Citation Nr: 1340252 Decision Date: 12/05/13 Archive Date: 12/20/13 DOCKET NO. 08-06 718 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for hypertension. 2. Entitlement to service connection for peripheral neuropathy. 3. Entitlement to a total disability rating for compensation purposes based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The Veteran had active duty service from August 1972 to August 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2006 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). This case was previously before the Board in November 2012, when other issues on appeal were resolved with decisions and the three issues remaining on appeal were remanded for additional development. The case was again before the Board in June 2013, when the issues remaining on appeal were again remanded to complete the required additional development. The Veteran testified at a Board videoconference hearing in June 2012. A transcript of the hearing is of record. This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future consideration of this appellant's case should take into consideration the existence of these electronic records. The issues of entitlement to a disability rating in excess of 10 percent for hypertension and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDING OF FACT The Veteran's peripheral neuropathy was not manifested during the Veteran's active duty service nor within one year thereafter, nor is peripheral neuropathy otherwise related to service or to a service-connected disability. CONCLUSION OF LAW The Veteran's peripheral neuropathy was not incurred in or aggravated by the Veteran's active duty service, nor may it be presumed to have been incurred in such service, nor has the disability been proximately caused by or permanently aggravated by service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (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; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Duty to Notify Upon receipt of a complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant pre-adjudication notice by letters dated in September 2004 and December 2004. The notification complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. The RO provided the appellant with additional notice in November 2010, subsequent to the initial adjudication. This letter provided notice of the types of evidence VA would assist him in obtaining as well as his own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The notification complied with the specificity requirements of Dingess v. Nicholson, 19 Vet. App. 473 (2006) identifying the five elements of a service connection claim; and Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. While the November 2010 notice was not provided prior to the initial adjudication, the claimant has had the opportunity to submit additional argument and evidence, and to meaningfully participate in the adjudication process. The claim was subsequently readjudicated in supplemental statements of the case, most recently in July 2013, following the provision of notice in November 2010. The VCAA notice was therefore effectively timely. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim is sufficient to cure a timing defect). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist Furthermore, the Board finds that there has been compliance with the assistance provisions set forth in the law and regulations. The record in this case includes the Veteran's service treatment records and all pertinent identified post-service medical records, including VA medical records. VA afforded the Veteran a physical examination in January 2013, obtained a further medical opinion addressing this claim in July 2013, and afforded the Veteran the opportunity to give testimony before the Board in June 2012. The Board finds that the January 2013 and July 2013 VA examination reports, read together, now properly address the critical questions at issue; the VA examination reports present sufficient discussion of the pertinent history, clinical findings, medical principles, and expert determinations informed by review of the claims file such that they present adequate and probative evidence addressing the medical questions raised by the Veteran's contentions in this case. All known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The VA medical opinions addressing the peripheral neuropathy issue in this case focus upon addressing the secondary theory of service connection; that is, they address the Veteran's contention that peripheral neuropathy is a result of service-connected hypertension. Concerning any theory of direct incurrence during service, the Board finds that a VA medical nexus opinion is not required in order to make a final adjudication. See McLendon v. Nicholson, 20 Vet. App. 79 (2006), states, that in disability compensation (service connection) claims, VA must provide a medical examination [for a nexus opinion, as applicable] when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. The Board finds that the standards set forth in McLendon are not met with regard to consideration of the peripheral neuropathy issue on a direct basis in this case. There is no credible evidence of an event, injury, or disease during service or within a presumptive period to satisfy the second McLendon requirement. The Veteran is not shown to have had any pertinent manifestations of peripheral neuropathy during service or for many years thereafter. The Board finds that the actions directed by the Board's prior remands have been adequately completed in this case. In particular, the Board again notes that the January 2013 and July 2013 VA examination reports now present the sought probative evidence addressing the pertinent medical questions at issue in this case. The medical opinions of record now adequately address all of the essential questions raised by the issue on appeal, in accordance with the prior Board remands. Additionally, the Veteran's previously missing VA treatment records have now been associated with the claims-file and made available for review. The Board finds that the actions directed by the prior remands have been completed in substantial compliance with the terms and purposes of those directives. VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision at this time. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c)(4). No additional pertinent evidence has been identified by the claimant. Analysis The Veteran claims entitlement to service connection for peripheral neuropathy. Essentially, the Veteran contends that he currently suffers from peripheral neuropathy primarily on the theory that the disability has resulted from his service-connected hypertension pathology or from certain prescription medications involved in the treatment of the hypertension. Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury or disease in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as organic diseases of the nervous system, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is warranted for a disability which is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310. The Court has also held that service connection can be granted for a disability that is aggravated by a service-connected disability and that compensation can be paid for any additional impairment resulting from the service-connected disorder. Allen v. Brown, 7 Vet. App. 439 (1995). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A veteran is competent to describe symptoms that he experienced in service or at any time after service when the symptoms he perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person); Layno, 6 Vet. App. at 469-71 (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness, but lay testimony is not competent to prove a particular injury or illness); see Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). The Board further notes that it has reviewed all of the evidence in the Veteran's claims file (featuring the VBMS claims-file) and in "Virtual VA," with an emphasis on the evidence relevant to the matter on appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. There is no controversy as to the fact that the Veteran currently is diagnosed with peripheral sensory neuropathy of the lower extremities. For the purposes of this decision, the Board accepts that the Veteran currently has a diagnosis of peripheral sensory neuropathy shown by the medical evidence, including as indicated in VA medical reports and the January 2013 VA examination report associated with this appeal. The threshold question in this case is whether there is a nexus (an etiological link though causation or aggravation) between the Veteran's peripheral neuropathy and his military service or with a service-connected disability. The Veteran's service treatment records do not suggest in-service onset or incurrence of the Veteran's peripheral neuropathy. No pertinent complaints or diagnoses suggestive of peripheral neuropathy are shown in any service treatment record, and the Veteran's June 1974 separation examination report shows that the Veteran was assessed by a trained medical professional to be clinically normal in all pertinent respects, including specifically his neurologic system and his lower extremities. The Board finds that the service treatment records present competent probative evidence that the Veteran did not have any pertinent disability or injury involving peripheral neuropathy during his active duty military service. The Board also notes that there is no evidence indicating the onset of any peripheral neuropathy within a year following the Veteran's military service. The Board observes that the Veteran has made no contention to the contrary, and there is no documentation of peripheral neuropathy treatment until decades after separation from service. There is no clear evidence of diagnosis or manifestation of peripheral neuropathy for at least a decade following service. Such a lengthy period following the Veteran's 1974 separation from active duty service without evidence of complaint or treatment for neuropathy weighs against the claim on a direct basis. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Because there is no competent evidence suggesting a causal link between the Veteran's claimed peripheral neuropathy and the Veteran's service, nor any evidence of peripheral neuropathy manifesting during service or during any presumptive period following service, the Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for peripheral neuropathy on a direct basis. The Veteran's contentions in this case do not feature a direct theory of service connection based upon in-service incurrence; rather, this appeal has been advanced featuring the theory that the Veteran's peripheral neuropathy warrants secondary service connection on the basis of being caused or aggravated by his service-connected hypertension pathology or the medical treatment thereof. A January 2013 VA examination report addresses the question of causation and presents a competent medical professional's opinion, informed by review of the claims-file and examination of the Veteran. The VA examiner concluded that the peripheral neuropathy "is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service connected" hypertension. The VA examiner explained a rationale for this opinion, citing specific pertinent medical literature and the facts of the Veteran's medical history and risk factors. The VA examiner notes that leading risk factors for peripheral neuropathy include alcoholism, which is part of the Veteran's medical history. The VA examiner explained finding no reference in the pertinent literature to either hypertension nor to the Veteran's specific anti-hypertensive medications as causal risk factors for peripheral neuropathy. A July 2013 VA medical opinion, informed by review of the available records, further addressed this issue with regard to the question of whether the Veteran's peripheral neuropathy may have been aggravated by his hypertension or any medication prescribed in the treatment of hypertension. The July 2013 VA medical opinion concludes that peripheral neuropathy is less likely than not aggravated beyond its natural progression by the Veteran's hypertension, and that "it is unlikely that any of the veteran's treatments for hypertension aggravated his peripheral neuropathy." The authoring medical physician presented a rationale citing that the Veteran's "symmetrical lower extremity peripheral sensory neuropathy ... is often attributed to conditions such as diabetes, B12 deficiency, and alcoholism. The veteran suffers from both of the latter two conditions." Furthermore, the physician explains that "hypertension has no effect on the structure or function of peripheral nerves and is not a medical condition which is documented to be associated with neuropathies; it would not aggravate a sensory symmetrical perip[h]eral neuropathy because there is no pathophysiological relationship between the two conditions." The VA physician additionally cited that the Veteran's medical records do not indicate that his hypertension medications have had any effect upon his peripheral neuropathy, and "[n]one of his hypertensive medications have a documented side effect or adverse reaction of peripheral neuropathy." The Board notes that the agency of original jurisdiction (AOJ) had previously cited VA examination reports and the August 2005 QTC medical opinion in adjudicating the peripheral neuropathy issue (in the January 2006 rating decision and the January 2008 statement of the case). However, the Board finds that the cited evidence discusses peripheral edema and peripheral vascular health, but does not meaningfully address the peripheral neuropathy issue in this case. The Board finds that the January 2013 and July 2013 VA medical opinions are probative evidence which, read together, adequately address the Veteran's contentions with competent medical determinations informed by the pertinent facts. The probative weight of the VA medical opinions is against the Veteran's claim because they conclude that it is less likely than not that the Veteran's current peripheral neuropathy is caused or aggravated by his service-connected hypertension. The Board finds that the probative evidence weighs against granting the claim of entitlement to service connection for peripheral neuropathy on any basis. The preponderance of the evidence is against finding any etiological link between for peripheral neuropathy and the Veteran's service. The competent evidence indicates that the Veteran peripheral neuropathy pathology was not manifested during service or within a presumptive period following service; the competent evidence indicates no nexus, through causation or aggravation, between the peripheral neuropathy and the Veteran's military service. Additionally, the competent probative evidence indicates that the Veteran's peripheral neuropathy has not been caused or aggravated by his service-connected hypertension. Conclusion The Board finds that the preponderance of the evidence is against the claim of entitlement to service connection for peripheral neuropathy on any basis. In reaching this decision, the Board has reviewed the entirety of the evidence of record but finds that there is no other evidence of record which probatively contradicts the findings presented in the most probative evidence discussed above with regard to the issue on appeal. The Board acknowledges that the claims file contains a quantity of other documents, but none of the information in these records substantially supports the Veteran's claim or otherwise contradicts the evidence deemed to be most probative in the discussion above. Here, the evidence weighs against finding that the Veteran's peripheral neuropathy is etiologically linked to military service or linked to his service-connected hypertension as he contends. The Veteran has been afforded a VA examination with medical opinions to ensure adequate competent medical evidence addressing the peripheral neuropathy service connection claim. The evidence now presents adequate medical information and opinion in connection with the claim; the January 2013 VA examination report and the July 2013 VA medical opinion together have provided clear findings and opinions with persuasive discussions of rationale weighing against the peripheral neuropathy service connection claim. The January 2013 and July 2013 VA examination reports discuss pertinent findings and opinions addressing, with persuasive rationale, the pertinent facts and evidence of record; the Board finds that the January 2013 and July 2013 VA examination reports are the most probative evidence of record on the questions pertinent to the Veteran's secondary service connection theory. Significantly, no competent medical opinion contradicts the VA examiners' conclusions or otherwise provides a basis for granting the Veteran's service-connection claim. The Board acknowledges that service connection may indeed be granted when a chronic disease or disability is not present in service, but there is evidence of continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). In this case, however, the most persuasive evidence persuasively establishes that the Veteran had no symptom complaints attributable to peripheral neuropathy during service or proximately following service. He had no shown diagnosis of peripheral neuropathy during service or proximately thereafter, and the Veteran has not contended, testified, or presented evidence to the contrary. The evidence in this case does not show continuity of symptomatology associated with a chronic disability for the purposes of application of 38 C.F.R. § 3.303(b). The Board acknowledges the Veteran's belief that his peripheral neuropathy is related to his service connected hypertension. However, there is no evidence of record showing that the Veteran has the specialized medical education, training, and experience necessary to render a competent medical opinion as to the diagnosis and etiology of a disability. The Board finds that questions of identifying the specific etiology or inter-relatedness of complex internal pathologies such as peripheral neuropathy and hypertension are medical questions requiring specialized knowledge and expertise; such questions are not generally resolvable through information available to lay senses. Consequently, the Veteran's own assertions as to the etiology of peripheral neuropathy have no probative value. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). See also Robinson v. Shinseki, 312 Fed. Appx. 336 (Fed. Cir. 2009) (non-precedential) (confirming that, in some cases, lay evidence will be competent and credible evidence of etiology). However, a determination concerning diagnosis of a specific complex internal disease or a determination concerning the possibility of a causal relationship between two different complex disease pathologies requires specialized training, and may therefore not be established by lay opinions on etiology or diagnosis. As the preponderance of the evidence is against the Veteran's claim of entitlement to service connection in this case, the benefit-of-the-doubt rule does not apply and this claim is denied. See 38 U.S.C.A. § 5107. ORDER Service connection is not warranted for peripheral neuropathy, to include as secondary to hypertension. To this extent, the appeal is denied. REMAND The Board has previously remanded the claim of entitlement to service connection for an increased rating for hypertension and the claim of entitlement to TDIU for necessary development including associating certain pertinent VA medical records (from January 2008 onward) with the claims-file for appellate review. That development has now been completed. Review of the added VA treatment records contains significant additional documentation of the Veteran reporting complaints of lower extremity pain and swelling, including involving his feet. The claims-file contains competent medical evidence that the Veteran's lower extremity complaints and symptoms are caused by peripheral edema and, in turn, that the Veteran's peripheral edema is a specific consequence of medical treatment for hypertension. For instance, the January 2013 VA examination report includes a discussion that "dependent edema ... also contributes to similar symptoms in the lower extremities," and an October 2010 VA medical record presents a nurse practitioner's statement that clearly and unequivocally explains: "[the Veteran] has developed secondary peripheral edema which is more likely than not related to the medicines which control his blood pressure." The Board finds that it is important to note that the Veteran has repeatedly expressed that he believes that he suffers significant impairment, including with regard to unemployability, associated with his peripheral edema. A November 2010 VA medical report shows that the Veteran expressly cited "pedal edema" as the reason he was unable to obtain or maintain employment. This appeal originally included the issue of entitlement to service connection for peripheral edema, and the Board denied this claim in November 2012. However, the Board's denial of service connection for peripheral edema was not predicated upon a negative determination on the etiology of the peripheral edema; rather, the Board denied service connection for peripheral edema on the specific basis of finding that the peripheral edema was a symptom of the service-connected hypertension and not a distinct diagnosable disability for which separate service connection can be established. Consistent with that determination, however, the Board must continue to recognize that the Veteran's contentions regarding the severity of disability associated with his hypertension includes the medically associated symptomatology of his lower extremity edema. To perform adequate and complete appellate review of the Veteran's claims of entitlement to an increased rating for his hypertension pathology and his claim of entitlement to TDIU in this case, the Board must give consideration to the Veteran's express and repeated contention that the hypertension-related peripheral edema symptomatology has caused substantial impairment. The specific symptomatology identified by the Veteran in advancing these claims must be considered by the Board's analysis; however, the Veteran's lower extremity and feet complaints associated with hypertension-related peripheral edema symptoms are not reasonably described or otherwise contemplated in any manner by the rating criteria for the hypertension disease process under Diagnostic Code 7101. 38 C.F.R. § 4.104, Diagnostic Code 7101. The AOJ development and adjudication of this appeal, including VA examinations, the January 2006 rating decision, and the statements of the case, have focused exclusively upon the Veteran's blood pressure readings and Diagnostic Code 7101 with regard to the hypertension. In light of the Veteran's clear and repeated contentions directing attention to his hypertension-related lower extremity symptomatology, the Board cannot proceed with informed appellate review of the hypertension rating issue or the TDIU issue without appropriate development addressing the significant symptom complaints of the lower extremities. The Board recognizes that this case is somewhat unusual in the regard that hypertension rating appeals may not customarily involve development of the evidence to inform application of Diagnostic Codes of the lower extremities. However, as this case involves clear contentions of symptomatology featuring the Veteran's difficulty with his lower extremities, and as the Veteran was denied service connection for the peripheral edema of the lower extremities specifically on the basis that the peripheral edema was a symptom associated with the hypertension rather than a separate diagnosable disability, the Board sees no alternative but to proceed with development of evidence concerning lower extremity disability as part of the claim for increased disability compensation for hypertension. Moreover, if any aspect of the Veteran's described lower extremity symptomatology attributable to his hypertension pathology cannot be appropriately compensated through application of the ratings schedule, then consideration of referral for an extraschedular rating should also be addressed by the AOJ. As the Veteran's appeal for TDIU is inextricably intertwined with the hypertension/peripheral edema issue being remanded at this time, adjudication of the TDIU issue must be deferred until completion of the actions directed in this remand. Indeed, the Veteran has expressly contended that he is unemployable due to the lower extremity symptoms from his peripheral edema. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be scheduled for a VA examination by an appropriate specialist (or specialists) to ascertain the nature and severity of the peripheral edema manifesting in symptoms of impairment the lower extremities that has been indicated as a symptom of medical treatment for service-connected hypertension. It is imperative that the claims file be made available to the examiner(s) for review. Any medically indicated special studies and tests should be accomplished. Examination findings should be clearly reported to allow for application of pertinent VA rating criteria. The VA examiner(s) should ensure that the report addresses each of the following: a) Please specifically identify, to the extent possible, each aspect of the Veteran's lower extremity symptom complaints attributable to peripheral edema; symptoms clearly medically attributable to a non-service-connected diagnosis, such as peripheral neuropathy, should be excluded from the assessment of the severity of the peripheral edema, but only symptoms clearly distinguishable from the peripheral edema should be so excluded. b) The essential purpose of this examination (or examinations) is to obtain a medical assessment of the severity and level of impairment associated of the Veteran's lower extremity symptom complaints that are attributable to his peripheral edema (as part of his service-connected hypertension pathology). The VA examination report(s) must include findings pertinent to allowing for application of any and all VA rating criteria for lower extremity disabilities which appropriately describe the Veteran's service-connected impairment and symptoms in this case. c) Please also describe the impact that the Veteran's peripheral edema has upon the Veteran's ability to obtain and maintain gainful employment. In making this assessment, please address the Veteran's lay statements asserting that he has been rendered unemployable due to lower extremity symptoms. The examiner should furnish a rationale for any medical opinions presented. 2. After completion of the above and any additional development which the RO/AMC may deem necessary, the RO/AMC should then review the expanded record and readjudicate the issue of entitlement to increased disability compensation for hypertension. Readjudication of the hypertension rating issue must clearly contemplate the lower extremity symptoms attributable to hypertension-related peripheral edema. The RO/AMC must also readjudicate the inextricably intertwined issue of entitlement to a TDIU; the TDIU readjudication must also include consideration of the Veteran's contentions concerning impairment of his lower extremities associated with service-connected hypertension. The RO/AMC should issue an appropriate supplemental statement of the case and give the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs