Citation Nr: 1321933 Decision Date: 07/09/13 Archive Date: 07/18/13 DOCKET NO. 08-29 507 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for diabetic retinopathy, to include as secondary to diabetes mellitus. 2. Entitlement to service connection for bilateral leg radiculopathy, to include as secondary to diabetes mellitus. 3. Entitlement to service connection for a prostate disability, to include as secondary to exposure to herbicides. 4. Entitlement to service connection for a liver disability, to include as secondary to diabetes mellitus. 5. Entitlement to service connection for bilateral peripheral vascular disease of the lower extremities, to include as secondary to exposure to herbicides. 6. Entitlement to service connection for a stomach disability, to include as secondary to exposure to herbicides. 7. Entitlement to an initial rating in excess of 30 percent for diabetic nephropathy. 8. Entitlement to an initial rating in excess of 20 percent for diabetes mellitus. 9. Entitlement to an initial rating in excess of 10 percent for neurogenic bladder, and a rating in excess of 20 percent as of May 13, 2009. 10. Entitlement to an initial rating in excess of 10 percent for hypertension. 11. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right upper extremity. 12. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left upper extremity. 13. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right lower extremity. 14. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left lower extremity. 15. Entitlement to an initial rating in excess of 10 percent for atherosclerotic heart disease and mild coronary artery disease. 16. Entitlement to a total disability rating based on individual unemployability due to service-connected disability. ATTORNEY FOR THE BOARD David S. Ames, Counsel INTRODUCTION The Veteran served on active duty from June 1967 to January 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. This case was remanded by the Board in March 2013 for additional development. In September 2010, the Veteran was provided with a statement of the case covering the issues of entitlement to an earlier effective date for assignment of a 20 percent rating for the Veteran's service-connected neurogenic bladder. While the Veteran subsequently perfected an appeal as to that issue, he had already perfected an appeal as to the rating assigned for his neurogenic bladder prior to May 13, 2009. A dispute as to the effective date assigned for a grant of a staged rating is essentially a dispute as to the rating assigned prior to the effective date of the staged rating. Accordingly, the Veteran's claim for an earlier effective date for the 20 percent rating is already part of his claim of entitlement to an initial rating in excess of 10 percent for neurogenic bladder. Therefore, the earlier effective date claim is redundant of the increased initial rating claim, and the Board shall consider the two independently perfected claims as a single increased initial rating claim for the purposes of future adjudication. The issues of entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) and entitlement to service connection for bilateral peripheral vascular disease of the lower extremities and a stomach disability are remanded to the RO via the Appeals Management Center, in Washington, D.C. FINDINGS OF FACT 1. An unappealed rating decision in April 2007 denied service connection for diabetic retinopathy. 2. The evidence received since the April 2007 rating decision is not material, and does not raise a reasonable possibility of substantiating the Veteran's diabetic retinopathy claim. 3. The competent evidence of record shows that the Veteran has never had a diagnosis of leg radiculopathy separate from his bilateral leg peripheral neuropathy. 4. The evidence of record does not demonstrate that the Veteran has a current diagnosis of a prostate disability which is related to service or to a service-connected disability. 5. The evidence of record does not demonstrate that the Veteran has a current diagnosis of a liver disability which is related to service or to a service-connected disability. 6. The medical evidence of record does not show that the Veteran's hypertension has ever been manifested by diastolic pressure of predominantly 110 or more or systolic pressure of predominantly 200 or more. 7. The medical evidence of record shows that the Veteran's diabetic nephropathy is manifested by occasional microalbuminuria and occasional edema and the Veteran has hypertension which is rated 10 percent disabling under Diagnostic Code 7101. 8. The medical evidence of record shows that the Veteran's diabetes mellitus is manifested by symptoms requiring insulin, an oral hypoglycemic agent, a restricted diet, and episodes of ketoacidosis or hypoglycemic reactions which do not require hospitalization or visits to a diabetic care provider. 9. The medical evidence of record shows that the Veteran's left upper extremity peripheral neuropathy is manifested by mild incomplete paralysis. 10. The medical evidence of record shows that the Veteran's right upper extremity peripheral neuropathy is manifested by mild incomplete paralysis. 11. The medical evidence of record shows that the Veteran's left lower extremity peripheral neuropathy is manifested by moderate incomplete paralysis. 12. The medical evidence of record shows that the Veteran's right lower extremity peripheral neuropathy is manifested by moderate incomplete paralysis. 13. The medical evidence of record shows that the Veteran's artherosclerotic heart disease and coronary artery disease is manifested by METs of greater than 7. 14. The medical evidence of record shows that, prior to May 13, 2009, the Veteran's neurogenic bladder was manifested by a daily voiding frequency of about 10, with nocturia of one or two times per night. 15. The medical evidence of record shows that, on and after May 13, 2009, the Veteran's neurogenic bladder was manifested by a daytime voiding interval of one to two hours, with three voidings per night. CONCLUSIONS OF LAW 1. The evidence received since the April 2007 rating decision is not new and material, and therefore, the claim of entitlement to service connection for diabetic retinopathy is not reopened. 38 U.S.C.A. §§ 5103A, 5107, 5108, 7104 (West 2002); 38 C.F.R. § 3.156 (2012). 2. Bilateral leg radiculopathy was not incurred in, or aggravated by, active service, nor is it proximately due to, or aggravated by, a service-connected disability. 38 U.S.C.A. §§ 1110, 1116, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.310 (2012). 3. A prostate disability was not incurred in, or aggravated by, active service and may not be presumed to have been so incurred, to include as due to herbicide exposure, nor is it proximately due to, or aggravated by, a service-connected disability. 38 U.S.C.A. §§ 1110, 1116, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 4. A liver disability was not incurred in, or aggravated by, active service and may not be presumed to have been so incurred, to include as due to herbicide exposure, nor is it proximately due to, or aggravated by, a service-connected disability. 38 U.S.C.A. §§ 1110, 1116, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 5. The criteria for an initial rating in excess of 10 percent for hypertension have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). 6. The criteria for an initial rating in excess of 30 percent for diabetic nephropathy have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.115a, 4.115b, Diagnostic Code 7541 (2012). 7. The criteria for an initial rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). 8. The criteria for an initial rating in excess of 10 percent for left upper extremity peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8616 (2012). 9. The criteria for an initial rating in excess of 10 percent for right upper extremity peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8616 (2012). 10. The criteria for an initial rating of 20 percent, but not higher, for left lower extremity peripheral neuropathy have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8620 (2012). 11. The criteria for an initial rating of 20 percent, but not higher, for right lower extremity peripheral neuropathy have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8620 (2012). 12. The criteria for an initial rating in excess of 10 percent for atherosclerotic heart disease and mild coronary artery disease have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7005 (2012). 13. The criteria for an initial rating in excess of 10 percent for neurogenic bladder, and a rating in excess of 20 percent as of May 13, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.115b, Diagnostic Code 7542 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the Veteran is harmless because of the thorough and informative notices provided throughout the adjudication and because the Veteran had a meaningful opportunity to participate effectively in the processing of the claims with an adjudication of the claims by the RO subsequent to receipt of the required notice. The record does not show prejudice to the Veteran, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006). Specifically, the Veteran was notified in letters dated in August 2007, April 2009, October 2009, August 2010, and March 2013. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls on party attacking agency determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran suggest actual knowledge of the elements necessary to substantiate the claims. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Thus, VA has satisfied its duty to notify the Veteran and had satisfied that duty prior to the adjudication in the supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the Veteran of any evidence that could not be obtained. The Veteran has not referred to any additional, unobtained, relevant, available evidence. VA has obtained examinations with respect to the claims decided herein. While an examination was not provided with respect to the diabetic retinopathy claim, such an examination is not required as the Veteran has not submitted new and material evidence related to that claim. 38 C.F.R. § 3.159(c) (2012). Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Diabetic Retinopathy An unappealed rating decision in April 2007 denied the Veteran's claim of entitlement to service connection for diabetic retinopathy on the basis that the medical evidence of record showed that the Veteran did not have diabetic retinopathy. The relevant evidence of record at the time of the April 2007 rating decision consisted of the Veteran's service medical records and various VA medical records and examination reports dated in January 2007 and February 2007. The Veteran did not file a notice of disagreement after the April 2007 rating decision. Therefore, the April 2007 rating decision is final based on the evidence then of record. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2012). A finally decided claim will be reopened in the event that new and material evidence is presented. 38 U.S.C.A. § 5108 (West 2002). New evidence means existing evidence not previously submitted to VA. Material evidence means existing evidence that by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (2012). In February 2009, a claim to reopen the issue of entitlement to service connection for diabetic retinopathy was received. Evidence of record received since the April 2007 rating decision includes VA medical records dated from April 2007 to February 2013 and a March 2009 letter from a private physician. All of the evidence received since the April 2007 rating decision is new in that it was not of record at the time of the April 2007 decision. However, none of the new evidence is material, as it does not demonstrate that the Veteran has ever had a diagnosis of diabetic retinopathy. While the March 2009 letter from a private physician discussed the impact of diabetes mellitus on the eyes, it only stated that the Veteran presented with glaucoma and fluctuating visual acuity. Accordingly, the March 2009 letter from a private physician does not provide a diagnosis of diabetic retinopathy. In addition, VA eye examination reports did not provide diagnoses of diabetic retinopathy in February 2009 and July 2009, while reports dated in January 2012 and July 2012 specifically found that the Veteran did not have diabetic retinopathy. Therefore, the new evidence does not include any evidence that the Veteran has ever had a diagnosis of diabetic retinopathy. Therefore, the Board finds that the evidence received since the April 2007 rating decision is not material, and does not raise a reasonable possibility of substantiating the claim. Since the additional evidence received since the April 2007rating decision is not material and does not raise a reasonable possibility of substantiating the Veteran's claims, it does not constitute new and material evidence sufficient to reopen the Veteran's claims of entitlement to service connection for diabetic retinopathy. As new and material evidence to reopen the finally disallowed claim has not been submitted, there is no reasonable doubt to be resolved in favor of the Veteran and the claim must remain denied. Annoni v. Brown, 5 Vet. App. 463 (1993). Service Connection Generally, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2012). In addition, service connection may be granted for any disease diagnosed after discharge, when all the evidence including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310(a) (2012). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by a service connected disability or aggravated by a service connected disability. 38 C.F.R. § 3.310(a) (2012); Allen v. Brown, 7 Vet. App. 439 (1995). The determination as to whether the requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999). Bilateral Leg Radiculopathy The Veteran's service medical records are negative for any complaints or diagnosis of leg radiculopathy. In a January 1969 service separation report of medical history, the Veteran denied having swollen or painful joints, cramps in his legs, and neuritis. On clinical evaluation, the Veteran's lower extremities were normal. After separation from service, in a January 2007 VA peripheral nerves examination report, the Veteran complained of peripheral neuropathy in the lower extremities. After physical and neurological examination, the diagnosis was moderate to severe sensory motor peripheral neuropathy. A January 2007 VA diabetes mellitus examination report stated that the Veteran had symptoms of peripheral neuropathy related to diabetes, including numbness, tingling, and pain in his feet. After physical and diagnostic examination, the diagnoses included peripheral neuropathy. A September 2007 VA outpatient medical report stated that, after neurologic examination, the diagnoses included peripheral neuropathy. A November 2009 VA outpatient medical report gave an assessment that included peripheral neuropathy. A March 2009 letter from a private physician stated that the Veteran had neuropathy that was related and secondary to diabetes mellitus. A May 2009 VA peripheral nerves examination report stated that, after physical and neurological examination, the diagnosis was moderate primarily sensory diabetic peripheral neuropathy. A May 2009 VA diabetes mellitus examination report stated that, after physical and diagnostic examination, the diagnoses included peripheral neuropathy. A September 2009 VA outpatient medical report stated that, after examination, the assessment included diabetic neuropathy. An October 2009 VA neurological examination report stated that, after diagnostic testing, the conclusion was that the Veteran had findings consistent with bilateral moderate carpal tunnel syndrome, but no signs of peripheral neuropathy. An October 2012 VA podiatry report gave an assessment of insulin dependent diabetes mellitus with peripheral neuropathy. The competent evidence of record shows that the Veteran has never had a diagnosis of leg radiculopathy separate from his bilateral leg peripheral neuropathy. While the medical evidence of record clearly demonstrates that the Veteran experiences neuropathic disabilities of the lower extremities, service connection for left and right leg peripheral neuropathy is already in effect. Accordingly, those disabilities are not for consideration in conjunction with the Veteran's radiculopathy claim. 38 C.F.R. § 4.14 (2012). There is no medical evidence of record that the Veteran has ever had a diagnosis of radiculopathy separate from his bilateral leg peripheral neuropathy. All medical reports of record which have provided a diagnosis of the Veteran's reported lower extremity neurological symptoms have given that diagnosis as peripheral neuropathy. The Veteran's statements are competent to demonstrate that he experiences neuropathic symptoms. Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 21 Vet. App. 191 (2007). However, the Veteran's statements are not competent to prove that his symptoms are caused by radiculopathy, as opposed to the already service-connected peripheral neuropathy. In this case, the medical diagnosis and causation involve questions that are beyond the range of common experience and common knowledge and require the special knowledge and experience of a trained physician. As he is not a physician, the Veteran is not competent to make a determination that any neurologic disability he currently experiences is radiculopathy, as opposed to peripheral neuropathy. Davidson v. Shinseki, 581 F.3d 1313 (2009); Barr v. Nicholson, 21 Vet. App. 303 (2007). The existence of a current disability is the cornerstone of a claim for VA disability compensation. Degmetich v. Brown, 104 F. 3d 1328 (1997); Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). In this case, there is no competent evidence of record that the Veteran has ever had a diagnosis of radiculopathy, independent of his service-connected peripheral neuropathy. Therefore, service connection for bilateral leg radiculopathy is not warranted. There is no competent evidence of record that the Veteran has ever had a diagnosis of bilateral leg radiculopathy, and the Board finds that the preponderance of the evidence is against the claim. Therefore, the claim is denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Herbicides A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any herbicide agent during that service. 38 U.S.C.A. § 1116(f) (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). The following diseases are deemed associated with herbicide exposure: AL amyloidosis, chloracne or other acneform diseases consistent with chloracne, diabetes mellitus type 2, Hodgkin's disease, all chronic B-cell leukemias, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma), Parkinson's disease, and ischemic heart disease. 38 U.S.C.A. § 1116 (West 2002); 38 C.F.R. §§ 3.307(a)(6)(iii), 3.309 (2012). In this case, the Veteran claims that he developed prostate and liver disabilities as the result of exposure to herbicides. The evidence of record shows that the Veteran served in Vietnam. He is therefore presumed to have been exposed to herbicide agents. 38 U.S.C.A. § 1116(f) (West 2002). However, the medical evidence of record does not show a current diagnosis of a presumptive disability. 38 C.F.R. § 3.309(e). While the medical evidence shows that the Veteran has received diagnoses of a fatty liver and benign prostatic hypertrophy, there is no medical evidence that the Veteran has ever received a diagnosis of prostate cancer or of any presumptive liver disability. Accordingly, presumptive service connection for a prostate disability and a liver disability is not warranted under 38 C.F.R. § 3.309(e). Notwithstanding the foregoing, the Veterans' Dioxin and Radiation Exposure Compensation Standards Act, Pub. L. No. 98-542, § 5, 98 Stat. 2724 (1984), does not preclude a veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); McCartt v. West, 12 Vet. App. 164 (1999). Prostate Disability The Veteran's service medical records are negative for a diagnosis of any prostate disability. After separation from service, a February 2007 VA genitourinary examination report included a physical examination of the Veteran's prostate, during which no abnormalities were noted. The diagnoses did not include a prostate disorder. A September 2007 VA urology report stated that, on physical examination, the Veteran's prostate was small and rubbery. The diagnoses did not include a prostate disorder. A March 2009 letter from a private physician stated that the Veteran presented with prostate problems. While the examiner commented on the presence and etiology of other genitourinary disorders, no further commentary was made with respect to the Veteran's prostate. A May 2008 VA prostate examination was normal. However, the medical evidence of record shows that the Veteran has been consistently provided with a prescription for his prostate since May 2008. An undated VA problem list included benign hypertrophy of the prostate without urinary obstruction. A January 2009 VA surgery note stated that the Veteran had been found to have an obstructive prostate. A May 2009 VA genitourinary examination report stated that, on physical examination, the Veteran's prostate was normal. The diagnoses did not include a prostate disorder. A November 2012 VA urology consultation report stated that the Veteran had previously been evaluated for urinary problems in 2009, at which time he was found to have benign prostatic hypertrophy. A March 2012 VA prostate examination was normal. The Board finds that the evidence of record does not demonstrate that the Veteran has a current diagnosis of a prostate disability which is related to service or to a service-connected disability. The Veteran's service medical records are negative for any diagnosis of a prostate disability. While the medical evidence of record shows that the Veteran has been found to have benign prostatic hypertrophy, there is no medical evidence of record of a prostate disability prior to May 2008, over 39 years after separation from service. Mense v. Derwinski, 1 Vet. App. 354 (1991); Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Furthermore, there is no medical evidence of record which relates any currently diagnosed prostate disability to service or to a service-connected disability. While the March 2009 letter made some comments regarding the etiology of the Veteran's genitourinary symptoms, service-connection is already in effect for neurogenic bladder and erectile dysfunction, which encompasses all relevant etiological comments made in the March 2009 letter. The letter did not give a specific diagnosis for the Veteran's reported prostate problems, and did not provide an etiological opinion which related any prostate diagnosis to service or a service-connected disability. The Veteran's statements are competent and credible as to the observable symptoms that he experiences. Barr v. Nicholson, 21 Vet. App. 303 (2007), Washington v. Nicholson, 21 Vet. App. 191 (2007). However, the Veteran's statements alone are not sufficient to prove that he has a current diagnosis of a prostate disability which is related to service or to a service-connected disability because he is not competent to provide a diagnosis or etiological opinion as to that complex medical issue. Davidson v. Shinseki, 581 F.3d 1313 (2009); Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the evidence of record does not demonstrate that the Veteran has a current diagnosis of a prostate disability which is related to service or to a service-connected disability. Therefore, the Board finds that service connection for a prostate disability is not warranted. The Board finds that the preponderance of the evidence is against the Veteran's claim. Therefore, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Liver Disability The Veteran's service medical records are negative for any diagnosis of a liver disability. After separation from service, an April 2007 VA abdominal sonogram gave an impression of hepatomegaly with fatty liver infiltration and/or hepatocellular disease. A subsequent September 2007 VA outpatient medical report stated that the sonogram was normal except for a fatty liver. The medical evidence of record shows that fatty liver has been consistently diagnosed since April 2007. A March 2009 letter from a private physician stated that the Veteran presented with a fatty liver. While the examiner commented on the presence and etiology of other disorders, no further commentary was made with respect to the Veteran's liver. In a May 2009 VA liver, gall bladder, and pancreas examination report the Veteran stated that he was first found to have elevated liver enzymes during routine laboratory testing in the private sector, and subsequently underwent a liver sonogram that revealed a fatty liver. He reported that the onset of his fatty liver was more than 15 years earlier. After physical and diagnostic examination, the diagnosis was fatty liver. The examiner opined that the Veteran's fatty liver was not caused by or a result of diabetes mellitus. The rationale was that the Veteran's fatty liver pre-existed his diabetes mellitus by more than 10 years. The Board finds that the evidence of record does not demonstrate that the Veteran has a current diagnosis of a liver disability which is related to service or to a service-connected disability. The Veteran's service medical records are negative for any diagnosis of a liver disability. While the medical evidence of record shows that the Veteran has been found to have fatty liver disease, there is no evidence of record that a liver disability was detected prior to 1994, approximately 25 years after separation from service. In addition, the earliest medical finding of record of any abnormality of the liver was in April 2007, approximately 38 years after separation from service. Mense v. Derwinski, 1 Vet. App. 354 (1991); Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Furthermore, there is no medical evidence of record which relates any currently diagnosed liver disability to service or to a service-connected disability. The only medical evidence of record which comments on the etiology of the Veteran's liver disability is the May 2009 VA liver, gall bladder, and pancreas examination report. That report found that the Veteran's fatty liver was not caused by or a result of the Veteran's diabetes mellitus. The Board finds that an examination with etiological opinion as to whether any liver disability is related to service is not needed because the record does not show any event, disease, or injury related to the liver in service. 38 C.F.R. § 3.159(c)(4) (2012). The Veteran's statements are competent and credible as to the observable symptoms that he experiences. Barr v. Nicholson, 21 Vet. App. 303 (2007), Washington v. Nicholson, 21 Vet. App. 191 (2007). However, the Veteran's statements alone are not sufficient to prove that he has a current diagnosis of a liver disability which is related to service or to a service-connected disability because he does not have the requisite medical training to provide an opinion or diagnosis. Davidson v. Shinseki, 581 F.3d 1313 (2009); Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the evidence of record does not demonstrate that the Veteran has a current diagnosis of a liver disability which is related to service or to a service-connected disability. Therefore, the Board finds that service connection for a liver disability is not warranted. The Board finds that the preponderance of the evidence is against the Veteran's claim. Therefore, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2012). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). 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 (2012). Consideration of the whole recorded history is necessary so that a rating may accurately compensate the elements of disability present. 38 C.F.R. § 4.2 (2011); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31 (1999). Staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The appeal of the Veteran's hypertension, diabetic nephropathy, diabetes mellitus, neurogenic bladder, peripheral neuropathy, and heart disease claims are based on the assignment of initial ratings following initial awards of service connection for these disorders. Therefore, evidence contemporaneous with the claim and the initial rating decisions are most probative of the degree of disability existing when the initial ratings were assigned and should be the evidence used to decide whether an original rating on appeal was erroneous. Fenderson v. West, 12 Vet. App. 119 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson v. West, 12 Vet. App. 119 (1999). Hypertension Service connection for high blood pressure was granted by an April 2007 rating decision and a 10 percent rating was assigned under 38 C.F.R. § 4.104, Diagnostic Code 7101, effective August 1, 2006. In January 2007 the Veteran's blood pressure readings were 155/92, 152/94, and 150/91. In August 2007 the Veteran's blood pressure readings were 140/90 and 131/85. In September 2007 the Veteran's blood pressure reading was 131/85. In November 2007 the Veteran's blood pressure reading was 124/75. In January 2008 the Veteran's blood pressure reading was 134/68. In May 2008 the Veteran's blood pressure reading was 143/79. In July 2008 the Veteran's blood pressure reading was 136/78. In August 2008 the Veteran's blood pressure reading was 150/71. In September 2008 the Veteran's blood pressure reading was 126/72. In November 2008 the Veteran's blood pressure reading was 131/71. In December 2008 the Veteran's blood pressure reading was 134/73. In March 2009 the Veteran's blood pressure reading was 125/76. In May 2009 the Veteran's blood pressure reading was 120/74. In July 2009 the Veteran's blood pressure reading was 127/69. In September 2009 the Veteran's blood pressure reading was 116/69. In November 2009 the Veteran's blood pressure reading was 137/74. In June 2010 the Veteran's blood pressure reading was 116/69. In July 2010 the Veteran's blood pressure reading was 135/71. In October 2010 the Veteran's blood pressure reading was 125/70. In May 2011 the Veteran's blood pressure reading was 116/56. In September 2011 the Veteran's blood pressure reading was 115/65. In October 2011 the Veteran's blood pressure reading was 126/68. In December 2011 the Veteran's blood pressure reading was 125/67. In March 2012 the Veteran's blood pressure reading was 126/69. In May 2012 the Veteran's blood pressure reading was 121/72. In July 2012 the Veteran's blood pressure reading was 118/61. In September 2012 the Veteran's blood pressure reading was 135/70. In October 2012 the Veteran's blood pressure reading was 125/63. In November 2012 the Veteran's blood pressure reading was 133/64. Under Diagnostic Code 7101, hypertensive vascular disease, hypertension, and isolated systolic hypertension warrant a 10 percent rating with diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; as a minimum rating for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted with diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2011). The medical evidence of record does not show that the Veteran's hypertension has ever been manifested by diastolic pressure of predominantly 110 or more or systolic pressure of predominantly 200 or more. The medical evidence of record includes 32 separate blood pressure readings taken since service connection for hypertension was first granted. None of those readings shows diastolic pressure of 110 or more or systolic pressure of 200 or more on any single occasion. Accordingly, a rating in excess of 10 percent is not warranted for the Veteran's hypertension. This issue has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's hypertension, the evidence shows no distinct periods of time during which his symptoms have varied to such an extent that a rating in excess of 10 percent would be warranted under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012); Fenderson v. West, 12 Vet. App. 119 (1999). Generally, rating a disability using either the corresponding or analogous diagnostic codes contained in the Schedule is sufficient. 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008); Fisher v. Principi, 4 Vet. App. 57 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria under the Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Schedule, and the assigned schedular rating is adequate, and no referral is required. When service-connected disability affects employment in ways not contemplated by the rating schedule, § 3.321(b)(1) is applicable. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities rating for hypertension inadequate. The Veteran's hypertension was rated under 38 C.F.R. § 4.104, Diagnostic Code 7101, the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's hypertension is manifested by diastolic pressure that has never been predominantly 110 or more or systolic pressure that has never been predominantly 200 or more. When comparing this disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the rating for his hypertension. A rating in excess of the currently assigned rating is provided for certain manifestations of hypertension, but the medical evidence shows that those manifestations are not present in this case. The criteria for a 10 percent rating for the Veteran's hypertension reasonably describe the Veteran's disability level and symptomatology and, therefore, the Board finds that the currently assigned schedular rating is adequate and no referral is required. To the extent that the Veteran's hypertension combines with other service-connected disabilities to impact his employability, that issue is covered by the Veteran's claim of entitlement to TDIU, which is being remanded below. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). The Board finds that the preponderance of the evidence of record shows that the Veteran's hypertension does not meet the criteria for a rating in excess of 10 percent. Therefore, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). Diabetic Nephropathy Service connection for diabetic nephropathy associated with diabetes mellitus was granted by an April 2007 rating decision and a 30 percent rating was assigned under 38 C.F.R. § 4.115b, Diagnostic Code 7541, effective August 1, 2006. A January 2007 VA diabetes mellitus examination report stated that the Veteran did not have any symptoms of diabetic nephropathy. On urine testing, the Veteran's microalbumin level was 65.4, and marked as high. There was no blood, granular-casts, or hyaline-casts in the Veteran's urine. On blood serum testing, the Veteran's creatinine level was 0.8. The diagnoses included microalbuminuria/diabetic nephropathy. The Veteran was found to have peripheral edema but it was reported to be due to a non-diabetic related etiology. A February 2007 VA genitourinary examination report stated that the Veteran did not have a history of acute nephritis. An April 2007 VA abdominal sonogram stated that the Veteran's kidneys were normal on examination. A June 2007 VA outpatient medical report stated that the Veteran's albumin level was 4.0, which was in the normal range. The Veteran was found to not have edema on examination in VA outpatient medical reports dated in August 2007, April 2008, August 2008, September 2008, November 2008, July 2009, September 2009, November 2009, June 2010, October 2010, December 2010, March 2011, May 2011, October 2011, December 2011, March 2012, July 2012, September 2012, October 2012, and November 2012. An April 2008 VA outpatient medical report stated that the Veteran's albumin level was 4.4, which was in the normal range. A November 2008 VA outpatient medical report stated that the Veteran's albumin level was 4.6, which was in the normal range. A December 2008 VA outpatient medical report stated that, on examination, the Veteran had +2 edema. A March 2009 VA outpatient medical report stated that the Veteran's albumin level was 4.7, which was in the normal range. On examination, the Veteran had +2 edema. A May 2009 VA genitourinary examination report stated that the Veteran did not have a history of renal dysfunction, renal failure, acute nephritis, or hydronephrosis. On urine testing, the Veteran's microalbumin was 6.8 mg/L. The diagnosis was microalbuminuria as an early manifestation of diabetic nephropathy, well controlled with angiotension receptor blocker. The disorder was reported to have no significant occupational effects and no effects on the Veteran's usual daily activities. A July 2011 VA outpatient medical report stated that, on examination, the Veteran had mild edema. A September 2011 VA outpatient medical report stated that, on examination, the Veteran had bilateral non-pitting edema. An October 2012 VA outpatient medical report gave an assessment of podiatry edema. Under Diagnostic Code 7541, renal involvement in diabetes mellitus is rated as renal dysfunction. 38 C.F.R. § 4.115b, Diagnostic Code 7541 (2012). Renal dysfunction warrants a 30 percent rating with albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension is at least 10 percent disabling under Diagnostic Code 7101. Renal dysfunction warrants a 60 percent rating with constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension is at least 40 percent disabling under Diagnostic Code 7101. 38 C.F.R. § 4.115a (2012). The medical evidence of record shows that the Veteran's diabetic nephropathy is manifested by occasional microalbuminuria and occasional edema. In addition, the medical evidence of record shows that the Veteran has hypertension which is 10 percent disabling under Diagnostic Code 7101. While the Veteran has been found to have microalbuminuria on multiple occasions, the Veteran's albumin levels were also found to be normal in June 2007, April 2008, November 2008, and March 2009. Accordingly, the medical evidence of record shows that any albuminuria the Veteran experiences is not constant in nature. There is no medical evidence of record that the Veteran has ever experienced a definite decrease in kidney function. Furthermore, the Veteran's hypertension does not warrant a rating of at least 40 percent under Diagnostic Code 7101. Therefore, the Board finds that a rating in excess of 30 percent for diabetic nephropathy is not warranted. This issue has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's diabetic nephropathy, the evidence shows no distinct periods of time during which his symptoms have varied to such an extent that a rating in excess of 30 percent would be warranted under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012); Fenderson v. West, 12 Vet. App. 119 (1999). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities rating for diabetic nephropathy inadequate. The Veteran's diabetic nephropathy was rated under the renal dysfunction section of 38 C.F.R. § 4.115a, the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's diabetic nephropathy is manifested by occasional microalbuminuria and occasional edema and the Veteran has hypertension which is 10 percent disabling under Diagnostic Code 7101. When comparing the disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the rating for his diabetic nephropathy. A rating in excess of the currently assigned rating is provided for certain manifestations of renal disorders, but the medical evidence shows that those manifestations are not present in this case. The criteria for a 30 percent rating for the Veteran's diabetic nephropathy reasonably describe the Veteran's disability level and symptomatology and, therefore, the Board finds that the currently assigned schedular rating is adequate and no referral is required. To the extent that the Veteran's diabetic nephropathy combines with other service-connected disabilities to impact his employability, that issue is covered by the Veteran's claim of entitlement to TDIU, which is being remanded below. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.115a (2012). In reaching this decision, the Board finds that the preponderance of the evidence of record shows that the Veteran's diabetic nephropathy does not meet the criteria for a rating in excess of 30 percent. Therefore, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). Diabetes Mellitus Service connection for diabetes mellitus, type 2, was granted by an April 2007 rating decision and a 20 percent rating was assigned under 38 C.F.R. § 4.119, Diagnostic Code 7913, effective August 1, 2006. A January 2007 VA diabetes mellitus examination report stated that the Veteran's diabetes was treated with an oral hypoglycemic agent. He did not have episodes of hypoglycemic reactions or ketoacidosis. The Veteran was instructed to follow a restricted or special diet, but he was not restricted in his ability to perform strenuous activities. The medical evidence of record shows that, throughout the entire period on appeal, the Veteran has been regularly advised to exercise. A May 2009 VA diabetes mellitus examination report stated that the Veteran's diabetes was treated with insulin. He had episodes of hypoglycemic reactions or ketoacidosis monthly or less often, but that they did not require hospitalization. The Veteran was instructed to follow a restricted or special diet, but he was not restricted in his ability to perform strenuous activities. The Schedule provides that assignment of a 20 percent rating is warranted for diabetes mellitus requiring insulin and a restricted diet, or; an oral hypoglycemic agent and a restricted diet. A 40 percent rating is warranted for diabetes mellitus requiring insulin, a restricted diet, and regulation of activities. A 60 percent rating is warranted 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 rated. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). Complications of diabetes mellitus are to be rated separately unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are considered part of the diabetic process. 38 C.F.R. § 4.119, Diagnostic Code 7913 at Note 1 (2012). The medical evidence of record shows that the Veteran's diabetes mellitus is manifested by symptoms requiring insulin, an oral hypoglycemic agent, a restricted diet, and episodes of ketoacidosis or hypoglycemic reactions which do not require hospitalization or visits to a diabetic care provider. The medical evidence of record does not show that the Veteran's diabetes mellitus has ever required regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). The medical evidence of record does not show that the Veteran has been instructed by a physician to regulate or restrict his physical activities due to problems controlling his blood sugar. In addition, the evidence of record shows that the Veteran is actively encouraged to engage in exercise. Accordingly, the preponderance of the evidence of record shows that the Veteran's activities have not been regulated as a result of his diabetes mellitus. Therefore, the Veteran's service-connected diabetes mellitus does not meet the criteria for a rating in excess of 20 percent under the provisions of Diagnostic Code 7913. The Board has considered rating the Veteran's service-connected diabetes mellitus, under all appropriate diagnostic codes. The medical evidence of record shows that the Veteran's service-connected diabetes mellitus has caused or aggravated diabetic nephropathy, neurogenic bladder, erectile dysfunction, hypertension, peripheral neuropathy, adjustment disorder, and heart disease. The Veteran has also claimed that other medical disorders are secondary to his service-connected diabetes mellitus. However, the ratings assigned for all of those disabilities are discussed separately in this decision or the Veteran has not perfected an appeal as to the rating assigned. In addition, service connection for all other additional disabilities that the Veteran has claimed as secondary to diabetes mellitus have been adjudicated separately, either in this decision or in other final decisions. Accordingly, additional separate ratings for complications of diabetes mellitus are not warranted. This issue has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's diabetes mellitus, the evidence shows no distinct periods of time during which his symptoms have varied to such an extent that a rating in excess of 20 percent would be warranted under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012); Fenderson v. West, 12 Vet. App. 119 (1999). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities rating for diabetes mellitus inadequate. The Veteran's diabetes mellitus was rated under 38 C.F.R. § 4.119, Diagnostic Code 7913, the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's diabetes mellitus is manifested by symptoms requiring insulin, an oral hypoglycemic agent, a restricted diet, and episodes of ketoacidosis or hypoglycemic reactions which do not require hospitalization or visits to a diabetic care provider. When comparing this disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the rating for his diabetes mellitus. A rating in excess of the currently assigned rating is provided for certain manifestations of diabetes mellitus, but the medical evidence shows that those manifestations are not present in this case. The criteria for a 20 percent rating for the Veteran's diabetes mellitus reasonably describe the Veteran's disability level and symptomatology and, therefore, the Board finds that the currently assigned schedular rating is adequate and no referral is required. To the extent that the Veteran's diabetes mellitus combines with other service-connected disabilities to impact his employability, that issue is covered by the Veteran's claim of entitlement to TDIU, which is being remanded below. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). In reaching this decision, the Board finds that the preponderance of the evidence of record shows that the Veteran's diabetic nephropathy does not meet the criteria for a rating in excess of 20 percent. Therefore, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). Peripheral Neuropathy Service connection for peripheral neuropathy of all four extremities was granted by an April 2007 rating decision and a 10 percent rating was assigned for each extremity effective August 1, 2006. The ratings for the Veteran's upper extremities were assigned under 38 C.F.R. § 4.124a, Diagnostic Code 8616, while the ratings for the Veteran's lower extremities were assigned under 38 C.F.R. § 4.124a, Diagnostic Code 8620. In a January 2007 VA peripheral nerves examination report, the Veteran complained of numbness in all four extremities. On physical examination, the Veteran had full muscle strength in all four extremities without motor function impairment. He had decreased sensation to vibration in the lower extremities, absent sensation to pain in the lower extremities, decreased sensation to pain in the upper extremities, and decreased sensation to light touch in all four extremities. His position sense was normal. Reflexes were normal in all joints, except the knees and ankles, where they were absent. The Veteran did not have any muscle atrophy, abnormal muscle tone or bulk, tremors, tics, or other abnormal movements. The nerve disorder did not affect the function of any joint and his gait and balance were normal. The diagnosis was moderate to severe sensory motor peripheral neuropathy. He did not have nerve paralysis or neuralgia, but he did have neuritis. The disorders had no significant effects on the Veteran's occupation and no effects on his usual daily activities. The medical evidence of record shows that the Veteran has consistently reported experiencing numbness, pain, and paresthesias in all four extremities since January 2007. An August 2007 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. A September 2007 VA outpatient medical report stated that, on neurologic examination, the Veteran had peripheral neuropathy. A November 2007 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. A May 2008 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. An August 2008 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. A September 2008 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. A December 2008 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. An April 2009 VA outpatient medical report stated that, on examination, the Veteran had decreased sensation in both feet. In a May 2009 VA peripheral nerves examination report, the Veteran complained of numbness, pain, and cramps in all four extremities. On physical examination, the Veteran had full muscle strength in all four extremities without motor function impairment. He had decreased sensation to vibration and pain in all four extremities, but his sensation to light touch and his position sense were normal. Reflexes were normal in all joints, except the knees, where they were reduced, and ankles, where they were absent. The Veteran did not have any muscle atrophy, abnormal muscle tone or bulk, tremors, tics, or other abnormal movements. The nerve disorder did not affect the function of any joint and his gait and balance were normal. The diagnosis was moderate primarily sensory diabetic peripheral neuropathy. The examiner noted that the Veteran presently had pain which had not been reported earlier. However the Veteran's objective neurological signs were similar to the previous examination without a motor component. He did not have nerve paralysis or neuralgia, but he did have neuritis. The disorders had no significant effects on the Veteran's occupation. They also had no effects on his recreation, feeding, bathing, dressing, toileting, and grooming; a mild effect on shopping and travelling; a moderate effect on chores; a severe effect on exercise; and prevented sports. A July 2009 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. A September 2009 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. An October 2009 VA electrodiagnostic study stated that the Veteran complained of paresthesias in both hands and feet. On physical examination, he had sensation diminished to light touch over the distal upper and lower extremities. After nerve conduction studies of all four extremities, the conclusion was that the findings were consistent with bilateral moderate carpal tunnel syndrome, with no signs of peripheral neuropathy. A November 2009 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. A June 2010 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. A July 2010 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. An October 2010 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. A December 2010 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. A March 2011 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. A September 2011 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. An October 2011 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. A December 2011 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. A March 2012 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. A May 2012 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. A July 2012 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. A September 2012 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. An October 2012 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. A November 2012 VA outpatient medical report stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. Under Diagnostic Code 8616, incomplete paralysis of the major and minor ulnar nerve warrants a 10 percent rating when it is mild in degree. A 20 percent rating is warranted for incomplete paralysis of the minor ulnar nerve which is moderate in degree. A 30 percent rating is warranted for incomplete paralysis of the major ulnar nerve which is moderate in degree; and incomplete paralysis of the minor ulnar nerve which is severe in degree. A 40 percent rating is warranted for incomplete paralysis of the major ulnar nerve which is severe in degree. 38 C.F.R. § 4.124a, Diagnostic Code 8616 (2012). The evidence of record does not clearly demonstrate whether the Veteran is right-handed or left-handed. However, the Board finds that the Veteran's upper extremity peripheral neuropathy is mild in degree, bilaterally. Therefore, a determination of handedness is irrelevant to the claims on appeal, as a 10 percent rating is warranted for mild incomplete paralysis of each upper extremity regardless of whether it is the major or minor extremity. 38 C.F.R. §§ 4.69, 4.124a, Diagnostic Code 8620 (2012). Under Diagnostic Code 8620, incomplete paralysis of the sciatic nerve warrants a 10 percent rating when it is mild in degree. A 20 percent rating is warranted for incomplete paralysis which is moderate in degree. A 40 percent rating is warranted for incomplete paralysis which is moderately severe in degree. 38 C.F.R. § 4.124a, Diagnostic Code 8620 (2012). With respect to diseases of the peripheral nerves, the term incomplete paralysis indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis for a particular nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a (2012). The medical evidence of record shows that the Veteran's bilateral peripheral neuropathy of the upper extremities has been manifested by mild incomplete paralysis in each arm throughout the entire period on appeal. There is no medical evidence of record that the Veteran has experienced any non-sensory symptoms due to his upper extremity peripheral neuropathy at any point during the period on appeal. The January 2007 and May 2009 VA peripheral nerves examination reports both found that the Veteran's muscles and reflexes were intact in his upper extremities. Accordingly, the Veteran's upper extremity peripheral neuropathy has been wholly sensory throughout the entire period on appeal. The Board notes that the January 2007 VA peripheral nerves examination report characterized the Veteran's peripheral neuropathy as being moderate to severe, while the May 2009 VA peripheral nerves examination report and the October 2009 VA electrodiagnostic study both characterized the disability as being moderate. However, all three reports were commenting on the severity of the Veteran's overall peripheral neuropathy, including that in his lower extremities. The medical evidence of record shows that the Veteran's lower extremity peripheral neuropathy warrants a characterization of moderate. Therefore, the Board finds that the characterizations of the severity of the Veteran's peripheral neuropathy do not include a specific evaluation of his upper extremities by themselves. As the medical evidence of record otherwise demonstrates that the Veteran's upper extremity peripheral neuropathy is wholly sensory in nature, the Board finds that the Veteran's upper extremity peripheral neuropathy is best characterized as being mild in severity, bilaterally. Accordingly, a rating in excess of 10 percent is not warranted for the Veteran's left or right upper extremity peripheral neuropathy disabilities at any point during the period on appeal. However, the medical evidence of record shows that the Veteran's bilateral peripheral neuropathy of the lower extremities has been manifested by moderate incomplete paralysis in each leg throughout the entire period on appeal. Unlike the Veteran's upper extremities, the Veteran's lower extremities demonstrate non-sensory symptoms of peripheral neuropathy. Specifically, the Veteran's reflexes were found to be absent in his knees and ankles in January 2007, while they were absent in the ankles and reduced in the knees in May 2009. Those symptoms exceed those contemplated by a rating for wholly sensory impairment. The Board notes that the January 2007 VA peripheral nerves examination report characterized the Veteran's peripheral neuropathy as being moderate to severe, while the May 2009 VA peripheral nerves examination report and the October 2009 VA electrodiagnostic study both characterized the disability as being moderate. Such findings are consistent with an overall characterization of the Veteran's lower extremity peripheral neuropathy as being moderate in degree. Accordingly, the Board finds that a 20 percent rating is warranted for each of the Veteran's lower extremity peripheral neuropathy disabilities. However, a rating in excess of 20 percent is not warranted for either of the Veteran's lower extremity peripheral neuropathy disabilities at any point during the period on appeal. The Board notes that the January 2007 VA peripheral nerves examination report characterized the disability as moderate to severe, and that the rating criteria for incomplete paralysis of the sciatic nerve includes a rating of 40 percent for moderately severe symptoms. However, the terms mild, moderate, moderately severe, and severe as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6 (2012). It should also be noted that use of terminology such as severe by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2012). In this case, the rating criteria for severe incomplete paralysis of the sciatic nerve specifically contemplated marked muscular atrophy. Therefore, the Board finds that a moderately severe rating would contemplate symptoms analogous to muscular atrophy to a degree that is less than marked in severity and other non-sensory symptoms. The Board finds that no such symptoms have been manifested with respect to the Veteran's bilateral lower extremities. The medical evidence of record shows that the only non-sensory symptoms that the Veteran experiences due to his lower extremity peripheral neuropathy are absent and diminished reflexes in his knees and ankles. While such symptoms might cause some impairment in earning capacity, the Board finds that a loss reflexes alone is not analogous to muscle atrophy, which is productive of more significant impairment in earning capacity, such as weakness and fatigue. 38 C.F.R. § 4.1 (2012). In addition, the subsequent May 2009 VA peripheral nerves examination report and the October 2009 VA electrodiagnostic study both characterized the disability as being moderate, which is more consistent with an overall severity of moderate rather than moderately severe. Finally, the Board notes that there are numerous VA outpatient medical reports dated throughout the entire period on appeal which stated that, on neurologic examination, the Veteran had no gross motor or sensory deficit. those reports constitute evidence that any non-sensory symptoms that the Veteran did experience were not significantly limiting or noticeable. Therefore, a rating in excess of 20 percent is not warranted for the Veteran's lower extremity peripheral neuropathy disabilities at any point during the period on appeal. These claims have also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's neurological symptoms, the evidence shows no distinct periods of time when his symptoms have varied to such an extent that ratings in excess of the currently assigned ratings, or those assigned herein, would be warranted under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012); Fenderson v. West, 12 Vet. App. 119 (1999). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disability ratings for left and right upper and lower extremity peripheral neuropathy inadequate. The Veteran's left and right upper and lower extremity peripheral neuropathy were rated under 38 C.F.R. § 4.124a, Diagnostic Codes 8616, 8620, the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's left and right upper extremity peripheral neuropathy is manifested by mild incomplete paralysis in each arm, while the Veteran's left and right lower extremity peripheral neuropathy is manifested by moderate incomplete paralysis in each leg. When comparing that disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the disability ratings assigned herein for his left and right upper and lower extremity peripheral neuropathy. Ratings in excess of the currently assigned ratings are provided for certain manifestations of neurological disorders of the extremities, but the medical evidence does not show that those manifestations are present. The criteria for 10 percent ratings for each of the Veteran's left and right upper extremity peripheral neuropathy disabilities, and 20 percent ratings for each of the Veteran's left and right lower extremity peripheral neuropathy disabilities, reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular ratings are adequate and no referral is required. To the extent that the Veteran's left and right upper and lower extremity peripheral neuropathy combine with each other and with other service-connected disabilities to impact his employability, that issue is covered by the Veteran's claim of entitlement to TDIU, which is being remanded below. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.124a, Diagnostic Codes 8616, 8620 (2012). The Board finds that the preponderance of the evidence is against the claim for increased ratings for peripheral neuropathy beyond those assigned herein. The medical evidence of record does not show findings that meet the criteria for initial ratings in excess of 10 percent for left or right upper extremity peripheral neuropathy or initial ratings in excess of 20 percent for left or right lower extremity peripheral neuropathy. Therefore, the claims for initial ratings in excess of 10 percent for the upper extremities and in excess of 20 percent for the lower extremities are denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). Heart Disease Service connection for artherosclerotic heart disease and mild coronary artery disease was granted by a December 2009 rating decision and a 10 percent rating was assigned under 38 C.F.R. § 4.104, Diagnostic Code 7005, effective March 23, 2009. An August 2007 VA outpatient medical report stated that a cardiac stress test was performed in April 2007. The report stated that the results showed a probable mild wall ischemia and other "barely mildly abnormal" results. A November 2008 VA medical report stated that the Veteran's perception of his activity limitation met New York Heart Association (NYHA) Class II, which contemplates slight limitation of physical activity, where he was comfortable at rest, but ordinary activity resulted in heart failure symptoms, including fatigue, dyspnea, palpitation, or angina pain. A January 2009 VA medical report stated that the Veteran's perception of his activity limitation met NYHA Class I, which contemplates no limitation of physical activity, where ordinary activity does not cause fatigue, dyspnea, palpitation, or angina pain. In a May 2009 VA heart examination report, the Veteran complained of episodes of chest discomfort during stressful situations. He stated that the episodes lasted for a few hours, occurred at least twice a month, and were relieved with rest. He denied shortness of breath, dyspnea, or fatigue. On cardiac stress testing, the Veteran metabolic equivalents (METs) were measured at 7 to 8. For rating diseases of the heart, one MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for rating, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2 (2002) Arteriosclerotic heart disease is rated under Diagnostic Code 7005. A 10 percent rating is warranted for arteriosclerotic heart disease with documented coronary artery disease resulting in workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication is required. A 30 percent rating is warranted for status post coronary bypass surgery resulting in workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 38 C.F.R. § 4.104, Diagnostic Code 7005 (2012). The medical evidence of record shows that the Veteran's artherosclerotic heart disease and coronary artery disease is manifested by METs of greater than 7. There is only one medical report of record which has measured the Veteran's METs. That report is the May 2009 VA heart examination report, which found that the Veteran's METs were at a level of 7 to 8. The Board notes that a METs of exactly 7 would warrant a 30 percent rating. However, the May 2009 report specifically found that the Veteran's METs was in the range of 7 to 8, which indicates a level somewhere in between 7 and 8. Therefore, the Veteran's METs, as measured in May 2009, were measured at greater than 7. Accordingly, a rating in excess of 10 percent is not warranted for the Veteran's heart disease. This issue has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's heart disease, the evidence shows no distinct periods of time during which his symptoms have varied to such an extent that a rating in excess of 10 percent would be warranted under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012); Fenderson v. West, 12 Vet. App. 119 (1999). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities rating for heart disease inadequate. The Veteran's heart disease was rated under 38 C.F.R. § 4.104, Diagnostic Code 7005, the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's artherosclerotic heart disease and coronary artery disease is manifested by METs of greater than 7. When comparing this disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the rating for his heart disease. A rating in excess of the currently assigned rating is provided for certain manifestations of heart disease, but the medical evidence shows that those manifestations are not present in this case. The criteria for a 10 percent rating for the Veteran's heart disease reasonably describe the Veteran's disability level and symptomatology and, therefore, the Board finds that the currently assigned schedular rating is adequate and no referral is required. To the extent that the Veteran's heart disease impacts his employability, that issue is covered by the Veteran's claim of entitlement to TDIU, which is being remanded below. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.104, Diagnostic Code 7005 (2012). In reaching this decision, the Board finds that the preponderance of the evidence of record shows that the Veteran's heart disease does not meet the criteria for a rating in excess of 10 percent. Therefore, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). Neurogenic Bladder Service connection for neurogenic bladder, incontinence, was granted by an April 2007 rating decision and a 10 percent rating was assigned under 38 C.F.R. § 4.115b, Diagnostic Code 7542, effective August 1, 2006. Subsequently, a July 2009 rating decision assigned a 20 percent rating under 38 C.F.R. § 4.115b, Diagnostic Code 7542, effective May 13, 2009. In a February 2007 VA genitourinary examination report, the Veteran reported that his daily voiding frequency was about 10, with nocturia of one or two times. He reported having a good voiding pattern except for urgency and denied incontinence and the use of absorbent materials. The Veteran had no history of urinary tract surgery or recurrent urinary tract infections. He used medication, but no catheterization, dilations, drainage procedures, or diet therapy. After physical examination, the diagnosis did not include any voiding dysfunction disorder. In an August 2007 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. In a September 2007 VA urology report, the Veteran reported experiencing urinary incontinence for the previous 18 months. He stated that it was mostly of the urgent type, with occasional stress incontinence. The Veteran denied a history of urinary tract infections and stated that he otherwise voided well. After physical examination, the impression was suspected hyperactive bladder. In an October 2007 VA outpatient medical report, the Veteran reported experiencing a history of urge incontinence which had resolved with medication. In a November 2007 VA outpatient medical report, the Veteran reported experiencing urinary incontinence. In a January 2008 VA outpatient medical report, the Veteran reported experiencing urinary incontinence. In a May 2008 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. A June 2008 VA urology report stated that the Veteran's peak flow was 27 milliliters and his urine residual was 0 millileters. A March 2009 letter from a private physician stated that the Veteran experienced urinary incontinence. In a March 2009 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. In a May 2009 VA genitourinary examination report, the Veteran reported experiencing urinary incontinence for over two years. He reported that he experienced urine leakage which was usually associated with lifting or carrying heavy objects or urgency. The report stated that the Veteran had been diagnosed with mild stress incontinence and had a good response to medication. The Veteran had no history of hospitalization or surgery for the disorder, trauma to the genitourinary system, or neoplasm. He also did not have general systemic symptoms due to genitourinary disease. The Veteran reported experiencing urinary urgency, but denied experiencing hesitancy, difficulty starting stream, weak or intermittent stream, dysuria, dribbling, straining to urinate, hematuria, urine retention, and urethral discharge. He reported having a daytime voiding interval of one to two hours, with three voidings per night. The Veteran denied ever experiencing renal colic, but he reported experiencing urinary leakage due to stress incontinence. The report stated that the Veteran's mild stress incontinence did not require any appliance or absorbent material. He denied a history of recurrent urinary tract infections, obstructed voiding, urinary tract stones, renal dysfunction, renal failure, acute nephritis, and hydronephrosis. After physical examination, the diagnosis was mixed (urge and stress) urinary incontinence. The disorder had no effect on the Veteran's feeding, bathing, dressing, toileting, and grooming; a severe effect on chores, shopping, recreation, and traveling; and prevented exercise and sports. In a July 2009 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. In a September 2009 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. In a November 2009 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. In a June 2010 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. In a July 2010 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. In an October 2010 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. In a March 2011 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. In a May 2011 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. In a September 2011 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. In a December 2011 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. In a March 2012 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. In a May 2012 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. In a July 2012 VA outpatient medical report, the Veteran denied voiding frequently and experiencing any genitourinary urinary symptoms. In a September 2012 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. In an October 2012 VA outpatient medical report, the Veteran reported experiencing urinary dribbling. After physical examination, the assessment was urinary incontinence. In a November 2012 VA outpatient medical report, the Veteran denied experiencing any genitourinary urinary symptoms. A December 2012 VA urology report stated that the Veteran's peak flow was 35 millileters and his urine residual was 11 millileters. Under Diagnostic Code 7542, neurogenic bladder is to be rated as voiding dysfunction. 38 C.F.R. § 4.115b, Diagnostic Code 7542 (2012). Voiding dysfunction is rated as urine leakage, frequency, or obstructed voiding. 38 C.F.R. § 4.115a (2012). All ratings under the criteria for urine leakage are based on the wearing of absorbent materials or the use of an appliance. 38 C.F.R. § 4.115a (2012). The medical evidence of record shows that the Veteran's neurogenic bladder has never required the wearing of absorbent materials or the use of an appliance. Therefore, a rating in excess of those currently assigned is not warranted based on urine leakage. Similarly, the only rating in excess of 10 percent under the criteria for obstructed voiding contemplates urinary retention requiring intermittent or continuous catheterization. 38 C.F.R. § 4.115a (2012). The medical evidence of record shows that the Veteran's neurogenic bladder has never required intermittent or continuous catheterization. Therefore, a rating in excess of those currently assigned is not warranted based on obstructed voiding. Under the criteria for urinary frequency, a 10 percent rating is warranted for daytime voiding interval between two and three hours, or; awakening to void two times per night. A 20 percent rating is warranted for daytime voiding interval between one and two hours, or; awakening to void three to four times per night. A 40 percent rating is warranted for daytime voiding interval less than one hour, or; awakening to void five or more times per night. 38 C.F.R. § 4.115a (2012). The medical evidence of record shows that, prior to May 13, 2009, the Veteran's neurogenic bladder was manifested by a daily voiding frequency of about 10, with nocturia of one or two times. That equates to a daytime voiding interval between two and three hours. There is no evidence of record that, prior to May 13, 2009, the Veteran experiencing a voiding frequency in excess of that reported in the February 2007 VA genitourinary examination report. Accordingly, a rating in excess of 10 percent is not warranted prior to May 13, 2009. The medical evidence of record shows that, on and after May 13, 2009, the Veteran's neurogenic bladder was manifested by a daytime voiding interval of one to two hours, with three voidings per night. There is no evidence of record that, on and after May 13, 2009, the Veteran experiencing a voiding frequency in excess of that reported in the May 2009 VA genitourinary examination report. The evidence does not show a daytime voiding interval of less than one hour or voiding five time per night. Accordingly, a rating in excess of 20 percent is not warranted on and after May 13, 2009. This issue has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's neurogenic bladder symptoms, the evidence shows no distinct periods of time during which his symptoms have varied to such an extent that ratings in excess of those already assigned would be warranted under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012); Fenderson v. West, 12 Vet. App. 119 (1999). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities rating for neurogenic bladder inadequate. The Veteran's neurogenic bladder was rated under 38 C.F.R. § 4.115b, Diagnostic Code 7542, the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. Prior to May 13, 2009, the Veteran's neurogenic bladder was manifested by a daily voiding frequency was about 10, with nocturia of one or two times; while on and after May 13, 2009, the Veteran's neurogenic bladder was manifested by a daytime voiding interval of one to two hours, with three voidings per night. When comparing that disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the ratings for his neurogenic bladder. Ratings in excess of the currently assigned ratings are provided for certain manifestations of neurogenic bladder, but the medical evidence shows that those manifestations are not present in this case. The criteria for the currently assigned ratings for the Veteran's neurogenic bladder reasonably describe the Veteran's disability level and symptomatology and, therefore, the Board finds that the currently assigned schedular ratings are adequate and no referral is required. To the extent that the Veteran's neurogenic bladder combines with other service-connected disabilities to impact his employability, that issue is covered by the Veteran's claim of entitlement to TDIU, which is being remanded below. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.115b, Diagnostic Code 7542 (2012). In reaching this decision, the Board finds that the preponderance of the evidence of record shows that the Veteran's neurogenic bladder does not meet the criteria for a rating in excess of 10 percent prior to May 13, 2009, and 20 percent on and after May 13, 2009. Therefore, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). (CONTINUED ON NEXT PAGE) ORDER New and material evidence not having been submitted, the claim to reopen the issue of entitlement to service connection for diabetic retinopathy is denied. Service connection for bilateral leg radiculopathy is denied. Service connection for a prostate disability is denied. Service connection for a liver disability is denied. An initial rating in excess of 30 percent for diabetic nephropathy is denied. An initial rating in excess of 20 percent for diabetes mellitus is denied. An initial rating in excess of 10 percent for neurogenic bladder, and a rating in excess of 20 percent as of May 13, 2009, is denied. An initial rating of 20 percent, but not higher, for left lower extremity peripheral neuropathy is granted. An initial rating of 20 percent, but not higher, for right lower extremity peripheral neuropathy is granted. An initial rating in excess of 10 percent for left upper extremity peripheral neuropathy is denied. An initial rating in excess of 10 percent for right upper extremity peripheral neuropathy is denied. An initial rating in excess of 10 percent for hypertension is denied. An initial rating in excess of 10 percent for atherosclerotic heart disease with mild coronary artery disease is denied. REMAND With respect to the Veteran's stomach disability claim, this issue has previously been denied on the basis that the medical evidence of record did not demonstrate the existence of a current disability. In a July 1968 service medical report, the Veteran complained of diarrhea, abdominal cramps, and fever for the previous six hours. After physical examination, the diagnosis was gastroenteritis, etiology unknown. After separation from service, a February 2012 VA medical report stated that a barium examination of the Veteran's upper gastrointestinal system gave an impression of thickened duodenal folds as seen with duodenitis and small hiatal hernia, while a barium enema gave an impression of universal colonic diverticulosis. Accordingly, the Board finds that there is medical evidence of an in-service stomach disorder and a current stomach disorder. The Veteran has never been provided with a VA medical examination with respect to his stomach disability claim. Therefore, the Board finds that a medical examination is needed to determine the nature and etiology of any current stomach disorder. 38 C.F.R. § 3.159(c)(4), 3.326 (2012). With respect to the Veteran's peripheral vascular disease claim, this issue has also previously been denied on the basis that the medical evidence of record did not demonstrate the existence of a current disability. A May 2009 VA diabetes mellitus examination report, stated that, after physical and diagnostic examination, the relevant diagnosis was peripheral edema due to venous insufficiency, which had a non-diabetic related etiology. An October 2012 VA podiatry report gave an assessment of podiatry edema. The Veteran was issued diabetic socks. Accordingly, the Board finds that there is medical evidence suggesting that the Veteran currently has a vascular disorder of the lower extremities, and there is medical evidence which suggests a possibility of a relationship between the Veteran's vascular disorder and his service-connected diabetes mellitus. While the May 2009 VA diabetes mellitus examination report stated that the Veteran's peripheral edema was not related to diabetes mellitus, it did not provide a rationale for that opinion nor did it state whether the edema was related to the Veteran's active service. In addition, the October 2012 podiatry report provides evidence that the Veteran was subsequently found to have edema which was secondary to diabetes mellitus. The Veteran has never been provided with a VA medical examination specifically with respect to his peripheral vascular disease claim. Therefore, the Board finds that an additional medical examination is needed to determine the nature and etiology of any current peripheral vascular disorder. 38 C.F.R. § 3.159(c)(4), 3.326 (2012). With respect to the Veteran's claim of entitlement to TDIU, total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a)(1) (2012). A total disability rating for compensation purposes may be assigned on the basis of individual unemployability when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only one service-connected disability, it must be rated at 60 percent or more. If there are two or more service-connected disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a) (2012). Individual unemployability must be determined without regard to any nonservice-connected disabilities or the Veteran's advancing age. 38 C.F.R. §§ 3.341(a), 4.19 (2012); Van Hoose v. Brown, 4 Vet. App. 361 (1993). If a Veteran does not meet the applicable percentage standards set forth in 38 C.F.R. § 4.16(a), a total rating due to unemployability is considered where the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16(b) (2012); Fanning v. Brown, 4 Vet. App. 225 (1993). Service connection is currently in effect for diabetic nephropathy, rated 30 percent; diabetes mellitus, rated 20 percent; neurogenic bladder, rated 20 percent; high blood pressure, rated 10 percent; peripheral neuropathy of the lower extremities, each separately rated 20 percent; peripheral neuropathy of the upper extremities, each separately rated 10 percent; adjustment disorder with depressed mood, rated 10 percent; and atherosclerotic heart disease and mild coronary artery disease, rated 10 percent. The Veteran's combined disability rating is 70 percent, effective August 1, 2006, and 80 percent, effective February 23, 2009, and may be adjusted with the increase to 20 percent for each lower extremity peripheral neuropathy in this decision. The Board notes that the Veteran does not have a single disability rated as 40 percent disabling or more. However, for the purposes of determining whether one 40 percent or one 60 percent disability exists, disabilities resulting from a common etiology or affecting a single body system will be combined as one disability. 38 C.F.R. § 4.16(a) (2012). In this case, all of the Veteran's disabilities have been granted as secondary to diabetes mellitus. Therefore, all of his disabilities result from a common etiology and will be combined as one disability for the purposes of determining whether the Veteran meets the criteria for entitlement to TDIU. Therefore, for the purposes of 38 C.F.R. § 4.16, the Veteran has had a single disability rated as 60 percent disabling or more. Therefore, the percentage criteria of 38 C.F.R. § 4.16(a) have been met. Unfortunately, the evidence of record does not clearly demonstrate whether the Veteran is unemployed and, if so, whether any unemployment is caused by his service-connected disabilities. The Veteran himself reported that he was employed as a salesman in a January 2007 VA peripheral neuropathy examination report, a January 2007 VA diabetes mellitus examination report, and a May 2009 VA peripheral nerves examination report. In a May 2009 VA mental disorders examination report, he also reported that he was employed, but stated that he was only working at 20 percent of the rate he previously worked because he did not have anyone to distribute supplies, and that he only worked as a hobby. In May 2009 VA genitourinary; liver, gallbladder, and pancreas; and diabetes mellitus examination reports, and in an October 2010 VA mental disorders examination report, the Veteran reported that he was not currently employed and had retired in 2006 due to issues variously reported as physical problems, widowhood, and psychiatric impairment. Finally, in a May 2009 claim, the Veteran reported that he had last worked as a salesman in January 2006. Those reports are contradictory as to the Veteran's employment status at various points in time and the Board is unable to determine if the Veteran is currently employed and, if not, when he became unemployed. Therefore, a remand is required to clarify his employment situation. In addition, the Board notes that the Veteran has been provided with multiple VA medical examinations which were asked to comment on whether his service-connected disabilities rendered him unemployable. However, all of these examinations only opined as to whether the specific disability being examined made the Veteran unemployable. The Veteran has never been provided with a VA examination to determine whether his service-connected disabilities, in combination, render him unemployable. Therefore, the Veteran must be provided with an additional medical examination to determine whether he is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities alone. 38 C.F.R. §§ 3.312(c)(3); 3.159(c)(4) (2012). Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for a VA examination to ascertain the existence and etiology of any stomach disability. The examiner must review the claim file and should note that review in the report. Based upon review of the service and post-service medical records, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any stomach disability found is due to, or was aggravated by, the Veteran's active service, to include complaints of gastroenteritis during service. The examiner must provide also provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any stomach disability found is due to, or is aggravated by, any service-connected disability, to specifically include diabetes mellitus. If any stomach disability found is attributable to factors unrelated to the Veteran's service and service-connected disabilities, the examiner should specifically so state. A complete rationale for all opinions must be provided. 2. Schedule the Veteran for a VA examination to ascertain the existence and etiology of any peripheral vascular disability. The examiner must review the claim file and should note that review in the report. Based upon review of the service and post-service medical records, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any peripheral vascular disability found is due to, or was aggravated by, the Veteran's active service. The examiner must provide also provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any peripheral vascular disability found is due to, or was aggravated by, any service-connected disability, to specifically include diabetes mellitus. If any peripheral vascular disability found is attributable to factors unrelated to the Veteran's service and service-connected disabilities, the examiner should specifically so state. A complete rationale for all opinions must be provided. 3. Schedule the Veteran for a VA examination to determine whether he is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities alone. The examiner must review the claims file and note that review in the report. The examiner must elicit from the Veteran and record for clinical purposes a full work and educational history. The Veteran must be asked to clarify previous statements that he was working in January 2007 and May 2009, but also that he had retired in January 2006. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's service-connected disabilities combine to preclude him from securing and following substantially gainful occupational experience. The examiner is instructed to provide the opinion without respect to the impact of the Veteran's age on his employability. If the Veteran is found to be employable, the examiner should explain what types of employment could be performed and what accommodations would be needed due to service-connected disabilities. A complete rationale for all opinions must be provided. 4. Then, readjudicate the claims. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. The Veteran 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or United States Court of Appeals for Veterans Claims for development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs