Citation Nr: 1319852 Decision Date: 06/20/13 Archive Date: 07/02/13 DOCKET NO. 07-36 023 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial evaluation in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to an evaluation in excess of 20 percent for service-connected diabetes mellitus, type II, with bilateral cataracts. 3. Entitlement to an evaluation in excess of 20 percent for service-connected peripheral neuropathy of the right lower extremity. 4. Entitlement to an evaluation in excess of 20 percent for service-connected peripheral neuropathy of the left lower extremity. 5. Entitlement to service connection for jungle rot of the feet. 6. Entitlement to service connection for a lung disability, to include as due to asbestos exposure. 7. Entitlement to service connection for a groin rash. 8. Entitlement to service connection for a left foot disability, to include calluses of the left foot and plantar fasciitis. 9. Entitlement to service connection for an upper respiratory disability. 10. Entitlement to service connection for sleep apnea. 11. Entitlement to service connection for pes planus. 12. Entitlement to service connection for benign prostatic hypertrophy, to include as due to herbicide exposure. 13. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Arif Syed, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1967 to April 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Veteran was scheduled to appear at the RO to have a personal hearing before a Veterans Law Judge. However, in January 2012 the Veteran withdrew his request for a hearing. See 38 C.F.R. § 20.704(e) (2012). The Board has reviewed the Veteran's claims folder and the record maintained in the Virtual VA paperless claims processing system. The issues of entitlement to increased disability ratings for diabetes mellitus and peripheral neuropathy of the right and left lower extremities as well as entitlement to service connection for a lung disability, sleep apnea, a left foot disability, upper respiratory problems, pes planus and benign prostatic hypertrophy and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's PTSD is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks as a result of episodic depression, sleep disturbances, nightmares, flashbacks, disturbance of motivation and mood, feelings of isolation, hypervigilance, and difficulty establishing and maintaining effective work and social relationships; it is not manifested by manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 2. The Veteran does not have a current diagnosis of jungle rot of the feet. 3. The Veteran does not have a current diagnosis of a groin rash. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 30 percent for PTSD are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. Jungle rot of the feet was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1101, 1110 (West 2002); 38 C.F.R. § 3.303 (2012). 3. A groin rash was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1101, 1110 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks entitlement to an increased rating for service-connected PTSD as well as entitlement to service connection for jungle rot of the feet and a groin rash. In the interest of clarity, the Board will discuss certain preliminary matters. The issues on appeal will then be analyzed and a decision rendered. The Veterans Claims Assistance Act of 2000 The Board has given consideration to the Veterans Claims Assistance Act of 2000 (VCAA). The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also defines the obligations of VA with respect to its statutory duty to assist a claimant in the development of his claim. See 38 U.S.C.A. §§ 5103, 5103A (West 2002). Notice The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). In the case at hand, the record reflects that the originating agency provided the Veteran with the required notice by letters mailed in December 2005, March 2006, and January 2011 and notice with respect to the effective-date and rating elements of the claims was included in the March 2006 and January 2011 letters. Duty to assist In general, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim for VA benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. The law affords that the assistance provided by VA shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In the instant case, the Board finds reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claims and there is no reasonable possibility that further assistance would aid in substantiating these claims. The evidence of record includes the Veteran's statements, his service treatment records, as well as VA and private treatment records. In general, VA's duty to assist includes obtaining records from the Social Security Administration (SSA). See Murincsak v. Derwinski, 2 Vet. App. 363 (1992). The record demonstrates that in March 2011, the RO attempted to obtain the Veteran's SSA records. In a subsequent April 2011 report, SSA informed VA that it did not have any of the requested records for the Veteran. The Veteran was informed of the negative response from the SSA in a statement of the case dated November 2011. Neither the Veteran nor his representative has since submitted or identified any outstanding evidence pertaining to his SSA records which could be obtained to substantiate the claims. Based upon this record, the Board finds that additional attempts to obtain the Veteran's SSA records, if any, would be futile. The Board also finds that the Veteran has not been prejudiced by the unavailability of the SSA records as he was notified of the unavailability of the records in the November 2011 statement of the case and was provided with an opportunity to respond. The Veteran was afforded VA examinations in March 2006 and July 2011 for his PTSD. He was also afforded a VA examination in March 2006 for his claimed groin and jungle rot of the feet disabilities. The examination reports reflect that the examiners interviewed and examined the Veteran, reviewed his past medical history, documented his current medical conditions, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. Furthermore, the March 2006 and July 2011 examination reports contain sufficient information to rate the Veteran's PTSD under the appropriate diagnostic criteria. The Board therefore concludes that the VA examination reports are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) [holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate]. The Board is cognizant of the fact that the Veteran's claims folder was available for July 2011 and March 2006 psychiatric examinations but not for the March 2006 examination for the Veteran's claimed groin and jungle rot of the feet disabilities. However, such did not have an adverse effect on the adequacy of the examinations. Notably, as previously indicated, the examiners fully considered the Veteran's complaints, to include his complaints of symptomatology attributed to his feet and groin. Physical examinations were then performed and sufficient information was provided to allow the Board to render an informed determination. The Board also notes that, as will be discussed below, the Veteran's TDIU claim is remanded for further evidentiary development, specifically to obtain an opinion as to whether his service-connected disabilities in the aggregate prevent him from obtaining substantially gainful employment. The Board further notes that the Veteran's PTSD is currently rated under 38 C.F.R. § 4.130, Diagnostic Code 9411, which contemplates occupational impairment. However, the Board finds that remand of his PTSD claim as inextricably intertwined with the TDIU claim is not warranted. Crucially, the July 2011 VA examiner specifically commented on the impact of the Veteran's PTSD on his employability. As such, the Board finds that sufficient evidence to consider occupational impairment of the Veteran's PTSD is of record and that he is not prejudiced thereby with adjudication of the PTSD claim. Thus, the Board finds that under the circumstances of this case, VA has satisfied the notification and duty to assist provisions of the law and that no further action pursuant to the VCAA need be undertaken on the Veteran's behalf. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2012). The Veteran has been accorded the opportunity to present evidence and argument in support of his claims. He has retained the services of an accredited representative. He withdrew his request for a hearing before a Veterans Law Judge. Accordingly, the Board will proceed to a decision as to the issues of entitlement to an increased disability rating for PTSD as well as entitlement to service connection for jungle rot of the feet and a groin rash. Higher evaluation for PTSD Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2012). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2012). The Court has held that an appeal from an initial rating is a separate and distinct claim from a claim for an increased rating. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126 (1999). See also Hart v. Mansfield, 21 Vet. App. 505 (2007) (holding, "staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings"). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." 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, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The Veteran's psychiatric disorder is currently rated under 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). This diagnostic code is deemed by the Board to be the most appropriate because it pertains specifically to the primary diagnosed disability in the Veteran's case-PTSD. In any event, with the exception of eating disorders, all mental disorders including PTSD are rated under the same criteria in the rating schedule. Therefore, rating under another diagnostic code would not produce a different result. Moreover, the Veteran has not requested that another diagnostic code be used. Accordingly, the Board concludes that the Veteran is appropriately rated under Diagnostic Code 9411. PTSD is to be rated under the general rating formula for mental disorders under 38 C.F.R. § 4.130. The pertinent provisions of 38 C.F.R. § 4.130 concerning the rating of psychiatric disabilities read in pertinent part as follows: 100 percent: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation or name. 70 percent: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. 50 percent: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty establishing effective work and social relationships. 30 percent: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). It is noted that the "such symptoms as" language of the diagnostic code listed above means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, as the Court also pointed out in that case, the list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Id. Accordingly, while each of the examples need not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. Put another way, the severity represented by those examples may not be ignored. Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See 38 C.F.R. § 4.130 (2012) [incorporating by reference the VA's adoption of the DSM-IV for rating purposes]. In addition to PTSD, for which service connection was established, the Veteran's treatment history indicates diagnoses of generalized anxiety disorder. See, e.g., a VA treatment record dated February 2008. Service connection has not been granted for this diagnosed psychiatric disability. It is now well-settled that the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability, in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). The medical evidence in the instant case does not clearly differentiate between the symptomatology associated with the Veteran's PTSD and that resulting from the generalized anxiety disorder. Accordingly, for the purposes of this decision, the Board will attribute all of the Veteran's psychiatric symptoms to his service-connected PTSD. The Veteran was afforded a VA examination for his PTSD in March 2006. He complained of nightmares and flashbacks from his period of military service in Vietnam and that he continues to have nervousness and depressed feelings with poor concentration and irritability. He also noted that he has been married since 1970 and had two children. However, he reported feelings of isolation and avoided crowds and loud noises. Upon examination, the VA examiner reported that the Veteran tended to isolate himself and that his mood was nervous and depressed every now and then. Moreover, his affect was constricted to a certain degree. The Veteran also reported that his irritability and short temper with nervousness and depression and feelings of isolation affected him on the job from time to time. However, his speech was coherent and relevant, thought processes were intact and he was able to communicate. Further, he denied hallucinations as well as suicidal or homicidal ideation. Orientation and memory were preserved, and insight and judgment were intact. The examiner determined that the Veteran was competent and capable of handling his financial and personal affairs. The examiner also reported that the severity of the Veteran's PTSD symptoms were mild. The Board notes that VA mental health evaluations dated from February 2008 to February 2012 document the Veteran's treatment for his PTSD. Notably, these records indicate that upon examination, the Veteran's appearance was clean, mentation was intact, demeanor was cooperative, attention was alert, orientation was intact, speech was normal, motor activity was within normal limits, thought process was logical and goal-oriented, abstract thinking was normal, average intelligence, normal judgment and insight, no suicidal or homicidal ideation, and no thought disturbances or hallucinations. Although a December 2009 mental health evaluation documents an anxious affect, multiple subsequent evaluations indicate euthymic affect. See, e.g., a VA treatment record dated March 2010. The Veteran also reported during the December 2009 evaluation that his wife can be demanding and controlling which causes irritability and anxiety. He reiterated these feelings during a June 2010 mental health evaluation. However, he indicated during September and November 2010 evaluations that he and his wife were getting along. The treatment records also document his mood as either "okay" or "good." The Board further notes that an April 2011 VA general examination indicates that a psychiatric examination of the Veteran revealed normal affect, mood, and judgment as well as no obsessive behavior or hallucinations and appropriate behavior, comprehension of commands, and average intelligence. The Veteran was provided a VA examination in July 2011. The Veteran reported that he is unemployable due to his PTSD. He also stated that he has a good relationship with his wife and has occasional social relationships. Further, he reported that he will "mope around the house" and attend football games. The examiner noted that the Veteran's current psychosocial functional status is mildly impaired. The Veteran reported that was employed as a computer technician, but had not worked since 2007 due to a low back condition. Upon examination, the VA examiner reported that the Veteran's appearance was clean and neatly groomed. He also reported unremarkable psychomotor activity, clear speech, cooperative attitude, normal affect, good mood, intact attention, normal orientation, unremarkable thought process and content, sleep impairment, no delusions, normal judgment and insight, good impulse control, normal hygiene, normal memory, and average intelligence. Furthermore, he reported no hallucinations, grossly inappropriate behavior, obsessive/ritualistic behavior, panic attacks, suicidal or homicidal thoughts, episodes of violence, or problems with activities of daily living. The examiner indicated that the Veteran has markedly diminished interest or participation in significant activities and feeling of detachment or estrangement from others, difficulty falling or staying asleep, irritability or outbursts of anger, and hypervigilance. He also reported mild social and occupational impairment due to PTSD. Pertinently, the examiner opined that the Veteran's PTSD does not render him umemployable or unable to secure and maintain substantially gainful employment, and that the Veteran is mildly impaired in his ability to engage in physical and sedentary employment due to PTSD. Based on the evidence of record, the Board finds that the Veteran is not entitled to a rating in excess of 30 percent for his PTSD. In this regard, the Board finds that, for the entire appeal period, such disability is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks as a result of episodic depressed mood, sleep disturbances, nightmares, flashbacks, irritability, feelings of isolation, and hypervigilance without more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. In this regard, the Board finds that the symptomatology manifested and the severity thereof, to specifically include the Veteran's episodic depression, sleep disturbances, nightmares, flashbacks, irritability, hypervigilance, and feelings of isolation, are contemplated in his current 30 percent rating. As indicated previously, a 50 percent rating is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The Board notes that the evidence of record indicates that the Veteran's PTSD is arguably manifested by disturbances of motivation and mood and a constricted affect. However, the Board finds that the Veteran's PTSD does not result in occupational and social impairment with reduced reliability and productivity. The Board notes that the Veteran's speech and memory have consistently been reported as normal. Further, judgment and abstract thinking has not been reported as impaired. Moreover, the Veteran does not report panic attacks during the course of the appeal. As discussed above, although the March 2006 VA examination noted his affect as constricted, and a December 2009 mental health evaluation documents an anxious affect, multiple subsequent evaluations indicate euthymic affect. Pertinently, his affect has not been described as flattened. There is also no evidence that he has difficulty in understanding complex commands. Additionally, the Veteran reported at the March 2006 VA examination that he has been married since 1970 and has two children, suggesting that he is able to maintain a social relationship. Although he reported during the December 2009 VA mental health evaluation that his wife causes him feelings of irritability and anxiety, he reported during subsequent evaluations that he gets along with her. He also reported at the July 2011 VA examination that he has occasional social relationships. The Board also notes his report at the July 2011 VA examination that he will "mope around his house." However, he also reported at that time that he has occasional social relationships and goes to football games. Both the March 2006 and July 2011VA examiners assessed the Veteran's social impairment due to PTSD as mild. Furthermore, the record indicates that the Veteran retired from work in 2007 due to a low back condition. As discussed above, the July 2011 VA examiner determined that the Veteran's PTSD was not severe enough to prevent gainful employment as his symptoms caused only mild impairment. Thus, the Board finds that the Veteran's PTSD symptomatology does not result in occupational impairment with reduced reliability and productivity. The Board finds the Veteran's reports of symptoms competent, credible and probative, however, the evidence as a whole does not show that the overall level of impairment resulting from PTSD approximates the criteria for a higher rating. Accordingly, the Board finds that the Veteran is not entitled to an initial rating in excess of 30 percent. The Board further notes that the evidence of record reflects that the Veteran has additional symptomatology including nightmares, flashbacks, mood swings, intrusive thoughts, feelings of isolation, and hypervigilance. See Mauerhan, supra. These symptoms are fully contemplated in the assigned evaluation. However, the Board finds that such symptoms do not more nearly approximate a rating in excess of 30 percent under the General Rating Formula as they are not of such a severity or frequency to result in occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. The Board also observes that the Veteran has been assigned GAF scores between 55 and 63, which indicate moderate to mild impairment with a GAF of 61 at his recent VA examination. The GAF scores of 55 and 63 are appropriately reflected in the assignment of a 30 percent disability rating. Moreover, the Board finds that, during such time period, the Veteran's PTSD symptomatology, described above, does not more nearly approximate a 70 or 100 percent rating. The Board notes that the Veteran has arguably evidenced disturbances of motivation and mood and difficulty adapting to stressful circumstances. In this regard, the Board notes that the Court of Appeals for the Federal Circuit (Federal Circuit) recently held in Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013) that "in the context of a 70 percent rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." However, the evidence does not show that the Veteran has occupational and social impairment with reduced reliability and productivity or with deficiencies in most areas, or, total occupational and social impairment. In this regard, the evidence fails to demonstrate such symptomatology as suicidal ideation; obsessional rituals to the extent that they interfere with routine activities; near-continuous panic or depression; speech intermittently illogical, obscure, or irrelevant; spatial disorientation; neglect of personal appearance and hygiene; inability to establish and maintain effective relationships; gross impairment in thought processes or communication; delusions or hallucinations; grossly inappropriate behavior; persistent danger of hearing self or others; intermittent inability to perform activities of daily living; disorientation to time or place; or memory loss. Again, while recognizing that these are examples of symptoms indicative of reduced reliability and productivity or with deficiencies in most areas, or, total occupational and social impairment, the Board finds that the symptoms and signs manifested by the Veteran are at most indicative of an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. In this regard, the VA examiners found that he has mild impairment resulting from PTSD and the evidence as a whole, as discussed above, does not show that the criteria for a higher rating are approximated. As such, for the foregoing reasons, the Board finds that the Veteran is not entitled to an rating in excess of 30 percent for PTSD. The Court has held that an appeal from an initial rating is a separate and distinct claim from a claim for an increased rating. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999). In this case, the evidence of record appears to support the proposition that the Veteran's service-connected PTSD has not changed appreciably during the period on appeal. There are no medical findings and no other evidence which would allow for the assignment of an increased disability rating during the period of time here under consideration. Specifically, as discussed above, the competent and probative evidence of record, to include the March 2006 and July 2011 VA examination reports as well as the VA treatment records indicate that the Veteran's PTSD symptomatology has remained relatively stable throughout the period. As such, there is no basis for awarding the Veteran a disability rating other than the currently assigned 30 percent for any time from November 5, 2005 to the present. In evaluating the severity of his service-connected PTSD, the Board also has considered whether referral for the disability at issue on an extra-schedular basis is warranted. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disability, with the established criteria shows that the rating criteria reasonably describe the level and symptomatology thereof. The criteria specifically provide for evaluation of the disabilities based upon the Veteran's PTSD with associated symptomatology, and they practicably represent the average impairment in earning capacity resulting from the Veteran's service-connected disabilities. See 38 C.F.R. § 4.1. Service connection for jungle rot of the feet and a groin rash Generally, service connection may be granted for disability or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Service connection presupposes a diagnosis of a current disability. See Rabideau v. Derwinski, 2 Vet. App. 141 (1992). A "current disability" means a disability shown by competent medical evidence to exist. See Chelte v. Brown, 10 Vet. App. 268 (1997). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Veteran is claiming entitlement to service connection for jungle rot of the feet and a groin rash. See, e.g., the Veteran's notice of disagreement dated May 2006. As noted above, in order for service connection to be granted, three elements must be present: (1) a current disability; (2) in-service incurrence of disease or injury; and (3) medical nexus. See Hickson, supra. With respect to element (1), the competent and probative evidence of record does not demonstrate that the Veteran is currently diagnosed with jungle rot of the feet or a groin rash. Specifically, the competent and probative evidence of record fails to show such disabilities. With regard to the Veteran's jungle rot of the feet and groin rash, he was provided a VA examination for such in March 2006. He reported that during his period of service in Vietnam, he had jungle rot of the feet and a fungal infection. He also reported that he gets a periodic groin rash for which he uses a cream. Upon examination of the Veteran's feet and groin, the VA examiner reported that a skin examination was negative for any groin rash, or any rash on the feet or tinea pedis. As such, there was no diagnosis to which the examiner could attach a chronic disabling condition. The March 2006 VA examination reports were based upon thorough review of the record, thorough examination of the Veteran, and thoughtful analysis of the Veteran's entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) [the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"]. The other medical evidence obtained or submitted in connection with the claim also fails to show that there is a disability manifested by a groin rash or a rash of the feet. The Board wishes to make it clear that it has no reason to doubt that the Veteran experiences certain symptoms such as skin irritation and itching. However, symptoms alone, without a diagnosed or identifiable underlying malady or condition, do not constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), dismissed in part and vacated in part on other grounds, Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). "Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). The Board notes that the Veteran, while entirely competent to report his symptoms both current and past (including skin irritation), as a lay person is not competent to associate any of his claimed symptoms to a groin rash or jungle rot of the feet. Such opinion requires specific medical training and is beyond the competency of the Veteran or any other lay person. In the absence of evidence indicating that the Veteran has the medical training to render medical diagnoses, the Board must find that his contention with regard to a diagnosis of a chronic groin rash or jungle rot of the feet to be of no probative value. See also 38 C.F.R. § 3.159(a)(1) (2012) [competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions]. Accordingly, the statements offered by the Veteran in support of his own claim are not competent evidence of a current jungle rot of the feet or groin rash. The Veteran has been accorded ample opportunity to present competent evidence of current disability in support of his claims of a groin rash and jungle rot of the feet. He has failed to do so. See 38 U.S.C.A. § 5107(a) (West 2002). The Court has held that "[t]he duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Because the competent evidence of record does not show a current groin rash or jungle rot of the feet, the first Hickson element is not met, and service connection is not warranted on that basis as to these claims. See Degmetich v. Brown, 104 F.3d 132 (Fed. Cir. 1997); see also Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) [service connection cannot be granted if the claimed disability does not exist]. In conclusion, for the reasons and bases expressed above, the Board finds that the preponderance of the evidence is against the Veteran's claims of entitlement to service connection for jungle rot of the feet and a groin rash. The benefits sought on appeal are accordingly denied. ORDER Entitlement to an initial evaluation in excess of 30 percent for service-connected PTSD is denied. Entitlement to service connection for a groin rash is denied. Entitlement to service connection for a left foot disorder is denied. REMAND Higher evaluation for diabetes mellitus and peripheral neuropathy of the right and left lower extremities Diabetes mellitus is rated under Diagnostic Code 7913 of the Rating Schedule. See 38 C.F.R. § 4.119. Diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated, is assigned a 100 percent disability rating. Diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated, is assigned a 60 percent disability rating. Diabetes mellitus requiring insulin, restricted diet, and regulation of activities is assigned a 40 percent disability rating. Diabetes mellitus requiring insulin and restricted diet, or use of an oral hypoglycemic agent and a restricted diet is assigned a 20 percent disability rating. Pertinently, the regulations stipulate that compensable complications of diabetes are to be evaluated separately, with noncompensable complications to be considered as part of the diabetic process under Diagnostic Code 7913. See 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1). The Board observes that the RO originally rated separately the Veteran's bilateral cataracts, which have been found to be related to his diabetes mellitus, as noncompensable (zero percent) disabling in a May 2009 rating decision. However, in adjudicating the Veteran's diabetes claim in the June 2011 rating decision, the RO combined the Veteran's diabetes mellitus with bilateral cataracts. Crucially, the Veteran's cataracts were not evaluated by the RO, nor has he been afforded a VA examination for his cataracts during the pendency of the appeal. Indeed, the most recent VA examination for the Veteran's cataracts is dated August 2008. Accordingly, the Board finds that a contemporaneous VA examination is warranted to ascertain the current severity of the Veteran's service-connected diabetes mellitus with bilateral cataracts. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) [Court determined that Board should have ordered contemporaneous examination of Veteran because a 23-month old exam was too remote in time to adequately support the decision in an appeal for an increased rating]; Charles v. Principi, 16 Vet. App. 370 (2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 C.F.R. § 3.159(c)(4) (2012) (holding a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient medical evidence to decide the claim). The issues of entitlement to increased disability ratings for peripheral neuropathy of the right and left lower extremities are inextricably intertwined with the claim of entitlement to an increased rating for diabetes mellitus with bilateral cataracts as the Veteran's neuropathy has been found to be related to his service-connected diabetes. See 38 C.F.R. § 4.119, Diagnostic Code 7913 (criteria for a total rating consider complications that would be compensable if separately rated). Also, examination of symptoms associated with the Veteran's diabetes may impact the neuropathy claims. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) [two or more issues are inextricably intertwined if one claim could have significant impact on the other]. Service connection for a lung disability The Veteran contends that his claimed lung disability is related to exposure to asbestos during service. See the March 2006 VA examination report. A review of his personnel records reveal that his military duties involved repairing missile launchers and that he also served as a mechanic. Given the nature of the Veteran's in-service duties, the Board recognizes that it is conceivable that the Veteran worked in close proximity to asbestos. Notably, some of the major in-service occupations involving exposure to asbestos include manufacture and installation of military equipment. M21-1MR, Part IV, Subpart ii, Chapter 2, §C(9)(f). The Veteran was afforded a VA examination in March 2006 for his claimed lung disability. He reported in-service asbestos exposure, although he denied any history of coughing, sputum production, or any hemoptysis. Upon examination, the VA examiner reported that the Veteran's lungs revealed slightly decreased breath sounds in the right lung base, but were otherwise normal. Radiographically, the Veteran had no evidence of asbestosis or silicosis. Indeed, no active pulmonary disease was identified, and the examiner therefore declined to diagnose the Veteran with a lung disability. In the absence of proof of present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). See also Degmetich v. Brown, 104 F.3d 1328 (1997) (also interpreting 38 U.S.C. § 1131 as requiring the existence of a present disability for VA compensation purposes). To be present as a current disability, there must be evidence of the condition at some time during the appeals period. Gilpin v. West, 155 F. 3d 1353, 1356 (Fed. Cir. 1998); see also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the Gilpin requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves). However, the Board recognizes the Court's decision in Romanowsky v. Shinseki, No. 11-3272 (U.S. Vet. App. May 9, 2013) which held that a claimant satisfies the current disability threshold when a disability exists at the time his or her claim was filed, even if the disability resolves prior to VA's adjudication of the claim. In this case, although a lung disability was not rendered during the March 2006 VA examination, the Board observes that a private treatment record dated February 2004 from D.G., M.D., noted that a review of a January 9, 2004 chest X-ray indicated findings consistent with silicosis. Although a private chest X-ray report dated January 27, 2004 from G.F., M.D. reveals that the Veteran's lungs were clear, the evidence of record is unclear as to whether a lung disability existed at the time the Veteran filed his service connection claim in November 2005. In light of the Court's decision in Romanowsky, the Board is of the opinion that a clarifying medical opinion would be probative in ascertaining whether the Veteran's previously diagnosed silicosis, or any other lung disability, resolved prior to the filing of his claim in November 2005, and if not, whether such disability is related to his military service. See Charles and McLendon, both supra; see also 38 C.F.R. § 3.159(c)(4) (2012). Service connection for pes planus A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto. 38 U.S.C.A. § 1111 (West 2002); 38 C.F.R. § 3.304(b) (2012). VA's General Counsel has held that to rebut the presumption of sound condition under 38 U.S.C. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. See VAOPGCPREC 3-2003 (July 16, 2003); see also Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004). The Court has held, however, that this presumption attaches only where there has been an entrance examination in which the later complained-of disability was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). In VAOPGCPREC 3-2003, VA's General Counsel noted that "[u]nder the language of [38 U.S.C. § 1111], VA's burden of showing that the condition was not aggravated by service is conditioned only upon a predicate showing that the condition in question was not noted at entry into service." With respect to a current disability, the current medical evidence of record documents a diagnosis of pes planus. See, e.g., the March 2006 VA examination report. The Veteran's February 1967 service entrance examination is absent complaints of or diagnosis of pes planus. Thus, the Veteran is presumed to have been in sound condition upon entry. However, there is no opinion of record that addresses whether there is clear and unmistakable evidence that the Veteran's pes planus preexisted military service and, if it did, whether there is clear and unmistakable evidence that the pes planus was not aggravated by service. See 38 U.S.C.A. §§ 1111, 1153 (West 2002), 1132; 38 C.F.R. §§ 3.304(b), 3.306 (2012); Wagner, supra; VAOPGCPREC 3-2003. In light of the foregoing, the Board finds that an opinion for such must be obtained. See 38 U.S.C.A. § 5103A(d) (West 2002); Barr, supra; McLendon, supra. Service connection for a left foot disability, sleep apnea, and upper respiratory problems The Veteran was afforded VA examinations in March 2006 to determine the etiology of his left foot disability, sleep apnea, and upper respiratory problems. Notably, the Veteran's claims folder was not available for these examinations. After examination of the Veteran, the VA examiner diagnosed the Veteran with calluses of the left foot and sleep apnea. Crucially, however, the VA examiner did not render opinions as to whether the Veteran's left foot disability and sleep apnea are related to military service. Additionally, although the VA examiner declined to diagnose the Veteran with a disability manifested by upper respiratory problems, the Board notes that the competent and probative evidence of record documents a diagnosis of allergic rhinitis during the period under consideration. See McClain, supra. There is no opinion of record as to whether the Veteran's diagnosed left foot disability, sleep apnea, and upper respiratory problems are related to his military service. In light of the foregoing, the Board is of the opinion that a medical opinion is warranted to ascertain the etiology of the Veteran's left foot disability, sleep apnea, and upper respiratory problems. See Charles and McLendon, both supra; see also 38 C.F.R. § 3.159(c)(4) (2012). Service connection for benign prostatic hypertrophy The Court has held that in disability compensation claims, VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. See McLendon, supra. As to current disability, the medical evidence of record documents a current diagnosis of benign prostatic hypertrophy. See, e.g., a private treatment record from G.G., D.O., dated October 2010. With respect to in-service disease, the Board notes that the Veteran's service treatment records, to include his April 1970 separation examination, are negative for complaints of, treatment for, or findings of benign prostatic hypertrophy. Indeed, the earliest document showing a history of symptoms related to benign prostatic hypertrophy is dated October 2001, more than 30 years after the Veteran's discharge from active duty. See a private treatment record from J.P., M.D., dated October 2001. Concerning in-service injury, the Board concedes the Veteran's in-service exposure to Agent Orange. Of particular importance in this regard is the fact that service personnel records confirm the Veteran's service in the Republic of Vietnam from January to August 1969. His exposure to herbicides is, therefore, presumed. See 38 U.S.C.A. § 1116(f). According to 38 C.F.R. § 3.309(e) (2012), certain diseases may be presumed to be related to exposure to herbicides; benign prostatic hypertrophy is not one of the listed diseases. Therefore, benign prostatic hypertrophy may not be presumed to be related to herbicide exposure. However, service connection based on direct causation may still be established pursuant to Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Furthermore, the Veteran contends that his current benign prostatic hypertrophy is related to his military service, specifically herbicide exposure. The Veteran was afforded a VA genitourinary examination in March 2006. The examiner noted that the Veteran had a history of prostatitis which was treated in the prior three to four years by his private physician, however, an opinion as to nexus was not provided. Accordingly, the examination was insufficient. TDIU The claim of entitlement to TDIU is inextricably intertwined with the claims remanded herein. In other words, the resolution of the Veteran's claims for service connection may impact his claim for TDIU. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) [two or more issues are inextricably intertwined if one claim could have significant impact on the other]. Accordingly, action on the TDIU claim is deferred at this time. Accordingly, the case is REMANDED for the following action: 1. Take appropriate steps to contact the Veteran and request that he provide or identify medical records pertaining to the treatment of the claims remanded herein that are not already of record. After obtaining proper authorization, obtain any relevant records from identified providers that are not already of record. If, after making reasonable efforts to obtain named non-VA records the AMC is unable to secure same, or if after continued efforts to obtain federal records it is concluded that it is reasonably certain they do not exist or further efforts to obtain them would be futile, the AMC must notify the Veteran and (a) identify the specific records the AMC is unable to obtain; (b) briefly explain the efforts that the AMC made to obtain those records; (c) describe any further action to be taken by the AMC with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 2. Thereafter, the Veteran should be afforded an examination to determine the current severity of his diabetes mellitus, type II, and any associated manifestations, including but not limited to peripheral neuropathy of the right and lower extremities and bilateral cataracts. The claims folder and a copy of this Remand must be made available to the examiner who should indicate on the examination report that the folder was reviewed in conjunction with the examination. The examiner should also evaluate and discuss the severity of all complications of diabetes mellitus, type II, that the Veteran experiences, to include, but not limited to, peripheral neuropathy of the right and lower extremities and bilateral cataracts. Furthermore, the examiner(s) should specifically address the following questions: a) Does the treatment for the Veteran's diabetes mellitus include the requirement of insulin, restricted diet, and the regulation of occupational and recreational activities? b) Does the Veteran experience episodes of ketoacidosis or hypoglycemic reactions? If so, the examiner should note the number of hospitalizations per year or number of visits to a diabetic care provider required as a result of such episodes. c) Does the Veteran's diabetes mellitus require more than one daily injection of insulin or involve the progressive loss of weight and strength? A complete explanation must be provided for all opinions offered, and the examiner must fully consider and discuss the Veteran's lay statements when offering an opinion. 3. The Veteran should be afforded an appropriate VA examination to determine the nature and etiology of his lung disability, sleep apnea, left foot disability, pes planus, upper respiratory problems, and benign prostatic hypertrophy. The Veteran's claims folder must be made available to the examiner prior to the examination. All tests and studies deemed necessary by the examiner should be performed. Based on a review of the claims folder and the clinical findings of the examination, the examiner must: a) Identify any current lung disability. b) If a lung disability is not identified, render an opinion as to when the lung disability resolved, in particular if it resolved prior to November 2005 when the Veteran filed his claim for VA benefits. Please discuss the January 9, 2004 chest X-ray indicating an impression of silicosis. c) If a lung disability is identified at any time during the period of time that is covered by this claim, provide an opinion as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that the disability is related to the Veteran's period of military service, to include his claimed exposure to asbestos. d) With respect to flat feet, address whether it is a congenital or developmental defect or disease. [Note: a disease generally refers to a condition that is considered capable of improving or deteriorating while a defect is generally not considered capable of improving or deteriorating. VAOPGCPREC 82-90 (1990) (citing Durham v. United States, 214 F.2d 862, 875 (D.C. Circuit 1954)]. Please provide a complete explanation for the opinion. e) If it is a congenital or developmental defect, explain whether it is at least as likely as not (a probability of 50 percent or greater) that there was a superimposed injury or disease in active duty that resulted in additional disability of the foot. Please provide a complete explanation for the opinion. f) If it is a disease, state whether it is clear and unmistakable (obvious, manifest, and undebatable) that pes planus pre-existed active service. Please provide a complete explanation for the opinion. g) If so, state whether it is clear and unmistakable (obvious, manifest, and undebatable) that pre-existing pes planus WAS NOT aggravated (i.e., permanently worsened) during service or whether it is clear and unmistakable (obvious, manifest, and undebatable) that any increase was due to the natural progress. Please provide a complete explanation for the opinion. h) If a response above is negative, provide an opinion as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that the Veteran's current pes planus disability began in or is etiologically related to his period of his military service. i) Provide an opinion as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that the Veteran's left foot disability (other than pes planus), to include calluses of the left foot and plantar fasciitis, began in or is etiologically related to his period of his military service. j) Provide an opinion as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that the Veteran's current upper respiratory problems, including allergic rhinitis, began in or are etiologically related to his period of his military service. k) Provide an opinion as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that the Veteran's current sleep apnea began in or is etiologically related to his period of his military service. l) Provide an opinion as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that the Veteran's current benign prostatic hypertrophy began in or is etiologically related to his period of his military service, to include presumed herbicide exposure therein. The examiner should indicate in his/her report that the claims folder was reviewed. A rationale for all opinions expressed should be provided. A report should be prepared and associated with the Veteran's VA claims folder. 4. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims should be readjudicated. If the claims remain denied, a supplemental statement of the case should be provided to the Veteran and his representative. After the Veteran has had an adequate opportunity to respond, the appeal should be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. See 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). ______________________________________________ S.S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs