Citation Nr: 1323992 Decision Date: 07/29/13 Archive Date: 08/07/13 DOCKET NO. 09-50 962 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus. 2. Entitlement to a disability rating in excess of 20 percent for diabetic peripheral neuropathy affecting the right leg. 3. Entitlement to a disability rating in excess of 20 percent for diabetic peripheral neuropathy affecting the left leg. 4. Entitlement to a disability rating in excess of 10 percent for diabetic peripheral neuropathy affecting the right arm. 5. Entitlement to a disability rating in excess of 10 percent for diabetic peripheral neuropathy affecting the left arm. 6. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities. 7. Entitlement to a disability rating in excess of 30 percent for post-traumatic stress disorder (PTSD). 8. Entitlement to a separate compensable disability rating for diabetic retinopathy. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran and his wife ATTORNEY FOR THE BOARD Heather J. Harter, Counsel INTRODUCTION The Veteran served on active duty from March 1967 to October 1969. He was awarded the Vietnam Campaign Medal, among other decorations, in connection with his service in Vietnam. These matters come before the Board of Veterans' Appeals (Board) from RO decisions of April 2009 and February 2012. The Veteran and his wife presented sworn testimony in support of his appeal during a May 2013 hearing conducted via videoconference before the undersigned Veterans Law Judge. In May 2013, the Veteran's representative submitted additional VA medical records along with a waiver of RO review. In a February 2011 phone call, the Veteran's wife indicated that the Veteran wished to file a claim for service connection for sleep apnea. It does not appear that either the Veteran himself or his representative has filed a formal claim for sleep apnea, however. This matter is also referred to the RO for appropriate action. The issues of entitlement to a disability rating greater than 30 percent for PTSD and entitlement to a separate compensable disability rating for diabetic retinopathy are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The veteran requires a restricted diet and medication for control of his diabetes, however, no activity restrictions have been recommended. 2. Diabetic peripheral neuropathy of the right leg and the left leg causes moderately severe incomplete paralysis. 3. Diabetic peripheral neuropathy of the right and left arm causes moderate incomplete paralysis. 4. The Veteran is unable to secure and follow a substantially gainful occupation by reason of his diabetes and diabetes complications. CONCLUSIONS OF LAW 1. A disability rating in excess of 20 percent is not warranted for diabetes. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.119 , Diagnostic Code 7913 (2012). 2. Separate disability ratings of 40 percent are warranted for diabetic peripheral neuropathy affecting each leg. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.124a, Diagnostic Code 8520 (2012). 3. A disability rating of 30 percent is warranted for diabetic peripheral neuropathy affecting the Veteran's major arm. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.124a, Diagnostic Code 8516 (2012). 4. A disability rating of 20 percent is warranted for diabetic peripheral neuropathy affecting the Veteran's minor arm. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.124a, Diagnostic Code 8516 (2012). 5. A total disability rating based upon individual unemployability due to service-connected disabilities is warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran contends his service-connected diabetes, peripheral neuropathy affecting the arms and legs, and PTSD are more disabling than is reflected by the currently-assigned disability ratings. He requests higher ratings for each disability. He also asserts that he is rendered unemployable by his service-connected disabilities and requests that a total disability rating based upon individual unemployability due to service-connected disabilities. Duties to notify and assist When an application for benefits is received, VA has certain notice and assistance requirements under the law. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). First, proper notice must be provided to a claimant before the initial VA decision on a claim for benefits and must: (1) inform the claimant about the information and evidence not of record 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. The VA is also required to inform the Veteran of how the VA assigns disability ratings and effective dates. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was provided with this information in a December 2011 letter prior to the decision on appeal. With regard to the VA examination reports which are of record, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations obtained in this case are adequate with regard to the issue decided herein. The examination reports relied upon were predicated on a review of the claims folder and the relevant medical records contained therein, except where noted; contains a description of the history of the disability at issue; and documents and considers the Veteran's complaints and symptoms. The examiners considered the available pertinent evidence of record, and provided a rationale for the opinions rendered, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue which is decided herein has been met. 38 C.F.R. § 3.159(c)(4). Service treatment records, VA treatment records, some private medical records, Social Security records, and VA examination reports have been obtained and reviewed in support of the Veteran's claims. All relevant records and contentions have been carefully reviewed. The Board therefore concludes that the VA's duties to notify and assist have been met with regard to the matters decided herein. Standard of review Once the evidence has been assembled, it is the Board's responsibility to evaluate the record. 38 U.S.C.A. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board must consider all the evidence of record and discuss in its decision all "potentially applicable" provisions of law and regulation. See 38 U.S.C. § 7104(a); Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). The Board is also required to provide a statement of reasons or bases for its determination, adequate to enable an appellant to understand the precise basis for its decision, as well as to facilitate further appellate review. See 38 U.S.C. § 7104(d)(1); Allday v. Brown, 7 Vet. App. 517, 527 (1995); Gilbert, 56 (1990). To comply with this requirement, the Board must analyze the credibility and probative value of the evidence, account for the evidence it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Governing laws and regulations Disability evaluations are assigned to reflect levels of current disability. The appropriate rating is determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In evaluating claims for increased ratings, the Board must evaluate the Veteran's condition with a critical eye toward the lack of usefulness of the body or system in question. 38 C.F.R. § 4.10. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. §§ 4.1, 4.41; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While a request for an increased rating must be viewed in light of the entire relevant medical history; where, as here, entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. 38 C.F.R. § 4.1; Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Because the level of a veteran's disability may fluctuate over time, the VA is required to consider the level of the veteran's impairment throughout the entire appeal period. In this respect, staged ratings are a sensible mechanism for allowing the assignment of the most precise disability rating-one that accounts for the possible dynamic nature of a disability while the claim works its way through the adjudication process. O'Connell v. Nicholson, 21 Vet. App. 89 (2007). In another relevant precedent, the Court noted that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. In reaching this conclusion, the Court observed that when a claim for an increased rating is granted, the effective date assigned may be up to one year prior to the date that the application for increase was received if it is factually ascertainable that an increase in disability had occurred within that timeframe. 38 U.S.C.A. § 5110. Hart v. Mansfield, 21 Vet. App. 505 (2007). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). History The Veteran filed his initial claim for VA compensation in September 2004. Based upon this claim, the RO granted service connection for diabetes, peripheral neuropathy affecting the arms and legs, and PTSD. Medical records dated in 2004 and 2005 show that the Veteran had diabetes for which he required insulin. He also had peripheral neuropathy affecting his hands and feet. These records, along with statements of the Veteran himself and supporting statements from various relatives, reflect that he was having trouble with the grip in his hands due to peripheral neuropathy, and that he was experiencing pain and decreased sensation in both feet to the point that he was reducing the amount of walking he did. He also complained of difficulty performing his job as a truck driver and heavy equipment operator due to the peripheral neuropathy affecting his hands and feet. Nerve conduction testing confirmed the diagnosis and supported the Veteran's complaints. In September 2007, the Veteran sustained an injury in the workplace, involving striking his chest on the steering wheel of a grader he was operating. He injured his pancreas during the accident, and required several months of hospitalization for the pancreas and secondary effects, including cardiac problems, respiratory problems, acute renal failure, an episode of hypoxic ischemic encephalopathy, and exacerbation of his underlying PTSD with anxiety. When he was discharged from the hospital he was given a disability retirement. The medical documentation regarding his disability retirement reflects that he was deemed to have been permanently and totally disabled due to memory loss and peroneal neuropathy caused by pancreatic rupture complicated by cardiac arrest, ischemic encephalopathy, and peroneal neuropathy. The current claim for increased disability ratings was received in May 2011. Thus, the time period at issue here is one year prior to the date that the application for increase was received, May 2010, until the present. Hart. Diabetes Historically, the Veteran was diagnosed with diabetes many years before he filed his September 2004 claim for service connection. He has been taking insulin and hypoglycemic agents for the control of his diabetes for many years as well. Review of the Veteran's medical records dated from 2010 to the present reveals that his diabetes was frequently described as "poorly controlled" or "uncontrolled." He was prescribed various combinations of different types of insulin, both oral and injected, during this time. During a July 2010 VA examination, the examiner noted that the Veteran was taking three medications for control of his diabetes, yet he continued to have unstable blood sugars. He also noted that the Veteran had hypoglycemic episodes five times a month, usually during the night. He had not required hospitalization or had episodes of ketoacidosis during the previous twelve months. The examiner noted that the Veteran followed a diabetic diet and was not required to regulate activities on account of diabetes. The examiner opined that the diabetes affected the Veteran's occupation because the Veteran was unable to operate equipment and unable to drive a vehicle due to diabetic neuropathy. Another VA examination was conducted in January 2012. The examiner noted that the veteran was having approximately five hypoglycemic episodes a month, usually during the night. He had not required hospitalization related to his diabetes during the previous year, and had not had any episodes of ketoacidosis. The examiner noted that the Veteran was following a diabetic diet, and was not required to regulate his activities on account of diabetes. Again, the examiner noted that the Veteran was unable to drive or operate equipment due to neuropathy and to brain injury from the hypoxic episode. The examiner specified that the Veteran had unstable ambulation due to the bipartite causes of peripheral neuropathy and right peroneal neuropathy related to the workplace accident. A June 2012 endocrinology treatment note reflects that the Veteran's complications of diabetes include neuropathy, but do not include vascular disease or kidney disease. The Veteran's treating physician noted that because of the 2007 injury to the Veteran's pancreas, he was at a much higher risk for volatile blood sugars. A March 2013 VA endocrinology progress note reflects the physician's assessment that the Veteran had, "Type 2 Diabetes Mellitus, now (ever since 2007) complicated by pancreatic insufficiency, uncontrolled and substantially worsened" since the most recent prior blood testing. After further testing, his insulin type and dosages were both increased. During the May 2013 hearing on appeal, the Veteran's wife testified that the Veteran's insulin shots had recently been increased from three times daily to five times daily. The Veteran indicated that he was not sure whether his doctor has prescribed any regulation of his activities on account of diabetes. Review of the Veteran's VA medical records reflect that he has regular visits with both the endocrinology department and with his primary care providers. His insulin dosages and schedule are frequently reviewed and amended. His activities have not been proscribed in any way, by his medical care providers, however. The Veteran's currently-assigned 20 percent disability rating reflects diabetes which requires insulin or an oral hypoglycemic agent and restricted diet. A higher 40 percent disability rating can be assigned when diabetes requires insulin, restricted diet, and regulation of activities. Diabetes which requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated is rated as 60 percent disabling. Diabetes which requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated, is rated as 100 percent disabling. Compensable complications of diabetes are to be separately evaluated unless they are part of the criteria used to support a 100 percent schedular evaluation. Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913. The currently-assigned 20 percent disability rating has been assigned to reflect diabetes requiring insulin and restricted diet, but no further restrictions or complications. Review of the medical evidence demonstrates that this is the appropriate rating, as no restrictions upon the veteran's activities have been imposed by his medical care providers, as would support the assignment of a 40 percent disability rating. Although he does have the diabetic complication of peripheral neuropathy affecting both legs and both arms, this disability is rated separately and thus may not be used to support the assignment of a higher disability rating under the provisions of Diagnostic Code 7913. 38 C.F.R. § 4.14. As discussed below, in the remand portion of this decision, diabetic retinopathy was recently identified in 2013, and the RO will review the facts to determine whether a separate disability rating for diabetic retinopathy is warranted. The Board recognizes that the Veteran's diabetes appears particularly difficult to control, and is often described as "uncontrolled" or "poorly controlled" by his care providers. However, absent activity regulation, he simply does not meet the criteria for a higher disability rating. The Board acknowledges that since all of the Veteran's extremities are significantly affected by diabetic neuropathy, the Veteran is likely limited from engaging in strenuous occupational or recreational activities. But as is thoroughly explained above, the Veteran is separately rated for all of his extremities, so affording the Veteran the next higher rating of 40 percent for diabetes mellitus would essentially be awarding the Veteran multiple ratings for the same manifestations, which would violate pyramiding under 38 C.F.R. § 4.14. The Board therefore finds that the currently-assigned 20 percent disability rating more nearly reflects the veteran's functional impairment resulting from diabetes, as he does not meet the schedular criteria set forth for the assignment of a higher disability rating under diagnostic Code 7913. The preponderance of the evidence is thus against the assignment of a disability rating greater than 20 percent for service-connected diabetes. Peripheral neuropathy As set forth above, the Veteran has peripheral neuropathy affecting all four extremities, which is secondary to his diabetes. He also has peroneal neuropathy in his right ankle, which causes foot drop, and further impairs his ambulation. The peroneal neuropathy, however, is unrelated to his diabetes, and was caused by the hypoxic episode related to his 2007 workplace injury. During a July 2010 VA examination, the examiner described the Veteran's peripheral neuropathy as involving both hands and both legs, in a stocking and glove distribution. The examiner noted increased numbness and tingling in both hands. Because of the neuropathy, the Veteran was unable to drive, unable to having feeling in his feet and legs, had decreased mobility, problems with lifting and carrying, decreased manual dexterity, and decreased strength in arms and legs. He also had unstable ambulation due to the neuropathy, as he used a cane and a brace on his right leg for walking. He needed assistance getting in and out of the tub due to his unstable gait. An August 2011 private neurological consultation note reflects complaints of numbness, poor balance, and weakness. He had normal muscle strength in all muscles except for his right ankle extensors, which had reduced strength. In addition to the right foot drop, his gait was noted to be wide based. He was unable to heel or toe walk on either the right or left side. He was unable to perform tandem walking on the left or the right. The report of a January 2012 VA examination reflects that the Veteran's peripheral neuropathy had been gradually worsening/progressing since the gradual onset in the 1990s. Upon examination, both hands and both legs felt cold. The neuropathy was in a stock and glove distribution, and had been confirmed upon the 2007 electromyography testing. The Veteran was taking Gabapentin with good efficacy for the neuropathy. The examiner noted that the Veteran was unable to drive, unable to having feeling in his feet and legs, had decreased mobility, problems with lifting and carrying, decreased manual dexterity, decreased strength in his arms and legs, and that the neuropathy had severe effects upon his ability to travel or drive. He also needed assistance getting in and out of the tub. The Veteran's gait was described as wide-spaced, with a right foot drop related to the nonservice-connected peroneal neuropathy. In a January 2012 report completed by the Veteran's private physician in support of a claim for aid and attendance benefits, he described the Veteran as having spasticity and incoordination in all extremities, so that he could not perform fine movements. A June 2012 VA neurological progress note reflects decreased sensation from the Veteran's knees distally and from the distal 1/3rd of his upper extremities. Again, his gait was noted to be wide based and unsteady. The neurologist rendered diagnostic assessments of severe sensorimotor polyneuropathy, intensive care unit neuropathy, right peroneal neuropathy, and "diabetic neuropathy with his diabetes still not under control." During the May 2013 hearing on appeal, the Veteran and his wife testified that the Veteran was losing his grip; having difficulty picking up objects such as coffee mugs, and that he was no longer able to play pool due to diminishing nerve function in his hands and wrists. The regulatory rating schedule provides that incomplete paralysis of the sciatic nerve which is severe with marked muscle atrophy will be rated as 60 percent disabling. Incomplete paralysis of the sciatic nerve which is moderately severe is rated as 40 percent disabling. Incomplete paralysis of the sciatic nerve which is moderate is rated as 20 percent disabling. 38 C.F.R. § 4.124a , Diagnostic Code 8520. In rating diseases of the peripheral nerves, adjudicators are instructed that the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each 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. In this case, the Veteran's diabetic neuropathy impairment affecting both legs is more than purely sensory in nature. He has loss of sensation, altered gait, and instability due to some level of loss of control over his legs and feet. His physicians have repeatedly explained that he cannot drive due to diabetic peripheral neuropathy. He requires a cane for balance. He does not have muscle atrophy related to his diabetic neuropathy, however. The only muscle atrophy identified in the record is in the right ankle and is caused by the nonservice-connected peroneal nerve injury. Because the Veteran's leg functions are impaired in addition to his leg sensation, the Board finds that 40 percent disability ratings for moderately severe incomplete paralysis due to diabetic neuropathy of each leg are warranted. The appeal is therefore granted to this extent. The preponderance of the evidence is against a higher disability rating, however, because he does not have marked muscle atrophy in either leg related to diabetic neuropathy. With regard to the impairment from diabetic peripheral neuropathy affecting the Veteran's arms, the regulatory rating schedule provides that severe incomplete paralysis of the ulnar nerve is rated as 40 percent disabling for the dominant, or major, arm; and 30 percent disabling for the non-dominant, or minor arm. Moderate incomplete paralysis of the ulnar nerve is rated as 30 percent disabling for the major arm, and 20 percent disabling for the minor arm. The currently-assigned 10 percent disability ratings reflect mild incomplete paralysis of each arm. 38 C.F.R. § 4.124a, Diagnostic Code 8516. Again, adjudicators are reminded that the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve. 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. In this case, the Veteran's diabetic neuropathy impairment affecting both forearms is more than purely sensory in nature. In addition to loss of sensation he has progressive loss of gripping function. The historical evidence of record reflects that as early as 2004 and 2005, his gripping function was diminished, and was affecting his job. The Veteran's hearing testimony that he can no longer play pool and has difficulty gripping a coffee mug corroborates that the neuropathy continues to impair his grip. In June 2012, his treating neurologist characterized his diabetic neuropathy as "severe" and also noted that it is "sensorimotor" in nature. Under these circumstances, the Board finds that the criteria for a disability rating reflecting moderate incomplete paralysis of the ulnar nerve is more nearly analogous to the symptoms reflected in the medical evidence and the lay evidence of record. Thus, the evidence supports a 30 percent disability rating for diabetic peripheral neuropathy affecting the Veteran's major arm and a 20 percent rating for his minor arm. 38 C.F.R. § 4.124a, Diagnostic Code 8516. The preponderance of the evidence is against the award of a higher disability rating, however, as impairment analogous to severe incomplete paralysis is not shown. In this regard, we note that no atrophy of hand, wrist, or arm muscles is shown, no contraction deformities or loss of flexion or adduction. The Board additionally observes that the RO has properly applied the bilateral factor to disability ratings assigned to diabetic peripheral neuropathy of the Veteran's legs and arms. Unemployability The Veteran's unemployability claim was received in March 2008. Total disability ratings for compensation based on individual unemployability may be assigned when the combined schedular rating for the service-connected disabilities is less than 100 percent and when it is found that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age, provided that, if there is only one such disability, this disability is ratable at 60 percent or more, or if there are two or more disabilities, there is at least one disability ratable at 40 percent or more and additional disabilities to bring the combined rating to 70 percent or more. For the purpose of one 60 percent disability or one 40 percent disability in combination, disabilities resulting from common etiology or a single accident will be considered as one disability. The Veteran's employment history, educational and vocational attainment as well as his particular physical disabilities are to be considered in making a determination on unemployability. It is further provided that the existence or degree of nonservice-connected disabilities or previous unemployability status will be disregarded where the percentages referred to in this paragraph for the service-connected disability or disabilities are met and in the judgment of the rating agency such service-connected disabilities render the Veteran unemployable. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In determining whether the veteran is entitled to a total disability rating based upon individual unemployability, neither his nonservice-connected disabilities nor his advancing age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. Van Hoose. The Veteran has been assigned a total combined rating of 70 percent since August 2004. The Veteran has been awarded service connection for PTSD, rated as 30 percent disabling; diabetes mellitus, rated as 20 percent disabling; peripheral neuropathy of the right leg, now rated as 40 percent disabling pursuant to this decision; peripheral neuropathy of the left leg, now rated as 40 percent disabling pursuant to this decision; peripheral neuropathy of the major arm, now rated as 30 percent disabling pursuant to this decision; peripheral neuropathy of the minor arm, rated as 20 percent disabling; and hypertension, rated as noncompensable or 0 percent disabling. The overall combined disability rating is thus 90 percent. 38 C.F.R. § 4.25. He also receives special monthly compensation for other complications of his diabetes. All of the Veteran's disabilities arise from service in Vietnam, either from herbicide exposure or traumatic psychological experience. As such all Veteran's disabilities are deemed to be of a common etiology. Thus, the Veteran meets the schedular criteria set forth in 38 C.F.R. § 4.16(a). This regulation also provides that adjudicators are to disregard the existence or degree of nonservice-connected disabilities or previous unemployability status if the Veteran is deemed to be unemployable due to his service-connected disabilities. Given the persuasive medical evidence that the Veteran is unable to drive or operate machinery due to his peripheral neuropathy, along with the evidence indicating his lower levels of educational achievement, and the mechanical requirement that he perform insulin injections five times a day, the Board finds that he is rendered unemployable due to his diabetes complications and symptoms, warranting the award of a total disability rating based on individual unemployability. The appeal for this benefit is therefore granted. ORDER A disability rating greater than 20 percent for diabetes mellitus is denied. A disability rating of 40 percent is granted for diabetic peripheral neuropathy affecting the right leg, subject to the laws and regulations governing the award of monetary benefits. A disability rating of 40 percent is granted for diabetic peripheral neuropathy affecting the left leg, subject to the laws and regulations governing the award of monetary benefits. A disability rating of 30 percent is granted for diabetic peripheral neuropathy affecting the Veteran's major arm, subject to the laws and regulations governing the award of monetary benefits. A disability rating of 20 percent is granted for diabetic peripheral neuropathy affecting the Veteran's minor arm, subject to the laws and regulations governing the award of monetary benefits. A total disability rating based upon individual unemployability due to service-connected disabilities is granted, subject to the laws and regulations governing the award of monetary benefits. REMAND During the May 2013 hearing on appeal, the Veteran testified that he believes his PTSD has worsened since January 2012, when the most recent VA psychiatric examination for purposes of compensation was conducted. He explained that he had been hospitalized at the Kernersville Medical Center in April 2013 for stabilization of his mental health. He also testified that he receives private, non-VA, medical care for PTSD. His VA treatment records reflect private care for PTSD, as well. The Veteran's representative requested in May 2013 that the VAMC download all electronic records contained in the Veteran's VA health care file into his VA adjudication claims file, as well as private medical records. Only VA-generated records were downloaded; no private treatment records and no mental health records were obtained. Because these records are relevant to the disability rating assigned to the Veteran's PTSD, they should be obtained prior to further review of this portion of the appeal. 38 C.F.R. § 3.159(c)(1). The Veteran's recent VA medical records dated in 2013 reflect diagnoses of diabetic retinopathy affecting both eyes. As explained above, 38 C.F.R. § 4.119 requires that compensable complications of diabetes must be identified and evaluated separately. Thus, the Veteran's diabetic retinopathy is part and parcel of his diabetes, and the rating schedule recognizes this implicit relationship. It follows that the rating for diabetic retinopathy is part and parcel of the Veteran's claim for an increased disability rating for diabetes, which was reviewed above. Therefore, upon remand, diabetic retinopathy must be officially listed on the rating sheet as a complication of diabetes and the RO should assign a separate disability rating, if appropriate. Accordingly, the case is REMANDED for the following action: 1. The RO should make all reasonable efforts to obtain any private health treatment records, psychiatric or otherwise, as may be reasonably identified by the Veteran. The RO should also associate with the record any additional VA medical records that may have come into existence since the appeal was last certified to the Board. If he requires assistance in obtaining any records, he must submit the appropriate release form. 2. After the development requested above has been completed to the extent possible, the RO should again review the record. Any further evidentiary development necessary to determine whether a compensable disability rating for the Veteran's diabetic retinopathy is appropriate should be accomplished at this point. Any further development pertaining to the Veteran's PTSD disability rating, such as providing another VA examination if warranted, should be accomplished as well. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs