Citation Nr: 1338175 Decision Date: 11/20/13 Archive Date: 12/06/13 DOCKET NO. 09-11 170 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to an initial rating in excess of 20 percent for service-connected diabetes mellitus type 2, associated with herbicide exposure, prior to March 12, 2013. 2. Entitlement to a rating in excess of 60 percent for service-connected diabetes mellitus type 2, associated with herbicide exposure, on or after March 12, 2013. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Eli White, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1962 to April 1966. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. No hearing was requested. Reviewing the procedural history of this matter, in October 2007, inter alia, the RO granted the Veteran's claim of entitlement to service connection for diabetes mellitus type II as associated with herbicide exposure, and assigned a 20 percent disability rating. In August 2008, the Veteran filed a Notice of Disagreement (NOD) with the rating decision, and the RO subsequently issued a Statement of the Case (SOC). The Veteran perfected his substantive appeal in March 2009. In a May 2012 Remand, the Board construed a September 2007 VA examination opinion as an informal claim of entitlement to service connection for coronary artery disease (CAD), to include as secondary to service-connected diabetes mellitus. The Board additionally construed the October 2007 rating decision and August 2008 NOD to encompass the claim of service connection for CAD, to include as secondary to diabetes mellitus. The Board then remanded the Veteran's claims of entitlement to a disability rating in excess of 20 percent for diabetes mellitus and entitlement to service connection for CAD, to include as secondary to diabetes mellitus, for additional development, which has been completed. In a June 2013 rating decision, the RO granted the Veteran's claim of entitlement to service connection for CAD, assigning a 10 percent disability rating effective April 30, 2011, and a 100 percent disability rating effective November 7, 2011. The Veteran has not filed an NOD with the June 2013 rating decision. It is not before the Board. In an August 2013 rating decision, the RO increased the Veteran's disability rating for service-connected diabetes mellitus to 60 percent disabling, effective March 12, 2013. As the award is not a complete grant of benefits, the issue remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). The Board notes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims (Court) held that a claim for a TDIU due to service-connected disability is part and parcel of an increased rating claim for that disability when raised by the record. In March 2013, the Veteran filed a VA Form 221-8940, Veteran's Application for Increased Compensation Based on Unemployability, and stated that he "[c]ould not work in the past 5 years." In accordance with Rice, the Board finds that the issue of TDIU has been raised, as part of the increased rating claim on appeal. Therefore, it is properly before the Board. The issues of entitlement to service connection for arterial fibrillation, to include as secondary to service-connected CAD, entitlement to service connection for lung cancer, to include as associated with herbicide exposure, entitlement to service connection for lobectomy, and service-connection for neuropathy, to include as secondary to diabetes mellitus, have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). See March 2013 VA Form 21-526b; see May 2013 Statement of Veteran's Representative; see March 2013 VA examination; see April 2013 Veteran's Statement (received May 2013). Therefore, the Board does not have jurisdiction over them and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. From April 30, 2007 to March 11, 2013, the evidence shows that the Veteran's diabetes mellitus type II was managed with oral medication, insulin, and restricted diet; it did not require regulation of activities. 2. As of March 12, 2013, the evidence shows that the Veteran's diabetes mellitus type II is manifested by symptoms requiring insulin, restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring one hospitalization per year, and diabetic nephropathy or renal dysfunction. 3. The medical evidence of record shows that the Veteran's diabetic nephropathy is manifested by persistent proteinuria (albuminuria), but no other functional limitation. 4. The Veteran is in receipt of special monthly compensation (SMC) based on housebound status, effective March 12, 2013, as a result of his 100 percent schedular total rating for CAD, and his separate rating of 60 percent of his service-connected diabetes mellitus. 5. As the Veteran is in receipt of SMC based on housebound, as of March 12, 2013, an award of TDIU after that date can result in no further benefit, and there remains no case or controversy concerning whether the Veteran is entitled to TDIU from March 12, 2013. 6. The evidence does not show that the Veteran's service-connected diabetes mellitus type II rendered him unable to secure or follow a substantially gainful occupation from April 30, 2007 to March 11, 2013. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 20 percent for diabetes mellitus type II have not been met for the period prior to March 12, 2013. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.102, 3.321(b), 4.1, 4.2, 4.3, 4.7, 4.10, 4.119, Diagnostic Code (DC) 7913. 2. The criteria for an evaluation in excess of 60 percent for diabetes mellitus type II have not been met for the period beginning on March 12, 2013. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.102, 3.321(b), 4.1, 4.2, 4.3, 4.7, 4.10, 4.119, DC 7913. 3. The criteria for a separate compensable rating for diabetic nephropathy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.115a, 4.115b, DC 7541 (2013). 4. The criteria for TDIU from April 30, 2007 to March 11, 2013, due to service-connected diabetes mellitus type II have not been met. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2013). 5. There is no question of law or fact involving the claim of entitlement to TDIU from March 12, 2013; this portion of the appeal is dismissed. 38 U.S.C.A. § 7105(d)(5) (West 2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Remand Compliance As noted above, this appeal involves a May 2012 Board remand for additional evidentiary development. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). While substantial compliance is required, strict compliance is not. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008), citing Dyment v. West, 13 Vet. App. 141, 146-147 (1999). In this case, the Board finds that the RO substantially complied with the Board's May 2012 remand instructions. Copies of the Social Security Administration (SSA) administrative decision and all medical records considered in the Veteran's claim for SSA disability benefits were obtained and associated with the claims file. The instruction to schedule the Veteran for a VA examination to determine the current severity of his service-connected diabetes mellitus and the etiology of any CAD was completed in March 2013. As will be discussed below, the Board finds that the examination report is adequate for rating purposes. Thus, the Board finds that there has been substantial compliance with the May 2012 Remand instructions. II. Veterans Claims Assistance Act of 2000 VA satisfied its duty to notify the Veteran pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of the evidence that is necessary, or would be of assistance, in substantiating their claims, and provide notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is warranted. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006). The VCAA applies to the instant claim. The notice required by the VCAA can be divided into three elements. Specifically, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). Notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In the instant case, the VCAA duty to notify was satisfied by way of letters sent to the Veteran in June 2007 and April 2013. The letters informed the Veteran of what evidence was required to substantiate his claim and of his and VA's respective duties for obtaining evidence. The letters also informed the Veteran of how ratings and effective dates are assigned. VA also has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of service and other pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). With respect to claims for increased ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2013). 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 RO has obtained the Veteran's service and VA treatment records and associated them with his claims file. In addition, VA afforded the Veteran adequate examinations and obtained adequate expert opinions in September 2007, March 2013, May 2013, and August 2013. The examiners considered the relevant history of the Veteran's condition, provided a detailed description of that condition, and provided an extensive analysis to support the conclusions reached. The March 2013 examination report additionally discussed the clinical findings as necessary to rate his diabetes mellitus under the applicable rating criteria, and discussed the impact of his disability on the Veteran's daily living. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007); Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure the examination is adequate). As VA satisfied its duties to notify and assist the Veteran, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. §§ 5103(a), 5103A, or 38 C.F.R. §3.159, and that the Veteran will not be prejudiced as a result of the Board's adjudication of his claim. III. Analysis 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. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt shall be resolved in favor of the claimant, and 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. 38 C.F.R. §§ 3.102, 4.3, 4.7. In addition, the Board will consider the potential application of the various other provisions of 38 C.F.R., Parts 3 and 4, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disorder in reaching its decision, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the issue involves the assignment of an initial rating for a disability following the initial award of service connection for that disability, as is the case with respect to the Veteran's claim for increased initial rating of his diabetes mellitus, the entire history of the disability must be considered, and separate ratings have been assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. Gilbert v. Derwinski, 1 Vet. App. 49, 50 (1990). If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. Id. III.A. Diabetes Mellitus Type II The Veteran contends that his service-connected diabetes mellitus is more disabling than his initial evaluation rating of 20 percent. The Board finds that the preponderance of the evidence shows that prior to March 12, 2013, the Veteran's diabetes mellitus has not approximated the criteria of a rating higher than 20 percent. The Board additionally finds that from March 12, 2013, the Veteran's diabetes mellitus has not approximated the criteria of a rating higher than 60 percent. III.A.1. Schedular Consideration The Veteran's diabetes mellitus is currently assigned a 20 percent disability evaluation prior to March 12, 2013, and a 60 percent disability rating effective from March 12, 2013, pursuant to 38 C.F.R. § 4.119, DC 7913. Under that diagnostic code, a 20 percent disability evaluation is warranted for diabetes mellitus requiring insulin and restricted diet; or, an oral hypoglycemic agent and restricted diet. A 40 percent disability evaluation is contemplated for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent disability evaluation is warranted for diabetes mellitus requiring insulin, a restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent evaluation is contemplated for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus progressive loss of weight and strength or complications that would be compensable if separately evaluated. Note (1) to DC 7913 provides that compensable complications of diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent disability rating under DC 7913. Noncompensable complications are considered part of the diabetic process under DC 7913. 38 C.F.R. § 4.119. In this case, private treatment records reflect that in April 2007, the Veteran was diagnosed with diabetes mellitus, instructed to begin a no-fat, no-cholesterol diet, and prescribed oral hypoglycemic medication. The Veteran was additionally advised to increase his exercise in connection with obesity. The Veteran underwent a VA examination for diabetes mellitus in September 2007. The claims file was not available for review; however the Veteran reported he was diagnosed with diabetes mellitus in November 2006, experienced hypoglycemia reactions one to two times in the past month, and was not hospitalized in the past year for ketoacidosis or hypoglycemic reactions. He additionally stated that he was restricted from lifting due to nonservice-connected chronic obstructive pulmonary disease (COPD), and that he had lost 32 pounds since his last examination. The Veteran reported that he took oral medication to treat his diabetes, and had no loss of strength. The examiner diagnosed the Veteran with diabetes mellitus type II, finding that it was fairly controlled, and that he had no neuropathy, nephropathy, or retinopathy as a result of his disability. The examiner further found that the Veteran has mild functional impairment due to his diabetes mellitus, but that his severe COPD has caused severe functional impairment. The examiner additionally opined that the Veteran's CAD is at least as likely related to his diabetes mellitus, and that his "dyslipedemia and hypertension is as likely due to his poorly controlled [diabetes mellitus]." Private treatment records from October to December 2008 show that the Veteran was treated with oral hypoglycemic agents and insulin, and was instructed to reduce his caloric intake and learn healthy eating concepts. His physician noted that the Veteran's suffered from obesity and that his activity was limited. The Veteran was encouraged to decrease his food portions and fat intake, and to increase his activity level. VA treatment records reflect that in January 2009, the Veteran stated that he "needs to eat salads to get better control of his [diabetes mellitus]," and was working with a nutritionist while struggling with multiple physical illnesses and weight gain. An October 2010 private treatment record reflects that the Veteran was referred for diabetes health education for instruction on self-injection of insulin. The medical plan did not include any recommendations regarding a restricted diet or regulation of activities. January and February 2012 private treatment records reflect that the Veteran was on insulin therapy and oral medication for his diabetes mellitus and was also put on salt restriction. In July 2012, the Veteran's physician noted that he was currently taking insulin and generally tried to adhere to his planned diet as suggested to him by his nutritionist. The physician further noted that the Veteran had a few episodes of dizziness in the past; however, his blood glucose monitoring at the times of those episodes indicated that the dizziness and symptoms were unlikely to be related to hypoglycemia. October 2012 VA treatment records reflect that the Veteran continued his diabetes mellitus medication dosage. His provider again noted that he had no history of retinopathy, neuropathy, or nephropathy, and that though he had lost 18 pounds since June 2012, his weight had stabilized. He further noted that the Veteran reported exercising less frequently due to a painful foot. The Veteran underwent another VA examination in connection with his diabetes mellitus in March 2013. The examiner reviewed the claims file and conducted an in person examination of the Veteran. The examiner noted that the Veteran was prescribed more than one injection of insulin per day as well as oral hypoglycemic agents. She stated that the Veteran requires regulation of his activities as part of his management of diabetes mellitus in that he experiences hypoglycemia about once per day with light activity and that he must eat crackers and drink juice or glucose tablets after activities such as walking, bending, light lifting, or walking up a few stairs. The examiner reported that the Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month, and had one episode of hypoglycemia requiring hospitalization in the past 12 months. It was noted that the Veteran did not have diabetic peripheral neuropathy, nephropathy, retinopathy, or renal dysfunction caused by diabetes mellitus, nor did he have progressive unintentional weight loss due to diabetes mellitus. The examiner found that the Veteran did have progressive loss of strength attributable to his diabetes. The examiner then opined that the Veteran's diabetes mellitus impacted his ability to work. Specifically, she noted that the Veteran is "unable to work in [a] light activity setting due to frequent episodes of hypoglycemia. Veteran may be able to work in sedentary environment if it did not require him to have [to] commute due to his frequent episodes of hypoglycemia." April 2013 VA treatment records note that the Veteran's diabetes mellitus was well controlled on insulin and his weight was stable. The examiner recommended that the Veteran continue exercise as tolerated and that he lose weight. Most recently, the Veteran was seen for another VA examination in August 2013, by the same examiner who conducted the March 2013 examination. The examiner again found that the Veteran was treated for diabetes mellitus with prescribed oral hypoglycemic agents and insulin with more than one injection per day, and that his diabetes requires the regulation of activities and diet. She reported that the Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month, and that he did not have any episodes of ketoacidosis or hypoglycemia requiring hospitalization in the past 12 months. The examiner found that the Veteran did not have progressive unintentional weight loss due to diabetes mellitus, but did have progressive loss of strength attributable to his diabetes. She further reported that the Veteran does, in fact, have diabetic nephropathy or renal dysfunction caused by his diabetes mellitus. Regarding the effect of the Veteran's diabetes mellitus on his functional impact, the examiner repeated her opinion as articulated in the March 2013 examination, noting that he is unable to work in a light activity setting due to his frequent episodes of hypoglycemia, but may be able to work in a sedentary environment if it did not require him to commute. Based on a careful review of the evidence of record, the Board concludes that staged ratings are appropriate with respect to this claim. Clinical records from April 7, 2007 to March 11, 2013, reflect that the Veteran was on a restricted diet and that insulin and oral medications were also required for treatment. However, there was no indication that regulation of activities was medically required. For purposes of providing a 40 percent disability rating for diabetes mellitus, the term "regulation of activities" requires medical evidence showing that occupational and recreational activities have been restricted. See Camacho v. Nicholson, 21 Vet. App. 360, 365 (2007). As described above, private and VA treatment records from January 2007 to March 2013 are silent regarding any regulation of the Veteran's activities due to his diabetes mellitus. Indeed, the Veteran's treatment records specifically show that his medical providers repeatedly recommended that he increase his activity level and exercise. Accordingly, there is no basis for the assignment of an evaluation in excess of 20 percent for the appeal period prior to March 12, 2013. On March 12, 2013, the Veteran underwent a VA examination in connection with his diabetes mellitus in which the examiner indicated that the Veteran continued to require insulin, oral medication, and a restricted diet, and additionally required regulation of activities. The examiner further noted that the Veteran had required one hospitalization due to a hypoglycemic reaction in the past year. In essence, as of that date, the record contains evidence supporting the assignment of a 60 percent evaluation for diabetes mellitus as of that date. See 38 C.F.R. § 4.119, DC 7913. The Board notes that based upon the evidence in this case, the exact onset of the Veteran's level of disability warranting a 60 percent rating cannot be determined with any certainty. The evidence of record does not contain a medical report or other documentation noting the exact or estimated date of the Veteran's hospitalization due to hypoglycemic reaction as referenced in the March 2013 examination, nor does it contain any evidence that the Veteran's activities were regulated as a direct result of his diabetes mellitus prior to the examination. Thus, the earliest that it can be factually ascertained that he met the criteria for a 60 percent rating is March 12, 2013, the date of his VA examination. The Board has further considered whether the Veteran may be entitled to an evaluation in excess of 60 percent for the period from March 12, 2013 to the present. Although the Veteran was found during the March 2013 and August 2013 examinations to have progressive loss of strength attributable to diabetes, and requires more than one daily injection of insulin - criteria included in a 100 percent rating under DC 7913 - at no time during the appeal period has he met all of the requisite criteria for a 100 percent rating. See Camacho, 221 Vet. App. 360 (holding that the criteria for rating diabetes mellitus are conjunctive, and that each element of the criteria is needed to meet the requirements for a specific evaluation). Specifically, the Veteran has never been found to require weekly visits to a diabetic care provider or to have experienced episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year, as required for a 100 percent rating. Moreover, though the Veteran has lost weight during the appeal period, medical records clearly reflect that this was intentional, and recommended based on his obesity; VA examinations additionally found that the Veteran has not had progressive unintentional weight loss attributable to his diabetes mellitus. Therefore, the Board concludes that the Veteran is not entitled to an evaluation in excess of 60 percent. The Board has also considered whether the Veteran has additional compensable complications of diabetes as instructed by Note (1) to DC 7913. 38 C.F.R. § 4.119. In this case, the evidence of record shows that the Veteran's hypertension is not related to his service-connected diabetes mellitus type II, and that his diabetic nephropathy is manifested by symptoms that do not rise to the level of being compensable. As noted above, the Veteran underwent a VA examination in connection with his diabetes in September 2007. In the accompanying report, the examiner noted that the Veteran has a history of hypertension, as likely due to diabetes mellitus. In March 2013, the Veteran was examined for a kidney condition, in which it was noted that he was diagnosed with diabetic nephropathy and had current renal dysfunction. The examiner specifically noted that the Veteran had symptoms of persistent protinuria (aluminura), and further that the Veteran did not have hypertension due to renal dysfunction or caused by any kidney condition. In the August 2013 VA examination, the examiner specifically listed only diabetic nephropathy when asked to identify recognized complications of the Veteran's service-connected diabetes mellitus. Additionally, she further opined that the Veteran's hypertension "has pre-existed the diabetic nephropathy[,] and [hypertension] has not worsened or needed additional medical intervention, making it less likely aggravated by diabetic nephropathy." Regarding the Veteran's hypertension as a complication of his diabetes, the Board finds that the March and August 2013 examinations are of more probative value on this issue than the September 2007 examination report, and are entitled to significant weight. The September 2007 examiner did not indicate why hypertension would likely be due to diabetes mellitus. In contrast, the August 2013 opinion fully articulated its reasoning and bases, noting the preexistence of hypertension and its lack of worsening in light of the Veteran's diabetes mellitus and diabetic nephropathy. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Accordingly, the Board finds that the Veteran's hypertension is not an additional compensable complication of his service-connected diabetes. That being said, the presence of hypertension is still relevant, with respect to the Veteran's diabetic nephropathy. Nephropathy related to diabetes mellitus is evaluated under DC 7541, which addresses renal involvement in diabetes mellitus, and is found in the Schedule of Ratings of the Genitourinary System. 38 C.F.R. § 4.115b (2013). DC 7541 instructs that disorders under this code are to be evaluated as renal dysfunction, which is found in 38 C.F.R. § 4.115a (2013). Under this Schedule of Ratings of the Genitourinary System, renal dysfunction is assigned a noncompensable evaluation when there is albumin and casts with a history of acute nephritis, or when hypertension is noncompensable under DC 7101. The next higher, 30 percent, evaluation is assigned when there is albumin constant or recurring with hyaline and granular casts or red blood cells, when there is transient or slight edema, or when hypertension is at least 10 percent disabling under DC 7101. A 60 percent rating is warranted where there is constant albuminuria with some edema; or definite decrease in kidney function; or, hypertension at least 40 percent disabling under DC 7101. An 80 percent evaluation is warranted where there is persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating is warranted for renal dysfunction where it requires regular dialysis, or precludes more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. Id. For the purposes of determining whether hypertension is compensable, that disability is evaluated under 38 C.F.R. § 4.104, DC 7101 (2013), which addresses hypertensive vascular disease, including hypertension and isolated systolic hypertension. Under DC 7101, a 10 percent evaluation is assigned when diastolic pressure is predominantly 100 or more, systolic pressure is predominantly 160 or more. A 10 percent evaluation is also the minimum evaluation assigned for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. Higher evaluations require worsening diastolic pressures. The August 2013 examiner noted that the Veteran had persistent proteinuria (albuminuria), and further indicated that it was the sole manifestation of the Veteran's nephropathy of record. Therefore, there is no evidence of decreased kidney function or other relevant findings that would warrant a compensable rating. Furthermore, although the Veteran has a current diagnosis of hypertension, VA treatment records dated March through May 2013 reflect that his hypertension is well-controlled and does not manifest by diastolic pressures predominantly over 100. As such, the medical evidence of record shows that the Veteran's diabetic nephropathy does not warrant a compensable rating at any point during the period on appeal. 38 C.F.R. § 4.115a. Accordingly, it is considered part of the diabetic process and a separate rating for diabetic nephropathy as a residual of diabetes mellitus is not warranted. 38 C.F.R. § 4.119, DC 7913 at Note (1). Having considered the concept of staged ratings in this case as discussed in Fenderson, supra, the Board concludes that entitlement to a disability rating in excess of 20 percent for diabetes mellitus type II, from April 30, 2007, to March 11, 2012, is not warranted, nor is a disability rating in excess of 60 percent from March 12, 2013. As the preponderance of the evidence is against this claim, the doctrine of reasonable doubt is not for application and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III.A.2. Diabetes Mellitus - Extraschedular consideration Also considered by the Board is whether referral is warranted for a rating outside of the rating schedule. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station 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. § 3.21(b)(1) (2013). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. 38 C.F.R. § 3.321(b). Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, the Board or the RO must determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id., at 115. If the schedular rating criteria 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. Id. 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. Extraschedular consideration is not warranted in this case. The record does not establish that the rating criteria are inadequate. To the contrary, the very symptoms that the Veteran describes are contemplated by the criteria found at 38 C.F.R. § 4.119. Moreover, more severe manifestations are contemplated by the rating schedule - including episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, none of which the Veteran has experienced. Those criteria allow for ratings for all of his symptoms and manifestations and for symptoms and manifestations significantly more severe. Therefore, the first prong of the Thun test is not satisfied, and referral for extraschedular consideration is not warranted. III.B. TDIU As noted above, in March 2013, during the pendency of this appeal, the Veteran filed a VA Form 221-8940, Veteran's Application for Increased Compensation Based on Unemployability, and stated that he "[c]ould not work in the past 5 years." The Court has held that a request for TDIU 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 a 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, 22 Vet. App. at 453. If the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether a total rating based on individual unemployability as a result of that disability is warranted. Id. at 455. Here, the Board finds that the TDIU issue currently before it is part and parcel of the Veteran's diabetes mellitus type II initial and increased rating claim, because TDIU was explicitly raised during the pendency of the appeal. For purposes of clarity, the relevant appeal period for the Veteran's claim of entitlement to TDIU is April 30, 2007 to the present, as associated with his claim of increased rating for diabetes mellitus type II. As described in more detail below, the Board notes that due to the increase in rating of the Veteran's service-connected CAD and diabetes mellitus type II during the appeal period, its consideration of entitlement to TDIU must be divided into two distinct stages in order to properly analyze TDIU on a schedular basis. The Board will address each stage in turn. III.B.1. TDIU: March 12, 2013 to the present VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Bradley v. Peake, 22 Vet. App. 280 (2008). This duty to maximize benefits requires VA to assess all of a claimant's disabilities to determine whether any combination of disabilities establishes entitlement to special monthly compensation (SMC) under 38 U.S.C.A. § 1114. See Bradley, 22 Vet. App. at 294. SMC is payable where the Veteran has a single service-connected disability rated as 100 percent and has an additional service-connected disability independently ratable at 60 percent or more, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. 38 C.F.R. § 3.350(i)(1) (2013). As of November 2011, the Veteran's service-connected CAD was evaluated as 100 percent disabling. As of March 2013, the Veteran's service-connected diabetes mellitus was evaluated as 60 percent disabling. Therefore, the RO granted SMC from March 2013, when the Veteran's schedular ratings met the criteria above. The Board observes that the RO correctly noted in its August 2013 Supplemental SOC that the Veteran is in receipt of SMC effective March 12, 2013. Thus, the issue of entitlement to TDIU based on his service-connected diabetes from March 2013 to the present is dismissed as moot, as the Veteran can receive no additional benefit from a grant of TDIU from March 2013 to the present. III.B.2 TDIU: April 2007 through March 2013 VA General Counsel opinion 6-99 addressed questions related to whether a claim for a TDIU may be considered when a schedular 100 percent rating is already in effect for one or more service-connected disabilities. Essentially, this opinion held that receipt of a 100 percent schedular rating for a service-connected disability rendered moot any pending claim for a TDIU and required dismissal of the TDIU claim. See Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994) (noting that a claim for TDIU presupposes that the rating for a condition is less than 100 percent). However, as the Court in Bradley v. Peake, 22 Vet. App. 280, 293-94 (2008), took a position contrary to the one reached in VAOPGCPREC 6-99, the General Counsel withdrew VAOPGCPREC 6-99, effective November 4, 2009. 75 Fed. Reg. 11229, 11230 (Mar. 10, 2010). Although no additional disability compensation may be paid when a total schedular disability rating is already in effect, Bradley recognized that a separate award of a TDIU predicated on a single disability may form the basis for an award of special monthly compensation. Bradley, 22 Vet. App. at 293-94. Thus, where a Veteran has a 100 percent schedular rating for a particular service-connected disability and subsequently claims TDIU for a separate disability or disabilities, VA must consider the TDIU claim despite the existence of the 100 percent rating. If VA finds that the separate disability warrants a TDIU independent of the other 100 percent rated disability, SMC should be awarded pursuant to 38 U.S.C.A. § 1114(s) (West 2002). See DVA Sum. Op. Gen. Counsel Prec., 75 Fed. Reg. 11229-04 (March 10, 2010) ("the logic of Bradley suggests that, "if a Veteran has a schedular total rating for a particular service-connected disability and subsequently claims TDIU for a separate disability, VA must consider the TDIU claim despite the existence of the schedular total rating and award SMC under section 1114(s) if VA finds the separate disabilit(ies) support a TDIU independent of the other 100 percent disability rating"). In the present case, the Veteran had a 100 percent rating for his service-connected CAD effective November 7, 2011; however, from November 7, 2011 through March 11, 2013, he did not have a separate and distinct service-connected disability rated at 60 percent or higher, and thus was not entitled to an award of SMC in addition to his 100 percent rating. This raises the issue of whether the Veteran is entitled to a TDIU rating prior to March 2013 for his diabetes mellitus type II. If so, the TDIU would satisfy the 100 percent service-connected disability requirement, and his 100 percent rated CAD would satisfy the additional requirement of a separate disability of 60 percent or more disabling, thus making SMC available for this Veteran as of November 2011. Accordingly, in order to fulfill its duty to maximize the Veteran's benefits, the Board must consider whether the Veteran is entitled to TDIU for his service-connected diabetes mellitus type II from April 2007 to March 2013. If such an award is warranted, the Veteran would be entitled to an award of TDIU from April 30, 2007 to November 7, 2011, and an additional award of SMC from November 7, 2011 to March 11, 2013, pursuant to 38 U.S.C.A. § 1114(s). Entitlement to a TDIU requires the presence of impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by his nonservice-connected disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2013). In reaching such determination, the central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The law provides that a TDIU may be granted where the schedular rating is less than total when the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16(a) (2013). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disability of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from common etiology or a single accident; (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action; or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16. In any event, it is the policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service connected disability shall be rated as totally disabled. 38 C.F.R. § 4.16(b). Thus, if a veteran fails to meet the applicable percentage standards enunciated in 38 C.F.R. § 4.16(a), an extraschedular rating is considered where he or she is unemployable due to a service-connected disability or disabilities. 38 U.S.C.A. § 4.16(b); see also Fanning v. Brown, 4 Vet. App. 225 (1993). The Board, however, does not have the authority to make such an assignment in the first instance. Rather, the Board may only grant a total rating under section 4.16(b) after the issue of extraschedular consideration has first been referred to and denied by VA's Director of Compensation & Pension Services. As an initial matter, the Board finds that the Veteran did not meet the schedular criteria for TDIU for the period from April 30, 2007 to March 11, 2013. Specifically, at no time during the appeal period did the Veteran have two or more service-connected disabilities with a combined rating of 70 percent or more, with one disability ratable at 40 percent or more. See 38 C.F.R. § 4.16(a). In addition, the Board finds that the medical evidence of record does not reveal that the Veteran was unable to secure or follow a substantially gainful occupation due solely to his service-connected diabetes mellitus type II, and thus referral for extraschedular consideration is not warranted. Private medical treatment records reflect that in December 2006, the Veteran was diagnosed with non-service connected COPD, hypertension, hyperlipidemia, allergic rhinitis, depression and anxiety, bladder cancer, insomnia and hematuria, suffered from obesity, and also experienced chronic chest pain with episodes of nausea and dizziness. In January 2007, the Veteran underwent a stent implantation and catheterization in association with his CAD. In a follow up visit that same month, his physician noted that though the Veteran was currently restricted from work, he was expected to be able to return to work following completion of a cardiopulmonary rehabilitation program and a stress test. In his 2007 application for Social Security Administration (SSA) disability benefits, the Veteran stated that he stopped working in December 2006 as a result of collapsing at work "due to severe dizzy spells, no energy and trouble breathing." He additionally stated that his ability to work was limited by COPD, emphysema, chronic bronchitis, diabetes mellitus type II, CAD, PTSD, and hip and back pain. He noted that he had trouble breathing, and could only walk for about a half an hour before he got out of breath and his hips and back hurt. The Veteran further stated that he could not lift more than 25 pounds and that "[i]f the weather is humid this really aggravates my condition." A November 2007 medical evaluation in connection with his SSA claim additionally stated that the Veteran left his employment as a general mechanic "because of COPD, emphysema, and chronic bronchitis." Though the Veteran was awarded SSA disability benefits in November 2007 due to severe mental and physical impairment, the evidence reflects that this determination was based in significant part on the Veteran's age and nonservice-connected disabilities. In coming to its decision, SSA noted that the Veteran was expected to "avoid even moderate exposure to humidity and fumes, odors and dust," and failed to describe with any further specificity which particular disabilities contributed to his unemployability. The analysis went on to state that the Veteran's determination of disability was made in reliance on vocational rule 202.06, which specifically contemplates the "advanced age" of the claimant in determining whether he or she is found to be disabled. See 20 C.F.R. § 404.1569, Appendix 2, Rule 202.06 (2013). In a March 2013 VA examination for diabetes mellitus, the examiner concluded that the Veteran's diabetes and resulting hypoglycemic reactions precluded him from employment requiring light, skilled work, which was required in his prior job as a mechanic. In view of the foregoing medical and treatment history, the Board finds that the evidence does not establish that the Veteran was unable to secure or maintain substantially gainful employment from November 7, 2011 to March 11, 2013, solely due to his service-connected diabetes mellitus. The Board does not doubt that the Veteran's service-connected diabetes mellitus had some effect on his employability for the period of November 7, 2011 to March 11, 2013. However, the schedular evaluation in effect for that disability during that time period adequately recognized his impairment resulting from his diabetes. In addition, the Veteran's medical treatment records reflect that he suffered from multiple non-service connected disabilities which had an effect on his ability to obtain or sustain employment, which his medical providers specifically cite as significantly contributing to his physical limitations. Though the Board recognizes that the March 2013 VA examiner found that he could not obtain or sustain substantially gainful employment as a mechanic due to his diabetes mellitus, there is no indication that his disability rendered him totally unemployable prior to that date. Indeed, the Veteran himself has repeatedly stated that he voluntarily left work due to breathing problems and limitations due to his non-service connected COPD, chronic bronchitis, and emphysema. Thus, for the reasons and bases set forth above, the preponderance of the evidence is against finding that his service-connected diabetes mellitus was of such severity so as to preclude his participation in any form of substantially gainful employment. The Board acknowledges that the Veteran was temporarily unable to work due to his service-connected CAD, and that he was found to be disabled for purposes of SSA benefits; however, the SSA decision analysis clearly describes that its determination relied on the Veteran's advanced age and non-service connected COPD, emphysema, and chronic bronchitis disabilities, rather than his diabetes mellitus type II. Accordingly, as the Veteran did not meet the schedular criteria for a TDIU from November 7, 2007 to March 11, 2013, and as the medical evidence of record does not indicate that the Veteran was unemployable solely due to his service-connected diabetes mellitus, the Board finds that an award of TDIU is not warranted. ORDER Entitlement to an initial disability rating in excess of 20 percent for diabetes mellitus type II, prior to March 12, 2013, is denied. Entitlement to a disability rating in excess of 60 percent for diabetes mellitus type II, from March 12, 2013, is denied. Entitlement to a TDIU for the period of April 30, 2007, to March 11, 2013, is denied. Entitlement to a TDIU for the period after March 12, 2013 is dismissed. ____________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs