Citation Nr: 1335726 Decision Date: 11/05/13 Archive Date: 11/13/13 DOCKET NO. 10-36 731 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to an increased rating for diabetes mellitus, type II, currently rated as 20 percent disabling. 2. Entitlement to an initial increased rating for peripheral neuropathy of the left lower extremity, currently rated as 10 percent disabling. 3. Entitlement to an initial increased rating for peripheral neuropathy of the right lower extremity, currently rated as 10 percent disabling. 4. Entitlement to an initial increased rating for coronary artery disease (CAD), currently rated as 10 percent disabling. 5. Entitlement to service connection for right upper extremity radiculopathy. 6. Entitlement to service connection for left upper extremity radiculopathy. 7. Entitlement to service connection for right lower extremity radiculopathy. 8. Entitlement to service connection for left lower extremity radiculopathy. 9. Entitlement to service connection for peripheral neuropathy of the left upper extremity. 10. Entitlement to service connection for peripheral neuropathy of the right upper extremity. 11. Entitlement to service connection for peripheral vascular disease (PVD) of the left lower extremity. 12. Entitlement to service connection for PVD of the right lower extremity. 13. Entitlement to service connection for a psychiatric disability, to include major depressive disorder (MDD) and posttraumatic stress disorder (PTSD). 14. Entitlement to service connection for chronic obstructive pulmonary disease (COPD). 15. Entitlement to service connection for hypertension. 16. Entitlement to service connection for prostate cancer. 17. Entitlement to service connection for asthma, to include respiratory dysfunction. 18. Entitlement to service connection for a spine disability. 19. Entitlement to a total disability rating for individual unemployability (TDIU). ATTORNEY FOR THE BOARD Emily L. Tamlyn, Counsel INTRODUCTION The Veteran served on active duty from December 1967 to October 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from several different rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. The claims of service connection for asthma or respiratory dysfunction and for a spine disability were denied in an April 2007 rating decision. The claim for entitlement to a TDIU was denied in a July 2009 rating decision. Although a claim for PTSD was denied in a November 2011 rating decision, the Board considers there to only be one claim for a psychiatric disability, consistent with Clemons v. Shinseki, 23 Vet. App. 1 (2009). Otherwise, the issues listed on the title page were denied in a March 2009 RO rating decision. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). The following issues 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: entitlement to an initial increased rating for CAD, currently rated as 10 percent disabling; entitlement to service connection for bilateral upper and lower extremity radiculopathy, a psychiatric disability, COPD, asthma/a respiratory disability, a spine disability; and entitlement to a TDIU. FINDINGS OF FACT 1. Diabetes mellitus is treated by insulin and a restricted diet but not regulation of activities. 2. Peripheral neuropathy of the left lower extremity has been manifested by mild sciatic neuritis. 3. Peripheral neuropathy of the right lower extremity has been manifested by mild sciatic neuritis. 4. Peripheral neuropathy is of the left upper extremity is caused by service-connected diabetes mellitus. 5. Peripheral neuropathy is of the right upper extremity is caused by service-connected diabetes mellitus. 6. The Veteran does not have PVD in the left lower extremity. 7. The Veteran does not have PVD in the right lower extremity. 8. The Veteran does not have hypertension. 9. The Veteran does not have prostate cancer. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 20 percent for type II diabetes mellitus have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.21, 4.119, Diagnostic Code (DC) 7913 (2013). 2. The criteria for an initial rating higher than 10 percent for peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.21, 4.123, 4.124, 4.124a, DC 8520 (2013). 3. The criteria for an initial rating higher than 10 percent for peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.21, 4.123, 4.124, 4.124a, DC 8520 (2013). 4. The criteria for service connection for peripheral neuropathy of the left upper extremity are met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2013). 5. The criteria for service connection for peripheral neuropathy of the right upper extremity are met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2013). 6. The criteria for service connection for PVD of the left lower extremity are not met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. § 3.303, 3.307, 3.309 3.310 (2013). 7. The criteria for service connection for PVD of the right lower extremity are not met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. § 3.303, 3.307, 3.309, 3.310 (2013). 8. The criteria for service connection for hypertension are not met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. § 3.303, 3.307, 3.309, 3.310 (2013). 9. The criteria for service connection for prostate cancer are not met. 38 U.S.C.A. §§ 1110, 1116, 5107(b) (West 2002); 38 C.F.R. § 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by re-adjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's appeal of the initial ratings arises from disagreement with downstream issues following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA for these claims. Adequate VCAA notice in an increased rating claim requires that the claimant be told that to substantiate a claim the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment; that should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes; and the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008); vacated and remanded in part Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Here, the Veteran was sent a letter in July 2008 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. The letter also explained what type of information and evidence was needed to establish a disability rating and effective date. No further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Social Security Administration (SSA) records are also in the file. Moreover, the statements in support of the claim are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. Several VA medical examinations were undertaken and several opinions are in file. For reasons explained further below, the Board finds these examinations and opinions to be fully adequate and takes into account all pertinent aspects of this case. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Increased/Initial Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2013). Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by a veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In addition, the entire history of a veteran's disability is also considered as well as the ability of a veteran to function under the ordinary conditions of daily life. 38 C.F.R. § 4.10. If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2013). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease/disability and above all, coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2013). Where 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. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for an increased rating claim or in the adjudication of an initial rating when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 506 (2007); Fenderson v. West, 12 Vet App 119 (1999). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2013). Diabetes Mellitus The Veteran's diabetes is currently rated under 38 C.F.R. § 4.119, DC 7913. Under DC 7913, a 20 percent rating is warranted when the diabetes requires the use of insulin or oral hypoglycemic agent, and a restricted diet. A 40 percent rating is warranted for diabetes that requires insulin, a restricted diet, and regulation of activities. A 60 percent rating is warranted for diabetes that 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. A 100 percent rating is warranted when diabetes 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. Id. "Regulation of activities" has been defined as the situation where the Veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,446 (May 7, 1996) (defining "regulation of activities," as used by VA in DC 7913). Medical evidence is required to show that occupational and recreational activities have been restricted. Middleton v. Shinseki, 727 F.3d 1172 (Fed. Cir. 2013); Camacho v. Nicholson, 21 Vet. App. 360 (2007). 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 under DC 7913. 38 C.F.R. § 4.119, DC 7913, Note (1) (2013). In his July 2008 claim, the Veteran asserted he had to take injections twice daily due to his diabetes mellitus. In March 2012, he stated that he lost weight. The evidence shows that the Veteran is on a restricted diet and taking insulin, but there has been no regulation of his activities in conjunction with his diabetes diagnosis. A March 2008 VA primary care record showed that he was noncompliant with insulin and needed to be consistent with diet and exercise. Medical evidence is required to show that the Veteran has restriction of activities. Camacho. There is no such evidence in this case. The August 2008 VA examination report for diabetes mellitus showed that the Veteran had been on insulin since 2005 and that his dose had been increased. He denied ketoacidosis or hypoglycemic reactions. He was on a low sugar diet and reported weight loss of six pounds. He denied having restricted activities. The diagnosis was diabetes mellitus, type II on insulin treatment, uncontrolled. In February 2010, a letter from Dr. C.M. noted the Veteran had dizziness, diabetes mellitus, erectile dysfunction and "cardiovascular problems." By May, VA primary care noted diabetes mellitus was controlled. In July, he received a new VA examination. His diabetes had been uncontrolled. He denied any hospitalizations. He was on a low sugar, restricted diet. He reported he lost weight but did not know the cause. He denied restriction of activities due to diabetes. He was taking oral hypoglycemic insulin shots. He denied side effects to medications. The diagnosis was diabetes mellitus on insulin treatment. The evidence shows the Veteran continued to be treated for diabetes mellitus and in May 2012 received a new VA examination. The Veteran was prescribed insulin (more than one injection per day), but he did not require the regulation of activities as part of his medical management. He did not visit his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions. He did have peripheral neuropathy, diabetic nephropathy and erectile dysfunction. Regarding the nephropathy, the examiner clarified he actually had microalbuminuria, which was an early manifestation of diabetic nephropathy. He had no other pertinent physical findings. Regarding functional impact, the May 2012 VA examiner stated that diabetes mellitus did impact his ability to work. For example, it had no effect on grooming, toileting, bathing and feeding; a mild effect on chores, shopping, recreation, traveling and dressing; a moderate effect on exercises; and sports were prevented. Given the evidence, the Board does not find evidence of regulation of activities which would warrant a rating higher than 20 percent for diabetes mellitus under DC 7913. See 38 U.S.C.A. §§ 1155, 5107(b); Camacho, 21 Vet. App. at 360; 38 C.F.R. §§ 4.7, 4.119, DC 7913. Separate compensable manifestations of diabetes are to be rated separately. The record shows that the Veteran has been found to have microalbuminaria. Microalbuminuria is albuminuria at a level too subtle to be measured by conventional means, often seen with the hyperfiltration of diabetes mellitus. Dorland's, p 1174. The rating schedule regarding the genitourinary system, states that albuminuria alone is not nephritis. Further, it is not to be separately rated or assigned when there is already disability from a disease from the heart unless the whole kidney is removed. 38 C.F.R. § 4.115 (2013). Here, the Veteran is already being separately rated for CAD, as well as erectile dysfunction. His kidney has not been removed. No separate rating is necessary for the presence of microalbuminuria. The Board also finds that no separate rating is warranted for the feet (see further below), eyes, or other parts of the body that could be potentially impacted by diabetes mellitus. While the Veteran reported blurry vision and progressive vision loss at the August 2008 VA examination, an eye examination was normal. In March 2009, a VA optometry record showed no retinal diabetic changes. In July 2010, a VA examination report showed the eyes were normal. In March 2011, a VA optometry report showed no diabetic retinopathy. Regarding the Veteran's weight loss contention, in September 2009, a VA primary care record showed he had a loss of appetite; an appetite disorder was diagnosed and it was unclear whether this was perhaps related to his recent diagnosis of HIV. However, this issue was addressed in the May 2012 VA examination report where the examiner clarified that he did not have progressive unintentional weight loss or loss of strength attributable to diabetes mellitus. In any case, weight loss would have to be present along with regulation of activities, which has not been shown. 38 C.F.R. § 4.119, DC 7913. Where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. See Hart, 21 Vet. App. at 509-510. However, the record does not support the assignment of different percentage evaluations during the time period on appeal. No staged rating is warranted. Pursuant to 38 C.F.R. § 3.321(b)(1) (2013), the Under Secretary for Benefits or the Director, Compensation Service, is authorized to approve an extraschedular evaluation 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 as to render impractical the application of the regular schedular standards." The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242, 244 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Initially, there must be a comparison between the level of severity and symptomatology of a claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here, the rating criteria fully contemplate the Veteran's disability as noted above. Other separate compensable ratings for manifestations of diabetes mellitus are considered and separately rated. See 38 C.F.R. § 4.119, DC 7319, Note 1. The rating criteria are therefore adequate to evaluate the Veteran's disability and referral for consideration of extraschedular rating is not warranted. 38 C.F.R. § 3.321(b)(1). Peripheral Neuropathy of the Left and Right Lower Extremities The peripheral neuropathy of the Veteran's lower extremities is currently rated under 38 C.F.R. § 4.124a, DC 8520 as paralysis of the sciatic nerve; he is receiving a 10 percent rating for each lower extremity. Paralysis of the sciatic nerve is rated as follows: a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent rating is warranted for moderate incomplete paralysis; a 40 percent rating is warranted for moderately severe incomplete paralysis; a 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy; and an 80 percent rating is warranted for complete paralysis resulting in the foot dangling and dropping, no possible active movement of muscles below the knee, and weakened or (very rarely) lost flexion of the knee. 38 C.F.R. § 4.124a, DC 8520. The rating schedule provides guidance for rating neurologic disabilities. With regard to rating neurologic disabilities, cranial or peripheral neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123. The maximum rating that can be assigned for neuritis not characterized by organic changes will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Cranial or peripheral neuralgia, usually characterized by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. 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. VA primary care records from March 2008 and September 2009 showed no gross motor or sensory deficits. In October 2009, a letter from Dr. C.M. stated that the Veteran had peripheral neuropathy symptoms with numbness, paresthesias, and loss of sensitivity in both lower limbs. The Veteran received a VA examination for peripheral neuropathy in August 2008. The claims file and medical records were reviewed. He had pain in his heels, ankles and back. He had no motor impairment. Vibration and light touch as well as pain sensation were decreased in the lower extremities only. A reflex examination was normal. He didn't have atrophy and joint function was not affected. The examiner diagnosed peripheral neuropathy and found there were no effects of the problem on usual daily activities. At the July VA examination for diabetes mellitus, he stated he had lower extremity weakness and it was noted he had a positive monofilament test. He was evaluated again by VA in May 2012. He was not on therapy for his bilateral lower peripheral neuropathy. He stated he had had numbness and occasional pain, which were described as "dull, mild, and intermittent." He also had moderate numbness. He had a slightly reduced grip and decreased vibration sensation; otherwise findings were normal. It was noted that an electromyography test (EMG) in August 2008 was normal. In discussing severity and nerve affected by the bilateral lower peripheral neuropathy, the examiner found that the sciatic nerve was normal bilaterally and there was no incomplete or complete paralysis. The femoral nerve was not affected. The examiner stated that peripheral neuropathy impacted the Veteran's ability to work. The Veteran is unemployed, so the examiner explained by analogy that the disabilities had no effect on grooming, toileting, bathing and feeding; a mild effect on chores, shopping, recreation, traveling and dressing; a moderate effect on exercises; and sports were prevented. This record shows that peripheral neuropathy of the lower extremities has been manifested by numbness and pain in the lower extremities since the effective date of service connection. Given that the findings were mild neurological symptoms that are wholly sensory and the otherwise normal neurological findings, the symptoms of the Veteran's peripheral neuropathy of the lower extremities more closely approximate the criteria for 10 percent ratings under DC 8520 and higher initial ratings are not warranted for the period on appeal. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.124a, DC 8520. As for an extraschedular rating, the Board finds the rating criteria fully contemplate the Veteran's disability as noted above. The Veteran's symptoms of pain and numbness are considered by the schedule here and he is being compensated for those symptoms. The rating criteria are therefore adequate to evaluate the Veteran's disability and referral for consideration of extraschedular rating is not warranted. 38 C.F.R. § 3.321(b)(1). Service Connection Generally Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, as the evidence shows that a present disability is not found for PVD, hypertension and prostate cancer further discussion is unnecessary. In addition, service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2013). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. § 3.310(a). The Board must determine the value of all pertinent lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). The evaluation of evidence generally involves a three step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible; in determining whether documents submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza, 7 Vet. App. 498. The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2) (West 2002). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (a medical opinion was not required to prove a nexus between a service-connected mental disorder and drowning which caused death). Lay evidence may be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Charles v. Principi, 16 Vet. App. 370 (2002). Laypersons have generally been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Peripheral Neuropathy of the Left and Right Upper Extremities The Board finds a current diagnosis of peripheral neuropathy of the left and right upper extremities via the May 2012 VA examination report, which noted symptoms of numbness sensation and occasional pain. Peripheral neuropathy is a well-known symptom secondary to the diabetes mellitus and the Veteran is already service-connected for the lower extremities due to peripheral neuropathy attributed to diabetes mellitus. All upper extremity nerves were found to be normal; however, as explained in the report, subjective symptoms can be used to diagnose the presence of diabetic peripheral neuropathy. As the Board finds the Veteran to be competent and credible in his report of symptoms, the benefit of the doubt rule is for application and peripheral neuropathy of the right and left upper extremities is related to service-connected diabetes mellitus; service connection is warranted. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 3.310. PVD of the Left and Right Lower Extremities The Board does not find that service connection for PVD is warranted because he has not been diagnosed with this disability; existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In his July 2008 claim, the Veteran stated he had poor circulation of the feet; he appeared to be claiming this problem was secondary to his service-connected diabetes mellitus. His service treatment records are silent for complaints, symptoms or diagnoses of PVD. March 2007 and 2008 VA primary care record showed no gross motor or sensory deficits. A March 2008 diabetic foot check only showed the Veteran had warmth, dryness, discoloration, and a callus on his feet. In August 2008, a VA examination report for the arteries and veins showed the Veteran claimed he had loss of circulation of the feet for the past ten years. He stated that while walking he had numbness and stiffness of the feet. He stated doctors told him he had loss of circulation of the feet. The course since its onset was intermittent with remissions. He did not report Raynaud's disease or any other past diagnosis of another arterial or venous disease. The physical examination showed the examiner found no findings of arterial or venous disease. The examiner stated there was a negative artery examination on the legs upon examination of the lower extremities. The Veteran failed to report for laboratory testing. A July 2010 VA examination showed that the skin and feet were normal. At the May 2012 VA examination, again PVD was not found and was not related to or aggravated by diabetes mellitus. The Board finds the Veteran is competent to report poor circulation symptoms of his feet since 1998 and is credible in his report. See 38 C.F.R. § 3.159(a)(2); Caluza, 7 Vet. App. 498. However, the Board finds no disability present despite constant visits and examinations for his diabetes mellitus over the years in addition to the negative finding at the August 2008 VA examination. See Degmetich, 104 F. 3d 1328; Brammer, 3 Vet. App. at 225. Reasonable doubt does not arise, and the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Hypertension For VA compensation purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. 38 C.F.R. § 4.104, Diagnostic Code (DC) 7101, note (1) (2013). Also, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id. Service treatment records do not show blood pressure readings that would show evidence of hypertension for VA purposes and the Veteran denied past readings of high blood pressure in his RMHs. In his July 2008 claim, the Veteran stated his diabetes mellitus caused hypertension. While some records show a high blood pressure reading, reference controlled hypertension or state treatment was being received for hypertension but there is no showing of hypertension for VA purposes (See December 2005 SSA evaluation, November 2007 VA primary care record, October 2009 Dr. C.M. letter, and March 2010 VA record). Several other records show the Veteran denied a history of hypertension (see April 2007 VA examination report and August 2008 diabetes mellitus VA examination report). In August 2008, the VA examination report for hypertension showed the Veteran failed to show up for laboratory testing. In July 2010, he received another hypertension examination. He stated he had no history of arterial hypertension, heart disease or medical treatment for arterial hypertension, heart disease or any other such treatment. He had a history of chronic smoking. He denied hypertension symptoms. There was no past diagnosis and he was receiving no treatment. Blood pressure readings were within normal limits when read three times on the day of the examination. The examiner concluded there was no evidence of hypertension. The Board finds the Veteran not competent on the issue of whether he has had hypertension. He never described any symptoms of hypertension. Hypertension, colloquially known as "the silent killer," is not like a broken leg. A broken leg can be visible to the eye and can be painful. See, Jandreau, 492 F.3d at 1377, footnote 4. As shown by the evaluations of the Veteran, hypertension is something shown through blood pressure readings, laboratory results and a cluster of specific symptoms. The Veteran is not competent to state he has had hypertension since service or that his hypertension is related to his service-connected diabetes mellitus. He has not stated any symptoms that he might be competent to report. Id. The Board finds no evidence of a diagnosis of hypertension for VA purposes in the record. See Degmetich, 104 F. 3d 1328; Brammer, 3 Vet. App. at 225. Reasonable doubt does not arise, and the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Prostate Cancer If a Veteran was exposed to an herbicide agent during service, certain listed diseases, including prostate cancer, are presumptively service-connected. 38 U.S.C.A. § 1116(b)(1) (West 2002); 38 C.F.R. §§ 3.307(a)(6)(i), 3.309(e) (2011). This presumption requires manifestation of the disease to a degree of 10 percent or more any time after service. 38 C.F.R. § 3.307(a)(6)(ii). A Veteran who "served in the Republic of Vietnam" between January 9, 1962 and May 7, 1975 is presumed to have been exposed during such service to an herbicide agent. 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in Vietnam. § 3.307(a)(6)(iii). The Veteran served in Vietnam (see record of assignments in service personnel record), however, he does not have a current diagnosis or findings of prostate cancer. The Board does not find the Veteran is competent to report he has prostate cancer. See, Jandreau, 492 F.3d at 1377, footnote 4. In his July 2008 claim, the Veteran stated he was diagnosed with prostate cancer and stated he had an operation on his prostate. At his August 2008 VA peripheral neuropathy examination he reported he had a history of prostate cancer. Service treatment records do not show diagnoses of cancer and the Veteran denied cancer on his RMH. The evidence shows that a March 2008 VA primary care record showed an elevated prostate-specific antigen (PSA) and a biopsy was ordered to rule out malignancy. The June 2008 operation and pathology reports show findings were nodular hyperplasia. As explained in the August 2008 VA genitourinary examination, the Veteran did not currently have or have a history of prostate cancer; the examiner referred to the pathology report. In May 2010, a VA nurse practitioner noted prostate enlargement after a digital examination. However, the May 2010 primary care record noted the past elevated PSA, and that he had hyperplasia by biopsy and that he was on a medication for benign prostatic hypertrophy. The Veteran does not have a past or current prostate cancer. An essential element of the claim is missing and the weight of the evidence is against service connection. See Degmetich, 104 F. 3d 1328; Brammer, 3 Vet. App. at 225. As a result, reasonable doubt does not arise and the claims are denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER An increased rating for diabetes mellitus, type II, currently rated as 20 percent disabling, is denied. An initial increased rating for peripheral neuropathy of the left lower extremity, currently rated as 10 percent disabling, is denied. An initial increased rating for peripheral neuropathy of the right lower extremity, currently rated as 10 percent disabling, is denied. Service connection for peripheral neuropathy of the left upper extremity is granted. Service connection for peripheral neuropathy of the right upper extremity is granted. Service connection for PVD is denied. Service connection for hypertension is denied. Service connection for prostate cancer is denied. REMAND The VA examination reports for an initial increased rating for CAD; service connection for a psychiatric disability; and service connection for COPD to be inadequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Further, the COPD claim lacks a VCAA notice letter. In June 2010, the RO denied claims for service connection for asthma or a respiratory disability and a spine disability. In October 2009, the Veteran filed a notice of disagreement (NOD) with this decision. A statement of the case (SOC) has not been issued. The Board is required to remand the appeal to the agency of original jurisdiction (AOJ) for the issuance of a SOC. Manlincon v. West, 12 Vet. App. 238 (1999). Entitlement to a TDIU and to service connection for radiculopathy are inextricably intertwined with these issues. In addition an opinion as to employability is required. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Send the Veteran a notice letter in compliance with the VCAA for his claim of service connection for COPD. 2. Schedule the Veteran for a VA cardiology examination to determine the current severity of his service- connected CAD. The examiner should review the claims folder in connection with the examination. Exercise stress testing should be conducted. The examiner must indicate whether dyspnea, fatigue, angina, dizziness, or syncope are produced at workloads of (1) three or less METs, (2) greater than three, but less than five METs, (3) greater than five, but less than seven METs, (4) greater than seven, but less than ten METs, or (5) greater than ten METs. If a laboratory determination of METs by exercise stress testing cannot be done for medical reasons, the examiner should provide an estimate of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope. The examiner also should indicate whether the Veteran's CAD requires continuous medication; whether there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray; whether there is evidence of chronic congestive heart failure; whether there is evidence of acute congestive heart failure within the last year and, if so, whether there was more than one episode; and whether there is any left ventricular dysfunction and, if so, whether the ejection fraction is (1) less than 30 percent, (2) 30 to 50 percent, or (3) more than 50 percent. 3. Send the claims file to a VA examiner for an opinion as to whether COPD had its onset in service or is otherwise related to a disease or injury in service. The examiner should review the claims folder and note such review in the examination report. The examiner should reference: * service treatment records showing a report, but not confirmation of, asthma at enlistment; * other service treatment records, to include a May 1969 service treatment records showing a diagnosis of asthmatic bronchitis and the RMH at separation showing the Veteran reported ENT trouble, hay fever, asthma, shortness of breath, and chest pressure/pain; * July 2005 Dr. D. record showing diagnoses of pneumonia, rule out lung pneumoconiosis with pulmonary fibrosis, COPD exacerbation, cigarette smoking and weight loss; * An August 2005 pathology showing BOOP (bronchopneumonia) and diffuse alveolar damage; * April 2007, August 2008 and July 2009 VA examination reports which do not address whether COPD was related to service or aggravated by any service-connected disabilities; and * A December 2010 VA infectious disease report showing a diagnosis of emphysema. The examiner should provide reasons for all opinions that take into account the Veteran's reports. 4. After the above development is completed, schedule the Veteran for a VA psychiatric examination. The claims folder and a copy of this remand must be provided to the examiner prior to the examination. The examiner should determine the diagnoses of any currently manifested psychiatric disorder(s) and should state whether it is at least as likely as not that any diagnosed psychiatric disability is related to service. The examiner should also state whether any psychiatric disability is related to any other service-connected disability and/or whether it is aggravated by any service-connected disability. The diagnosis must be based on examination findings, all available medical records, complete review of comprehensive testing for PTSD, and any special testing deemed appropriate. The examiner's attention is especially directed toward the following evidence: * A May 1969 service treatment record which noted a history of asthma and states the medication was of no help but "appears to be mostly anxiety;" * An October 1969 RMH showing the Veteran denied nervous trouble; * A December 2005 SSA evaluation showing the Veteran reported depression since July 2005; * An April 2006 SSA evaluation showing a diagnosis of MDD, mild; * An August 2008 VA examination report which did not address whether any psychiatric disability was directly due to service or whether any psychiatric disability was aggravated by a current service-connected disability; * An October 2009 Dr. C. M. letter showing diagnoses of PTSD, general anxiety disorder, and MDD; * An October 2010 VA initial psychiatric consultation showing a diagnosis of psychotic disorder not otherwise specified, rule out schizoaffective disorder, depressed and HIV psychosis; * A February 2011 VA PTSD examination showing only MDD (no opinion given) and * A November 2011 mental health history record showing the Veteran reported depression's onset of being since he was on active duty in Vietnam. Reasons (supported by accurate facts) should be given for all conclusions reached. 5. Obtain an opinion from a vocational specialist, physiatrist, or rehabilitation physician, if available, or other suitable medical professional, if not, as to whether the Veteran's service connected disabilities prevent him from performing gainful employment for which his education and occupational experience would otherwise qualify him. 6. If there are periods when the Veteran was unemployed, but did not meet the requirements for TDIU, refer the case to the Director of VA's Compensation and Pension Service, for adjudication in accordance with the provisions of 38 C.F.R. § 4.16(b). Issue a SOC to the Veteran with regard to the claims for service connection for asthma, to include a respiratory disability and a spine disability. These issues should not be certified to the Board unless a sufficient substantive appeal is received. 7. If the decision remains in any way adverse to the Veteran, issue a supplemental statement of the case (SSOC). The case should then be returned to the Board, if otherwise in order. The appellant 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. 2013). ______________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs