Citation Nr: 1341065 Decision Date: 12/12/13 Archive Date: 12/20/13 DOCKET NO. 05-20 481 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to an increased disability rating in excess of 20 percent for diabetes mellitus. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus. 3. Entitlement to an effective date earlier than May 20, 2008 for the grant of service connection for loss of use of the bilateral lower extremities. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD T. Blake, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1968 to August 1970. This case comes before the Board of Veterans' Appeals (Board) on appeal from March 2004 and October 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. In March 2004, the RO denied service connection for hypertension. In October 2008, the RO continued the 20 percent disability rating for diabetes mellitus and granted service connection for loss of use of the bilateral lower extremities. The Veteran and his spouse testified before the undersigned Veterans Law Judge at a December 2011 videoconference hearing. A copy of the transcript is of record in the physical claims file. In a March 2012 decision, the Board, in pertinent part, remanded the issues listed on the title page for additional development and adjudicative action. The case has been returned to the Board for further appellate review. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system and the "Virtual Benefits Management System (VBMS)" to ensure a total review of the evidence. Since issuance of the last Supplemental Statement of the Case (SSOC) in January 2013, additional medical evidence was obtained and associated with the file on the VBMS; however, such evidence is not pertinent to the claims on appeal. Thus, a remand for initial RO consideration is not required. See 38 C.F.R. § 20.1304(c) (2013). FINDINGS OF FACT 1. All relevant evidence necessary to decide the Veteran's appeal has been obtained. 2. For the entire increased rating period on appeal, the service-connected diabetes mellitus more closely approximates a manifestation of requiring insulin and restricted diet. 3. The Veteran did not sustain cardiovascular injury or disease or experience chronic symptoms of hypertension in service. 4. Hypertension did not manifest to a compensable degree within one year of separation from service and symptoms of hypertension have not been continuous since separation from service. 5. The Veteran's hypertension is not related to his active service or proximately caused by or aggravated by his service-connected diabetes mellitus. 6. The Veteran's claim for entitlement to service connection for loss of use of the bilateral lower extremities was received on May 20, 2008, which was not within one year after separation from service and is later than the date entitlement arose. CONCLUSIONS OF LAW 1. The criteria for an increased disability rating in excess of 20 percent for diabetes mellitus have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.2, 4.3, 4.7, 4.119, Diagnostic Code (DC) 7913 (2013). 2. The criteria for service connection for hypertension, to include as secondary to service-connected diabetes mellitus, have not been met. 38 U.S.C.A. §§ 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2013). 3. The criteria for entitlement to an effective date earlier than May 20, 2008 for the grant of service connection for loss of use of the bilateral lower extremities have not been met. 38 U.S.C.A. §§ 5101(a), 5110 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.1(p), 3.151(a), 3.155(a), 3.400(b)(2)(i) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Although the Board has an obligation to provide reasons and bases supporting these decisions, there is no need to discuss, in detail, the extensive evidence of record. Indeed the United States Court of Appeals for the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims on appeal. Higher Rating for Service-Connected Diabetes Mellitus Disability evaluations are determined by the application of the schedule of ratings which is based on average impairment of earning capacity. See U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In a January 2008 statement, via a VA Form 21-4138, the Veteran requested an increase for his diabetes mellitus because it has gotten worse over time. In an October 2009 statement, via a VA Form 21-4138, the Veteran asserted he is unable to exercise adequately due to his peripheral neuropathy caused by his diabetes mellitus. He also reported a VA physician medically mandated a regulation of activities. At the December 2011 Board hearing, the Veteran testified that his diabetes mellitus has worsened in the past three to five years by having to wear compressed socks and two-leg brace and swelling of his neuropathy, feet, and legs. In this regard, it is important for the Veteran to understand that his reported symptoms regarding the lower extremities are contemplated in the currently-assigned 20 percent disability ratings for peripheral neuropathy of the bilateral lower extremities. Pursuant to the rating criteria for the endocrine system, the service-connected diabetes mellitus is rated at 20 percent disabling, effective May 20, 2008. A 20 percent evaluation is warranted when insulin and a restricted diet, or an oral hypoglycemic agent and a restricted diet, is required. 38 C.F.R. § 4.119, DC 7913. Important for this case, a 40 percent rating is assigned when insulin, a restricted diet, and regulation of activities are required. Id. A 60 percent evaluation is warranted when diabetes mellitus requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. Id. A 100 percent rating is warranted when diabetes mellitus requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Id. Complications of diabetes mellitus are to be evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Id. at Note (1). Noncompensable complications are considered part of the diabetic process under DC 7913. Id. After a full review of the record, the Board finds that the evidence is against a disability rating in excess of 20 percent for the service-connected diabetes mellitus for any period. As discussed below, the evidence of record indicates the service-connected disability more closely approximates a manifestation of requiring insulin and restricted diet. At the March 2008 VA examination for diabetes mellitus, the examiner noted mild effects of the diabetes mellitus on chores, moderate effects on shopping, recreation, and travelling, and severe effects on sports, providing evidence against this claim of high probative weight. The Veteran exhibited weight gain of 10 percent compared to baseline (229 pounds), was diagnosed with venous insufficiency, and current treatment listed (unspecified) medication. At the August 2008 VA examination for diabetes mellitus, current treatment listed insulin and oral medication. Summary of his medical history noted, in pertinent part, the Veteran was instructed to follow restricted or special diet, no episodes of hypoglycemic reactions or ketoacidosis, and no restriction in ability to perform strenuous activities. He weighed 305 pounds and there were no reported effects from his diabetes mellitus on usual daily activities. In a May 2012 VA Disability Benefits Questionnaire (DBQ) medical opinion, a VA physician opined: [T]he Veteran's diabetes alone causes no limitation in the [Veteran's] activities. [H]is diabetes is well controlled. [H]e can't do strenuous activities due to his severe knee [osteoarthritis] and coronary artery disease, but as his diabetes is well controlled, it would cause no limitations. [I]f the Veteran were having very fluctuating blood sugars, this would limit his activities. [H]owever, the [Veteran's] diabetes is well controlled. Furthermore, throughout the course of this appeal, VA outpatient treatment records reveal his ongoing complaints and treatment for diabetes mellitus. Specifically, the Veteran was advised to exercise (March 2007, May 2007, and February 2008) and was stressed the importance of exercise (July 2007). Such medical evidence does not support a finding that a 40 percent evaluation is warranted based on a regulation of his activities and actually providers highly probative evidence against such a finding. The Board notes the Veteran is currently service connected for peripheral neuropathy of the bilateral lower and upper extremities and erectile dysfunction due to the service-connected diabetes mellitus. These service-connected disabilities are currently not on appeal with the Board. In this regard, it is important for the Veteran to understand that a problem that the Veteran is having that is compensated by one service connected disability evaluation cannot be used as a basis to award the Veteran more compensation in another disability evaluation for the same problem, such as this one. The Board has considered all other potentially applicable provisions of 38 C.F.R. Parts 3 and 4, as required by the Court in Schafrath v. Derwinski. However, after careful review of the available diagnostic codes and the lay and medical evidence of record, the Board finds there are no other diagnostic codes that provide a basis to assign a higher evaluation than the currently assigned rating for the service-connected disability on appeal. Therefore, fully considering the lay and medical evidence of record, the Board finds that a disability rating in excess of 20 percent is not warranted for the Veteran's diabetes mellitus for any period as it more closely approximates a manifestation of requiring insulin and restricted diet and does not demonstrate the requirement of regulated activities. 38 C.F.R. §§ 4.3, 4.7. An extra-schedular rating may be provided in exceptional cases. 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). In this case, the Board finds that the symptomatology and impairment of the Veteran's diabetes mellitus is specifically contemplated by the schedular rating criteria, and no referral for extra-schedular consideration is required. The schedular rating criteria, DC 7913, specifically provides for the Veteran's restricted diet and use of insulin. Such symptomatology is contemplated in the currently assigned disability rating under DC 7913. See 38 C.F.R. § 4.119. Moreover, the Board notes that the Veteran's erectile dysfunction is currently noncompensa0b le and he is separately service-connected for peripheral neuropathy of the bilateral lower and upper extremities due to the service-connected diabetes mellitus. As a result, referral for extra-schedular consideration for the service-connected diabetes mellitus is not required. Service Connection for Hypertension Under 38 C.F.R. § 3.303(a), service connection means that the facts, as shown by the evidence, establishes that a particular injury or disease was incurred coincident with service. It may be granting by affirmatively showing inception or aggravation during service. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection can also be established through application of statutory presumptions, including for chronic diseases, such as cardiovascular-renal disease, when manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (the term cardiovascular-renal disease includes hypertension). Under 38 C.F.R. § 3.303(b), if a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. When the fact of chronicity in service (or during the presumptive period) is not adequately supported, then a showing of continuity after discharge is required to support the claim. The provisions of 38 C.F.R. § 3.303(b) have been interpreted as an alternative route to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 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). When a claimed disorder is not included as a presumptive disorder, direct service connection may nevertheless be established by evidence demonstrating that the disease was in fact "incurred" during service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995); Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). In making all determinations, the Board must consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In an October 2003 informal claim, via a VA Form 21-4138, the Veteran requested service connection for hypertension as secondary to his diabetes mellitus. In a March 2004 rating decision, the RO granted service connection for diabetes mellitus. For VA purposes, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. See 38 C.F.R. § 4.104, DC 7101, Note (1) (2013). Hypertension is demonstrated when the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension is demonstrated when the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. Id. After a review of all the evidence, both lay and medical, the Board finds the Veteran did not manifest hypertension or chronic symptoms of hypertension during service. Review of the service treatment records shows no complaints or manifestations of hypertension. In fact, his blood pressure readings were 136/82 at the March 1968 entrance examination and the following in February 1969: 154/108, 150/80, 160/88, and 128/88. Isolated readings of systolic blood pressure at 160mm and diastolic blood pressure at 108mm is insufficient to show predominance of 160mm or greater and 90mm or greater, respectively, to demonstrate a finding of hypertension during active service. The evidence of record does not show hypertension manifested to a compensable degree within one year of separation from service nor did the Veteran have symptoms of hypertension continuously since separation from service. In fact, post-service treatment records show hypertension was first diagnosed in 1997. An August 2008 VA general medical examination report listed a current diagnosis of hypertension with onset in 1974 based on a diagnosis on a routine examination. A May 2012 VA DBQ examination report for hypertension also listed a current diagnosis of hypertension; however, the examiner noted onset in 1978 based on the Veteran's reported history of starting blood pressure medications in 1978. Whether the Veteran's hypertension first manifested in 1974, 1978, or 1997, such manifestations were multiple years after separation from service. As a result, service connection for hypertension is not warranted on a presumptive basis. See 38 C.F.R. §§ 3.307, 3.309. Moreover, the evidence, particularly the competent and credible medical opinions of record, demonstrates that hypertension is not related to service or his service-connected diabetes mellitus. The August 2008 VA general medical examination report noted the Veteran's hypertension occurred after active service. On VA examination in May 2012, the VA DBQ examiner noted review of the Veteran's VA outpatient treatment records and documented the Veteran's medical history. The examiner also conducted a thorough physical examination and affirmed the Veteran's current diagnosis of hypertension. The examiner marked "the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness." It was explained that: The Veteran was not diagnosed with hypertension and started on medications until well after his discharge. Thus, his hypertension did not have its onset in service. Although he has diabetes, he has no evidence for diabetic nephropathy. Unless diabetes causes nephropathy, it has no impact on hypertension. Thus, his diabetes has had no impact on his hypertension. His hypertension is well controlled and causes him no limitations. In a subsequent June 2012 addendum report, the same VA examiner noted review of the claims file and reported that "the findings, assessments, and diagnosis remain unchanged from the previous exam[ination]." Since there is no nexus between service and/or a service-connected disability, particularly the diabetes mellitus, and the current disability, and as the evidence is likewise negative with respect to whether the service-connected diabetes mellitus aggravated the Veteran's hypertension, service connection cannot be granted on a direct or secondary basis. The Board acknowledges the Veteran is competent to report symptoms that one experiences as it comes through the use of one's senses. See Layno, 6 Vet. App. at 470. However, he is not competent and with the appropriate medical training and expertise to offer an opinion on a medical matter, including the etiology of his hypertension. See Bostain v. West, 11 Vet. App. 124, 127 (1998); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). The question of causation, in this case, involves a complex medical issue that the Veteran is not competent to address (such as whether the Veteran's hypertension is caused or aggravated by his service-connected diabetes mellitus). See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). For these reasons and bases discussed above, the Board finds that the evidence is against the claim for service connection for hypertension. As a result, this claim must be denied and the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Earlier Effective Date for the Grant of Service Connection for Loss of Use of the Bilateral Lower Extremities The Veteran contends that he is entitled to an effective date earlier than May 20, 2008 for the grant of service connection for loss of use of the bilateral lower extremities because there was an inferred and/or informal claim filed for this disability on April 11, 2002. With regard to an appeal for disability compensation based on direct service connection, the effective date will be the date following separation from active service or date entitlement arose if claim was received within one year after separation from service; otherwise, date of receipt of claim, or date entitlement arose, whichever is later. 38 C.F.R. § 3.400(b)(2)(i). A specific claim in the form prescribed by the Secretary of VA must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA. See 38 U.S.C.A. § 5101(a)(1); 38 C.F.R. § 3.151(a). A "claim" is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). Any communication or action, indicating intent to apply for one or more benefits under the laws administered by VA may be considered an informal claim. 38 C.F.R. § 3.155(a). In this case, the Veteran was separated from service in August 1970, as shown on his DD Form 214. On May 19, 2004, the RO received the Veteran's Statement in Support of Claim, via a VA Form 21-4138, for which he requested service connection for loss of use of the left foot due to gunshot wound. In a March 2005 rating decision, the RO denied service connection for loss of use of left foot. With respect to the current claim on appeal, on May 20, 2008, the RO contacted the Veteran and a VA Form 119 documents he requested service connection for loss of use of the left leg secondary to service-connected conditions. The Board notes that neither the May 2004 nor May 2008 informal claims were received within one year after separation from service in August 1970. Therefore, the Board considers whether the later of date of receipt of claim, or date entitlement arose, is the proper effective date for the grant of service connection for loss of use of the bilateral lower extremities. As noted above, the date of receipt of the Veteran's claim for entitlement to service connection for loss of use of the bilateral lower extremities is on May 20, 2008. A review of the record indicates that at the earliest, a July 2003 VA examination report for the joints reveal objective findings that the Veteran is unable to bear full weight on the right lower extremity because of the discomfort in the hip and knee on the right side. Subsequently, an April 2005 VA examination report for the spine documented the Veteran is confined to a wheelchair and is totally disabled. In a June 2007 VA examination report for peripheral nerves, the examiner noted the Veteran has no motion of the entire right lower extremity and less than 50 percent motion of the left lower extremity. In a July 2007 addendum report, the examiner clarified the Veteran has evidence of moderate to severe motor and sensory impairment in the left lower extremity with diminished muscle strength of all muscles of the left lower extremity to about 50 percent. The Veteran also has impaired sensory perception in the left lower extremity to all sensory modalities including light touch, vibration, and pinprick in wide extension and distribution affecting all peripheral nerves of the left lower extremity. As such, the record reflects that the earliest the dates "entitlement arose" can be established from the evidence of record is July 2003 for the right lower extremity and April 2005 for the left lower extremity. Since the date of receipt for the claim is May 20, 2008, which is later than the earliest dates that can be construed as the dates entitlement arose in July 2003 and April 2005, the Board finds the currently assigned effective date of May 20, 2008 is properly assigned for the grant of service connection for loss of use of the bilateral lower extremities. See 38 C.F.R. § 3.400(b)(2)(i). At the December 2011 Board hearing, the Veteran asserts that there was a misunderstanding during the May 2008 report of contact with VA and he meant to seek clarification on his April 11, 2002 claim for Aid and Attendance due to the exact same signs and symptoms from loss of use of his lower extremities, which were subsequently service connected. He asserts that the April 11, 2002 claim for Aid and Attendance, February 26, 2003 notice of disagreement, and VA examination reports dated April 2005, June 2007, and July 2007 should collectively constitute an inferred and/or informal claim for loss of use of the bilateral lower extremities. Thus, the effective date should go back to 2002. Pursuant to the Veteran's contentions, the Board considers whether an informal claim was received or should have been inferred prior to the date of receipt of the informal claim on May 20, 2008. Although the medical evidence of record, discussed above, shows that the earliest dates of objective findings of loss of use of the bilateral lower extremities was in July 2003 and April 2005, such evidence does not constitute an informal claim for service connection benefits because such notations do not reflect any intent expressed to VA from the Veteran to claim compensation benefits for his loss of use of the bilateral lower extremities. See 38 C.F.R. § 3.155. It is important for the Veteran to understand the fact that the Veteran was assessed with loss of use of the bilateral lower extremities in these circumstances does not put VA on notice that he is filing a claim with VA for service connection and compensation. Simply stated, if the Veteran, or any Veteran, is treated by VA at a VAMC it does not put VA on notice that the Veteran thinks this disability is related to his military service. Over time, that VA has treated many disabilities regarding Veterans that have no connection with their military service, therefore, treatment for a problem, in and of itself, does not provide a basis to find that an informal claim has been filed. There are some minimal actions the Veteran himself must take to start VA compensation for a disability related to service. One of the most basic of actions is to file a claim with the VA to put VA on notice his belief that this disability is related to service. Moreover, no communication from the Veteran reflecting an intent to apply for service connection for loss of use of the bilateral lower extremities was submitted to VA prior to May 20, 2008. Id. The Board acknowledges the Veteran filed an Application in Acquiring Specially Adapted Housing or Special Home Adaptation Grant (Aid & Attendance), via a VA Form 26-4555, in April 2002. He did not specifically note any remarks on the application. In an April 2002 rating decision, the RO denied entitlement to the requested claim because neither of the required conditions were shown, to include the loss of use of both lower extremities. In April 2003, the Veteran submitted an untimely notice of disagreement to the April 2002 rating decision and reported "[his] disabilities do in fact qualify [him] for this benefit," which again did not specify any intent to seek disability compensation benefits for loss of use of the bilateral lower extremities (a service connection claim). His claim at this time, rather than supporting his claim, provide evidence against this claim as it clearly does not indicate the claim was being filed, while other claims were being filed. In an August 2003 Decision Review Officer (DRO) decision, the RO granted Special Monthly Compensation (SMC) based on loss of use of the right lower extremity, effective July 22, 2002. The August 2003 Statement of the Case (SOC) continued the previous denial because the medical evidence did not show loss of use of the left lower extremity. Then in October 2003, the Veteran submitted a substantive appeal, via a VA Form 9, to the Board, and the issue of Aid and Attendance was denied in the March 2012 Board decision. In this regard, VA is not required to anticipate any potential claim for a particular benefit where no intention to raise it was expressed. Brannon v. West, 12 Vet. App. 32, 35 (1998); Talbert v. Brown, 7 Vet, App. 352, 356-57 (1995). As noted above, the Veteran specifically requested service connection for loss of use of the left lower extremity in May 2004 and he did not specify the basis of his April 2002 claim for Aid and Attendance as entitlement to service connection for loss of use of the bilateral lower extremities. Thus, the Board finds an informal claim of service connection for loss of use of the bilateral lower extremities prior to May 20, 2008 may not have been inferred based on the above. Based on these findings, and applying the regulation that provides the proper effective date for disability compensation based on direct service connection, the Board finds the effective date of May 20, 2008 for the grant of service connection for loss of use of the bilateral lower extremities is correct, and an earlier effective date is precluded by law and regulation. See 38 U.S.C.A. § 5110(a), (b)(1); 38 C.F.R. § 3.401(b)(2)(i). Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board finds that the duty to notify has been satisfied by January 2004, March 2008, and April 2012 letters. Regarding the duty to assist, the evidence of record includes personal statements from the Veteran, VA outpatient treatment records, and multiple VA examination reports. The Veteran was also provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge in December 2011. There is no indication that additional records exist or, if they did, that they would provide a basis to grant this claim. The Board finds that the Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). See Bryant v. Shinseki, 23 Vet. App. 488 (2010). Pursuant to the Board's March 2012 remand instructions, the RO sent the Veteran an April 2012 letter informing him of how to substantiate a claim for service connection for loss of use of the bilateral lower extremities and how VA assigns effective dates. The RO also arranged for a VA DBQ examination and medical opinion in May 2012 and June 2012 addendum report. That examination report and medical opinions reflect the examiner considered the evidence of record and the reported history of the Veteran, conducted a thorough examination of the Veteran, noting all findings necessary for proper adjudication of the matter, and explained the rationale for the opinions offered. Hence, the Board concludes that the May 2012 examination and medical opinions and June 2012 addendum report were adequate and substantially complied with the March 2012 remand instructions. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes); see also Dyment v. West, 13 Vet. App. 141 (1999) (a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where there is substantial compliance with the Board's remand instructions); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board finds no further assistance to the Veteran with the development of evidence is required. See 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). ORDER An increased disability rating in excess of 20 percent for diabetes mellitus is denied. Service connection for hypertension, to include as secondary to service-connected diabetes mellitus, is denied. An effective date earlier than May 20, 2008 for the grant of service connection for loss of use of the bilateral lower extremities is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs