Citation Nr: 1607265 Decision Date: 02/25/16 Archive Date: 03/04/16 DOCKET NO. 14-09 302 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to an increased rating for diabetes mellitus, type II, currently rated 20 percent disabling. 2. Entitlement to an initial increased rating for posttraumatic stress disorder (PTSD), currently rated 50 percent disabling. 3. Entitlement to service connection for peripheral neuropathy, bilateral lower extremities, claimed as due to or aggravated by service-connected diabetes mellitus, type II. 4. Entitlement to service connection for peripheral neuropathy, bilateral upper extremities, claimed as due to or aggravated by service-connected diabetes mellitus, type II. 5. Entitlement to service connection for erectile dysfunction, claimed as due to or aggravated by service-connected diabetes mellitus, type II. 6. Entitlement to service connection for renal insufficiency, claimed as due to or aggravated by service-connected diabetes mellitus, type II. 7. Entitlement to service connection for hypertension. 8. Entitlement to service connection for sleep apnea. 9. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for tinnitus. 10. Entitlement to service connection for ischemic heart disease. 11. Entitlement to a total disability rating due to individual unemployability (TDIU) as a result of service-connected disabilities. 12. Entitlement to a TDIU for the period prior to July 19, 2011. REPRESENTATION Veteran represented by: Michael Woods, Attorney-at-Law WITNESS AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD M.W. Kreindler, Counsel INTRODUCTION The Veteran served on active duty from July 1961 to May 1989. These matters came to the Board of Veterans' Appeals (Board) from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In a May 2010 rating decision, the RO denied entitlement to an increased rating for diabetes mellitus, and denied entitlement to service connection for peripheral neuropathy, bilateral lower and upper extremities, erectile dysfunction, and renal insufficiency. A notice of disagreement was filed in June 2010, a statement of the case was issued in February 2014, and a substantive appeal was received in March 2014. In a September 2011 rating decision, the RO granted entitlement to service connection for PTSD, assigning a 50 percent disability rating, effective July 19, 2011. A notice of disagreement was filed in November 2011 with regard to the disability rating assigned. A statement of the case was issued in August 2013 and a substantive appeal was received in September 2013. The Veteran testified at a Board hearing in August 2014; the transcript is of record. In a January 2015 rating decision, the RO denied entitlement to service connection for ischemic heart disease, and entitlement to a TDIU. A notice of disagreement was filed in June 2015. The Board will take jurisdiction of entitlement to a TDIU per Rice v. Shinseki, 22 Vet. App. 447 (2009). In a May 2015 rating decision, the RO denied entitlement to service connection for hypertension and sleep apnea, and determined that new and material evidence was not received to reopen the claim of entitlement to service connection for tinnitus. A notice of disagreement was filed in June 2015. The issues of entitlement to an increased rating for diabetes mellitus, the service connection issues, and entitlement to a TDIU for the period prior to July 19, 2011, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if any further action is required on his part. FINDINGS OF FACT 1. For the entire period contemplated by this appeal, the Veteran's PTSD has resulted in occupational and social impairment with deficiencies in most areas due to such symptoms as suicidal ideation, impaired impulse control, difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships. 2. The Veteran's service-connected PTSD precludes substantially gainful employment, effective July 19, 2011. CONCLUSIONS OF LAW 1. For the entire period contemplated by this appeal, the criteria for an evaluation of 70 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.130, Code 9411 (2015). 2. The criteria for a TDIU have been met for the period from July 19, 2011. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19, 4.25 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper notice from VA must inform the claimant of any information and medical or lay 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 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. In July 2011, a VCAA letter was issued to the Veteran with regard to his PTSD service connection claim. Such letter notified the Veteran of what information and evidence is needed to substantiate his claim, as well as what information and evidence must be submitted by the claimant, what information and evidence will be obtained by VA, and the evidence necessary to support a disability rating and effective date. Id; but see VAOPGCPREC 1-2004; Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Since the PTSD issue in this case (entitlement to an initial increased rating) is a downstream issue from that of the award of service connection, another VCAA notice is not required. The letter has clearly advised the Veteran of the evidence necessary to substantiate his claim. Next, VA has a duty to assist the Veteran in the development of the claims. 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 with regard to the PTSD and TDIU issues. The Veteran was afforded VA examinations in August 2011, October 2012, and November 2014 that assessed the severity of his PTSD. The claims file contains the Veteran's service treatment records, identified post-service treatment records, and lay statements and testimony from the Veteran. No additional evidence has been identified by the Veteran with regard to his PTSD and claim for a TDIU. The United States Court of Appeals for Veterans Claims has interpreted the provisions of 38 C.F.R. § 3.103(c)(2) as imposing two distinct duties on VA employees, including Board personnel, in conducting hearings: The duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam). At the Veteran's hearing the issues were identified, namely the need for evidence of worsening PTSD disability. There was a discussion of possible evidence that could substantiate the claim. The Board notes that following the Board hearing, the Veteran underwent a VA examination to assess the severity of his PTSD. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Increased rating Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Nevertheless, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. Ap. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. 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. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. 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, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. The Veteran contends that a rating in excess of 50 percent is warranted for his PTSD. A rating of 50 percent is assignable for 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 per week; difficulty in understanding complex commands; impairment of short- and long-term memory (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. A rating of 70 percent is assignable for 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; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. A 100 percent evaluation is assignable for 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. When evaluating mental health disorders, the factors listed in the rating criteria are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating; analysis should not be limited solely to whether a Veteran exhibited the symptoms listed in the rating scheme. Rather, the determination should be based on all of a veteran's symptoms affecting his level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The GAF score 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) (DSM-IV). VA implemented DSM-V, effective August 4, 2014. The Secretary, VA, has determined, however, that DSM-V does not apply to claims certified to the Board prior to August 4, 2014. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). Since the Veteran's appeal was certified to the Board prior to August 4, 2014, DSM-IV is still the governing directive for his appeal. The scores assigned under the Global Assessment of Functioning (GAF) scale are an important consideration under DSM-IV. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996). They reflect the psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness. GAF scores between 61 and 70 reflect either 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, has some meaningful interpersonal relationships. By comparison, GAF scores between 51 and 60 reflect either moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks); or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with co-workers), and GAF scores between 41 and 50 reflect either serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting); or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores between 31 and 40 reflect either some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). Also, the Board notes that the joining of schedular criteria in the rating schedule by the conjunctive "and" in a diagnostic code does not always require all criteria to be met, except in the case of diagnostic codes that use successive rating criteria, where assignment of a higher rating requires that elements from the lower rating are met. Tatum v. Shinseki, 23 Vet. App. 152 (2009). In evaluating the present case, the Board finds that the Veteran's symptomatology meets the criteria for assignment of a 70 percent disability rating for the entire period contemplated by this appeal. The evidence, as described in detail below, fails to show total occupational and social impairment, precluding an evaluation of 100 percent for any portion of the rating period on appeal. Based on review of the evidence detailed hereinabove and review of the entirety of the record, the Board finds that a 70 percent disability rating is warranted from July 19, 2011, which corresponds to the date service connection was established for PTSD. An August 2011 VA examiner assigned a GAF score of 55 accounting for past combat traumas, increasing social isolation, some passive suicidal ideation, and some increase in marital discord due to emotional withdrawal and irritability. The Veteran reported hypervigilance and passive suicidal ideation. He reported intrusive memories, almost complete isolation, nightmares, distress when exposed to stimuli, loss of interest in social activities, emotional withdrawn and detachment, and has reported marital problems related to his symptoms. An October 2012 VA examiner assigned a GAF score of 55 reflective of occupational and social impairment with reduced reliability and productivity. On mental status examination, the examiner noted difficulty in establishing and maintaining effective work and social relationships; suicidal ideation; sleep impairment; panic attacks more than once a week; depressed mood; suspiciousness; anxiety; irritability or outbursts of anger; difficulty concentrating; hypervigilance; feeling of detachment or estrangement from others; and, restricted range of affect. An October 2014 VA examiner determined that the Veteran's PTSD is manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. His PTSD is manifested by hypervigilance, problems with concentration and sleep disturbance. His symptoms include depressed mood; suspiciousness; anxiety; chronic sleep impairment; mild memory loss; flattened affect; disturbances of motivation and mood; difficulty in maintaining and establishing effective work and social relationships; and, difficulty in adapting to stressful circumstances. The Board finds that based on the symptomatology described by the Veteran to the VA examiners, findings by VA examiners, review of VA treatment records, and his testimony before the Board, a 70 percent rating is warranted in contemplation of his PTSD symptomatology. The Board acknowledges that not all of the criteria for a 70 percent rating have been met; however, the evidence supports a finding of occupational and social impairment with deficiencies in most areas due to his PTSD. Specifically, objective findings have shown suicidal ideation; impaired impulse control; difficulty in adapting to stressful circumstances; and, an inability to establish and maintain effective relationships. The Board has determined that the 70 percent disability rating more appropriately contemplates his PTSD symptomatology. A 100 percent disability rating is not warranted for any period contemplated by this appeal as the subjective complaints and objective findings do not reflect a persistent danger of hurting self or others, nor any of the other symptomatology contemplated by a 100 percent rating. There have been no objective findings of gross impairment in thought processes or communications; persistent delusions or hallucinations; grossly inappropriate behavior; intermittent inability to perform activities of daily living; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. There is no indication that he is unable to perform activities of daily living including maintenance of personal hygiene. Likewise, his memory problems were characterized as mild. Total social impairment has not been shown. Indeed, the Veteran remains married, still goes out to eat with his wife at off hours and participates to some extent in household chores. He maintains an interest in reading. At the most recent examination, he indicated having a friend that he would meet up with about once monthly and another friend with whom he talked on the phone several times per week. Additionally, he attended football games. Thus, as detailed hereinabove, the Veteran's psychiatric symptomatology is best contemplated by a 70 percent disability rating, but a 100 percent disability rating is not warranted for any period. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Extraschedular Consideration In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The rating criteria for PTSD contemplates the Veteran's disability, to include any interference with employment. The manifestations associated with the Veteran's PTSD is specifically contemplated in the rating criteria. The rating criteria are therefore adequate to evaluate the Veteran's disability and referral for consideration of an extraschedular rating is, therefore, not warranted. TDIU Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. §§ 3.340, 4.16(a). If, however, there is only one such disability, it shall be ratable at 60 percent or more, and, if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Service connection is in effect for PTSD, rated 70 percent disabling, effective July 19, 2011, and diabetes mellitus, rated 20 percent disabling, effective May 8, 2001. Thus, the minimum percentage requirements for a TDIU set forth in 38 C.F.R. § 4.16(a) have been met. Entitlement to a total rating must be based solely on the impact of the veteran's service-connected disabilities on his ability to keep and maintain substantially gainful employment. See 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). The evidence of record reflects that the Veteran worked as a heating/AC technician from September 1989 to January 2010. 05/01/2014 VBMS entries, VA 21-8940 Veterans Application for Increased Compensation Based on Unemployability and VA 21-4192 Request for Employment Information in Connection with Claim for Disability. The November 2014 VA examiner opined that the Veteran is unemployable due to the impact of his PTSD on his concentration, thought organization, social comfort, ability to cooperate and communicate with others in normal circumstances, and ability to tolerate frustration and control his anger in conflict situations. The examiner opined that it was unlikely that the Veteran could work a full day or work regularly and reliably because of his PTSD. The Board finds evidentiary support to conclude that the Veteran's PTSD precludes substantially gainful employment. For the above reasons, entitlement to a TDIU is granted, effective July 19, 2011, which corresponds to the date service connection was established for PTSD. ORDER Entitlement to a disability rating of 70 percent for PTSD is granted. Entitlement to a TDIU is granted, effective July 19, 2011. REMAND Diabetes mellitus, type II The Veteran asserts that due to his insulin dependent diabetes mellitus his diet is restricted, he has to regulate his activities, and has to regulate his exercise. 09/20/2014 Virtual VA entry, Hearing Transcript at 3-5. The Veteran's most recent VA examination was conducted in October 2009. The Veteran should be afforded a VA examination to assess the severity of his diabetes mellitus. Peripheral neuropathy, bilateral upper and lower extremities The Veteran asserts that he has peripheral neuropathy of the bilateral upper and lower extremities due to his service-connected diabetes mellitus, type II. Unfortunately, there is conflicting evidence on this question. In October 2012, the Veteran underwent a VA examination. 10/30/2012 VBMS entry, VA Examination. The examiner summarized the medical records, noting that the Veteran first related numbness and tingling in all extremities in January 2007, at which time he was undergoing treatment for Hepatitis C, diagnosed in 2006. The examiner noted that Hepatitis C and its treatment can also cause a generalized peripheral neuropathy. In September 2007, he reported that he was doing much better, that he had completed his Hepatitis C treatment, and that he now only had numbness/tingling/pain to the tips of his left D 1-3 fingers - worse with rest and while he drives - at which time it travelled to his forearm and arm to the shoulder. Monofilament examination was normal. Neck films obtained in September 2007 for complaint of "radicular pain in his left upper extremity" showed degenerative C3-4 and C6-7 interspace changes causing mild acquired spondylosis and mild foraminal narrowing. No hand, foot, or back films, or neck CT were in the chart. In October 2009, the Veteran was seen for EMG/NCS for complaint of numbness in left palmar fingertips of all fingers which went up to the shoulder. He said on that occasion that he also had intermittent tingling in the palmar right fingers as well, mostly with inactivity, and pins and needle/electric shock type feeling in both feet in the instep, mostly in the AM, and which woke him from sleep (the latter symptoms were consistent with clinical plantar fasciitis.) The Veteran complained of occasionally dropping objects once a week or so. No difficulty turning doorknobs or keys in the ignition. No tripping or falling. He was currently in the middle of a flare of gout at the time, which affected his entire foot from the ankles to the toes bilaterally. He also had right knee pain with this particular flare, as well as back pain. He has gouty flares perhaps 2-3 times a week. The examiner referenced an October 2009 study showing prolonged distal latencies of the median sensory nerve bilaterally, together with EMG findings consistent with bilateral carpal tunnel syndrome, moderate on the right and severe on the left, and wrist splints and stretches were advised. In addition, there were bilateral prolonged peroneal and left sural distal latencies, decreased tibial and right peroneal motor amplitudes and EMG changes thought to be primarily related to the Veteran's gout and plantar fasciitis. Shoe inserts were advised. The Veteran has had multiple normal monofilament and pedal pulse examinations, most recently in August 2012. Visual foot examinations have been remarkable for large bunions on both feet. The Veteran stated today that he continued to have the same symptoms. He feels his left foot is somewhat worse than the right. The intermittent tingling in his hands has not changed any, but his symptoms of pain on waking have improved with the wrist splints and stretches. Upon assessment, the examiner found a mildly abnormal examination. There were diminished motor amplitudes of the bilateral tibial motor nerves, consistent with tarsal tunnel syndrome. This would most likely be due to the Veteran's known severe plantar fasciitis, bunion deformity and periodic gouty attacks. Physical and examination was improved from his examination in October 2009 (at which point the Veteran was in the midst of a gouty flare.) There was no evidence of a generalized peripheral neuropathy; the Veteran's sural sensory nerves and peroneal nerves are intact with the exception of prolonged F waves, reflecting the Veteran's bilateral gouty syndrome. Upper extremity and needle examination were not performed today, as one cannot develop a generalized peripheral neuropathy affecting the upper extremities before developing one affecting the lower extremities, and since the Veteran stated he did not have any change in his upper extremity symptoms today from his 2009 exam, and has known bilateral carpal tunnel syndrome diagnosed in October 2009 electrodiagnostic studies, which was moderate on the right and severe on the left. The Veteran was not interested in surgery at this time, so it was agreed to defer the needle examination. The examiner opined that the Veteran does not have a generalized peripheral neuropathy. The examiner stated that the Veteran has carpal tunnel syndrome and tarsal tunnel syndrome bilaterally. He does not have a generalized peripheral neuropathy based on his last studies in 2009. See 11/07/2012 VBMS entry, VA Examination at 28. Correspondence dated in August 2014 from the Veteran's VA treating physician reflects that the Veteran has peripheral neuropathy of both his upper .and lower extremities. The treating physician stated that with those cases with a known cause, diabetes is the leading cause of this condition. Thus, the physician opined that the Veteran's peripheral neuropathy of both the arms and legs is more likely than not (greater than 50 percent chance) the result: of his diabetes mellitus, type II. In May 2015, the Veteran underwent a VA examination with Dr. S.R.D. 05/11/2015 VBMS entry, C&P Exam. The examiner, again, found that the Veteran did not have diabetic peripheral neuropathy but did not provide a diagnosis to account for the abnormal findings related to the upper and lower extremities. Given the inconsistent and contradictory findings noted above, the Veteran should be afforded a VA examination to assess the nature and etiology of his claimed peripheral neuropathy, bilateral upper and lower extremities. Erectile dysfunction In November 2012, the Veteran underwent a VA examination. The examiner opined that it is less likely than not that the Veteran's erectile dysfunction is due to his diabetes mellitus. The examiner stated that the Veteran is on multiple medications for his hypertension, which is known to cause erectile dysfunction, and furthermore, he has a small left testicle. Correspondence dated in August 2014 from the Veteran's treating physician notes that erectile dysfunction is common in men, with an increase in frequency in men with vascular disease, diabetes mellitus, or with neuropathy. It is a common side effect of medications. The Veteran has been taking some medications for hypertension that have been associated with erectile dysfunction. The physician opined that the Veteran's erectile dysfunction is at least as likely as not (equal or greater than a 50 percent chance) caused by his diabetes mellitus. In light of the conflicting opinions, the Veteran should be afforded a VA examination to assess the etiology of his erectile dysfunction. Also, the November 2012 opinion did not address aggravation. Renal insufficiency A July 2010 nephrology consultation reflects the examiner's findings that chronic renal disease that is likely more related to the hypertension than the diabetes based upon the low urinary protein, good diabetic control, and lack of diabetic eye disease. The examiner noted that African Americans are particularly prone to the renal disease associated with the hypertension. 08/28/2013 Virtual VA entry, CAPRI at 50. In November 2012, the Veteran underwent a VA examination. The examiner opined that the Veteran's chronic kidney disease is not due to or a result of his diabetes mellitus. The examiner explained that the Veteran has had normal renal function with mild proteinuria in 2005, at which time diabetes mellitus had been diagnosed for three years for which he was on insulin and oral medications, hypertension had been diagnosed for 10 years, and chronic gout had been diagnosed. His nephropathy was attributed primarily to his hypertension although gouty nephropathy is somewhat more likely given that he has frequent flares. His nephropathy has gotten much worse since then, whereas his hypertension and diabetes mellitus have remained fairly well controlled. A VA physician has opined that the Veteran's chronic renal disease is likely more related to the hypertension than the diabetes based upon the low urinary protein, good diabetic control, and lack of diabetic eye disease, however, given that both the hypertension and the diabetes mellitus are individually well controlled, it seems reasonable that the Veteran's gout is the major player here. Such opinions, however, do not address aggravation. Correspondence dated in August 2014 from the Veteran's treating physician reflects that the Veteran has suffered progressive renal insufficiency that has correlated well with the duration of his diabetes. While other conditions may cause renal failure, diabetes is the leading cause. The examiner opined that the Veteran's renal failure is more likely than not (greater than 50 percent chance) a result of his diabetes mellitus, type II. In light of the conflicting opinions, the Veteran should be afforded a VA examination to assess the etiology of his renal insufficiency. TDIU for the period prior to July 19, 2011 The Veteran's claim of entitlement to a TDIU is inextricably intertwined with the issues being remanded, and thus the Board will defer consideration of the appeal with regard to entitlement to a TDIU for the period prior to July 19, 2011. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). In light of these matters being remanded, associate updated VA treatment records from the Fayetteville VA Medical Center (VAMC) dated from May 22, 2015 with the Virtual folders. See Bell v. Derwinski, 2 Vet. App. 611 (1992). Hypertension, sleep apnea, tinnitus and ischemic heart disease In a May 2015 rating decision, the RO denied entitlement to service connection for hypertension and sleep apnea, and determined that new and material evidence had not been received to reopen the claim of service connection for tinnitus. In June 2015, the Veteran filed a notice of disagreement. Remand is necessary for issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). In a January 2015 rating decision, the RO denied entitlement to service connection for ischemic heart disease. In June 2015, the Veteran filed a notice of disagreement. Remand is necessary for issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following actions: 1. Associate with the virtual folders from the Fayetteville VAMC for the period from May 22, 2015. 2. Schedule the Veteran for a VA examination to ascertain the current severity of his diabetes mellitus, type II. The examiner should review the Virtual folders in conjunction with the examination. The examiner should indicate whether the Veteran's diabetes mellitus, type II, requires insulin, oral hypoglycemic agent, restricted diet, and/or regulation of activities. If the Veteran has hypoglycemic reactions or ketoacidosis episodes, the examiner should state how long they last and what kind of care is necessary. 3. Schedule the Veteran for a VA examination with a physician with appropriate expertise in order to ascertain the nature and etiology of his claimed peripheral neuropathy of the bilateral upper and lower extremities. It is imperative that the Virtual folders be reviewed in conjunction with the examination. Any medically indicated special tests, including x-rays, should be accomplished, and all special test and clinical findings should be clearly reported. The examiner should respond to the following: a) Please state whether any peripheral neuropathy, upper extremities, are at least as likely as not (50 percent or greater probability) caused by diabetes mellitus, type II. b) Please state whether any peripheral neuropathy, upper extremities, has at least as likely as not (50 percent or greater probability) been aggravated (e.g., permanently worsened beyond the normal progression of that disease) by diabetes mellitus? If aggravation is found, the examiner should also state, to the extent possible, the baseline level of disability prior to aggravation. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. c) Please state whether any peripheral neuropathy, lower extremities, is at least as likely as not (50 percent or greater probability) caused by diabetes mellitus. d) Please state whether any peripheral neuropathy, lower extremities, has at least as likely as not (50 percent or greater probability) been aggravated (e.g., permanently worsened beyond the normal progression of that disease) by diabetes mellitus? If aggravation is found, the examiner should also state, to the extent possible, the baseline level of disability prior to aggravation. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. Please provide reasons for these opinions. All pertinent evidence, including both lay and medical, should be considered. 4. Schedule the Veteran for a VA examination with a physician with appropriate expertise in order to ascertain the nature and etiology of his claimed erectile dysfunction. It is imperative that the Virtual folders be reviewed in conjunction with the examination. Any medically indicated special tests, including x-rays, should be accomplished, and all special test and clinical findings should be clearly reported. The examiner should respond to the following: a) Please state whether erectile dysfunction is at least as likely as not (50 percent or greater probability) caused by diabetes mellitus, type II. b) Please state whether erectile dysfunction has at least as likely as not (50 percent or greater probability) been aggravated (e.g., permanently worsened beyond the normal progression of that disease) by diabetes mellitus? If aggravation is found, the examiner should also state, to the extent possible, the baseline level of disability prior to aggravation. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. Please provide reasons for these opinions. All pertinent evidence, including both lay and medical, should be considered. 5. Schedule the Veteran for a VA examination with a physician with appropriate expertise in order to ascertain the nature and etiology of his claimed renal insufficiency. It is imperative that the Virtual folders be reviewed in conjunction with the examination. Any medically indicated special tests, including x-rays, should be accomplished, and all special test and clinical findings should be clearly reported. The examiner should respond to the following: a) Please state whether renal insufficiency is at least as likely as not (50 percent or greater probability) caused by diabetes mellitus, type II. b) Please state whether renal insufficiency has at least as likely as not (50 percent or greater probability) been aggravated (e.g., permanently worsened beyond the normal progression of that disease) by diabetes mellitus? If aggravation is found, the examiner should also state, to the extent possible, the baseline level of disability prior to aggravation. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. Please provide reasons for these opinions. All pertinent evidence, including both lay and medical, should be considered. 6. If any of the benefits sought on appeal are not granted in full, issue a supplemental statement of the case. The case should then be returned to the Board, if otherwise in order. 7. Issue a statement of the case with regard to the issues of entitlement to service connection for hypertension, sleep apnea, and ischemic heart disease, and whether new and material evidence has been received to reopen the claim of entitlement to service connection for tinnitus. These issues should not be certified to the Board unless the Veteran submits a timely substantive appeal. 8. Thereafter, the AMC should review the expanded record and determine if the benefits sought for all perfected issues can be granted. If the claims remain denied, then the AMC should furnish the Veteran and his representative with a supplemental statement of the case, and afford a reasonable opportunity for response before returning the record to the Board for further review. The Veteran and his attorney have the right to submit additional evidence and argument on the 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). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs