Citation Nr: 1602761 Decision Date: 01/29/16 Archive Date: 02/05/16 DOCKET NO. 09-42 459 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a rating in excess of 20 percent for diabetes mellitus, type II. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD James R. Springer, Associate Counsel INTRODUCTION The Veteran had active duty service from September 1965 to September 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In November 2015, the Veteran and his spouse testified at a Board hearing before the undersigned Veterans Law Judge sitting at the RO. A transcript of the hearing has been associated with the record on appeal. During the hearing, the undersigned held the record open for 60 days to allow for the submission of additional evidence; however, no additional evidence was added to the record within that time period. This appeal was processed using the Virtual VA and Veteran Benefits Management System (VBMS) and Virtual VA paperless claims processing systems. The issue of entitlement to a rating in excess of 20 percent for diabetes mellitus, type II, is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT Throughout the entire appeal period, the Veteran's service-connected PTSD has resulted in no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as anger and irritability, without the threat of physical violence; occasionally depressed mood; chronic sleep impairment, including nightmares; infrequent suicidal ideation; recurrent and intrusive distressing recollections and dreams related to his military experiences; avoidance behaviors, including avoiding the news and crowds; hypervigilance and suspiciousness; anxiety; pressured speech; and mild impairment in memory, without more severe manifestations that more nearly approximate occupational and social impairment with reduce reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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. With respect to the increased rating claim on appeal, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. Sept. 4, 2009). In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In this case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a letter dated in July 2006, sent prior to the rating decision issued in September 2007, advised the Veteran of the evidence and information necessary to substantiate his claim for an increased rating for his PTSD, as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, this letter advised him of the information and evidence necessary to establish an effective date in accordance with Dingess/Hartman, supra. Next, VA has a duty to assist the Veteran in the development of a claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In this regard, the record contains the Veteran's service treatment records, post-service VA treatment records, Social Security Administration (SSA) records, and VA examination reports from August 2007 and May 2015. Moreover, the Veteran's statements, including his testimony before the undersigned during his November 2015 Board hearing, in support of the claim are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. As noted above, the Veteran was afforded two VA examinations in conjunction with his claim for an increased rating for PTSD in August 2007 and May 2015. Neither the Veteran nor his representative has alleged that these VA examinations are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected PTSD as they include interviews with the Veteran, a review of the record, and full mental status examinations, addressing the relevant rating criteria. Moreover, neither the Veteran nor his representative have alleged that his PTSD has worsened in severity since the May 2015 VA examination. Rather, with respect to the PTSD, they argue that the evidence reveals that the Veteran's PTSD has been more severe than the currently assigned 30 percent rating for the duration of the appeal period. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (the passage of time alone, without an allegation of worsening, does not warrant a new examination). Therefore, the Board finds that the examinations of record are adequate to adjudicate the Veteran's claim for an increased rating and no further examination is necessary. The Veteran also offered testimony before the undersigned Veterans Law Judge at a Board hearing in November 2015. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. At the November 2015 Board hearing, the undersigned Veterans Law Judge noted the issue on appeal. Additionally, testimony regarding the nature and severity of the Veteran's service-connected PTSD was solicited, to include the type and frequency of the symptoms he experiences as a result of such disability, as well as the impact such have on his social and occupational functioning, to include his employment. Therefore, not only was the issue "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Furthermore, the undersigned held the record open for any additional 60 days to allow the Veteran an opportunity to submit additional evidence in support of his claim, but nothing pertinent to the claim decided herein was submitted. There is no indication that there was outstanding evidence needed for a fair adjudication of the issue decided herein. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claim decided herein based on the current record. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. 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 in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). When 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the Veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, are expected in all instances. 38 C.F.R. § 4.21. Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). The Veteran's service-connected PTSD is evaluated as 30 percent disabling under the criteria of Diagnostic Code 9411. See 38 C.F.R. § 4.130. PTSD is evaluated under VA's General Rating Formula for Mental Disorders. Under the formula, a 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet App 436, 442-3 (2002). On the other hand, if the evidence shows that a Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Id. at 443. The United States Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Ultimately in Mauerhan, the Court upheld the Board's decision noting that the Board had considered all of the Veteran's psychiatric symptoms, whether listed in the rating criteria or not, and had assigned a rating based on the level of occupational and social impairment. Mauerhan, supra at 444. In Vasquez-Claudio v. Shinseki, F.3d 112, 117 (Fed. Cir. 2013), the Court also held that a Veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. The Court further held that, in assessing whether a particular disability rating is warranted requires a two-part analysis, including (1) an initial assessment of the symptoms displayed by the Veteran and, if they are of the kind enumerated in the regulation and (2) an assessment of whether those symptoms result in the occupational and social impairment contemplated by that particular rating. See id. at 118. Indeed, considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). The Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). A GAF score of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 indicates moderate symptoms, or moderate difficulty in social, occupational, or school functioning. A GAF score of 61 to 70 reflects some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and with some meaningful interpersonal relationships. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). An assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126, VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). The Veteran's claim for an increased rating was received on May 11, 2006. The pertinent evidence of record consists of VA examinations conducted in August 2007 and May 2015, VA treatment records, and lay statements from the Veteran and his spouse, including testimony to the undersigned Veterans Law Judge during his November 2015 hearing. In May 2006, the Veteran reported that he was in good spirits and that things were less stressful at home since his son began home schooling. In August 2006, the Veteran reported that he was doing better with his anger and irritability. He was reportedly in good spirits, his mood and affect were within normal limits, and his insight and judgment were both good. He stated that he limited how much news he watched so that his PTSD was not exacerbated. He was found to be no risk of harm to himself or others. Later that month, the Veteran again reported less stress at home. He appeared to be calm and not excitable as much as before. His speech was somewhat pressured. He stated that he had intrusive memories and shortened sleep. He rated his irritability as a five out of ten. He stated that he and his wife continued to argue over their son, and he felt as though he was not being appreciated for the things he did around the house. Upon examination, the Veteran was alert and oriented; his affect was wide-ranging and his mood was cheerful; and he was mildly restless. He denied any delusions, hallucinations, or suicidal or homicidal ideation. His speech was increased in production and his cognition was intact. Both his judgment and insight were good. In November 2006, the Veteran was reported as "doing better." The Veteran's therapist noted that his wife was recently involved in an armed robbery at her place of employment and was shot in the head but fortunately survived. Upon examination, his mood was depressed, and his affect was sad. He displayed coherent thought processes; he denied hallucinations, delusions, or homicidal or suicidal ideation; and his insight and judgment were good. In December 2006, the Veteran again reported avoiding the news. He complained of intrusive memories and shortened sleep. He rated his irritability as a five out of ten. He stated that, following his wife's injury, he had been managing at home, but that he sometimes felt overwhelmed. He rated his mood as ranging from a two to eight out of ten. He reported good support from friends and extended family. He was alert and oriented. His affected was wide ranging, and his mood was cheerful. He was mildly restless. His psychiatrist opined that, due to the Veteran's ongoing psychiatric conditions, he did not appear to be employable. In April 2007, the Veteran reported that he was having problems with his thirteen year-old son, and that he and his wife argued. He felt as though he was less irritable, and he dismissed the impact that his behavior had on his family. Again, he reported good support from his friends and extended family. He appeared to be depressed, angry, and sad. In August 2007, the Veteran underwent a VA examination. During the examination, the Veteran reported worsening mood and symptoms since his wife was shot. He stated that he felt down and overwhelmed at times, as well as guilty for the way he treated his wife prior to her accident. The Veteran stated that, since his wife was released from the hospital, he gives her medication, helps her bathe and get dressed, and transfers her to her wheelchair. He stated that he had a very bad relationship with his sons, and that they did not help with his wife or the household responsibilities. He reported doing the laundry, shopping, cooking, cleaning, and other chores independently. In addition to doing his household duties, the Veteran reported helping a friend deliver newspapers, talking to his mother on the phone, and visiting friends or family. He reported that he was the president of his motorcycle club and that he was active with that group. He also stated that he was a member of a number of Veteran Service Organizations and social clubs, but he did not attend frequently. During the examination, the Veteran was oriented to time, place, and person; he maintained eye contact; and he showed a full range of affect. His speech was logical and coherent, and there was no evidence of a thought disorder. He described his mood as "kind of down," but denied any suicidal and homicidal ideation, other than thoughts about the robbery suspects that shot his wife. With regard to his anger and irritability, the Veteran stated that it was pretty good, and he denied any physical altercations over the past couple of years. With regard to the PTSD diagnostic criteria, the Veteran reported intrusive thoughts and memories of his in-service experiences. He described nightmares, and said that he avoided discussing any graphic details of his in-service experiences. He stated he was uncomfortable in crowds, and that he avoids them as much as possible. He expressed that he did not like the dark, and that he was worried about his future. With regard to any arousal symptoms, the Veteran stated he only got four to five house of sleep a night, and that he usually slept with a pistol. The examiner noted that the Veteran's treatment records reflected persistent irritability, but improved angry outbursts without any physical altercation. The examiner opined that the Veteran had significant depressive symptoms; however, the examiner found that the Veteran's depressive symptomatology did not warrant a separate diagnosis. The Veteran was diagnosed with PTSD and a personality disorder, not otherwise specified (NOS), and he was assigned a GAF score of 55 due to moderate PTSD and depression. The examiner also stated that it would be infeasible for the Veteran to engage in sufficient retaining for gainful employment in a new occupation of a sedentary nature. Thus, the examiner opined that the Veteran was unemployable. However, with regard to the effects on his social functioning, the examiner reasoned that, because of the Veteran's friendships, his positive extended family relationships, and his activity in social organizations, his PTSD only had a minimal impact on his social functioning. In August 2007, the Veteran stated that he was doing well, and that he had a busy schedule with the housework, bills, and children. The Veteran was not as angry/aggressive and depressed as he was during his April 2007 visit likely due to his wife's progression and his adaptation to her situation. Upon examination, the Veteran's mood and affect were found to be depressed, angry, and sad. He denied suicidal and homicidal ideation, delusions, and hallucinations. Both his insight and judgment were found to be good, and he displayed a coherent thought process. The Veteran was assigned a GAF score of 45. In June 2009, the Veteran underwent a VA examination in connection with his claim for an increased rating for his service-connected headaches. During the examination, the Veteran reported getting panic attacks. With regard to suicide, the Veteran stated that he thought about it. He stated that he cried a few weeks ago, and he opined that he would not be able to handle a visit to the Vietnam War Memorial. The Veteran's judgment was assessed as normal, and there were no complaints of problems associated with memory, attention, concentration, or executive functions. The Veteran's social interaction was found to be occasionally inappropriate, and he was found to be always oriented. An August 2009 VA treatment record documents the Veteran's GAF scores from November 2004 to August 2009. From May 2006 to August 2009, the assigned GAF scores ranged from 44 to 55, with an average score of 49. An August 2009 VA treatment note found the Veteran's mood to be improved, and he was doing well. His mood and affect were both within normal limits, he denied suicidal and homicidal ideation, his thought processes were coherent, he denied hallucinations or delusions, and both his insight and judgment were noted as being good. Subsequent mental status examinations in October and November 2009 were consistent with the August 2009 results. In October 2009, the Veteran reported that his mood had improved, and that he was taking care of his wife and his sons. In November 2009, the Veteran described his mood as up and down but usually "mellow." He stated that he did get upset with his seventeen year-old son, but he stated that he was able to control his anger. He also stated he had difficulty sleeping, that he had nightmares a few times a week, and that he had to avoid triggers of his in-service experiences, including the news. The Veteran did not verbalize any hopeless, helpless, or worthless feelings. In February 2010, the Veteran reported that he was feeling better. He was joking and speaking loudly at times. He discussed some family situations, and he was advised to exhibit more patience and understanding. The physician noted that the Veteran continued to be easily irritated, and that he continued to have intrusive thoughts. Upon mental status examination, the Veteran was alert, oriented, and well groomed. He was engaging during the visit and was spontaneous with information. His affect was wide-ranging, and his mood euthymic. There was no evidence of delusions, hallucinations, or suicidal or homicidal ideations. His speech was organized, although somewhat pressured. His cognition was intact, and his judgment and insight were good. Subsequently mental status examinations in May, September, and October of 2010 yielded similar findings. In May 2010, the Veteran reported getting upset and depressed at time. He stated that a close friend had recently died which made him sad. Also, he stated he was upset with in life in general when he saw a person on drugs. He stated he still got irritable, but said that his medication kept him in control. He slept well, but reported nightmares twice a week. In September 2010, he discussed watching a television program regarding suicides among Veterans, and he stated that someone in his Marine Corps league club had committed suicide. He discussed feeling of sadness and remorse for the families and friends. In October 2010, the Veteran described his mood as up and down, and that he would get upset with his son, although he denied any explosive episodes. He stated that he avoided confrontations, and he tried to stay laid back. He reported only sleeping four to five hours, and that he had a good energy level. He still reported nightmares. In another VA treatment record from October 2010, the Veteran reported continued nightmares, avoidance behaviors, being on guard, and feelings of numbness or detachment from others. He stated that, although he had thoughts of suicide in the past, he said he never would do that because of what it would do to his wife. Later that month, the Veteran reported suicidal thoughts and feeling depressed about life, getting old, and his medical condition. He stated he had no plan. In February 2011, the Veteran stated that he was doing alright, and that he was still taking care of his wife and sons. He stated that he did not have any suicidal thoughts. He reported that friends from his military service contacted him about attending reunions, and he said he intended to attend one in New York. In another February 2011 VA treatment note, the Veteran reported that he was doing ok. In addition to caring for his wife, he said he got together with friends in his motorcycle club. He said that, although he argues, his anger was under better control. He complained of nightmares a few times per week. Mental status examination revealed that he was alert, oriented, and well groomed. He was pleasant, engaged, and spontaneous. His affect was wide-ranging, and his mood was euthymic. He denied hallucinations, delusions, and suicidal and homicidal ideation. His speech was organized, his cognition was intact, and his judgment and insight were good. Subsequent mental status examinations in April, June, August, and December 2011 revealed similar results. In March 2011, the Veteran was noted as doing better, and he said that the relationship between him and his wife was ok, and that the relationship between him and his sons was better. He reported that he was looking forward to better weather so that he could ride with his motorcycle club and attend its activities. In April 2011, the Veteran reported that he was still doing ok, but that he still would get upset and irritable, including with family members. He stated he was sleeping well, but that he still had occasional nightmares. He was anxious for better weather to arrive so that he could fix cars and trucks, and he could plant his garden. In June 2011, the Veteran stated that he and his wife were going out for dinner to celebrate their thirtieth wedding anniversary. He reported that he was still taking care of his wife, and he was doing the chores around the house. He also stated that he continued to be involved in his motorcycle club and its activities. In August 2011, the Veteran described his mood as good. He stated that he still got irritable, but that he was able to calm himself. He reported getting only three to four hours of sleep. In December 2011, the Veteran again stated that he was not getting as upset as he would in the past, but that he was still occasionally angry or irritable. He was sleeping better due to new medications, but he still experienced nightmares one to two times per week. He stated that he thought about the innocent people killed in Vietnam and that it bothered him. In January 2012, the Veteran reported that he and he wife were planning to move out of their house. Upon examination, he was casually dressed, he was pleasant and talkative, and his speech was within normal limits. He exhibited a full range of affect, and his mood was stable. He was oriented, his though processes and content were coherent, logical, and goal-directed. He denied homicidal or suicidal ideations. His judgment and insight were both good. VA mental status examinations in March, May, June, August, October, and December 2012 reflect similar findings. In March 2012, the Veteran reported that he was awaiting admission into a VA PTSD treatment program. He stated that he tried to not let things bother him. He was noted to be in good spirits, joking at times, and reflecting on the meaning of life at others. He stated that he was volunteering his time at his friends butcher shop. He was assigned a GAF score of 60. Later that same month, the Veteran reported the following symptoms of PTSD: recurrent and intrusive recollections of his in-service stressors; recurrent nightmares or distressing dreams of his in-service stressors; intense psychological distress when exposed to reminders about his military service and stressors; efforts to avoid trauma associated thought, feelings, or conversations; efforts to avoid activities, places, or people that arouse recollections; difficulty falling or staying asleep; and irritability or outbursts of anger. In May 2012, the Veteran reported that he was doing well, but that he was concerned over his wife's condition. In June 2012, the Veteran reported that he was doing well, and that he recently started a PTSD treatment group program; he was optimistic about the group. He said his mood was up and down, and that he had occasional nightmares. He still expressed problems with irritability, but that he was able to control his anger. Later that same month, the Veteran was assigned a GAF score of 60. In August 2012, the Veteran expressed frustration over not having control in his home, but he stated that he had complete control in his motorcycle group. In October 2012, the Veteran described his mood as stable. He stated that his wife thinks he is crabby, and that he and his wife still argued; however, the Veteran attributed that to him needing to raise his voice due to her hearing impairment. He stated that he was getting along well with his son, and he denied any angry outbursts. He reported sleeping about five hours, and that he had a good energy level. He reported dreaming about fellow servicemembers from Vietnam, but said that they were not nightmares. In December 2012, the Veteran was described as being in good spirits. He said his depression had decreased, and that he and his wife were getting along better. In February 2013, the Veteran stated that the last few months had been stressful and that his wife had been hospitalized for heart surgery. He stated that, although she was doing well, he was still concerned and worried. He stated that he still would get upset and angry, but stated that it took a lot to set him off. He stated that he still had intrusive memories and nightmares of his military service. Mental status examination revealed that he was casually groomed and dressed. He made good eye contact, his demeanor was open, and cooperative, and his psychomotor activity was normal. His mood was euthymic, his affect was appropriate, and his speech was normal. No delusions or hallucinations were evident, he denied any feelings of hopelessness, and he denied homicidal and suicidal ideation. His insight and judgment were both found to be good. VA mental status examinations in May, July, October, and December 2013 reflect similar findings. In May 2013, the Veteran stated that he still suffered from intrusive memories, but felt as though his irritability was in better control than in past. In July 2013, the Veteran reported that he was doing well, and stated that he was able to let things go and was able to avoid arguments with his son. He stated that he still had occasional nightmares and intrusive thoughts, but he denied that such were distressing. In October 2013, the Veteran reported that things were still going okay with him and his family. In December 2013, the Veteran's symptoms were found to be managed with medication, and he reported no PTSD symptoms of significance. In January 2014, the Veteran reported that his mood was stable. He said he got depressed sometimes, and that he would not get irritable unless someone bothered him. He stated that he still argued with his wife. He stated he wanted to travel with her, although she did not want to. He said that he planned on taking a trip on his motorcycle next summer and stopping to see a friend. The psychiatrist noted that he was joking and was in good spirits. He did not discuss any PTSD symptoms. Mental status examination revealed that he was alert and oriented, he had normal grooming, and was casually dressed. His mood was euthymic, his affect was normal, and his speech was normal. His conversation was goal directed, spontaneous, and relevant, and his did not express feelings of hopeless or worthlessness. There were no delusions, hallucinations, or homicidal or suicidal ideations. His cognitive function was intact, and his judgment and insight were good. VA mental status examinations in March, April, June, September, and December 2014 reflect similar findings. In March 2014, the Veteran reported little to no PTSD symptoms. He stated that his irritability declined, and that he was getting along better with his wife. He also stated that he was active, despite being hospitalized for a fever and cold. In April 2014, the Veteran had maintained his good spirits and he appeared calmer. He still reported intrusive memories, but he stated that he planned on attending a reunion of Veterans this summer. In June 2014, the Veteran reported little to no PTSD symptoms. He stated that his irritability had declined and that he and his wife were going on a three-state vacation. The Veteran was reportedly still caring for his wife and was helping his sons find employment. In September and December 2014, the Veteran again reported little to no PTSD symptoms. He stated that his irritability had declined and that he was getting along better with his wife. In March 2015, the Veteran reported distress due to nightmares and intrusive memories. He also reported distress due to the passing of some buddies due to illness or aging. He stated that he was looking forward to warmer weather and riding his motorcycle. Mental status examination revealed casual dress, pleasant demeanor and talkative, and slightly pressured speech. His mood was euthymic, he was oriented, and his thought process was tangential and required refocusing. His insight and judgment were found to be fair. In April 2015, the Veteran reported a good mood, and he denied any problems. He said that he had been less irritable, and that he was not depressed. He stated that he was getting along better with his sons, and that he had a generally good relationship with his wife. Mental status examination revealed that the Veteran was alert and oriented, he was groomed and casually dressed, and his mood was euthymic and his affect normal. His speech was normal, and his conversation was goal directed, spontaneous, and relevant. He denied feelings of hopelessness or worthlessness, as well as suicidal or homicidal ideation. There was also no evidence of hallucinations of delusions. Both his judgment and insight were good. In May 2015, the Veteran underwent another VA examination. After a full examination, the examiner opined that the Veteran's PTSD resulted in no more than occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. With regard to the PTSD diagnostic criteria, the Veteran was reported as experiencing recurrent, involuntary, and intrusive memories of his stressors, recurrent and distressing dreams of his stressors, dissociative reactions, including flashbacks, and intense or prolonged psychological distress at exposure to internal or external cues. The Veteran was noted as avoiding distressing memories, thoughts, feelings, and external reminders of his stressors and military service. The Veteran was found to have a persistent negative state, as well as a persistent, distorted cognition about the cause or consequence of the stressor that leads the Veteran to blame himself. Symptoms included hypervigilance, problems with concentration, and chronic sleep disturbances. The examiner also found that that the Veteran's PTSD caused a significant distress or impairment in social, occupational, or other important areas of functioning. Other symptoms included depressed mood, anxiety, and suspiciousness. The examiner noted the Veteran to be mildly distressed during the exam. The Veteran stated that he felt guilt, and that he blamed himself for the killing of civilians during the War. He reported hypervigilance, including needed to check for the exit when he entered a room. Finally, the Veteran reported concentration and sleep difficulties, including waking up numerous times during the night. In May 2015, the Veteran reported that he was still experiencing nightmares and upsetting though regarding his in-service experiences, but that he was able to use distraction techniques to manage his mood. In November 2015, the Veteran and his wife testified before the undersigned Veterans Law Judge. The Veteran stated that he had participated in multiple PTSD programs over the years, and that he received weekly treatment. The Veteran's wife stated that the Veteran's mood fluctuated very quickly, and that he slept with anything he can find that could be a weapon. He stated that sometimes he slept with a pistol. His wife also reported that the Veteran had a spotlight to shine on anyone who entered his bedroom or house. He stated that did not get out as often as he and his wife wanted. The Veteran and his wife stated his anger affected his relationship with his wife and sons. He stated that he did not like to be in crowds, like shopping or attending sport events. He stated that he had some memory problems, like forgetting where he put something. Considering such evidence in light of the criteria noted above, the Board finds that the Veteran's PTSD does not result in occupational and social impairment with reduced reliability and productivity. As such, the Board finds that the Veteran does not meet the criteria for the next higher rating, 50 percent. As noted above, a 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. With respect to the symptomatology considered under the 50 percent rating criteria, while the Veteran's affect was noted to be sad on three occasions in November 2006, April 2007, and August 2007, the Veteran's VA treatment records predominantly reflect a wide-ranging or full affect. Furthermore, besides being pressured, the Veteran's speech was noted as being logical, coherent, and normal. There is nothing in the record to suggest that the Veteran has any difficulty communicating. Additionally, there is nothing in the record suggesting that he suffered from a significant impairment of short- and long-term memory. In fact, during the June 2009 VA headaches examination, the Veteran denied any memory problems, and during the November 2015 hearing, the Veteran reported only some memory problems, such as forgetting where he set something down. At no point during the appeal has the Veteran displayed impaired judgment, impaired abstract thinking, or difficulty in establishing and maintaining effective work and social relationships. For instance, the Veteran has been able to maintain a relationship with his wife for over thirty years. Additionally, although VA treatment records reflect a strained relationship between the Veteran and his sons, he nevertheless maintained a relationship with them. Furthermore, the Veteran reported other positive relationships, including friends and extended family. Finally, the evidence of record reflects that the Veteran was the head of his motorcycle group and that he participated in many of the group's activities. Instead, the Board finds that the Veteran's PTSD has been manifested by symptoms that are of the type, extent, frequency, and/or severity that is indicative of no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. In this regard, the Board notes that the Veteran's symptoms include the following: anger and irritability, without the threat of physical violence; occasionally depressed mood; chronic sleep impairment, including nightmares; infrequent suicidal ideation; recurrent and intrusive distressing recollections and dreams related to his military experiences; avoidance behaviors, including avoiding the news and crowds; hypervigilance and suspiciousness; anxiety; pressured speech; and mild impairment in memory. Such symptomatology is consistent with the criteria listed under the 30 percent rating. The Veteran's functioning can be described as satisfactory as he has routine behaviors, is capable of not only self-care, but also the care of his wife, and is able to engage in generally normal conversation. Additionally, the Veteran is consistently noted to be "doing better" or improving. For example, in August 2006 and December 2006, the Veteran's mood was described as cheerful. Throughout the appeal period, the Veteran described his ability to control his anger and irritability as improving, and in treatment records dated from December 2012 onward, the Veteran was described as being in "good spirits." As the criteria for the next higher 50 percent rating are not met, it logically follows that the criteria for any higher evaluation are also not met. In this regard, the Board notes that, during the pendency of the appeal, the Veteran has endorsed some symptoms that are considered under the 70 percent disability rating. For example, the Board notes the Veteran's complaints of suicidal ideation in June 2009 and October 2010; however, throughout the appeal period, the Veteran has predominantly denied suicidal and homicidal ideations. For example, with regard to the June 2009 notation of suicidal thoughts, treatment records immediately preceding and following that notation refect the Veteran's denial of suicidal ideation. Furthermore, with regard to the October 2010 notations, the Veteran stated that, although he thought about suicide, he never considered actually doing it and that he did not have a plan. And once again, subsequent VA treatment record consistently reflect the Veteran denial of suicidal ideation. With regard to other symptoms considered listed under the 70 percent disability rating, the Board notes that the Veteran's VA treatment provider and the August 2007 VA examiner opined that the Veteran's PTSD symptomatology would make it difficult for him to adapt to a work setting, and some of his VA treatment providers indicated he was unemployable. However, the Board finds that such symptoms are not of such a severity or frequency to more nearly approximate the occupational and social impairment contemplated by the higher ratings. As such, the Board finds that the Veteran is not entitled to a rating in excess of 30 percent. The Board further notes that the evidence of record reflects that the Veteran has additional symptomatology that is not enumerated in the rating schedule, including nightmares, an exaggerated startle response, hypervigilance, and anger and irritability. See Mauerhan, supra. However, the Board finds that such symptoms do not more nearly approximate a rating in excess of 30 percent under the General Rating Formula as they are not such of a severity or frequency to result in occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. The Board also notes that during this period, the Veteran's GAF score ranged between 44 and 60. As indicated above, a GAF score of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 indicates moderate symptoms, or moderate difficulty in social, occupational, or school functioning. A GAF score, while not dispositive, is nevertheless highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). Although the Veteran was assigned GAF scores reflecting moderate to serious symptoms, the Board finds that the Veteran is not entitled to a rating in excess of 30 percent. Although GAF scores ranging from 41 to 50 reflect serious symptoms, the Board notes that the Veteran's mental status examinations conducted throughout the appeal period detail only mild to moderate symptoms indicative of a 30 percent rating. For example, the August 2007 VA treatment record that assigned a GAF score of 45 also noted the Veteran's statement that he was doing well, and that he had a busy schedule with the housework, bills, and children. The record also noted that the Veteran was adapting to his wife's situation. Although he was depressed, angry, and sad, he nevertheless denied suicidal and homicidal ideation, delusions, and hallucinations; his insight and judgment were good; and he displayed a coherent thought process. Therefore, as the Veteran's PTSD symptoms, as detailed previously, are contemplated by his current 30 percent evaluation, a higher rating is not warranted based solely on the GAF scores assigned. The Board acknowledges that the Veteran, in advancing this appeal, believes that his PTSD is more severe than the assigned disability rating reflects. In this regard, he is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay evidence has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. The Board has considered whether additional staged ratings under Hart, supra, as appropriate for the Veteran's PTSD; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning any staged rating for this disability is not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's PTSD with the established criteria found in the rating schedule. The Board finds that the Veteran's psychiatric symptomatology is fully addressed by the rating criteria under which it is currently evaluated. In this regard, the Board notes that the Federal Circuit provided guidance in rating psychiatric disabilities, emphasizing that the list of symptoms under a given rating is nonexhaustive. Vazquez-Claudio, supra. The psychiatric symptoms present in this case are either listed in the schedular criteria or are similar in kind to those listed, as discussed above. Review of the record does not reveal that the Veteran suffers from any symptoms of PTSD that are not contemplated in the nonexhaustive list of symptoms found in the schedular criteria. Furthermore, the Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. However, in this case, even after affording the Veteran the benefit of the doubt under Mittleider v. West, 11 Vet. App. 181 (1998), there is no additional impairment that has not been attributed to a specific rated disability. The Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected PTSD. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture and, therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Accordingly, this is not an exceptional circumstance in which extra-schedular consideration may be required to compensate the Veteran for disability that can be attributed only to the combined effect of multiple conditions. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Finally, the Court has held that a request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if the disability upon which entitlement to TDIU is based has already been found to be service-connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In the September 2007 rating decision on appeal, a claim for a TDIU was considered and denied by the RO. The Veteran did not appeal such decision. Such adjudication reflects the permissive bifurcation of the increased rating claim from the TDIU claim. See Roebuck v. Nicholson, 20 Vet. App 307, 315 (2006) (acknowledging that the Board can bifurcate a claim and address different theories or arguments in separate decisions); Holland v. Brown, 6 Vet. App. 443, 447 (1994) (holding that "it was not inappropriate" for the Board to refer a TDIU claim to the RO for further adjudication and still decide an increased-ratings claim). Moreover, while acknowledging the Rice decision, in Locklear v. Shinseki, 24 Vet. App. 311(2011), the Court held that it is permissive for VA to address a claim for TDIU independently of other claims, including increased rating and service connection claims. Id. at 315. Given the foregoing, the Board concludes that the TDIU claim was separately adjudicated and not perfected for appellate review. Accordingly, the Board does not have jurisdiction over the claim and need not refer or remand the matter. In sum, Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 30 percent for his PTSD. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against higher or separate ratings, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. ORDER A rating in excess of 30 percent for PTSD is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and there is a complete record upon which to decide the Veteran's remaining claim so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The Veteran contends that he is entitled to an increased rating for his service-connected diabetes mellitus. Diabetes mellitus is rated under Diagnostic Code 7913. 38 C.F.R. § 4.119. In addition to the criteria evaluating diabetes mellitus, Diagnostic Code 7913 also allows for the separate evaluation of complications of diabetes mellitus, so long as those complications are of such a severity to warrant a compensable rating under the appropriate diagnostic code. In connection with his claim for an increased rating, the Veteran underwent two VA examinations in July 2007 and May 2015. Also of record are the Veteran's VA treatment records and his lay statements including his testimony before the undersigned. Unfortunately, however, the Board finds that a remand is necessary as the evidence of record is nevertheless inadequate to decide the Veteran's claim. A review of the Veteran's VA treatment records show that, in addition to his diagnosis and treatment for peripheral vascular disease, he has been diagnosed with and treated for diabetic neuropathy. For example, In October 2006, the Veteran complained of pain and tingling in his feet. In a June 2009 VA headaches examination, the Veteran was diagnosed with "Type 2 diabetes mellitus, with neuropathy," greater in his lower extremities than his upper extremities. In a February 2011 VA treatment record, it was noted that the Veteran was started on a medication for pain and neuropathy back in December 2006. In an April 2014 letter, the Veteran's VA treating physician noted that, in addition to diabetes mellitus and peripheral vascular disease, the Veteran also suffered from diabetic peripheral neuropathy. Finally, a March 2015 VA treatment record noted that the Veteran suffered from diabetic peripheral neuropathy and was on medication for treatment. The July 2007 and the May 2015 VA examiners noted that the Veteran suffered from peripheral vascular disease that pre-dated his diabetes mellitus. However, despite the Veteran's VA treatment records showing a diagnosis of, and treatment for, diabetic peripheral neuropathy, both examiners found that there were no additional deficits or complications, including any neurological manifestations, of the Veteran's diabetes mellitus. Neither examination report discussed the Veteran's VA treatment records showing a diagnosis of and treatment for diabetic neuropathy. The Court has held that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion . . . must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Moreover, once VA undertakes the effort to provide an examination for a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Given that the Veteran's VA treatment records reflect a diagnosis of, and treatment for, diabetic peripheral neuropathy, as well as the lack of any medical opinion addressing the nature, etiology, and severity of such, the Board finds that an addendum opinion is necessary to address such matter. Finally, although the current record contains VA treatment records concerning the Veteran's service-connected diabetes mellitus, additional records may exist that have not already been associated with the claims file. Therefore, while on remand, the Veteran should be given an opportunity to identify any VA or non-VA healthcare provided that has treated him for his diabetes mellitus that is not already of record. If the Veteran responds, such identified record should be obtained for consideration in the appeal. Accordingly, the case is REMANDED for the following action: 1. Furnish the Veteran a letter requesting that he provide information and, if necessary, authorization, to enable the AOJ to obtain any additional VA or non-VA treatment records pertinent to the claim on appeal. Specifically request that the Veteran provide, or provide appropriate authorization so as to allow VA to obtain, any outstanding private records. For private records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. After all outstanding records have been associated with the claims file, return the claims file to the VA examiner who conducted the May 2015 examination. The entire claims file, to include a copy of this Remand, must be made available to and be reviewed by the examiner. If the May 2015 examiner is not available, the claims file should be provided to an appropriate medical professional so as to render the requested opinion. The need for additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of the full record, the examiner must offer an opinion on the following questions: The examiner should identify the nature and severity of all diabetic complications. The examiner should specifically indicate whether the Veteran suffers from peripheral neuropathy in his upper and/or lower bilateral extremities as a result of his service-connected diabetes mellitus. If so, the examiner should indicate the nature and severity of such peripheral neuropathy. The examiner should also identify and describe in detail all manifestations of the Veteran's diabetes mellitus, including whether it requires the use of insulin or the regulation of activities. The examiner should specifically note the number of episodes of ketoacidosis or hypoglycemic reactions that have required hospitalizations, and the frequency with which he sees his diabetic care provider. In addressing such inquiries, the examiner should take into consideration all of the evidence of record, to include the Veteran's VA treatment records showing a diagnosis of and treatment for diabetic peripheral neuropathy, as well as the Veteran's lay statements concerning his symptomatology, including his complaints of pain, numbness, and tingling, in his upper and lower bilateral extremities, accepted medical principles, and objective medical findings. All opinions expressed must be accompanied by supporting rationale. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs