Citation Nr: 1338162 Decision Date: 11/20/13 Archive Date: 12/06/13 DOCKET NO. 07-16 696 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial evaluation in excess of 20 percent for diabetes mellitus, type II, with diabetic retinopathy, hypertension, diabetic right foot ulcer and impotence. 2. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy of the right lower extremity, prior to September 27, 2005, and in excess of 20 percent thereafter. 3. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy of the left lower extremity, prior to September 27, 2005, and in excess of 20 percent thereafter. 4. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy of the right upper extremity (dominant), prior to March 26, 2012, and in excess of 30 percent thereafter. 5. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy of the left upper extremity (non-dominant), prior to March 26, 2012, and in excess of 20 percent thereafter. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.N. Moats, Counsel INTRODUCTION The Veteran served on active duty from September 1967 to September 1969. This case comes before the Board of Veterans' Appeals (the Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran testified before the undersigned Acting Veterans Law Judge at the RO in August 2011. A transcript of the hearing has been associated with the claims file. The Board previously remanded this case for further development in February 2012. By way of background, the Board notes that service connection for diabetes mellitus, type II, was granted in a January 2005 rating decision. Additional evidence was received within one year of the January 2005 determination, and while the submission of additional evidence does not extend the period for initiation of an appeal by submission of a notice of disagreement, additional evidence submitted by the Veteran within one year of the rating decision in question requires application of 38 C.F.R. § 3.156(b) and a consideration of whether such additional evidence is new and material evidence. 38 C.F.R. § 3.156(b) (2013); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); see also Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). The additional evidence received within one year of the January 2005 rating decision has been deemed new and material, and as such, the January 2005 rating decision is not final pursuant to 38 U.S.C.A. § 7105. In addition, in a May 2005 rating decision, service connection was granted for peripheral neuropathy of the bilateral upper and lower extremities and the Board construes the Veteran's September 2005 correspondence as a timely notice of disagreement with the initial evaluations assigned for the upper and lower extremity peripheral neuropathy. Therefore, the issues regarding the evaluation of peripheral neuropathy of the bilateral upper and lower extremities are on appeal from the May 2005 rating decision. The Board further notes that in a February 2006 rating decision, the evaluation assigned for right lower extremity peripheral neuropathy was increased to 20 percent, effective September 27, 2005, and the evaluation for left lower extremity peripheral neuropathy was also increased to 20 percent, effective September 27, 2005. Moreover, in a March 2013 rating decision, the RO increased the evaluation for right upper extremity peripheral neuropathy to 30 percent, effective March 26, 2012, and increased the evaluation for left upper extremity peripheral neuropathy to 20 percent, effective March 26, 2012. Since the increases do not constitute a full grant of the benefits sought, the increased rating issues remain in appellate status and the issues have been characterized as set forth on the front page of this decision. AB v. Brown, 6 Vet. App. 35, 39 (1993). The Board also observes that the United States Court of Veterans Appeals (Court) has held that a request for a total disability rating due individual unemployability as a result of service-connected disabilities (TDIU), whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if the disability upon which entitlement to TDIU is based has already been found to be service-connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). However, during the course of the Veteran's increased rating claim, a claim for TDIU was granted by the RO in a June 2010 rating decision. The Veteran has not appealed the effective date assigned. Such adjudication reflects the permissive bifurcation of the increased rating claim from the TDIU claim. See Roebuck v. Nicholson, 20 Vet. App. 307, 315 (2006) (acknowledging that the Board can bifurcate a claim and address different theories or arguments in separate decisions); Holland v. Brown, 6 Vet. App. 443, 447 (1994) (holding that "it was not inappropriate" for the Board to refer a TDIU claim to the RO for further adjudication and still decide an increased-ratings claim). Moreover, while acknowledging the Rice decision, in Locklear v. Shinseki, 24 Vet. App. 311 (2011), the Court held that it is permissive for VA to address a claim for TDIU independently of other claims, including increased rating and service connection claims. Id. at 315. Given the foregoing, the Board concludes that the TDIU claim was separately adjudicated and granted, and not perfected for appellate review. As a final preliminary matter, the Board notes that, in addition to the paper claims file, there is a Virtual VA paperless claims file. A review of such file reveals that with the exception of additional VA treatment record dated to March 2013, the records are either duplicative of the evidence contained in the paper claims file or not pertinent to the issues being decided herein. The issue of entitlement to an initial evaluation in excess of 20 percent for diabetes mellitus, type II, with hypertension, retinopathy, a right foot ulcer and impotence is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. For the entire appeal period, i.e., since VA received his initial claim on May 16, 2005, the Veteran's service-connected peripheral neuropathy of the right lower extremity has more nearly approximated severe incomplete paralysis of the external popliteal nerve, but has not been productive of complete paralysis. 2. For the entire appeal period, i.e., since VA received his initial claim on May 16, 2005, the Veteran's service-connected peripheral neuropathy of the left lower extremity has more nearly approximated severe incomplete paralysis of the external popliteal nerve, but has not been productive of complete paralysis. 3. For the entire appeal period, i.e., since VA received his initial claim on May 16, 2005, the Veteran's service-connected peripheral neuropathy of the right upper extremity (dominant) has more nearly approximated moderate incomplete paralysis of the median nerve, but has not been productive of severe incomplete paralysis or complete paralysis. 4. For the entire appeal period, i.e., since VA received his initial claim on May 16, 2005, the Veteran's service-connected peripheral neuropathy of the left upper extremity (non-dominant) has more nearly approximated moderate incomplete paralysis of the median nerve, but has not been productive of severe incomplete paralysis or complete paralysis. CONCLUSIONS OF LAW 1. Effective May 16, 2005, the criteria for the assignment of an initial 30 percent rating, but no higher, for peripheral neuropathy of the right lower extremity have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.124a, Diagnostic Code 8521 (2013). 2. Effective May 16, 2005, the criteria for the assignment of an initial 30 percent rating, but no higher, for peripheral neuropathy of the left lower extremity have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.124a, Diagnostic Code 8521 (2013). 3. Effective May 16, 2005, the criteria for the assignment of an initial 30 percent rating, but no higher, for peripheral neuropathy of the right upper extremity (dominant) have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.124a, Diagnostic Code 8515 (2013). 4. Effective May 16, 2005, the criteria for the assignment of an initial 20 percent rating, but no higher, for peripheral neuropathy of the left upper extremity (non-dominant) have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.124a, Diagnostic Code 8515 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist 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, 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. Accordingly, 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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). 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 readjudication of the claim. See Mayfield, 444 F.3d at 1328; see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In the instant case, the Veteran's claims decided herein arise from an appeal of the initial evaluations following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and 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. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him 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 Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, post-service reports of VA treatment and VA examinations. As noted above, a review of Virtual VA reveals additional VA treatment records dated to March 2013, which were obtained pursuant to the Board's February 2012 remand. Moreover, the Veteran's statements, including his Board hearing testimony, in support of the claim are of record. The Board has carefully reviewed such statements and concludes 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 claims. Additionally, the Veteran was afforded VA examinations in November 2005, December 2006, September 2008, February 2011 and March 2012 to evaluate the severity of his service-connected peripheral neuropathy of the bilateral upper and lower extremities. The most recent examination was conducted pursuant to the Board's February 2012 remand. The Board finds that the VA examinations are adequate because, as discussed below, they were based upon consideration of the Veteran's pertinent medical history, his lay assertions and current complaints, and because they provide detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Furthermore, the Veteran has not asserted, and the evidence does not show, that his symptoms have materially worsened since the most recent March 2012 evaluation. See 38 C.F.R. §§ 3.326, 3.327 (2013) (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect.); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The Board accordingly finds no reason to remand for further examination in connection with the peripheral neuropathy claims. Additionally, in August 2011, the Veteran was provided an opportunity to set forth his contentions during a hearing before an Acting Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the DRO or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the August 2011 hearing, the Acting Veterans Law Judge enumerated the issues on appeal. Also, information was solicited regarding the current severity of the Veteran's peripheral neuropathy of the upper and lower extremities and the functional impact it has on his daily life and employment. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. To the extent any such notice may have been inadequate, this was effectively cured both by actual knowledge as evidence by statements and questions of the Veteran's authorized representative at the hearing, as well as by the Board providing such explanation of the issues and suggesting submission of evidence in the subsequent remand the Board issued to develop these claims. As such, the Board finds that, consistent with Bryant, the Acting Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claims. 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). Finally, the Board finds that there was substantial compliance with the February 2012 remand directives with respect to the issues being decided herein. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). Nonetheless, it is only substantial compliance, rather than strict compliance, with the terms of a remand that is required. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to an internal medicine specialist requested by the Board); Dyment v. West, 13 Vet. App. 141 (1999). In particular, the Board in February 2012 directed the RO obtain additional VA treatment records from October 2010 to the present. As noted above, such records have been associated with the Veteran's Virtual VA record. Further, the RO was also directed to schedule the Veteran for a VA examination. As noted above, the Veteran was afforded a VA examination in March 2012 that is adequate for appellate review. Finally, the RO was directed to adjudicate the issue of entitlement to special monthly compensation based on the loss of use of the upper extremities, which was done in an August 2012 rating decision. Accordingly, the Board finds that there has been substantial compliance with the February 2012 Board remand directives with respect to the issues being decided herein and, therefore, no further remand is necessary. See Stegall, 11 Vet. App. at 268; D'Aries, 22 Vet. App. at 104. II. Laws and Regulations Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). As in the instant case, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. at 126. Under the anti-pyramiding provision of 38 C.F.R. § 4.14 (2013), the evaluation of the "same disability" or the "same manifestation" under various diagnoses is to be avoided. The Court held, in Esteban v. Brown, 6 Vet. App. 259 (1994), that for purposes of determining whether the appellant is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of, or overlapping with, the symptomatology of the other conditions. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). The Board notes that VA may consider other analogous rating criteria if warranted under the facts and circumstances of a case. See 38 C.F.R. § 4.20 (2013) (stating that when an unlisted condition is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous). Specifically, evaluation of a service-connected disability in accordance with schedular criteria that closely pertain to an analogous disease in terms of functions affected, anatomical localization, and symptomatology, is permitted. Id. For purposes of the analyses below, the Board observes that the terms "mild," "moderate" and "severe" are not defined in VA regulations, and the Board must arrive at an equitable and just decision after having evaluated the evidence. 38 C.F.R. § 4.6. Under 38 C.F.R. § 4.123 (2013), neuritis (characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating) is to be rated on the scale for the nerve involved, with a maximum equal to severe incomplete paralysis. This code further provides that for neuritis (other than for the sciatic nerve) not characterized by the organic changes referred to the maximum rating will be that for moderate incomplete paralysis. Under 38 C.F.R. § 4.124 (2013), neuralgia (characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve) is to be rated with a maximum equal to moderate incomplete paralysis. The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture 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 (2013). Hyphenated diagnostic code have been used in the instant case because is has been determined that the Veteran's diabetic peripheral neuropathy was considered an unlisted condition that required rating by analogy. See 38 C.F.R. § 4.27 (2013). The RO has rated the Veteran's peripheral neuropathy of the lower extremities, by analogy, under 38 C.F.R. § 4.124a, Diagnostic Code 8599-8521 for paralysis of the external popliteal nerve (common peroneal), which is the primary nerve affecting the foot. Under Diagnostic Code 8521, a 10 percent rating is assigned for mild incomplete paralysis of the external popliteal nerve. A 20 percent rating is assigned for moderate incomplete paralysis of the external popliteal nerve and a 30 percent rating is assigned for severe incomplete paralysis of the external popliteal nerve. Complete paralysis of the external popliteal nerve; foot drop and slight droop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes warrants a maximum 40 percent rating. 38 C.F.R. § 4.124a, Diagnostic Code 8521. As the medical evidence shows also possible involvement of the sciatic nerve, the Board also noted that Diagnostic Code 8520 provides the rating criteria for paralysis of the sciatic nerve. Under Diagnostic Code 8520, a 10 percent rating requires mild incomplete paralysis of the sciatic nerve. A 20 percent rating requires moderate incomplete paralysis of the sciatic nerve. A 40 percent rating requires moderately severe incomplete paralysis of the sciatic nerve. A 60 percent rating requires severe incomplete paralysis with marked muscular atrophy. An 80 percent rating requires complete paralysis, whereby the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. The RO has rated the Veteran's peripheral neuropathy of the upper extremities, by analogy, under 38 C.F.R. § 4.124a, Diagnostic Code 8599-8515 for paralysis of the median nerve. Under this code, incomplete paralysis of the median nerve of the major hand warrants a 10 percent rating when mild, a 30 percent rating when moderate, and a 50 percent rating when severe. Complete paralysis of the median nerve of the major hand warrants a 70 percent rating. Further, incomplete paralysis of the median nerve of the minor hand warrants a 10 percent rating when mild, a 20 percent rating when moderate, and a 40 percent rating when severe. Complete paralysis of the median nerve of the minor hand warrants a 60 percent rating. 38 C.F.R. § 4.124a, Diagnostic Code 8515. As the medical evidence shows also possible involvement of the ulnar and radial nerves, the Board also notes that Diagnostic Code 8514 provides rating criteria for paralysis of the radial nerve and Diagnostic Code 8516 provides the rating criteria for paralysis of the ulnar nerve. Under Diagnostic Code 8514, mild incomplete paralysis of the musculospiral nerve (radial nerve) of either upper extremity, or moderate incomplete paralysis in the minor extremity warrants a 20 percent rating. A 30 percent rating is warranted for moderate incomplete paralysis of the radial nerve in the major extremity. Severe incomplete paralysis of the radial nerve in the minor extremity warrants a 40 percent rating, and the same in the major extremity warrants a 50 percent rating. Complete paralysis of the radial nerve in the minor extremity warrants a 60 percent rating, and such warrants a maximum 70 percent rating in the major extremity. Complete paralysis of the radial nerve contemplates symptoms such as drop of hand and fingers, perpetual flexion of the wrist and fingers, adduction of the thumb with the thumb falling within the line of the outer border of the index finger, an inability to extend the hand at the wrist, an inability to extend the proximal phalanges of the fingers, and inability to extend the thumb, and inability to move the wrist laterally, weakened supination of the hand, weakened extension and flexion of the elbow, and the loss of synergic motion of the extensors which seriously impairs the hand grip. (Total paralysis of the triceps occurs only as the greatest rarity). 38 C.F.R. § 4.124a, Diagnostic Code 8514. Under Diagnostic Code 8516, mild incomplete paralysis warrants a 10 percent rating; moderate incomplete paralysis warrants a rating of 20 percent; severe incomplete paralysis warrants a 30 percent rating; and a maximum evaluation of 50 percent is warranted for complete paralysis of the ulnar nerve, which is defined as being manifested by the 'griffin claw' deformity due to flexor contraction of the ring and little fingers, very marked atrophy in the dorsal interspace and thenar and hypothenar eminences; loss of extension of the ring and little fingers, inability to spread the fingers (or reverse), inability to adduct the thumb; and weakened flexion of the wrist. As the Veteran is right-handed (dominant), the major ratings apply to the right upper extremity and the minor ratings apply to the left upper extremity. III. Factual Background The Veteran filed a claim seeking service connection for peripheral neuropathy of the bilateral upper and lower extremities associated with diabetes mellitus, type II, on May 16, 2005. Prior to this claim, the Veteran was afforded a VA examination in October 2004 to assess the severity of his diabetes mellitus, type II, and associated complications. Importantly, physical examination revealed that light touch, vibratory and pinprick sensation was markedly decreased in the lower third of both legs. However, sensation was normal in the upper extremities. An April 2005 VA treatment record observed that the Veteran reported numbness in both hands and feet. The numbness was tingling and painful. Physical examination showed that radial pulses were 2+, DP pulses were 1+, and there was trace edema in both lower extremities. Sensation was decreased to light touch in both lower extremities up to distal 1/3 of lower legs. Sensory examination of the hands was less clear, but appeared to be decreased in at least the 4th and 5th fingers. Motor examination was 5/5. Reflexes were 1/4 biceps, 1/4 brachioradialis, 1/4 patellar and 0/4 Achilles. The Veteran underwent a nerve conduction study in April 2005. The impression was that there was electrodiagnostic evidence of a generalized moderate/severe demyelinating and axonal polyneuropathy that was both motor and sensory. It affected distal more than proximal nerves and was chronic and symmetric. The electrodiagnostic picture was consistent with a clinical diagnosis of diabetic peripheral neuropathy. An addendum by a staff physician agreed with the diagnosis of peripheral neuropathy. In May 2005, the RO granted service connection for peripheral neuropathy of the bilateral upper and lower extremities, effective the date of claim, May 16, 2005, and assigned a 10 percent rating to each extremity. Although the RO treated it as a claim for an increase, as discussed in the introduction, new and material evidence was received within the appeal period and must be considered with the original claim under 38 C.F.R. § 3.156(b). A September 2005 VA treatment record noted diminished sensation to monofilament on bilateral foot. The Veteran was afforded a VA examination in November 2005 for evaluation of peripheral neuropathy. The Veteran reported chronic pain in both lower extremities, which he described as sharp in nature as well as loss of feeling in both legs. He indicated that he had last worked in July 2004 because he had to quit truck driving as he could not feel the accelerator or brake pedals and was afraid he might have an accident. Neurological examination revealed normal tendon reflexes, but no pathological reflexes. Sensory examination revealed decreased vibratory and pinprick reflexes in all four extremities in a stocking glove distribution up to the wrist in the hands and up to the knees in lower extremities. The examiner diagnosed diabetic neuropathy in all four extremities, moderately severe. The examiner opined that the peripheral neuropathy had been accentuated since the previous examination in October 2004. Again, as noted above, in a February 2006 determination, the RO increased the Veteran's ratings for the low extremities to 20 percent for each leg, effective September 27, 2005, the date the Veteran filed his claim for increase. The Veteran was afforded another VA examination in December 2006. The Veteran reported numbness in both feet to the mid tibial levels for the last few years. He also had numbness in several fingers of the right and left hands of more recent onset. There was also pain in the feet. On neurological examination, the right upper extremity exhibited normal biceps reflex, decreased pinprick in the ulnar distribution of the right fourth and fifth fingers. There was no muscle atrophy or weakness. With respect to the left upper extremity, reflexes were biceps jerk 2+ and brachialradialis 3+. Sensory examination showed decreased sensation to pinprick in the fourth, fifth and middle fingers. Light touch was diminished in the third, fourth and fifth fingers in the left hand. The right lower extremity exhibited knee jerk 2+ and ankle jerk trace. Sensation to pinprick was diminished to the upper tibial level on the right and vibration was diminished in the foot as well as light touch involvement the foot to the mid tibia. In the left lower extremity, knee jerk was 2+ and ankle was zero. Pinprick and light touch were diminished in the mid tibial level and vibration was diminished in the foot. There was no muscle atrophy or deformity in the hands or feet and no Tinel's sign in the hands. The diagnoses were peripheral neuropathy, right upper extremity, which was an ulnar nerve mono-neuropathy; sensory peripheral neuropathy of the left upper extremity involving both portions of the ulnar and median nerve; moderate sensory and painful peripheral neuropathy of the of the right lower extremity and moderate sensory and mild painful neuropathy of the left lower extremity. In his April 2007 substantive appeal for his lower extremities, the Veteran reported that he experienced pain and swelling in his legs constantly. He indicated that he had some paralysis in his feet and continued to assert that a higher rating was warranted. He also reported that the numbness was not above his knees and he needed a cane to walk. He claimed that he was very limited in his total movements. A June 2007 VA EMG of the upper extremities showed evidence of moderate, axonal and demyelating polyneuropathy. There was also evidence bilateral carpal tunnel syndrome. A contemporaneous VA treatment record observed bilateral carpal tunnel syndrome per EMG and a history of median nerve paralysis as well as polyneuropathy. The Veteran reported severe numbness in hands and feet to the point of being disabled and retired from driving. The Veteran was afforded another VA examination in September 2008. The Veteran again reported numbness in his feet from the toes up to the midcalf, which had progressively worsened for the last four or five years. He also had numbness in his fingers of both the right and left hands with complaints of numbness and pain in his upper extremities which had been ongoing since 2005. The examiner observed the findings of the June 2007 EMG of the upper extremities. On neurological examination, in the right upper extremity, there was normal biceps and triceps reflexes, but decreased sensation to light touch and pinprick in th right four and fifth digits. The left upper extremity showed biceps reflex was 2+. There was decreased sensation to pinprick in the fourth and fifth digits as well as the middle finger. Bilateral lower extremities exhibited knee jerk 2+ with absent ankle jerk. Sensation was decreased to light touch vibration in the bilateral feet up to the midcalf. There was no muscle atrophy seen in the upper and lower extremities. The impression was peripheral neuropathy of the right upper extremity nerve mononeuropathy and left upper extremity peripheral neuropathy; and peripheral neuropathy of the lower extremities. The Veteran was afforded another VA examination in February 2011. The claims file was reviewed. The Veteran again reported numbness, stinging and burning sensations in this hands constantly, which had been ongoing for 1-1/2 to two years. He also reported the same symptoms in his feet and legs for the last seven to eight years. Walking and standing aggravated his feet and legs. Again, the June 2007 EMG results were observed. On physical examination, the Veteran had absent deep tendon reflexes in the upper and lower extremities, loss of pinprick sensation in the upper and lower extremities, and loss of vibratory sensation in the upper and lower extremities. There was no muscle atrophy present. In pertinent part, the diagnosis was peripheral neuropathy, severe, in the right and left upper and lower extremities. A follow up February 2011 VA treatment record also observed marked absence of sensation through both feet and above. The assessment was severe diabetic peripheral neuropathy. Follow up treatment records continued to show that the Veteran reported the same symptoms as noted above. At the August 2011 Board hearing, the Veteran again asserted that his symptoms of his lower extremities were more severe than the current 20 percent rating assigned for each extremity. He reported weakness, loss of sensation and loss of control. He used a walker for assistance with ambulation. He also had knee braces. He also indicated that he had been asked if he would be interested in getting a riding scooter. He reported limited ability on a daily basis. He could only walk 30 to 40 yards before experiencing problems. He also testified that the symptoms of his upper extremities were more severe than the 10 percent assigned for each extremity. He reported that his was right hand dominant. He would drop things more with his right arm because could not control it. He also reported that another nerve conduction study of the upper extremities was going to be done at some point in the near future. On remand, the Veteran was afforded another VA examination to assess the severity of his peripheral neuropathy in March 2012. It was again observed that the Veteran was right-hand dominant. The Veteran reported moderate intermittent pain, paresthesias and/or dysesthesias and numbness in all the extremities. On examination, strength was 5/5 throughout. With respect to the upper extremities, deep tendon reflexes were 2+ in the biceps, triceps and brachioradialis. In the lower extremities, knee reflexes were 2+ and ankle was zero. Light touch testing was normal with the exception in the right and left foot and toes where it was noted to be decreased. Position sense was normal in all of the extremities. Vibration and cold sensation was normal in the upper extremities, but decreased in both lower extremities. There was no muscle atrophy or trophic changes present. The examiner determined that the Veteran had mild incomplete paralysis of the radial nerve, median nerve and ulnar nerve in both extremities. The examiner also determined that the Veteran had mild incomplete paralysis of the sciatic nerve. The femoral nerve was determined to be normal. The examiner determined that the Veteran's peripheral neuropathy did not affect his ability to work. Additional VA treatment records continued to show marked absence of sensation throughout both feet and gave an assessment of severe diabetic peripheral neuropathy that was being treated with gabapentin. However, no indication was given that another nerve conduction study had been performed. Again, in an April 2013 rating decision, the RO granted a 30 percent rating for peripheral neuropathy of the right upper extremity as the dominant hand, effective the date of the examination, March 26, 2013, and a 20 percent rating for peripheral neuropathy of the left lower extremity as the non-dominant hand. IV. Analysis Peripheral Neuropathy of the Bilateral Lower Extremities The Board now turns to whether initial higher ratings are warranted for peripheral neuropathy of the right and left lower extremities. Initially, the Board finds that throughout the course of the appeal from the date of claim filed on May 16, 2005, when resolving the benefit of the doubt in favor of the Veteran, the Veteran's peripheral neuropathy more nearly approximates severe incomplete paralysis of the external popliteal nerve under Diagnostic Code 8521. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Although the most recent examiner characterized the Veteran's disability as moderate (and indicated only mild impairment of the sciatic nerve), VA treatment records as well as previous VA examiners have indicated that the Veteran's peripheral neuropathy of the lower extremities is considered severe. VA treatment records document "marked" absence of sensation through both feet and above. The evidence also shows that the Veteran must use assistive devices to ambulate and he has no ankle jerk reflexes. Moreover, the Veteran has reported being unable to feel his feet at times as well as weakness when standing and walking. It appears that the Veteran's symptoms have been consistent through the course of the appeal with indications of severe impairment documented in the April 2005 nerve conduction study. As such, the Board finds that when resolving the benefit of the doubt in favor of the Veteran, initial 30 percent ratings for severe incomplete paralysis for peripheral neuropathy of both the right and left lower extremities are warranted, effective March 16, 2005. However, the Board finds that initial ratings in excess of 30 percent is not warranted for peripheral neuropathy of the right and left lower extremities under Diagnostic Code 8521. There is no competent medical evidence of complete paralysis to warrant a maximum 40 percent rating. Importantly, there has simply been no evidence of foot drop and slight droop of all toes to warrant a 40 percent rating under this code. No range of motion of restrictions have been observed and there has been no finding of muscle atrophy in the lower extremities. In sum, the Board finds that the Veteran's disability picture is consistent with a 30 percent rating under Diagnostic Code 8521 for severe incomplete paralysis of the external popliteal nerve. The Board notes that the March 2012 VA examiner appeared to indicate that the sciatic nerve was also affected. However, the examiner found that it was no more than mild incomplete paralysis of the sciatic nerve. As such, a rating in excess of 30 percent would not be warranted under Diagnostic Code 8520 for incomplete paralysis of the sciatic nerve as there must be finding of moderately severe incomplete paralysis. Moreover, separate ratings under each of these diagnostic codes (Diagnostic Codes 8521 and 8520) would entail compensating the Veteran twice for the same symptoms. See 38 C.F.R. § 4.14. Under the anti-pyramiding provision of 38 C.F.R. § 4.14, the evaluation of the "same disability" or the "same manifestation" under various diagnoses is to be avoided. Again, in Esteban, the Court held that for purposes of determining whether the appellant is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of, or overlapping with, the symptomatology of the other conditions. As the primary symptoms pertain to diminished sensation in the feet, the most appropriate diagnostic code is 8521 pertaining to the external popliteal nerve. The Board has also considered whether the Veteran is entitled to a higher or separate rating under any other applicable diagnostic code referable to nerves. However, the medical evidence does not show that any other nerves have been affected. Again, the Veteran's symptoms are adequately contemplated under the currently assigned 30 percent ratings. Therefore, a higher or separate rating under any other diagnostic code pertaining to the impairment of nerves, is not warranted. Likewise, as there are no other symptoms outside of the previously discussed neurological impairments, the Board finds that no other diagnostic codes are potentially applicable. The Board has reviewed and considered the Veteran's statements regarding the severity of his peripheral neuropathy of the lower extremities. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disabilities on appeal have been more severe than the assigned disability ratings reflect. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. Moreover, the Board has contemplated the Veteran's statements concerning his symptoms when assigning the current 30 percent ratings from the date of claim. The Board has considered whether staged ratings under Fenderson are appropriate for the Veteran's service-connected peripheral neuropathy of the lower extremities; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. In conclusion, initial 30 percent ratings, but no higher, are warranted for the Veteran's service-connected peripheral neuropathy of the right and left lower extremities, effective May 16, 2005. The Board, however, finds that the preponderance of the evidence is against ratings in excess of 30 percent for the appeal period. In denying higher ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. Peripheral Neuropathy of the Bilateral Upper Extremities The Board now turns to whether initial higher ratings are warranted for peripheral neuropathy of the bilateral upper extremities. As noted above, the RO assigned a 30 percent rating for peripheral neuropathy of the right upper extremity and a 20 percent rating for peripheral neuropathy of the left upper extremity, effective March 26, 2012. After reviewing the totality of the evidence dating back to the original date of claim, when resolving the benefit of the doubt in favor of the Veteran, the Board finds that the Veteran's peripheral neuropathy has more nearly approximated moderate incomplete paralysis of the median nerve under Diagnostic Code 8515 throughout the course of the appeal from the date of claim, May 16, 2005. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. In this regard, the April 2005 nerve conduction study characterized the Veteran's neuropathy as moderate/severe. Moreover, the November 2005 VA examination also described the Veteran's peripheral neuropathy as moderately severe. Importantly, the June 2007 EMG of the upper extremities found evidence of moderate axonal and demyelinating polyneuropathy. Thus, it appears that the Veteran's symptoms have been consistent throughout the course of the appeal. Accordingly, the Board finds that when resolving the benefit of the doubt in favor of the Veteran, an initial 30 percent rating for moderate incomplete paralysis for peripheral neuropathy of the right upper extremity (dominant) and an initial 20 percent rating for moderate incomplete paralysis and left upper extremity (non-dominant) is warranted, effective March 16, 2005. However, based upon the evidence of record, the Board finds that ratings in excess of 30 percent and 20 percent disabling, respectively, are not warranted for the Veteran's service-connected peripheral neuropathy of the right and left upper extremities. In this regard, although the Veteran's disability has been characterized as severe at times, the Board notes that the neurological findings on clinical testing are not shown to more closely approximate a severe incomplete paralysis or complete paralysis of the median or ulnar nerves. There has been no evidence of atrophy or loss of tone in the muscles, loss of muscle strength, significantly decreased motor function or sensory loss, or complete paralysis. The June 2007 EMG clearly described the Veteran's disability as only moderate. Moreover, the March 2012 examiner only observed moderate impairment. Further, the March 2012 VA examiner described the Veteran's peripheral neuropathy involving the median, radial, and ulnar nerves as causing only mild incomplete paralysis of the right and left sides. As such, initial ratings in excess of 30 percent and 20 percent disabling are not warranted for the Veteran's service-connected peripheral neuropathy of the right and left upper extremities Diagnostic Codes 8515 and 8516. Although the March 2012 VA examiner noted that the Veteran demonstrated mild incomplete paralysis of the radial and ulnar nerves as well as the median of the upper right and left extremities, separate ratings under each of these diagnostic codes (Diagnostic Codes 8514, 8515 and 8516) would entail compensating the Veteran thrice for the same symptoms. See 38 C.F.R. § 4.14. Further, higher ratings are only available under Diagnostic Codes 8514 and 8516 for impairment of the radial and ulnar nerves when incomplete paralysis of the nerve is found to be severe. For the same reasons discussed above, the Board finds that the Veteran's peripheral neuropathy of the nerves more nearly approximates moderate incomplete paralysis. The Board has also considered whether the Veteran is entitled to a higher or separate rating under any other applicable diagnostic code referable to nerves. However, the medical evidence does not show that any other nerves have been affected. Again, the Veteran's symptoms are adequately contemplated under the currently assigned 30 percent rating for the right upper extremity and 20 percent rating for the left upper extremity. Therefore, a higher or separate rating under any other diagnostic code pertaining to the impairment of nerves, is not warranted. Likewise, as there are no other symptoms outside of the previously discussed neurological impairments, the Board finds that no other diagnostic codes are potentially applicable. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his peripheral neuropathy of the upper extremities. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disabilities on appeal have been more severe than the assigned disability ratings reflect. Again, the Veteran is competent to report observable symptoms. Layno, 6 Vet. App. at 465. In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. Moreover, the Board has contemplated the Veteran's statements concerning his symptoms when assigning the current 30 percent rating for the right upper extremity and 20 percent rating for the left upper extremity from the date of claim. The Board has considered whether staged ratings under Fenderson are appropriate for the Veteran's service-connected peripheral neuropathy of the upper extremities; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. In conclusion, an initial 30 percent rating, but no higher, is warranted for the Veteran's service-connected peripheral neuropathy of the right upper extremity, effective May 16, 2005; and an initial 20 percent rating, but no higher, is warranted for the Veteran's service-connected peripheral neuropathy of the left upper extremity, effective May 16, 2005. The Board, however, finds that the preponderance of the evidence is against ratings in excess of 30 percent and 20 percent for peripheral neuropathy of the right and left upper extremities, respectively for the appeal period. In denying such ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. Extraschedular Consideration Additionally, the Board will address whether the case should be referred for extraschedular consideration. In general, the schedular disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The application of such schedular criteria was discussed in great detail above. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the RO is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2013). An extraschedular 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. Id. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected peripheral neuropathy of both the upper and lower extremities with the established criteria found in the rating schedule. The Board finds that the Veteran's symptomatology is fully addressed by the rating criteria under which such disability is rated. In this regard, the Veteran's assigned disabilities ratings contemplate his current neurological deficits. There are no additional symptoms that are not addressed by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disabilities. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are 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 extraschedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd, 9 Vet. App. At 96. ORDER Effective May 16, 2005, entitlement to an initial 30 percent rating, but not higher, for peripheral neuropathy of the right lower extremity is granted, subject to the laws and regulations governing payment of monetary benefits. Effective May 16, 2005, entitlement to an initial 30 percent rating, but not higher, for peripheral neuropathy of the left lower extremity is granted, subject to the laws and regulations governing payment of monetary benefits. Effective May 16, 2005, entitlement to an initial 30 percent rating, but not higher, for peripheral neuropathy of the right upper extremity is granted, subject to the laws and regulations governing payment of monetary benefits. Effective May 16, 2005, entitlement to an initial 20 percent rating, but not higher, for peripheral neuropathy of the left upper extremity is granted, subject to the laws and regulations governing payment of monetary benefits. REMAND In regard to the diabetes mellitus rating issue, the Board finds that a remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. In this case, a remand is necessary in order to comply with certain remand directives set forth in the February 2012 Board remand. A Court or Board remand confers upon the appellant the right to compliance with that order. Stegall, 11 Vet. App. at 271; D'Aries, 22 Vet. App. at 105 (holding that there must be substantial compliance with the terms of a Court or Board remand). As observed in the prior Board remand, the February 2011 VA examination report noted that mild chronic renal insufficiency and onychomycosis of the feet were at least as likely as not related to service-connected diabetes mellitus; thereby, raising the matter of entitlement to service connection in regard to these issues. In the prior remand, the Board found that since the outcome of these claims may impact the Veteran's claim for an increased rating for diabetes mellitus, the issues of entitlement to service connection for renal insufficiency and for onychomycosis to be inextricably intertwined with that of the evaluation of diabetes mellitus. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Under 38 C.F.R. § 4.119, Diagnostic Code 7913 (2013), Note 1 instructs to evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. Because the issues are inextricably intertwined, the Board remanded these for development and initial adjudication. However, review of the claims file reveals that these issues have not been adjudicated by the RO as directed. Moreover, in the February 2012 remand, the Board also directed the RO to consider whether separate ratings were warranted for the Veteran's associated hypertension, diabetic retinopathy, right foot ulcer and impotence. Nevertheless, again, review of the claims file reveals that the RO did not consider whether separate ratings were warranted as directed. As such, the issue of entitlement to a higher rating for diabetes mellitus, type II, must be returned to the RO for compliance with the prior remand directives. Further, the Veteran was afforded an eye examination in April 2012. In the examination report, the examiner noted that a visual field test was done and would accompany the report. However, this record has not been associated with the claims file. As this report is pertinent to the issue on appeal, it must be obtained. Moreover, to ensure that the record reflects the current severity of the Veteran's service-connected diabetes mellitus, type II, and associated complications, the Board finds that a more contemporaneous VA examination is needed to properly evaluate this disability. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. See also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the veteran with a thorough and contemporaneous medical examination); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered contemporaneous). Lastly, the RO should obtain any additional VA treatment records dated from March 2013 to the present. See 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, this issue is REMANDED for the following actions: 1. Associate VA medical records dated from March 2013 with the claims file. 2. Obtain the April 2012 Visual Field Test done in association with the April 2012 VA eye examination and associate it with the claims file. 3. After associating any outstanding records with the claims file, schedule the Veteran for an appropriate VA examination(s) to ascertain the extent and severity of his service-connected diabetes mellitus, type II, and associated retinopathy, hypertension, right foot ulcer, impotence, and related symptoms, to include renal insufficiency and onychomycosis. The claims folder should be made available for review in conjunction with the examination. The examiner should specifically determine whether treatment of the Veteran's diabetes mellitus requires regulation of activities (avoidance of strenuous occupational and recreational activities); the examiner should also determine whether the Veteran's diabetes mellitus causes episodes of either ketoacidosis or hypoglycemic reactions that require one or two hospitalizations per year or twice a month visits to a diabetic care provider, and address the severity of all associated disorders, to include hypertension, retinopathy, a right foot ulcer and impotence. A complete rationale for all opinions must be provided. 4. Thereafter, develop and adjudicate the issues of entitlement to service connection for renal insufficiency and onychomycosis secondary to diabetes mellitus. 5. Finally, readjudicate the remaining issue on appeal, to include consideration of whether a separate rating is warranted for hypertension, retinopathy, a right foot ulcer, or impotence. If the benefit sought on appeal remains denied, a supplemental statement of the case should be provided to the Veteran and his representative and the Veteran should be afforded a reasonable opportunity to respond thereto. The appellant has the right to submit additional evidence and argument on the matter 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 Court of 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). ______________________________________________ RYAN T. KESSEL Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs