examinations. While private treatment records showed muscle strength of 4/5 with atrophy in 2004, this finding appears to have been incidental and is not consistent with the findings of both the 2004 and 2009 VA examinations. More importantly, electrodiagnostic testing in November 2004 showed only mild motor axonal peripheral neuropathy. Thus, increased ratings of 10 percent, but not higher, are warranted under DC 8515. As of November 2, 2012 As of November 2, 2012, the Veteran has been assigned 30 percent and 20 percent disabling evaluations for his service-connected peripheral neuropathy of the right and lower extremities, respectively, pursuant to 38 C.F.R. § 4.12a, DC 8515. As noted above, consideration of DC 8516 is also appropriate. Based upon the evidence of record, the Board finds that increased ratings in excess of 30 percent and 20 percent disabling are not warranted for the Veteran's service-connected peripheral neuropathy of the right and left upper extremities, as of November 2, 2012. In this respect, the Board notes that the neurological findings on clinical testing are not shown to more closely approximate a severe incomplete paralysis or complete paralysis of the median or ulnar nerves. Based on results from the November 2012 VA examination, there has been no evidence of atrophy or loss of tone in the muscles, loss of muscle strength, significantly decreased motor function or sensory loss, or complete paralysis. Further, the November 2012 VA examiner described the Veteran's peripheral neuropathy involving the median nerve and ulnar nerves as causing moderate incomplete paralysis of the right and left sides. The musculocutaneous nerve was described as normal. As such, increased ratings in excess of 30 percent and 20 percent disabling are not warranted for the Veteran's service-connected peripheral neuropathy of the right and left upper extremities, as of November 2, 2012, under DC 8515, 8516, or 8517. The Board notes that the November 2012 VA examiner also noted that the Veteran demonstrated moderate incomplete paralysis of the ulnar nerve of the upper right and left extremities, DC 8516. The Board acknowledges this finding, but points that separate ratings under each of these diagnostic codes (DC 8515 and 8516) would entail compensating the Veteran twice for the same symptoms (both prior to and since November 2, 2012). See 38 C.F.R. § 4.14. The Veteran is competent to report his symptoms, and the Board does not doubt the sincerity of the Veteran's belief that his service-connected peripheral neuropathy of the right and left upper extremities, as of November 2, 2012 have worsened. However, the objective clinical findings do not support his assertions for the reasons stated above. As the preponderance of the evidence is against the Veteran's claims for increased ratings in excess of 30 percent and 20 percent for his service-connected peripheral neuropathy of the right and left upper extremities, as of November 2, 2012, the benefit-of-the-doubt doctrine is not for application, and increased ratings must be denied. See 38 U.S.C.A. § 5107(b; Gilbert, 1 Vet. App. at 55. Extraschedular Consideration The Board has also considered whether referral for an extraschedular rating is appropriate. In this regard, the Board notes that ratings are generally based on average impairment, and that the rating schedule represents, as far as is practicable, the average impairment of earning capacity. See 38 C.F.R. § 3.321(a), (b) (2012). However, to afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.3211 (b) (2012). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. at 115-16. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, and is therefore found to be inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as 'governing norms. Id. Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. Id. As noted above, the Veteran's peripheral neuropathy of the bilateral upper and lower extremities primarily involves numbness, weakness, and pain. Such impairment is specifically contemplated by the rating criteria. See 38 C.F.R. § 4.124a, DCs 8515, 8516, 8517, 8520, 8521, 8522. Accordingly, the Board finds that the Veteran does not present such an exceptional or unusual disability picture that the available schedular evaluations for his peripheral neuropathy of the bilateral upper and lower extremities are inadequate. Therefore, the Board concludes that referral for consideration of an extraschedular rating is not warranted in this case. See Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). ORDER Entitlement to an initial rating in excess of 10 percent prior to November 2, 2012 and 20 percent thereafter for peripheral neuropathy of the right lower extremity is denied. Entitlement to an initial rating in excess of 10 percent prior to November 2, 2012, and 20 percent thereafter for peripheral neuropathy of the left lower extremity is denied. Entitlement to an initial 10 percent rating, but not higher, prior to November 2, 2012, for peripheral neuropathy of the right upper extremity is granted. Entitlement to an initial 10 percent rating, but not higher, prior to November 2, 2012, for peripheral neuropathy of the left upper extremity is granted. Entitlement to a rating in excess of 20 percent, from November 2, 2012 forward, for peripheral neuropathy of the left upper extremity is denied. Entitlement to a rating in excess of 30 percent, from November 2, 2012 forward, for peripheral neuropathy of the right upper extremity is denied. REMAND Although the Board sincerely regrets the additional delay, remand is necessary to ensure that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration. The Board finds that this appeal must be remanded to obtain adequate examinations and opinions that comply with the directives of the September 2012 remand. A Court or Board remand confers upon the appellant the right to compliance with that order. Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). Additionally, where VA provides the Veteran an examination in a service connection claim the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). An adequate examination and medical opinion addresses the appropriate theories of entitlement and provides a supporting rationale for any medical opinion. See Stefl v. Nicholson, 21 Vet. App. 120, 123-25 (2007). When the matter was before the Board in September 2012, a remand was ordered. The remand directed that an examination of the Veteran be conducted to determine the etiology of his current vision disorders. Specifically, it was requested that the VA examiner provide an opinion as to whether it is at least as likely as not that any current vision disorder was (a) proximately due to, (b) the result of, or (c) aggravated by the Veteran's service-connected diabetes mellitus, type II. However, the Board finds that the examination report does not comply with the specific directives mentioned above. Upon review of the claims file, the Veteran was afforded a VA eye examination in November 2012. The VA examiner diagnosed the Veteran with senile cataracts in both eyes, blepharitis, dry eye, temporal pterygium right eye, pinguecula, and mild cellophane maculopathy. The VA examiner concluded that the Veteran's visual disorders are less likely than not proximately due to or the result of the Veteran's service-connected disability. The VA examiner explained that the Veteran's loss of vision is due to senile cataracts and refractive error, and the Veteran's symptoms are due to blepharitis and associated dry eye. The VA examiner further explained that there is no diabetic retinopathy in both eyes, and mild cellophane maculopathy of the right eye does not affect visual acuity and is not related to the service-connected diabetes mellitus, type II. As to the nuclear sclerosis of his lenses, the VA examiner explained that it was age-related and not secondary to his service-connected diabetes mellitus, type II. Similarly, the Veteran's loss of vision is not secondary to the service-connected diabetes mellitus, type II. The Board acknowledges the VA examiner's conclusion, but finds that the VA examiner failed to provide an opinion as to whether or not the Veteran's vision problems, claimed generally as "loss of vision," are aggravated by his service-connected diabetes mellitus, type II. With regard to the Veteran's claim for service connection for hypertension, the Board noted in the September 2012 remand that the September 2009 VA examination report shows that the examiner provided the opinion that hypertension is not caused or aggravated by the service-connected diabetes mellitus, type II, as the diagnosis of hypertension predates the diagnosis of diabetes mellitus, type II, and microalbuminuria is not present. However, the Board noted that the record contains a statement from a private physician certifying that his diabetes alters his hypertension. As such, the Board requested an addendum opinion from the September 2009 VA examiner that explicitly resolves the findings in the September 2009 VA examination report with the private physician's contentions. Additionally, the Board requested that the examiner provide an explanation of the significance of the lack of microalbuminuria in reaching the conclusion that the Veteran's hypertension is not caused or aggravated by his diabetes mellitus, type II. Again, the Board finds that the examination report does not comply with the specific directives mentioned above. In October 2012, the Veteran was afforded an internal medicine VA examination. After physical examination testing, the VA examiner diagnosed the Veteran with hypertension and concluded that it is not the result of or aggravated by his service-connected diabetes mellitus, type II. The VA examiner stated that the hypertension diagnosis predates diabetes mellitus diagnosis and there is no microalbuminuria present in the last laboratory testing completed. The VA examiner failed to provide an opinion that explicitly resolves the findings in the examination report with the private physician's contentions and failed to explain the significance of the lack of microalbuminuria in reaching the conclusion that the Veteran's hypertension is not caused or aggravated by his diabetes mellitus, type II. With regard to the claim for a TDIU, the Board noted in the September 2012 remand, that since the Veteran was not service-connected for arteriosclerotic heart disease at the time an opinion was obtained with regard to his unemployability, a medical opinion should be obtained on the extent of the Veteran's occupational impairment that duly considers the impairment caused by his arteriosclerotic heart disease, in addition to the impairment caused by his service-connected diabetes mellitus, type II; peripheral neuropathy of the bilateral upper and lower extremities; and residual fracture of the second, third, and fourth metatarsals. Again, the Board finds that the examination report does not comply with the specific directives mentioned above. At November 2012 VA examinations for peripheral neuropathy and foot disabilities, the Veteran's employability as it relates to his service-connected peripheral neuropathy of the bilateral upper and lower extremities and residual fracture of the second, third, and fourth metatarsals was discussed. There was no mention of whether the Veteran's service-connected arteriosclerotic heart disease and diabetes mellitus, type II, either alone or in the aggregate, render him unable to secure or follow a substantially gainful occupation. As such, because of the aforementioned procedural deficiencies, the Board's remand instructions were not complied with, and another remand is needed in order to ensure compliance. If any action required by a remand is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. While the Board regrets the delay, another remand is required. See Stegall v. West, 11 Vet. App. 268 (1998). As the case must be remanded for the foregoing reasons, all updated VA treatment records should be obtained. Finally, the Board finds that the Veteran submitted a timely notice of disagreement (NOD) with regards to the September 2012 rating decision that granted service connection for arteriosclerotic heart disease and assigned a 10 percent disability rating, effective August 13, 2004. Consequently, the Board must remand this issue for the RO to issue a statement of the case (SOC) and give him an opportunity to perfect an appeal of such issue by submitting a timely substantive appeal. Manlicon v. West, 12 Vet. App. 238 (1999). To ensure that VA has met its duty to assist the Veteran in developing the facts pertinent to the claim and to ensure full compliance with due process requirements, the case is again REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Issue a Statement of the Case to the Veteran, addressing the issue of entitlement to an initial rating in excess of 10 percent for arteriosclerotic heart disease. He must be advised of the time limit in which he may file a Substantive Appeal. Then, only if the appeal is timely perfected, should the issue be returned to the Board for further appellate consideration, if otherwise in order. 2. Make arrangements to obtain a complete copy of the Veteran's treatment records from the VA Medical Center in San Juan and/or Rio Piedras, Puerto Rico, dated since January 2013. 3. After the Veteran's medical records have been obtained, return the Veteran's claims file to the physician who conducted the November 2012 eye examination to render an addendum opinion. If the same examiner is not available, a different examiner should be asked to review the claims folder and provide the requested opinion. The claims folder and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current vision disorder was (a) proximately due to, (b) the result of, or (c) aggravated by the Veteran's service-connected diabetes mellitus, type II. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 4. Return the Veteran's claims file to the physician who conducted the October 2012 hypertension examination to render an addendum opinion. If the same examiner is not available, a different examiner should be asked to review the claims folder and provide the requested opinion. The claims folder and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. Based on the review of this Remand and the claims folder, to include consideration of the Veteran's lay statements of record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension was (a) proximately due to, (b) the result of, or (c) aggravated by his service-connected diabetes mellitus, type II. In providing this opinion, the examiner should address the Veteran's assertion that he was diagnosed with diabetes mellitus in 1998 and his private physician's assertion that his diabetes alters his hypertension. Furthermore, the examiner should provide an explanation of the significance of the lack of microalbuminuria in determining that the Veteran's hypertension is not caused or aggravated by his diabetes mellitus, type II. In other words, the examiner should provide a reasoned explanation linking the findings made with the conclusion provided to facilitate review by the Board. 5. Schedule the Veteran for a TDIU examination. The claims file and a copy of this Remand must be made available to and reviewed by the examiner in conjunction with the examination. The examiner should indicate in the report that the claims file was reviewed. Any indicated tests and studies are to be conducted. The examiner should provide an opinion as to whether it is at least as likely as not (50% or greater probability) that the Veteran's service-connected disabilities (i.e., arteriosclerotic heart disease; diabetes mellitus, type II; peripheral neuropathy of the bilateral upper and lower extremities; and residual fracture of the second, third, and fourth metatarsals), either alone or in the aggregate, render him unable to secure or follow a substantially gainful occupation. Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. The examiner must provide a comprehensive report including a complete rationale for all conclusions reached. 6. Next, review the medical examination reports obtained to ensure that the remand directives have been accomplished, and return the case to the examiner(s) if all questions posed are not answered. 7. Finally, readjudicate the claims on appeal. If the benefits remain denied, the Veteran should be provided with a supplemental statement of the case (SSOC), and the case should be returned to the Board. 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). ______________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs