Citation Nr: 1335914 Decision Date: 11/05/13 Archive Date: 11/13/13 DOCKET NO. 07-27 882 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to an evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to an evaluation in excess of 20 percent for type II diabetes mellitus. 3. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD and type II diabetes mellitus. 4. Entitlement to service connection for arthritis, to include as secondary to service-connected type II diabetes mellitus. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Paul Sorisio, Senior Counsel INTRODUCTION The Veteran had active service from September 1967 to April 1969. These matters come before the Board of Veterans' Appeals (BVA or Board) from November 2006 and May 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. In December 2011, a Travel Board hearing was held before the undersigned Veterans Law Judge and a transcript of that hearing is of record. In December 2012, the Board remanded the above-captioned claims for additional development. The Board also remanded the issue of entitlement to service connection for peripheral neuropathy (including as secondary to service-connected diabetes mellitus), which was granted in a June 2013 rating decision. This rating decision assigned noncompensable evaluations for both left and right lower extremity peripheral neuropathy, effective September 1, 2008 and 20% ratings for each lower extremity, effective April 3, 2013. Accordingly, the Board considers this issue to be fully resolved and, thus, outside the scope of its jurisdiction. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (holding that where an appealed claim for service connection is granted during the pendency of the appeal, a second Notice of Disagreement must thereafter be timely filed to initiate appellate review of the claim concerning 'downstream' issues, such as the compensation level assigned for the disability and the effective date); see also 38 C.F.R. § 20.200 (2013). Significantly, the Veteran's representative appears to be challenging the ratings assigned in the June 2013 rating decision for the lower extremity peripheral neuropathy. In a September 2013 Written Brief, the representative stated, "[t]he [V]eteran is entitled to the higher ratings from the date of claim, not of the recent examination." Because, as explained above, the Board no longer has jurisdiction over the peripheral neuropathy issues, the disagreement with ratings assigned in the June 2013 rating decision is referred to the Agency of Original Jurisdiction (AOJ) for appropriate action. Additionally, the issues of entitlement to service connection for ischemic heart disease, cardiomegaly, and hyperhidrosis of the feet and hands (including associated with diabetes mellitus) were raised by a June 2013 statement. Further, the September 2013 Brief by the Veteran's representative raised a claim of clear and unmistakable error (CUE) in a May 2009 rating decision that denied service connection for hyperhidrosis. The Veteran's representative also appears to be raising entitlement to a total disability rating based on individual unemployability (TDIU) in the September 2013 Brief. The representative stated that the "TDIU claim raised by the [V]eteran has not yet been decided" and that the Veteran is entitled to "TDIU since leaving work." The AOJ has not made a determination regarding TDIU via a rating decision or statement of the case. The Board notes that where the AOJ has not yet rendered a decision on the matter, there is no decision for the Board to consider on appeal and referral for the RO to make the initial review or determination is appropriate. See Locklear v. Shinseki, 24 Vet. App. 311, 315 (2011) (concluding that where the Secretary bifurcates two matters, they may be adjudicated separately); see also Holland v. Brown, 6 Vet. App. 443, 447 (1994) (noting that "it was not inappropriate" for the Board to refer a TDIU issue to the RO for further adjudication and still decide an increased-rating claim). Here, the Board finds that referral of the TDIU matter is appropriate because it is not part of the underlying increased rating claims decided by the Board. Indeed, TDIU is raised where there is evidence of unemployability. See Comer v. Peake, 552 F.3d 1362, 1367 (Fed.Cir.2009) ("[A] claim to TDIU benefits is not a free-standing claim that must be pled with specificity; it is implicitly raised whenever a pro se veteran, who presents cogent evidence of unemployability, seeks to obtain a higher disability rating."). In the instant case, the Veteran is represented by a Veterans Service Organization and there is no evidence of unemployability. Rather, there is evidence that the Veteran is not employed because he retired from his occupation as a teacher several years ago. Further, the statements in the September 2013 Brief are vague and do not appear to tie the claimed TDIU matter to a specific service-connected disability. Based on the foregoing, the Board finds that TDIU should be referred to the AOJ for additional action. In sum, the following issues: 1) disagreement with evaluations assigned in the June 2013 rating decision for lower extremity peripheral neuropathy; 2) CUE in a May 2009 rating decision regarding hyperhidrosis; 3) service connection for ischemic heart disease and cardiomegaly; 4) new and material evidence to reopen service connection for hyperhidrosis of the feet and hands (including associated with diabetes mellitus); and 5) TDIU have yet to be adjudicated by the AOJ in the first instance; therefore, the Board does not have jurisdiction over them. As such, the Board REFERS these issues to the AOJ for appropriate action. The issues of entitlement to service connection for hypertension and arthritis are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's PTSD was manifested by no more than occupational and social impairment with reduced reliability and productivity, as shown by disturbances in concentration and mood, frequent panic attacks and difficulty in establishing and maintaining effective work and social relationships. 2. The evidence does not show that it is medically necessary for the Veteran to avoid strenuous occupational and recreational activities regarding his diabetes mellitus. CONCLUSIONS OF LAW 1. The criteria for an increased evaluation of 50 percent, but no higher, for PTSD, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2013). 2. The criteria for an evaluation in excess of 20 percent for type II diabetes mellitus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.119, Diagnostic Code 7913 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The VCAA applies to the instant issues. VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2013); 38 C.F.R. § 3.159(b) (2013); Quartuccio v. Principi, 16 Vet. App. 183 (2002). 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 C.F.R. § 3.159(b)(1). The notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim, defined to 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. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Finally, notice should be provided to a claimant before the initial unfavorable AOJ decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, VA sent the Veteran notice letters dated in July 2006, September 2006, and April 2009. These letters provided him with adequate notice. Subsequently, in November 2006, the RO adjudicated PTSD in the first instance, and the Veteran filed a timely appeal as to the RO's determination. In a May 2009 rating decision, the AOJ denied a higher rating for the Veteran's diabetes mellitus. Accordingly, with respect to notice, there is no prejudice to the Veteran in the Board's proceeding with the issuance of a decision on the merits as to this claim. Regarding VA's duty to assist, all relevant evidence necessary for an equitable resolution of the issue on appeal has been identified and obtained, to the extent possible. The evidence of record includes service treatment records; VA treatment records; the reports of July 2006, December 2008, April 2009, March 2013, and April 2013 VA examinations; multiple lay statements; and the transcript of the December 2011 Board hearing. The Veteran and his representative have not identified any outstanding relevant evidence. Concerning the examinations, the Board finds the PTSD examinations of record are adequate for evaluation purposes as the examiners recorded pertinent history and performed an objective examination of the Veteran. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The Board will discuss the adequacy of the March 2013 VA examination in the merits discussion below. There is also substantial compliance with the Board's December 2012 Remand directives in that updated VA treatment records were obtained, and the Veteran was provided with VA examinations to determine the nature and severity of his service-connected PTSD and diabetes mellitus. Also, in compliance with the Board's directives, the AMC sent the Veteran a letter in January 2013 requesting that he authorized VA to obtain private records. The Veteran did not respond. In fact, after the June 2013 supplemental statement of the case, the Veteran returned a form requesting expeditious processing and noting that he did not have any evidence to submit regarding his appeal. The Veteran recently was provided an opportunity to set forth his contentions during the December 2011 hearing before the undersigned. The United States Court of Appeals for Veterans Claims (Court) has held that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board and that a Veterans Law Judge has a duty to explain fully the issues and a duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). The record reflects that at the December 2011 hearing the undersigned set forth the issues to be discussed at the hearing, focused on the elements necessary to substantiate the claims, and sought to identify any further development that was required to help substantiate the claims. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. Accordingly, appellate review may proceed without prejudice to the Veteran with respect to his claims. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). II. PTSD Disability evaluations are determined by the application of the Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2013). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual disorders in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2013). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (2013). In evaluating mental disorders such as PTSD, the Board must consider all the evidence of record, determine the nature of the appellant's overall disability picture, and then look to the list of symptoms outlined in the diagnostic criteria as examples that can provide guidance in determining the severity of the appellant's condition. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Under Mauerhan, VA must consider "all the evidence of record that bears on occupational and social impairment," and then "assign a disability rating that most closely reflects the level of social and occupational impairment a veteran is suffering." Id. at 440-41. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2013). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2013). Under Diagnostic Code 9411, a 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); or the inability to establish and maintain effective relationships. A 100 percent rating is assigned for PTSD under Diagnostic Code 9411 where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. After reviewing the medical and lay evidence of record, the Board finds that the Veteran's PTSD symptoms reflect occupational and social impairment with reduced reliability and productivity, and are most appropriately encompassed by the criteria for a 50 percent rating outlined above, but no higher. In particular, at the July 2006 VA examination the Veteran reported increased arousal, to include insomnia, irritability, and mild hyperviligance. He also experienced signs and symptoms of numbing and avoidance to go along with feelings of alienation and estrangement. This examiner further noted that the Veteran was relatively socially withdrawn and irritable. At the December 2008 VA examination, he reported little change in his social functioning since the last examination. He did report limited social interaction outside of his immediate family. The Board finds such social interaction to be consistent with social impairment demonstrated by difficulty in establishing and maintaining effective relationships. The most recent PTSD examination indicates the Veteran has been married for over 43 years to his spouse. It was noted that there is bickering and talk of divorce, but they remained together to help with grandchildren. He kept in touch with his 4 children. The Board again finds this evidence to most nearly approximate impaired social life with a difficultly in maintaining those relationships. Indeed, while the Veteran may have difficulty in his family relationships, he does maintain them. The Veteran's PTSD also led to problems and difficulties in the workplace, resulting in time off from work. At the July 2006 examination he reported missing approximately 30 days during the last (school) year due to depression and impaired concentration. He reported that he was able to perform his job well when there. The December 2008 VA examination reflects similar complaints about missing work. Again, though, the Veteran stated he enjoyed work and there were no complaints about his performance. The most recent April 2013 VA PTSD examination reflects the Veteran last worked about 4 years ago after retiring. It was noted that towards the end of his 34 years as a special education teacher his PTSD symptoms included lack of sleep and concentration problems. It was further noted that he decided to retire at the age of 62, functioned well in his capacity of teacher, has not worked since, and holds a master's degree plus 75 additional credits. Additionally, the July 2006 and December 2008 VA examination reports evaluated the Veteran as having a Global Assessment of Functioning (GAF) score of 53. More recently, the April 2013 VA examiner assigned a GAF score of 60. GAF reports from the VA treatment notes were consistently noted to be 55 or 60 throughout the appeal period. These GAF scores are consistent with moderate impairment in social and occupational functioning and are reflective of social and occupational impairment most congruent with a 50 percent rating. See American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) 46-47 (4th ed. 1994). However, the preponderance of the evidence is against a finding that the Veteran's PTSD symptoms warranted the next higher 70 percent rating. In broad terms, the evidence of record does not show occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, and judgment. Specifically, for example, the record contains no evidence of intermittently illogical, obscure, or irrelevant speech (December 2008 VA examination notes that he spoke "fluently with normal intonation, rhythm, and volume", to include noting speech was essentially unimpaired); spatial disorientation (December 2008 VA examination noted "alert man oriented in three spheres"); neglect of personal appearance and hygiene (July 2006 VA examination noted the Veteran to be "casually dressed, appropriately groomed"); or obsessional rituals which interfere with routine activities (Veteran denied such at the April 2013, December 2008, and July 2006 VA examinations). Regarding suicidal/homicidal ideations, the December 2008 VA examination noted infrequent passive suicidal ideation without intent or plan. However, the April 2013 examiner did not report suicidal ideation and the July 2006 examiner actively noted that the Veteran denied suicidal/homicidal ideation/intent/plan. Even considering the Veteran's passive suicidal ideation in December 2008, the totality of the evidence throughout the appeal period does not demonstrate that a higher rating is warranted, to include a staged rating. Concerning near-continuous panic or depression affecting ability to function independently, appropriately, and effectively, the Veteran has been noted to suffer from panic attacks occurring several times per week; however, the record has not shown that these anxiety attacks are near-continuous, or have affected his ability to function independently, appropriately and effectively. Indeed, to the contrary, the July 2006 and December 2008 VA examination reports reflect that he was able to perform his teacher job without detriment when at work. Regarding his ability to adapt, the record shows that the Veteran's PTSD has led to some work difficulties, but he has reported, he gets along with his students, his two assistants, and a student teacher. Regarding social and familial relationships, the Veteran is able to maintain relationships with his family members, to include his children and grandchildren. Despite some marital difficult such as bickering and requests to divorce, he remains married to his wife and he keeps in contact with his 4 children. Socially, his only friends are associated with his PTSD treatment group that he attends one time per week. His hobbies, like walking and going to the beach, he prefers to do when few people are present. Such evidence does not reflect an inability to establish and maintain effective relationships. In sum, when viewing the relevant evidence of record in conjunction with the Veteran's GAF scores, the Board finds that the Veteran's overall disability picture is more nearly approximated by the next-higher 50 percent initial evaluation reflecting occupational and social impairment with reduced reliability and productivity. 38 C.F.R. § 4.7. However, the manifestations of these symptoms have not caused him deficiencies in most areas, such as work, family relations, judgment, thinking, or mood that would warrant a higher 70 percent rating. As the Veteran's symptoms have been relatively consistent over the appeal period (see, e.g., GAF scores from 2006 to 2013 ranging between 53 and 60), staged evaluations are not warranted. The preponderance of the evidence is against a higher (70 percent) rating, and the benefit of the doubt rule does not apply to this situation. III. Diabetes mellitus The Veteran contends that a rating higher than 20% is warranted for his service-connected diabetes mellitus. Pursuant to 38 C.F.R. § 4.119, DC 7913 (2013), a 20% disability rating is warranted for service-connected diabetes mellitus "[r]equiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet," and a 40% disability rating is warranted for service-connected diabetes "[r]equiring insulin, restricted diet, and regulation of activities." "Regulation of activities" is defined as "avoidance of strenuous occupational and recreational activities." 38 C.F.R. § 4.119, DC 7913. The Court has held that "for a claimant to be entitled to a 40% disability rating, the evidence must show that it is medically necessary for a claimant to avoid strenuous occupational and recreational activities," and that "medical evidence is required to support this criterion of a 40% disability rating-regulation of activities." Camacho v. Nicholson, 21 Vet. App. 360, 361, 364 (2007). There is no question that the Veteran's service-connected diabetes mellitus requires insulin. See January 2012 and May 2012 VA treatment notes (reflecting medication of "Lantus 10 unit" and "Increase Lantus 13 units, respectively); March 2013 Disability Benefits Questionnaire (DBQ) (prescribing insulin - 1 injection per day). There is also no question that the Veteran is on a restricted diet. See April 2009 VA examination report (noting that the Veteran "is on a restricted diet"); March 2013 DBQ (noting treatment with a restricted diet). Thus, the issue of whether a rating in excess of 20% is warranted turns on whether the Veteran has regulation of activities. After reviewing the evidence of record pertinent to this question, the Board finds that it does not show that it is medically necessary for the Veteran to avoid strenuous occupational and recreational activities. In this regard, the April 2009 VA examination report states that the Veteran has no "restriction of activity secondary to diabetes." This examiner added that diabetes mellitus does not affect his occupation or activities of daily living. The VA treatment records also do not show that it is medically necessary for the Veteran to regulate his activities. For example, a January 2013 VA record notes "Exercise: Walking 10-15mins/day x5 days/week" and that the Veteran "continues to participate in the MOVE program." Another VA treatment record from November 2012 notes that the Veteran's exercise includes yard work. An October 2009 VA record similarly notes that the Veteran "walks regularly." The March 2013 VA examiner (on a DBQ) marked a box "yes" indicating that the Veteran requires regulation of activities as part of medical management of his diabetes mellitus. The DBQ then notes, "If yes, provide one or more examples of how the Veteran must regulate his or her activities." The examiner responded, "needs to get daily exercise." The Note positioned directly below this response states: "For VA purposes, regulation of activities can be defined as avoidance of strenuous occupational and recreational activities with the intention of avoiding hypoglycemic episodes." There is nothing to suggest that the examiner did not act in the capacity of a physician, to include when the examination report was signed. While the examiner marked the box indicating a regulation of activities, the typed response describing the regulation actually recommends that the Veteran engage in daily exercise. Thus, despite the examiner marking the "yes" box for regulation of activities, the Board finds when the examination report is read as a whole, the totality of this report indicates that the Veteran should engage in, not avoid, strenuous activities. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (stating that a medical report "must be read as a whole"). As such, this examination report does not medically indicate that regulation of the Veteran's activities is required. The Court has noted that the successive nature of the rating criteria in DC 7913 requires that all criteria be met to establish entitlement to a higher rating. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009); Camacho, 21 Vet. App. at 366. As the Veteran's diabetes mellitus does not require the regulation of activities, the Board finds that a rating in excess of 20% is not warranted. Because the preponderance of the evidence is against the claim, it is denied. 38 U.S.C.A. § 5107; but see Tatum, 23 Vet. App. at 156 (finding that, under Camacho, § 4.7 is not applicable to the application of Diagnostic Code 7913). IV. Extraschedular consideration The Board has also considered whether referral for extraschedular ratings is appropriate. 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. Therefore, initially, 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. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the rating 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. In the second step of the inquiry, however, 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 those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (2013). Related factors include "marked interference with employment" and "frequent periods of hospitalization." Id. When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 Compensation and Pension Service for completion of the third step - a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. As noted above, the Veteran's PTSD symptoms primarily involve panic attacks, anxiety, social isolation, plus a disturbance in mood and concentration and difficulty in maintaining effective work and social relationships. These symptoms and the Veteran's level of impairment are specifically contemplated by the rating criteria under DC 9411, which reasonably describe the Veteran's disability. Additionally, the rating criteria set forth by DC 7913 directly capture the Veteran's diabetes mellitus symptoms and treatment. He undergoes daily insulin injections and restricts his diet. These are directly contemplated by DC 7913. Complications related to his service-connected diabetes mellitus, such as peripheral neuropathy and erectile dysfunction, are service-connected, rated separately, and not the subject of the instant appeal. In sum, there is no indication in the record that the rating criteria for either increased rating disability at issue are inadequate to reflect the Veteran's level of disability, nor is the Veteran's disability picture shown to be exceptional or unusual. Therefore, referral for assignment of an extraschedular evaluation in this case is not in order. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). ORDER Entitlement to an evaluation of 50 percent, but no more, for PTSD is granted, subject to the rules and regulations governing the payment of VA monetary benefits. Entitlement to an evaluation in excess of 20 percent for diabetes mellitus is denied. REMAND After granting the petition to reopen the issue of service connection for hypertension, the Board remanded for additional development related to the merits of the issue. A remand by the Board confers on the Veteran or other claimant, as a matter of law, the right to compliance with the remand orders. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (noting that the Veteran is entitled to substantial, but not strict, compliance with a remand order). In the Board's last Remand (issued in December 2012), the examiner was directed "to opine whether the Veteran's hypertension is at least as likely as not (50 percent or greater probability) related to an event, injury, or disease in service, to include his presumed exposure to an herbicide agent (i.e., Agent Orange)." The April 2013 medical opinion DBQ does not contain an answer related to this direct service connection question. The December 2012 Board remand also asked the examiner to opine "whether the Veteran's hypertension is at least as likely as not (50 percent or greater probability): . . . or (b) chronically aggravated by, any service-connected disability, to include his service-connected PTSD and/or diabetes mellitus." The April 2013 medical opinion DBQ is also deficient in this regard because the examiner did not answer the "aggravation" part of the secondary service connection claim. Further, the last Board remand also instructed the AOJ to "readjudicate all issues on appeal, considering all evidence of record." The June 2013 supplemental statement of the case does not list or otherwise readjudicate this issue. Based on the foregoing, the Board finds that this issue must be remanded again. Additionally, the April 2013 medical opinion DBQ notes that hypertension is less likely than not proximately due to or the result of the Veteran's service-connected condition. Regarding the reasoning behind this opinion, the examiner stated, "The rationale for my opinion is that the veteran has normal kidney function." This response appears to go to whether the Veteran's hypertension is proximately due to or the result of his service-connected diabetes mellitus. However, the examiner is not clear that this is the case. The Board is not able to step in and make this medical conclusion. It must support its conclusions with independent medical evidence. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Thus, the Board finds that a remand is necessary to obtain a thorough rationale in answering this medical question. Regarding service connection for arthritis, the evidence reflects persistent or recurrent symptoms of pain in the hands and low back. VA treatment records reflect an active problem of arthritis (ICD-9-CM 716.90). The ICD code means arthropathy, unspecified, site unspecified. The June 1967 report of medical history at induction notes that the Veteran complained of swollen or painful joints. The Veteran had the same complaint on the report of medical history taken in April 1969 at the time of separation. As the Veteran noted pain in joints in service and he currently has pain in joints, the Board finds that a VA examination is necessary to decide this claim. See, e.g., Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that the continuity of symptomatology provisions of 38 C.F.R. § 3.303(b) only apply to a chronic disease listed in § 3.309(a), which includes arthritis). Additionally, the Veteran's representative submitted a medical article with the September 2013 Brief titled "Musculoskeletal Complications of Diabetes Mellitus." Because the Veteran is service-connected for diabetes mellitus and this article provides an indication that his musculoskeletal pain may be related to this service-connected disability, the Board finds an opinion regarding secondary service connection should also be obtained on remand. Accordingly, the case is REMANDED for the following actions: 1. Arrange for the Veteran to undergo an appropriate VA examination to determine the etiology of the Veteran's hypertension. A copy of this Remand and all relevant medical records should be made available to the examiner. The examiner is asked to opine whether the Veteran's hypertension is at least as likely as not (50 percent or greater probability) related to an event, injury, or disease in service, to include his presumed exposure to an herbicide agent (i.e., Agent Orange). If the examiner finds that the Veteran's hypertension is not directly related to service, the examiner is asked to opine whether the Veteran's hypertension is at least as likely as not (50 percent or greater probability): (a) proximately due to, or (b) chronically aggravated by, any service-connected disability, to include his service-connected PTSD and/or diabetes mellitus. The examiner is asked to discuss, as appropriate, the evidence submitted by the Veteran from internet sources, to include a source noting that PTSD is associated with an increased likelihood of cardiovascular problems and one source noting an Institute of Medicine study linking exposure to Agent Orange to high blood pressure. A thorough rationale, to include reference to relevant evidence of record as appropriate, should be provided for all opinions expressed. If the examiner is unable to provide a requested opinion, a supporting rationale must be given concerning why the opinion cannot be provided. 2. Arrange for the Veteran to undergo an appropriate VA examination to determine the etiology of the Veteran's arthritis. A copy of this Remand and all relevant medical records should be made available to the examiner. The examiner is first asked to list the joints where arthritis is present. For the joints where arthritis is present, the examiner is asked to opine whether the Veteran's arthritis of that joint is at least as likely as not (50 percent or greater probability) related to an event, injury, or disease in service, to include noted swollen or painful joints in service. If the examiner finds that the Veteran's arthritis is not directly related to service, the examiner is asked to opine whether the Veteran's arthritis is at least as likely as not (50 percent or greater probability): (a) proximately due to, or (b) chronically aggravated by, any service-connected disability, to include his service-connected PTSD and/or diabetes mellitus. The examiner is asked to discuss, as appropriate, the evidence submitted by the Veteran's representative discussing the musculoskeletal complications of diabetes mellitus and a possible association noted on page 64 of the VA PTSD clinical practice guide. A thorough rationale, to include reference to relevant evidence of record as appropriate, should be provided for all opinions expressed. If the examiner is unable to provide a requested opinion, a supporting rationale must be given concerning why the opinion cannot be provided. 3. After all of the above has been completed, readjudicate the issues on appeal, considering all evidence of record. If the benefits sought are not granted, issue a supplemental statement of the case and afford the Veteran and his representative an appropriate opportunity to respond. The case should then be returned to the Board, as appropriate. 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 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). ______________________________________________ Laura H. Eskenazi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs