Citation Nr: 1602348 Decision Date: 01/20/16 Archive Date: 01/27/16 DOCKET NO. 13-25 060 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an evaluation greater than 20 percent for diabetes mellitus with erectile dysfunction on a schedular basis. 2. Entitlement to an evaluation greater than 20 percent for diabetes mellitus with erectile dysfunction on an extraschedular basis. 3. Entitlement to an evaluation greater than 20 percent for peripheral neuropathy of the left upper extremity associated with diabetes mellitus on a schedular basis. 4. Entitlement to an evaluation greater than 20 percent for peripheral neuropathy of the left upper extremity associated with diabetes mellitus on an extraschedular basis. 5. Entitlement to an evaluation greater than 20 percent for peripheral neuropathy of the right upper extremity associated with diabetes mellitus on a schedular basis. 6. Entitlement to an evaluation greater than 20 percent for peripheral neuropathy of the right upper extremity associated with diabetes mellitus on an extraschedular basis. 7. Entitlement to an evaluation greater than 10 percent prior to July 14, 2015 and in excess of 20 percent from that date for peripheral neuropathy of the left lower extremity associated with diabetes mellitus on a schedular basis. 8. Entitlement to an evaluation greater than 10 percent prior to July 14, 2015 and in excess of 20 percent from that date for peripheral neuropathy of the left lower extremity associated with diabetes mellitus on an extraschedular basis. 9. Entitlement to an evaluation greater than 10 percent prior to July 14, 2015 and in excess of 20 percent from that date for peripheral neuropathy of the right lower extremity associated with diabetes mellitus on a schedular basis. 10. Entitlement to an evaluation greater than 10 percent prior to July 14, 2015 and in excess of 20 percent from that date for peripheral neuropathy of the right lower extremity associated with diabetes mellitus on an extraschedular basis. 11. Entitlement to a compensable evaluation for diabetic retinopathy. 12. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU). ATTORNEY FOR THE BOARD Scott Shoreman, Counsel INTRODUCTION The Veteran had active service from August 1980 to December 1992. This matter comes before the Board of Veterans' Appeals (Board) from an August 2012 rating decision of the above Department of Veterans Affairs (VA) Regional Office (RO). The issue of entitlement to service connection for bone spurs of the heels and feet has been raised by the record in a September 2012 statement, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). This claim was previously before the Board in May 2015, at which time the Board remanded it for additional development. The requested development has been completed on the issues of entitlement to increased ratings for diabetes mellitus with erectile dysfunction and bilateral upper and lower extremity peripheral neuropathy on a schedular basis, and the claims are properly before the Board for appellate consideration. The issues of entitlement to increased evaluations for diabetes mellitus with erectile dysfunction and bilateral upper and lower extremity neuropathy on an extraschedular basis, an increased evaluation for diabetic retinopathy, and to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. Diabetes mellitus with erectile dysfunction is characterized by use of insulin, oral hypoglycemic agents, and a restricted diet. 2. Peripheral neuropathy of the left upper extremity associated with diabetes mellitus is characterized by mild incomplete paralysis of the musculospiral nerve. 3. Peripheral neuropathy of the right upper extremity associated with diabetes mellitus is characterized by mild incomplete paralysis of the ulnar nerve. 4. For the entire claims period, peripheral neuropathy of the left lower extremity associated with diabetes mellitus has been characterized by moderate paralysis of the sciatic nerve. 5. For the entire claims period, peripheral neuropathy of the right lower extremity associated with diabetes mellitus has been characterized by moderate paralysis of the sciatic nerve. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 20 percent for diabetes mellitus with erectile dysfunction on a schedular basis have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.7, 4.119, Diagnostic Code 7913 (2015). 2. The criteria for an evaluation in excess of 20 percent for peripheral neuropathy of the left upper extremity associated with diabetes mellitus on a schedular basis have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.7, 4.124a, Diagnostic Code 8516 (2015). 3. The criteria for an evaluation in excess of 20 percent for peripheral neuropathy of the right upper extremity associated with diabetes mellitus on a schedular basis have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.7, 4.124a, Diagnostic Code 8514 (2015). 4. The criteria for an evaluation of 20 percent prior to July 14, 2015 for peripheral neuropathy of the left lower extremity associated with diabetes mellitus on a schedular basis have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.7, 4.124a, Diagnostic Code 8520 (2015). 5. The criteria for an evaluation in excess of 20 percent from July 14, 2015 for peripheral neuropathy of the left lower extremity associated with diabetes mellitus on a schedular basis have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.7, 4.124a, Diagnostic Code 8520 (2015). 6. The criteria for an evaluation of 20 percent prior to July 14, 2015 for peripheral neuropathy of the right lower extremity associated with diabetes mellitus on a schedular basis have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.7, 4.124a, Diagnostic Code 8520 (2015). 7. The criteria for an evaluation in excess of 20 percent from July 14, 2015 for peripheral neuropathy of the right lower extremity associated with diabetes mellitus on a schedular basis have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.7, 4.124a, Diagnostic Code 8520 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it 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 C.F.R. § 3.159 (2015); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Such notice must advise that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Id.; 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.159, 3.326 (2014); see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004). Prior to initial adjudication of the Veteran's claim, letters dated in April 2011 and September 2011 fully satisfied the duty to notify provisions of VCAA. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Next, VA has a duty to assist a Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2015). The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains service treatment records and VA treatment records. The Veteran had VA examinations in July 2015. Findings from the examination reports are adequate for the purposes of deciding the claims on appeal. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Therefore, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claim, and no further assistance to develop evidence is required. II. Increased Ratings Disability ratings are based upon VA's Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4 (2015). The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity in civil occupations. 38 U.S.C.A. § 1155 (West 2014). The disability must be viewed in relation to its history. 38 C.F.R. § 4.1 (2015). A higher evaluation shall be assigned where the disability picture more nearly approximates the criteria for the next higher evaluation. 38 C.F.R. § 4.7 (2015). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, 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). The evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14 (2015). A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). A. Diabetes with Erectile Dysfunction The Veteran is seeking an evaluation in excess of 20 percent for diabetes mellitus with erectile dysfunction. Diagnostic Code 7913 provides ratings for diabetes mellitus. Diabetes mellitus requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet, is rated 20 percent disabling. Diabetes mellitus requiring insulin, restricted diet, and regulation of activities is rated 40 percent disabling. Diabetes mellitus requiring 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 rated, is rated 60 percent disabling. 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 either progressive loss of weight and strength or complications that would be compensable if separately rated, is rated 100 percent disabling. Note (1) to Diagnostic Code 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 rating (under Diagnostic Code 7913). Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. Note (2) provides that, when diabetes mellitus has been conclusively diagnosed, the adjudicator is not to request a glucose tolerance test solely for rating purposes. 38 C.F.R. § 4.119. Diagnostic Code 7522 provides that deformity of the penis with loss of erectile power is rated 20 percent disabling, and the adjudicator is to review for entitlement to special monthly compensation under 38 C.F.R. § 3.350. 38 C.F.R. § 4.115b. In every instance where the schedule does not provide a zero percent rating for a diagnostic code, a zero percent rating shall be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. May 2010 VA treatment records indicate that the Veteran's diabetes was being treated with pioglitazone and insulin. The Veteran had a VA examination in May 2011 at which it was noted that his treatment consisted of pioglitazone and Novolin insulin. His home blood sugar readings were generally between 85 and 165 with one reading of 275 in the past six months. There were not episodes of hypoglycemia reactions or ketoacidosis. The Veteran had not been instructed to follow a restricted diet and was not restricted in his ability to perform strenuous activities. He had erectile dysfunction that was most likely due to diabetes mellitus. On examination there were not any diabetic skin abnormalities. A form completed by a VA treating physician in October 2011 indicates that the Veteran's diabetes required insulin, restricted diet, and regulation of activities. The remarks section of the form states that the Veteran needed to avoid strenuous occupational and recreational activities to keep his blood sugar on an even keel. The handwriting in the remarks section of the form is different than the handwriting of the physician's printed name. Furthermore, the handwriting of the remarks section is similar to the handwriting from the September 2012 form that the Veteran completed in regards to a claim for TDIU. Therefore, no probative value can be given to the October 2011 physician's statement because it appears to have been at least partially forged by the Veteran. At a January 2013 examination related to a Social Security examination, it was noted that the Veteran was taking oral medication and using insulin for diabetes. At January 2015 VA treatment the Veteran was noted to have severely uncontrolled type II diabetes with neurological manifestations. The Veteran had a VA examination in July 2015 at which it was noted that the Veteran's diabetes was managed by a restricted diet and insulin. The examiner wrote that the Veteran did not require regulation of activities as part of the management of diabetes. The Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemia less than two times a month. There had been no hospitalizations for episodes of ketoacidosis or hypoglycemia in the past 12 months. The examiner opined that it was less likely than not that it was medically necessary for the Veteran to avoid strenuous activity. It was noted that there had not been any incidents requiring medical treatment for hypoglycemia in the past 12 months. The Veteran said that he was frustrated over his inability to control his diabetes due to the inability to exercise due to back pain. The examiner wrote that the limitations in regards to activity were not due to the need to avoid hypoglycemia but by the lumbar degenerative disc disease. The Veteran had been advised by his neurologist to avoid putting strain on his back. The examiner noted the handwriting discrepancy on the October 2011 physician's statement and that the physician previously encouraged activity. The examiner felt that the Veteran's erectile dysfunction was at least as likely as not due to diabetes mellitus. The Veteran did not have a voiding dysfunction or renal dysfunction due to diabetes mellitus. The Board finds that the Veteran is not entitled to an evaluation in excess of 20 percent for diabetes with erectile dysfunction. While the Veteran requires insulin, oral hypoglycemic agents, and a restricted diet, he did not have restriction of activities due to diabetes, as is required for a 40 percent evaluation. See 38 C.F.R. § 4.120, Diagnostic Code 7913. As discussed above, the October 2011 statement from the treating physician is given no probative value because it appears to be at least in part a forgery. There were no findings that activities were limited due to diabetes from the treatment records. The May 2011 VA examiner felt that the Veteran was not restricted in his ability to perform strenuous activities. The July 2015 VA examiner opined that the limitations in regards to activity were due to lumbar degenerative disc disease and not the need to avoid hypoglycemia. In addition, the Veteran's erectile dysfunction does not qualify for a separate compensable evaluation because the record does not show and the Veteran does not state that there has been a deformity of the penis, removal of the glans or more than half the penis, or atrophy or removal of the testicles. See 38 C.F.R. § 4.115b, Diagnostic Codes 7520, 7521, 7522, 7523, 7524. B. Peripheral Neuropathy The Veteran is seeking evaluations in excess of 20 percent for peripheral neuropathy of the upper extremities associated with diabetes mellitus. He is also seeking evaluations in excess of 10 percent prior to July 14, 2015 and in excess of 20 percent from that date for peripheral neuropathy of the lower extremities associated with diabetes mellitus. The record, including the July 2015 VA examination report, indicates that the Veteran is left hand dominant. Diagnostic Code 8514 provides ratings for paralysis of the musculospiral nerve (also known as the radial nerve). Mild incomplete paralysis is rated 20 percent disabling on the major side and 20 percent on the minor side; moderate incomplete paralysis is rated 30 percent disabling on the major side and 20 percent on the minor side; and severe incomplete paralysis is rated 50 percent disabling on the major side and 40 percent on the minor side. Complete paralysis of the radial nerve, with drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity, is rated 70 percent disabling on the major side and 60 percent on the minor side. 38 C.F.R. § 4.124a. Diagnostic Code 8515 provides that moderate incomplete paralysis is rated 30 percent disabling on the major side and 20 percent on the minor side; and severe incomplete paralysis is rated 50 percent disabling on the major side and 40 percent on the minor side. Complete paralysis of the median nerve, with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to palm; flexion of wrist weakened; pain with trophic disturbances, is rated 70 percent disabling on the major side and 60 percent on the minor side. 38 C.F.R. § 4.124a. Diagnostic Code 8516 provides ratings for paralysis of the ulnar nerve. Moderate incomplete paralysis is rated 30 percent disabling on the major side and 20 percent on the minor side; and severe incomplete paralysis is rated 40 percent disabling on the major side and 30 percent on the minor side. Complete paralysis of the ulnar nerve, the "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers, cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened, is rated 60 percent disabling on the major side and 50 percent on the minor side. 38 C.F.R. § 4.124a. Diagnostic Code 8520 provides ratings for paralysis of the sciatic nerve. Mild incomplete paralysis is rated 10 percent disabling; moderate incomplete paralysis is rated 20 percent disabling; moderately severe incomplete paralysis is rated 40 percent disabling; and severe incomplete paralysis, with marked muscular atrophy, is rated 60 percent disabling. Complete paralysis of the sciatic nerve, the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost, is rated 80 percent disabling. 38 C.F.R. § 4.124a. The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. At May 2010 VA treatment the Veteran reported neuropathies that were getting progressively worse. His hands and feet were constantly tingly and painful. The Veteran wrote in April 2011 that the tingling, numbness, burning, and stabbing pain in his feet and hands and other parts of his body had increased tremendously during the past 15 years. At a May 2011 VA examination, the Veteran complained of decreased sensation in his hands and feet that he had progressed over the past 15 to 16 years. There had been almost constant pain in the bottom of the feet for the past ten years. He had been taking medication for neuropathy since 2000 without side effects. On examination, the lower and upper extremities had normal reflexes. The upper extremities had decreased vibration and pain/pinprick from the wrists to the fingers, and the lower extremities had decreased vibration and pain/pinprick from the ankles to the toes. Light touch was decreased progressively from the ankles to the toes. Position sense was normal in the upper extremities and slightly decreased in the lower extremities. There were dysesthesias on the lower extremities but not in the upper extremities. The examiner noted that the Veteran had problems going up and down stairs because he could not feel the placement of his feet. At August 2011 private treatment the Veteran complained of a month of constant numbness in the last digit of the left hand with weakness in the hand. He also had numbness in the last two toes of the right foot and back pain with some shooting into the bilateral anterior calves. The Veteran was diagnosed with diabetic neuropathy with numbness of the fourth and fifth right toes consistent with other superimposed localized disease. Superimposed ulnar neuropathy and lumbosacral radiculopathy were more likely. An August 2011 nerve conduction study showed sensorimotor neuropathy with mixed axonal and demyelinating features consistent with but not diagnostic of diabetic neuropathy. At an October 2011 VA examination it was noted that the Veteran's symptoms had been progressive since the mid-1990s. There was increased numbness in the hands and feet. He reported intermittent falling due to difficulty being aware of where he placed his feet. The Veteran had difficulty dressing at times due to bilateral upper extremity neuropathy. His index finger intermittently locked on the steering wheel while driving. The diabetic peripheral neuropathy caused mild constant pain in the extremities and moderate intermittent pain in the upper extremities. There were not paresthesias and/or dysesthesias in any of the extremities, and there was mild numbness in all of the extremities. Muscle strength was full in the extremities, deep tendon reflexes were normal, and light touch was decreased to the hands/fingers and normal otherwise in the extremities. Vibration sensation was decreased in all four extremities and position sense of the index fingers and great toes was normal. The examiner diagnosed the Veteran with bilateral mild incomplete paralysis of the upper extremities in the radial and median nerves and incomplete paralysis of the left ulnar nerve. In regards to the lower extremities, the Veteran was diagnosed with bilateral, mild incomplete paralysis on the left, mild incomplete paralysis of the right sciatic nerve, and bilateral incomplete paralysis of the femoral nerve. The examiner noted that the Veteran was able to hold his drink bottle with one hand and grip his cane with his other hand without difficulty and could remove his shoes and socks and put his shoes back on. There was an antalgic gait due to the low back and right knee conditions. There was no evidence of proprioceptive difficulties with walking, tremors in either hand, or trigger finger during the examination. At a January 2013 examination for the Veteran's Social Security claim, he was diagnosed with probable diabetic neuropathy with decreased pinprick, light touch, and vibratory sense in the lower third of the low legs and feet. The numbness had caused him to trip and fall over the past few years, and he used a cane due to poor balance. At a July 14, 2015 VA examination the Veteran reported that he experienced numbness, especially in his feet, and decreased sensation extending to the ankles. This resulted in an unsteady gait because he could not feel where he was stepping. The Veteran used a cane and walker for ambulation. The hands also had numbness, which was greater at the fingertips and not as severe as with the feet. The Veteran said that he was advised by his treating neurologist not to drive due to chronic low back pain with neuropathy and diabetic peripheral neuropathy. He had mild pain in the upper and lower extremities, mild numbness in the upper extremities, and moderate numbness in the lower extremities. On examination, muscle strength and reflexes in the extremities were normal. Light touch was normal to the shoulders and knees, decreased to the hands/fingers and ankles/lower legs, and absent in the foot/toes. Vibration sensation was normal in the upper extremities and decreased in the lower extremities. The examiner felt that the upper extremities had mild incomplete upper extremity paralysis in the median and ulnar nerves and that the lower extremities had mild incomplete paralysis in the sciatic nerves. The Board finds that the Veteran is entitled to an increased evaluation of 20 percent prior to July 14, 2015 for each lower extremity because the record shows that the incomplete paralysis was moderate. See 38 C.F.R. § 4.124a, Diagnostic Code 8520. The record shows that prior to July 14, 2015 the Veteran repeatedly reported difficulty walking due to not being able to feel his feet. At the May 2011 VA examination the examiner felt that the Veteran had lower extremity dysesthesias. The Veteran does not qualify for ratings greater than 20 percent for the entire claims period for bilateral lower extremity neuropathy because the record does not show moderately severe paralysis of the sciatic nerve. See 38 C.F.R. § 4.124a, Diagnostic Code 8520. The VA examinations show that the Veteran was found to have mild incomplete paralysis of the sciatic nerves. At the July 2015 VA examination the numbness in the lower extremities was noted to be moderate. Motor strength in the lower extremities has been normal. Therefore, the Board finds that the bilateral lower extremity neuropathy has not been consistent with moderately severe sciatic nerve paralysis, as contemplated for a 40 percent evaluation. See id. In regards to the upper extremities, the Veteran does not qualify for evaluations in excess of 20 percent for upper extremity neuropathy. The record does not show moderate incomplete paralysis of the musculospiral, median, or ulnar nerves, as required for a 30 percent evaluation for the left, or major, upper extremity. See 38 C.F.R. § 4.124a, Diagnostic Codes 8514, 8515, 8516. In addition, the record does not show severe incomplete paralysis of the musculospiral, median, or ulnar nerves, as required for a higher evaluation for the right, or minor, upper extremity See id. The VA examiners felt that the Veteran had no greater than mild incomplete paralysis in the upper extremities. Therefore, the Veteran does not qualify for evaluations in excess of 20 percent for upper extremity neuropathy. C. Other Considerations Finally, in light of the holding in Hart, supra, the Board has considered whether the Veteran is entitled to "staged" ratings for his service-connected diabetes mellitus with erectile dysfunction and bilateral peripheral neuropathy of the upper and lower extremities, as the Court indicated can be done in this type of case. Based upon the record, we find that at no time during the claims period have the disabilities on appeal been more disabling than as currently rated under the present decision of the Board. ORDER An evaluation in excess of 20 percent for diabetes mellitus with erectile dysfunction on a schedular basis is denied. An evaluation in excess of 20 percent for peripheral neuropathy of the left upper extremity associated with diabetes mellitus on a schedular basis is denied. An evaluation in excess of 20 percent for peripheral neuropathy of the right upper extremity associated with diabetes mellitus on a schedular basis is denied. Subject to the law and regulations governing payment of monetary benefits, an evaluation of 20 percent for peripheral neuropathy of the left lower extremity associated with diabetes mellitus on a schedular basis prior to July 14, 2015 is granted. An evaluation in excess of 20 percent for peripheral neuropathy of the left lower extremity associated with diabetes mellitus on a schedular basis from July 14, 2015 is denied. Subject to the law and regulations governing payment of monetary benefits, an evaluation of 20 percent for peripheral neuropathy of the right lower extremity associated with diabetes mellitus on a schedular basis prior to July 14, 2015 is granted. An evaluation in excess of 20 percent for peripheral neuropathy of the right lower extremity associated with diabetes mellitus on a schedular basis from July 14, 2015 is denied. REMAND Once VA undertakes the effort to provide an examination, it must obtain a fully adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). At June 2015 VA eye treatment the Veteran was diagnosed with mild bilateral non-proliferative retinopathy. The July 2015 VA examiner noted the diagnosis but did not perform an eye examination or indicate whether the mild bilateral non-proliferative retinopathy caused any functional impairment. Therefore, the Veteran must be scheduled for a VA examination for diabetic retinopathy before it can be determined if the Veteran is entitled to a separate compensable evaluation. When evidence of unemployability is submitted during the appeal from an assigned disability rating, a claim for a TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Here, the record suggests that the Veteran's service-connected disabilities affect his ability to work. The rating assigned for diabetic retinopathy may have an impact on whether the Veteran qualifies for a TDIU. As such, the claims are inextricably intertwined and must be considered together, and a decision by the Board on the Veteran's TDIU claim would, at this point, be premature. See Henderson v. West, 12 Vet. App. 11, 20 (1998). In addition, any development affecting the TDIU issue may have an impact on the complete picture of the Veteran's service-connected disabilities and their effect on his employability as it pertains to extraschedular consideration. See Brambley v. Principi, 17 Vet. App. 20, 24 (2003). Thus, the issue of entitlement to extraschedular ratings for diabetes mellitus with erectile dysfunction and bilateral upper and lower extremity peripheral neuropathy will also be remanded. VA treatment records to July 2015 have been associated with the claims file. Therefore, the RO should obtain all relevant VA treatment records dated from July 2015 to the present before the remaining issues are decided on the merits. Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's VA treatment records from July 2015 to the present. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge of the nature, extent and severity of his diabetes mellitus, upper and lower extremity peripheral neuropathy, and diabetic retinopathy, and the impact of these conditions on his ability to work. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 3. Request that the appellant provide sufficient information, and, if necessary, authorization, to obtain any medical and hospitalization records, medical statements, and any other medical evidence not already of record relating to his claims. Document all unsuccessful attempts to obtain such records. There must be at least two attempts made to obtain any private treatment records for which the appellant submits the proper authorization. 4. Thereafter, schedule the Veteran for an appropriate VA examination to identify the nature, extent and severity of all manifestations of his service-connected diabetic retinopathy. The claims folder should be made available to and reviewed by the examiner and all necessary tests should be performed. 5. Then readjudicate the appeal. If the benefits sought on appeal are not granted in full, the RO should issue the Veteran a supplemental statement of the case and provide an opportunity to respond. 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 2014). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs