Citation Nr: 1328583 Decision Date: 09/06/13 Archive Date: 09/16/13 DOCKET NO. 07-07 663 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for cellulitis, to include as secondary to diabetes mellitus. 2. Entitlement to an effective date earlier than July 12, 2001, for the grant of service connection for diabetes mellitus. 3. Whether new and material evidence has been received to reopen the previously denied claim for service connection for hypertension, to include as secondary to diabetes mellitus or posttraumatic stress disorder (PTSD) and, if so, whether service connection is warranted. 4. Entitlement to service connection for diabetic retinopathy, to include as secondary to diabetes mellitus. 5. Entitlement to service connection for a right foot disability, to include as secondary to service-connected diabetes mellitus or cerebral vascular accident (CVA). 6. Entitlement to an increased rating for diabetes mellitus, currently rated as 20 percent disabling. 7. Entitlement to an increased initial rating for cataracts, rated as noncompensable until February 18, 2005, and as 20 percent disabling thereafter. 8. Entitlement to an initial rating higher than 10 percent for residuals of a CVA. 9. Entitlement to a total disability rating based upon individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Gregory Keenum, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Erdheim, Counsel INTRODUCTION The Veteran served on active duty from May 1971 to May 1974. This matter comes before the Board of Veterans' Appeals (Board) from January 2006, January 2007, October 2007, March 2008, and August 2008 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO) that respectively denied service connection for retinopathy and cellulitis, granted service connection for a CVA and for cataracts, denied an increased rating and earlier effective date for diabetes mellitus and declined to reopen the previously denied claim for service connection for hypertension, and denied service connection for a right foot disability. In January 2012, the RO denied the Veteran's claim for a TDIU. In November 2009, the Board remanded the claims for additional development. The issues of entitlement to service connection for a right foot disability, for an increased rating for residuals of a CVA, and for a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. In a written statement submitted at his July 2009 hearing, the Veteran requested that his appeal with regard to the issue of service connection for cellulitis be withdrawn. 2. The Veteran filed a formal claim of entitlement to service connection for diabetes mellitus in July 2002. This claim was subsequently granted in an October 2002 rating decision, with an initial disability rating of 20 percent, and an effective date of July 12, 2001. 3. The Veteran filed a notice of disagreement in October 2003, contesting the rating, and then a notice of disagreement in March 2004, contesting the effective date of July 12, 2001. However, he did not timely perfect his appeal by filing a VA Form 9 following the issuance of a January 2005 statement of the case. Therefore, the October 2002 rating decision became final. 4. In a statement received in April 2005, after the expiration of his appeal period for filing a VA Form 9, the Veteran filed a claim to reopen the claim for an earlier effective date for his service-connected diabetes mellitus. He did not also allege clear and unmistakable error (CUE) in the October 2002 rating decision. 5. The Veteran's April 2005 statement constitutes an impermissible freestanding claim for an earlier effective date. 6. In an October 2002 rating decision, the RO denied service connection for hypertension. The Veteran was notified of this decision and of his right to appeal but his Form 9 was not timely. 7. The evidence added to the record since the last final decision is not cumulative of the evidence previously considered, contributes to a more complete picture of the Veteran's claim for service connection for hypertension, and creates a reasonable possibility of an allowance of the claim. 8. Hypertension is not shown to be causally or etiologically related to any disease, injury, or incident during service, did not manifest within one year of the Veteran's discharge from service, and was not caused or aggravated by the service-connected diabetes. 9. The Veteran does not have a current diagnosis of diabetic retinopathy; the Veteran's hypertensive retinopathy was not caused or aggravated by his service or his service- connected disabilities. 10. Throughout the pendency of the appeal, the Veteran's diabetes mellitus has required daily oral medication and diet restrictions, with the use of insulin as needed, and hypoglycemic episodes, but regulation of activities is not required. He has related erectile dysfunction with no evidence of penile deformity. 11. Throughout the pendency of the appeal, the Veteran's cataracts have been primarily manifested, at worst, by a corrected visual acuity of 20/40 in one eye and 20/40 in the other eye. The disability has not resulted in any visual field loss or muscle abnormality. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal regarding the issue of service connection for cellulitis have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5)(West 2002 & Supp. 2012); 38 C.F.R. § 20.204 (2012). 2. The October 2002 rating decision that granted service connection for diabetes mellitus is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.302, 20.1103 (2012). 3. The Veteran's free standing claim of entitlement to an effective date earlier than July 12, 2001, for the grant of service connection and assignment of a 20 percent rating for diabetes mellitus, is barred as a matter of law. 38 C.F.R. §§ 20.101 (2012); Rudd v. Nicholson, 20 Vet. App. 296 (2006). 4. The October 2002 rating decision that denied service connection for hypertension is final. 38 U.S.C.A. § 7104(b)(West 2002); 38 C.F.R. § 20.1103 (2012). 5. New and material evidence has been received to reopen the claim of entitlement to service connection for hypertension. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a)(2012). 6. Hypertension was not incurred in or aggravated by the Veteran's active duty military service, nor may it be presumed to have been incurred in or aggravated by such service, nor was it caused or aggravated by a service- connected disability. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102 , 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 7. The Veteran's hypertensive retinopathy was not incurred in or aggravated by the Veteran's active duty military service nor was it caused or aggravated by a service- connected disability. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102 , 3.159, 3.303, 3.310 (2012). 8. The criteria for an evaluation in excess of 20 percent for diabetes mellitus with erectile dysfunction have not been met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. 3. 159, 4.119 Diagnostic Code (DC) 7913 (2012). 9. Prior to February 18, 2005, the criteria for a compensable rating for the Veteran's cataracts have not been met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159, 4.84, Diagnostic Codes (DCs) 6006, 6028, 6080 (2008). 10. Since February 18, 2005, the criteria for a rating in excess of 20 percent for the Veteran's cataracts have not been met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159, 4.84, Diagnostic Codes (DCs) 6006, 6028, 6080 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Withdrawal A substantive appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. §§ 20.202, 20.204(b) (2012). Withdrawal may be made by the appellant or by his authorized representative, except that a representative may not withdraw a Substantive Appeal filed by the appellant personally without the express written consent of the appellant. 38 C.F.R. § 20.204(c) (2012). In March 2007, the Veteran submitted a VA Form 9, Appeal to Board of Veterans' Appeals , perfecting his appeal as to the issues of entitlement to service connection for cellulitis, as identified in the February 2007 statement of the case. At his July 2009 hearing, the Veteran, through his representative, and in a written statement, stated that he no longer wished to pursue that claim. The Board finds that the Veteran's oral statement, transcribed at the hearing, and his accompanying written statement, indicating his intention to withdraw the appeal satisfies the requirements for the withdrawal of a substantive appeal. As the Veteran has withdrawn his appeal as to the issue of entitlement to service connection cellulitis, there remain no allegations of errors of facts or law for appellate consideration concerning that issue. The Board therefore has no jurisdiction to review the issue. Accordingly, the issue of entitlement to service connection cellulitis is dismissed. I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Kent v. Nicholson, 20 Vet. App. 1 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements in regard to new and material evidence claims require VA to send a specific notice letter to the claimant that: (1) notifies him or her of the evidence and information necessary to reopen the claim (i.e., describes what is meant by new and material evidence); (2) identifies what specific evidence is required to substantiate the element or elements needed for service connection that were found insufficient in the prior denial on the merits; and (3) provides general VCAA notice for the underlying service connection claim. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, with regard to the claim for service connection for retinopathy, a June 2005 letter, sent prior to the initial January 2006 rating decision, advised the Veteran of the evidence and information necessary to substantiate his claim for service connection on a secondary basis, as well as his and VA's respective responsibilities in obtaining such evidence and information. He was also informed of the regulations pertaining to direct service connection during the appeal period. With regard to the claim for an increased rating for diabetes mellitus, an October 2007 letter, sent prior to the March 2008 rating decision, advised the Veteran of the evidence and information necessary to substantiate his claim, as well as his and VA's respective responsibilities in obtaining such evidence and information. That letter also addressed the Veteran's claim to reopen the previously denied claim for service connection for hypertension, in that the Veteran was advised of the need to submit new and material evidence in order to reopen his claim and was provided with the definition of new and material evidence. He was also advised as to why the claim was previously denied. As such, the Board finds that the October 2007 letter complied with the notice requirements as articulated in Kent, supra, and the duty to notify. Finally, in June 2011, the Veteran was advised of the evidence and information necessary to substantiate his TDIU claim. Additionally, many of these letters, including specifically in April 2007 and after, advised the Veteran of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. The Veteran's claims were readjudicated in statements of the case and supplemental statements of the case after prior notice provided to him in compliance with Dingess/Hartman, and thus any error in timing notice is cured. See Mayfield, supra. With regard to the claims for increased ratings for a CVA and cataracts, the Veteran has appealed with respect to the propriety of the initially assigned rating and effective date from the original grant of service connection. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). In this case, the Veteran's claims were granted and an initial rating and effective date were assigned in the rating decisions on appeal. Therefore, as the Veteran has appealed with respect to the initially assigned ratings, no additional 38 U.S.C.A. § 5103(a) notice is required because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Relevant to the duty to assist, the Veteran's service treatment records, VA treatment records, private treatment records, and Social Security Administration records have been obtained and considered. The Veteran has not identified any additional, outstanding records necessary to decide his pending appeal. The Board notes that the Veteran was afforded VA examinations in order to determine the etiology of his retinopathy and hypertension, and was afforded VA examinations to assess the severity of his diabetes mellitus, CVA, and cataracts. The Board finds that the VA examinations are adequate to decide all of these claims because they include clear etiological opinions with regard to the service connection claims and contain findings that meet the criteria in the rating schedule for the increased rating claims. With regard to the claim for an earlier effective date for the grant of service connection for diabetes mellitus, the Board notes, as set forth in more detail below, the facts in this case are not in dispute and the Veteran's appeal must be dismissed as a matter of law. Thus, the VCAA is not applicable in this case. Pratt v. Nicholson, 20 Vet. App. 252 (2006); Mason v. Principi, 16 Vet. App. 129, 132 (2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001) (holding that the VCAA is not applicable to matters in which the law, and not the evidence, is dispositive); see also VAOPGCPREC 5- 2004 (holding that under 38 U.S.C. § 5103(a), VA is not required to provide notice of the information and evidence necessary to substantiate a claim where that claim cannot be substantiated because there is no legal basis for the claim or because undisputed facts render the claimant ineligible for the claimed benefit). The Board finds that there has been substantial compliance with the previous November 2009 remand, as described above. The Veteran was also provided with a hearing related to his present claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires the VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, the VLJ explained the issue on appeal and inquired as to any outstanding evidence. And, through questioning by his representative, the Veteran volunteered his treatment history and symptoms since service, thus fully describing the nature and severity of his disabilities. Accordingly, the Veteran is not shown to be prejudiced on this basis. The Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the hearing complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis Earlier Effective Date The procedural history in this case is not in dispute. The Veteran initially filed a claim for service connection for diabetes mellitus in July 2002. In an October 2002 rating decision, the RO granted the Veteran's claim for service connection and assigned an initial disability rating of 20 percent, effective from July 12, 2001. In October 2003, the Veteran filed a notice of disagreement to that decision, and then in March 2004, he filed a notice of disagreement with the effective date assigned to the grant of service connection for his claim. The RO issued a statement of the case in January 2005. However, the Veteran did not perfect his appeal by filing a VA Form 9 in a timely fashion, within 60 days of notice of the statement of the case. In April 2005, the RO received a statement from the Veteran noting his continued dissatisfaction with the effective date of July 12, 2001. By letter dated in October 2007, the RO treated the Veteran's claim as a new claim, rather than a timely filed appeal. A rating decision was issued on March 2008. Therefore, it was clear that the April 2005 correspondence was considered to be a new claim. In fact, the April 2005 correspondence requested that the RO "reopen the claim." In pertinent part, applicable law and regulations generally provide that the effective date of an evaluation and award of pension, compensation or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400. However, in Rudd v. Nicholson, 20 Vet. App. 296, 299-300 (2006), the United States Court of Appeals for Veterans Claims (Court) held that once a rating decision which establishes an effective date becomes final, the only way that such a decision can be revised is if it contains clear and unmistakable error (CUE). The Court noted that any other result would vitiate the rule of finality. In other words, the Court found that there are no freestanding claims for an earlier effective date. When such a freestanding claim for an earlier effective date is raised, the Court held that such an appeal should be dismissed. Id. The record shows that the Veteran ultimately failed to perfect his appeal by filing a VA Form 9, following the issuance of the January 2005. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.302. The October 2002 rating decision became final as to the establishment of an effective date of July 12, 2001, for the award of a 20 percent rating for diabetes mellitus. 38 U.S.C.A. § 7105(d); 38 C.F.R. § 20.1103 (2012). Based on the aforementioned procedural development, the Veteran's appeal must be dismissed as a matter of law. In Rudd, the Court held that there was no "freestanding" earlier effective date claim which could be raised at any time after a RO decision became final. See Rudd, 20 Vet. App. at 300. The Court further indicated that because "there is no proper claim . . .," the matter must be dismissed. Id. New and Material Evidence In an October 2002 decision, the RO denied the Veteran's claim of entitlement to service connection for hypertension. At the time, the RO determined that because the Veteran had not been diagnosed with diabetic kidney disease, his diabetes had not caused or aggravated his hypertension. There was also no indication that his hypertension was related to his service because his service records were negative for hypertension and he was not diagnosed with hypertension within one year following separation from service. Thus, the RO denied the claim. The Veteran filed a timely notice of disagreement to that decision, and a statement of the case was issued in January 2005. However, he did not file a timely formal appeal, and thus his submission in April 2009, more than 60 days of receiving notice of the statement of the case, was considered to be a new claim. The claim of entitlement to service connection may be reopened if new and material evidence is submitted. Manio v. Derwinski, 1 Vet. App. 140 (1991). The Veteran filed the application to reopen the claim in April 2009. Under the applicable provisions, new evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with the 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(a) (2012). In determining whether evidence is new and material, the credibility of the new evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). The Board finds that new and material evidence sufficient to reopen the claim has been received. Since the last denial in October 2002, the Veteran's representative has submitted evidence stating that hypertension was a risk factor for complications in diabetes. Then, at his July 2009 hearing, the Veteran testified that his hypertension was not under control and that it was affected by his dosage of insulin. This new evidence was not before decision makers previously, and has a reasonable possibility of substantiating the Veteran's claim, or at least necessitated invocation of the duty to assist to obtain a VA examination and opinion, which was accomplished. Accordingly, the record includes new evidence that creates a reasonable possibility of an allowance of the claim. 38 C.F.R. § 3.156(a) (2012). Additionally, the Board finds that the new evidence is not cumulative of the evidence considered at the time of the prior final decision. Thus, the Board finds that new and material evidence sufficient to reopen the Veteran's claim has been received, and thus, the claims are reopened. As the Board has determined that new and material evidence has been submitted to reopen the claim for service connection for hypertension, it is necessary to consider whether the Veteran would be prejudiced by the Board proceeding to a decision on the merits. In this case, as discussed above, the Veteran had been provided with the laws and regulations pertaining to consideration of the claim on the merits, namely, the evidence necessary to substantiate the claim, significantly, on a secondary basis, the Veteran's contention. Given that the Veteran had adequate notice of the applicable regulations, the Board finds that the Veteran would not be prejudiced by the Board's review of the merits of the claim at this time. Bernard v. Brown, 4 Vet. App. 384 (1993). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a) . Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may be granted with evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in- service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by evidence of (i) the existence of a chronic disease in service during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or evidence of continuity of symptomatology. If the disability claimed is not considered to be a chronic disease under 38 C.F.R. § 3.307, credible lay evidence of continuous symptoms may establish service connection. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases to a degree of 10 percent within one year from the date of termination of such service, such as hypertension, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Hypertension The Veteran contends that his hypertension was caused or aggravated by his diabetes mellitus in that it has been poorly controlled due to his diabetes mellitus. Service treatment records are negative for notation of elevated blood pressure or a diagnosis of hypertension. Post-service treatment records reflect that the Veteran was first diagnosed with hypertension in approximately 1985. A 1987 VA record shows a diagnosis of hypertension, but no diagnosis of diabetes mellitus. Records dated in the late 1990s show both a diagnosis of hypertension and diabetes mellitus. Records dated in the 1990s reflect continuing treatment for hypertension, which was continuously noted as controlled, as well as treatment for noninsulin dependent diabetes mellitus. An October 2002 VA medical opinion, without any examination or indication of review of the claims file, states that the Veteran's diabetes had not caused his hypertension because the two conditions were both diagnosed in 1985 and there was no evidence of diabetic kidney disease. On February 2005 VA examination, the Veteran reported that his blood pressure had remained controlled and his medication had been increased through the years. After reviewing the claims file, the examiner noted the history of the Veteran's hypertension since service. The examiner concluded that the Veteran's essential hypertension, which was stable, was not caused or aggravated diabetes mellitus. On December 2010 VA examination, the examiner reviewed the chronology of the Veteran's hypertension and diabetes mellitus and determined that while hypertension was diagnosed sometime between 1985 and 1987, his diabetes was not definitively diagnosed until 1990. The examiner noted that research article submitted by the Veteran's attorney. The examiner determined that it was less likely than not that the Veteran's diabetes mellitus caused or aggravated his hypertension. The examiner explained that the article submitted by the Veteran did not present a rationale for the control of blood pressure in diabetics that was lower than the standard. Moreover, the article did not discuss aggravation of hypertension by diabetes. The examiner went on to explain that the Veteran's diabetes was diagnosed 5 years after his diagnosis of hypertension, and his hypertension has remained controlled throughout the past years. Moreover, the VA's definition of a relationship between diabetes and hypertension as not generally conceded unless there was evidence of renal dysfunction. There was no evidence of renal insufficiency in the current case. First, the Board has considered whether service connection is warranted for hypertension on a presumptive basis. However, the record fails to show that the Veteran manifested hypertension to a degree of 10 percent within the one year following his service discharge. Rather, the evidence, to include the Veteran's own statements, indicate that he was first diagnosed with hypertension in around 1985. As such, presumptive service connection is not warranted for hypertension. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. The Board also finds that there is no indication that the Veteran's hypertension was caused or aggravated by his service on a direct basis. In that regard, the service treatment records are negative for a diagnosis of hypertension, the first indication of a diagnosis of hypertension is not until 1985, more than a decade following service separation, and a medical professional has not related the current hypertension to service. To the contrary, the medical opinions in this case found that hypertension began many years following service. Thus, there is no indication of chronicity in service or continuity of symptoms since service. Significantly, the Veteran has not contended that his hypertension was caused or aggravated by his service. Thus, service connection for hypertension on a direct basis is not warranted. Next, with regard to whether the Veteran's hypertension was caused or aggravated by his service-connected diabetes mellitus, the Board finds that the evidence weighs against such a finding. To that extent, the Board places great probative weight on the three VA examinations finding no relationship between the Veteran's hypertension and his diabetes mellitus, with particular weight on the December 2010 opinion. All VA examiners in this case have determined that there was no objective evidence to suggest any relationship between the Veteran's diabetes and hypertension. The December 2010 VA examiner explained that there was no indication of causation, since the treatment records showed that the Veteran's diabetes was first diagnosed after he was diagnosed with hypertension. Moreover, there was no indication of aggravation because there was no history of uncontrolled hypertension, nor was there any indication of renal dysfunction, as the 2002 VA opinion also found. Those opinions comport with the record, which shows controlled hypertension and no indication of renal dysfunction. Although the Veteran has submitted an article in support of his claim, as the 2010 VA examiner pointed out, the article did not address the issue of aggravation, thus it is not applicable to the claim. Accordingly, and because there is no probative medical evidence to the contrary, service connection for hypertension on a secondary basis is not warranted. Retinopathy The Veteran contends that he currently suffers from diabetic retinopathy that was caused or aggravated by his diabetes mellitus, and which causes him blurry vision. Service treatment records are negative for any indication of vision complaints or diagnoses. Post-service treatment records reflect that on VA eye examinations conducted in July 2000, November 2006, and March 2008, the Veteran was assessed to have diabetes mellitus without diabetic retinopathy. In November 2006 and March 2008, he was noted to have hypertension with mild retinopathy. Those records clearly show that his retinopathy was of hypertensive etiology, rather than diabetic. On June 2011 VA eye examination, no other eye disability other than cataracts was diagnosed. In this case, while there is a diagnosis of hypertensive retinopathy, the Veteran is not service-connected for hypertension. There is also no indication in the medical records that his hypertensive retinopathy was caused or aggravated by his diabetes. There is no diagnosis of diabetic retinopathy, even on repeated examination. Absent a diagnosis of diabetic retinopathy, the disability for which the Veteran is claiming service connection, service connection cannot be established. Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Accordingly, the Veteran's claim of entitlement to service connection for diabetic retinopathy must be denied. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Conclusions The Board notes that the Veteran has contended on his own behalf that his hypertension and diabetic retinopathy are related to his military service, or, in the alternative, his service-connected diabetes mellitus. While he is competent to testify as to his hypertensive and vision symptomatology, he is not competent or qualified, as a layperson, to render an opinion concerning the complex medical relationship between hypertension and diabetic retinopathy and service, or between hypertension and diabetic retinopathy and diabetes mellitus. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). While the Board acknowledges that the Federal Circuit has held that lay testimony could, in certain circumstances, constitute competent nexus evidence, see Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009), in the instant case, the Board finds that the question regarding the potential relationship between hypertension and diabetic retinopathy and service as well as between hypertension and diabetic retinopathy and diabetes mellitus to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, the Board finds the Veteran's statements regarding a nexus between his hypertension and diabetic retinopathy and service or his service-connected diabetes mellitus to be of little probative value as he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). Therefore, the Board finds that the probative value of the VA opinions of record outweigh the probative value of the Veteran's statements, as described above. Consequently, as there is no competent and probative evidence linking the Veteran's hypertension and diabetic retinopathy to his military service or to his service-connected diabetes mellitus, service connection for such disabilities is not warranted. The Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims of entitlement to service connection for diabetic retinopathy and hypertension. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C.A. § 5107. Increased Ratings Ratings for service-connected disabilities are determined by comparing the veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2012). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating 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 (2012). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Diabetes Mellitus The Veteran's diabetes mellitus has been rated 20 percent disabling under Diagnostic Code 7913. DC 7913 provides for a 20 percent rating where the diabetes mellitus requires 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, restricted diet, and regulation of activities. A 60 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). Complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are deemed part of the diabetic process. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1)(2012). Turing to the evidence of record, a November 2007 private record reflects that the Veteran was admitted to the emergency room for low blood glucose. He had taken oral medication the day of admission but had not eaten lunch. His blood sugar level was stabilized. Because of reported episodes of hypoglycemia in the previous months, his Glyburide was discontinued. One week later at the VA, his Glyburide was reinstated. On April 2009 VA examination, the Veteran reported being on Glyburide daily. He denied episodes of ketoacidosis. He had had three hypoglycemic reactions in the last three years. He was trying to restrict his diet. There was no indication that a physician had prescribed restrictions on strenuous activities to prevent the hypoglycemic reactions. He reported erectile dysfunction which the examiner concluded was likely related to his diabetes mellitus. On December 2010 VA examination, it was noted that the Veteran had been instructed to use a sliding scale of Insulin if his glucose level reached greater than 150. He denied symptoms of diseases that would be related to his diabetes. He reported that he had started lifting light weights and had noticed some improvement to his glucose numbers. He declined penile examination but denied deformity. In July 2011, the Veteran submitted statements from friends and family members stating that his diabetes caused him to experience hypoglycemic episodes causing fainting, focusing on the 2007 episode in particular. On October 2011 VA examination, examination of the penis was normal. Restriction of activity due to diabetes was not noted. First, the Board finds that a higher 20 percent rating for diabetes mellitus is not warranted. In order to meet the criteria for a higher rating of 40 percent, the Veteran must have been told by a physician that he should avoid any strenuous occupational or recreational activities. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). The available evidence does not support the finding that the Veteran has been prescribed or advised to avoid strenuous occupational and recreational activities due to his diabetes, as is required in order to warrant a higher rating of 40 percent. Moreover, when reviewing the higher evaluations, although the Veteran has experienced hypoglycemic episodes, he has not been shown to have hypoglycemic episodes requiring hospitalization on a yearly basis or that require twice monthly treatment by a diabetic care provider. Thus, he does not meet the criterion requiring regulation of activity so as to warrant a 40 percent evaluation and he does not meet criteria above the 40 percent rating. Lastly, although the Veteran has erectile dysfunction related to his diabetes, a review of the records is negative for an indication of penile deformity. Thus, it does not appear that the Veteran suffers from accompanying erectile dysfunction that would warrant a compensable rating as a manifestation of his diabetes mellitus. See 38 C.F.R. § 4.115b, Diagnostic Code 7522 (2012). Cataracts The Veteran contends that a higher rating is warranted for his cataracts because he suffers from blurry vision. While this appeal was pending, the rating schedule for evaluating disabilities of the eyes was revised and amended. See 73 Fed. Reg. 66543 -54 (Nov. 10, 2008). Diseases of the eye are now rated under a General Rating Formula, under 38 C.F.R. § 4.79 (2012). However, as the new criteria are only applicable to claims filed on or after December 10, 2008, and the Veteran's claim was pending prior to that time, the Board will only consider the criteria under the prior regulations set forth under 38 C.F.R. §§ 4.75, 4.76, 4.77 4.84, 4.84a (2008). Preoperative senile and other cataracts (excluding traumatic, which is DC 6027) are rated on impairment of vision. 38 C.F.R. § 4.84a. Impairment of vision includes an examination of the visual acuity (§ 4.75), field of vision (§ 4.76) and muscle function (§ 4.77). For visual acuity, § 4.75 states that funduscopic and ophthalmological findings must be recorded. The best distant vision obtainable after correction by glasses will be the basis of rating (except keratoconus). If there is a difference of more than 4 diopters of spherical correction between the two eyes, the best possible visual acuity of the poorer eye without glasses, or with a lens of not more than 4 diopters difference from that used with the better eye will be taken as the visual acuity of the poorer eye. Impairment of central visual acuity is assessed by using table V; compensable impairment of 10 percent starts when the visual acuity is at least 20/50 in at least one eye. 38 C.F.R. § 4.84a, DC 6079, Table V. For field vision, measurement is made when there is a disease of the optic nerve or when otherwise indicated. 38 C.F.R. § 4.76. For muscle function, the measurement of muscle function will be undertaken only when the history and findings reflect disease or injury of the extrinsic muscles of the eye, or of the motor nerves supplying these muscles. 38 U.S.C.A. § 4 .77. Turning to the evidence of record, in March 2003, the Veteran's corrected visual acuity was 20/20, bilaterally. He was diagnosed with bilateral cataracts, mild. On February 2005 VA examination, review of the optometry notes revealed that the Veteran's best corrected vision was 20/20, bilaterally. On examination, he had 20/20 vision bilaterally. There was no evidence of visual field defect. On September 2008 VA examination, corrected visual acuity in the right eye was 20/40, and corrected visual acuity in the left eye was 20/40. There was no indication of a visual field defect. There was trace nuclear scleroris, not significant. On June 2011 VA examination, corrected visual acuity in the right eye was 20/25, and corrected visual acuity in the left eye was 20/25. There was no indication of a visual field defect. In this case, the Veteran is in receipt of a 0 percent rating for cataracts until February 18, 2005, and a 20 percent rating thereafter, based upon a visual field defect. The Board finds that an increased rating is not warranted at anytime during the appeal period, as despite the RO's finding of visual field defect, a review of the record is negative for any such defect, including on February 2005 VA examination. Rather, the VA examinations and treatment records dated throughout the appeal period show vision that is better than 20/50, no visual field defect, and no other muscle abnormality of the eye. Therefore, a higher rating is not warranted. III. Other Considerations An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra- schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra- schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected diabetes mellitus, erectile dysfunction, and cataracts with the established criteria found in the rating schedule. As discussed in detail previously, the Veteran's symptomatology is fully addressed by the rating criteria under which such disability is rated. There are no additional symptoms that are not addressed by the rating schedule. Therefore, the Board finds that rating criteria reasonably describes the Veteran's disability level and symptomatology for his service-connected disabilities. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Moreover, to the extent that the Veteran's disabilities may interfere with his employability, such interference is addressed by the schedular rating criteria. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Therefore, the Board finds that there are no attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra- schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). The Board has considered whether a higher rating might be warranted for any period of time during the pendency of this appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). However, the weight of the credible evidence demonstrates that higher ratings for diabetes mellitus, erectile dysfunction, and cataracts are not warranted anytime during the appeal period. As the preponderance of the evidence is against the claims, the claims must be denied. 38 U.S.C.A. § 5107(b)(West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER The issue of entitlement to service connection for cellulitis is dismissed. The claim of entitlement to an effective date earlier than July 12, 2001, for the grant of service connection and assignment of a 20 percent rating for diabetes mellitus, is dismissed. As new and material evidence sufficient to reopen a claim for service connection for a hypertension was received, the Veteran's previously-denied claim was reopened; however, service connection for hypertension is denied. Service connection for retinopathy is denied. A rating in excess of 20 percent for diabetes mellitus with erectile dysfunction is denied. A compensable rating for cataracts prior to February 18, 2005, or rating in excess of 20 percent for cataracts since February 18, 2005, is denied. REMAND Right Foot Disability The Veteran contends that his right foot disability was caused or aggravated by his service-connected diabetes mellitus and CVA. Specifically, he contends that because of his 2006 CVA and complications of diabetes, he became weak and fell from a ladder while working on his house and incurred a right ankle fracture necessitating surgery. He further asserts that because of his diabetes, his wound did not heal properly and he has chronic edema and pain of the ankle. Service treatment records are negative for a right foot injury or diagnosis of a right foot disability. Post- service treatment records reflect that that in 2006, the Veteran underwent surgery for a right ankle fracture. A December 2007 private follow-up record reflects that the Veteran was having pain and discomfort along the peroneal tendons distally but was doing well. He still had some limitation of motion. There was chronic mild edema. The assessment was status post calcaneus fracture and subsequent hardware removal with chronic lateral foot pain. The physician stated that it was likely the Veteran's diabetes was contributing to some of his chronic edema and discomfort, but it was thought that a lot of this was mechanical in nature due to lack of range of motion of the previous fracture of his hindfoot. On September 2008 VA examination, the examiner determined that it was not possible to establish a relationship between the Veteran's CVA and later right ankle fracture without resort to mere speculation. No further rationale was provided. On December 2010 VA examination, the Veteran's stasis ulcer and dermatitis of the right foot, previously diagnosed, was concluded to be related to his right ankle fracture and not to his diabetes mellitus. The examiner declined to provide an opinion as to whether his diabetes had aggravated his right foot disability because such opinion was not clearly asked by the RO. Thus, it remains unclear whether the Veteran's current right ankle disability was caused or aggravated by his diabetes mellitus or CVA. Accordingly, a new VA examination and opinion is necessary to fairly assess the claim. In that regard, the records surrounding the right ankle fracture and surgery are not of record and an attempt to obtain those records should be made. Residuals of a CVA Further clarification is necessary to determine the extent of the Veteran's residuals of his 2006 CVA, including tremors of the hands, a cognitive disorder, and urinary urgency. In that regard, private treatment records reflect that in February 2006, the Veteran underwent neurological consultation following a fall in the shower. The Veteran reported having a sore neck and a headache. He reported being lightheaded. He was noted to be slow to answer questions and his mental processing seemed mildly slowed. Examination resulted in the assessment of unsteady gait and dizziness. It was thought that he might have a slight concussion causing some imbalance, or a subdural hematoma given his earlier falls and history of alcoholism. There were slight hints of parkinsonism on examination that did not fit with the acute onset of symptoms. A subsequent MRA of the neck showed a normal study and a MRA of the head showed a possible right PICA occlusion. On November 2006 VA examination, the Veteran reported that in January 2006, he had blacked out in the shower and fell. He had awoken on the floor of the tub and had undergone testing, including MRI testing. He was treated with Aspirin and Vytorin. He reported that since the stroke, he felt that his balance was a little off. He could walk straight but felt himself swaying a little bit. He felt that his memory was not as good as before. He did not require any speech or language therapy and had no focal neurological deficits. Physical examination was normal but for tremors at rest and with activities, though the Veteran reported having had tremors for a while that occurred when nervous. On September 2008 VA examination, the Veteran reported that he had recovered from the CVA. He reported little change since the previous examination. He reported tremors in his hands three to four times per week. He reported difficulty with gait. He had urinary urgency and incontinence if he waited too long. He had occasional fatigability. He had a history of memory loss. Physical examination showed that he walked with an antalgic gait. The diagnosis was residuals of a CVA. Physical examination had shown no residual muscle weakness or sensory loss. There were no significant effects on occupation. On April 2009 VA psychiatric evaluation, the Veteran reported that his memory was becoming worse "all the time." He reported some problems with attention and concentration, speech and language, as well as confusion and disorientation. Mental status examination was normal but there was evidence of slowness to initiate speech, perhaps secondary to anxiety and reflective of retrieval problems. Following neurocognitive examination, the examiner concluded that the Veteran had subjective symptoms of memory problems and objective findings of a pattern of mild to moderate neuropsychological impairment. He had a cognitive disorder in the context of low average premorbid abilities. He had repeated memory problems that interfered with his ability to perform several instrumental activities of daily living. He also had symptoms of major depression that was not related to his CVA. The assessment was cognitive disorder, not otherwise specified, and major depressive disorder, recurrent, moderate. A GAF of 55 was assigned as it relates to his cognitive disorder. On October 2011 VA examination, the Veteran reported insomnia related to his CVA. He reported urinary frequency. It appears that the Veteran has a moderate cognitive disability related to his CVA which warrants a separate rating. However, he has also reported other symptoms, such as a possible urinary disability and tremors. In light of his current 10 percent rating, the question arises whether separate ratings are warranted without overlapping. Thus, a VA examination is necessary to determine the extent of the Veteran's CVA residuals prior to assignment of separate ratings. TDIU The Veteran contends that his service-connected disabilities preclude employment. At his hearing and to various VA examiners, he stated that he had not worked since 2000. However, he has also submitted written statements and has stated at other times that he last worked in 2006. On his July 2011 claim for TDIU, he reported that he had last worked part time in April 2006, but had lost 6 months of work during that time due to his diabetes, CVA, and cataracts. In December 2010, a VA examiner, a physician's assistant, found that the Veteran suffered from a cognitive disorder due to his service-connected CVA. The examiner went on to conclude that the Veteran's complications from the 2006 CVA incident prevented him from being able to do any type of occupational task due to residual cognitive impairment. That should be considered a permanent and total disability that caused individual unemployability. In August 2011, another VA examiner, a neuropsychologist, upon conducting neurocognitive testing, determined that the Veteran had a mild cognitive impairment status post CVA. The examiner concluded that the Veteran had cognitive problems that impacted his ability to work, such as difficulties with his ability to adapt to a changing work environment and an impairment in ability to follow instructions and keep track of tasks. He showed problems in his ability to learn and think clearly. The examiner also noted, however, that it was not possible to differentiate between the symptoms of his cognitive disorder and his ongoing alcohol use and depression. The examiner felt that both his alcohol use and major depression were more of an impact on his functional abilities than his cognitive disorder. With regard to the service-connected diabetes and cataracts, no VA examiner or other physician has found that those disabilities impact or prevent substantially gainful employment. Currently, the Veteran has a total combined disability evaluation of 40 percent. However, on remand, he may be granted ratings that would meet the scheduler criteria for a TDIU. Either way, his claim for TDIU should be reconsidered, on either a scheduler or extraschedular basis, with the receipt of an additional VA opinion. Accordingly, the case is REMANDED for the following actions: 1. Request that the Veteran identify the records relating to his right ankle injury and surgery. After securing any necessary authorization from him, obtain all identified treatment records. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, notify the Veteran and allow him the opportunity to provide such records. 2. Schedule the Veteran for a VA examination to determine the etiology of the Veteran's right foot disability. The examiner should review the claims file. The examiner is requested to provide a thorough rationale the opinions reached. a) Diagnose the Veteran's current right foot disability, addressing whether he has residuals of the previous right ankle fracture and whether he has a skin disability related to the fracture. b) The examiner should provide an opinion as to whether it is at least as likely as not (within the realm of 50 percent probability or greater) that the Veteran's diabetes mellitus or CVA caused or aggravated his right foot disability, taking into account the Veteran's assertions that his ankle disability was caused by his diabetes and CVA which lead him to fall and injure his ankle, and his contention that his right ankle was slow to heal and still caused him pain due to his diabetes. If the examiner cannot provide a rationale for these questions without resort to speculation, the reasons for such should be clearly explained. 3. Schedule the Veteran for a VA examination to determine the current nature and severity of his CVA residuals, to include, but not limited to, tremors of the hands and urinary disability. The examiner is requested to clearly state the Veteran's CVA residuals and the severity of those residuals. The examiner should also provide an opinion as to whether the residuals of the Veteran's CVA, including any cognitive disorder, prevents him from gainful employment. 4. Then, after ensuring any other necessary development has been completed, readjudicate the Veteran's claims for service connection for a right foot disability, to include as secondary to the service-connected diabetes and CVA, for an increased rating for residuals of a CVA, to include consideration of separate ratings for the Veteran's cognitive disorder and any other diagnosed residuals, and for a TDIU. If any benefit sought on appeal remains denied, provide the Veteran and his representative with a Supplemental Statement of the Case and allow the Veteran an appropriate opportunity to respond thereto. Thereafter, return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs