Citation Nr: 1608312 Decision Date: 03/02/16 Archive Date: 03/09/16 DOCKET NO. 10-25 091 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a bilateral eye disability. 2. Entitlement to service connection for renal dysfunction. 3. Entitlement to service connection for urinary incontinence. 4. Entitlement to service connection for a heart disability. 5. Entitlement to service connection for fecal incontinence. 6. Entitlement to a compensable disability rating for peripheral vascular (arterial) disease, right lower extremity, for the period prior to September 13, 2013. 7. Entitlement to a compensable disability rating for peripheral vascular (arterial) disease, left lower extremity, for the period prior to September 13, 2013. 8. Entitlement to a disability rating in excess of 40 percent for peripheral vascular (arterial) disease, right lower extremity, for the period from September 13, 2013. 9. Entitlement to a disability rating in excess of 40 percent for peripheral vascular (arterial) disease, left lower extremity, for the period from September 13, 2013. 10. Entitlement to service connection for hypertension. 11. Entitlement to a separate compensable rating for peripheral neuropathy, right lower extremity, for the period prior to September 7, 2012. 12. Entitlement to a separate compensable rating for peripheral neuropathy, left lower extremity, for the period prior to September 7, 2012. 13. Entitlement to a separate compensable rating for peripheral neuropathy, right upper extremity, for the period prior to September 7, 2012. 14. Entitlement to a separate compensable rating for peripheral neuropathy, left upper, for the period prior to September 7, 2012. 15. Entitlement to service connection for a low back disability. 16. Entitlement to service connection for a cervical spine disability. 17. Entitlement to service connection for a left knee disability. 18. Entitlement to service connection for a right knee disability. 19. Entitlement to service connection for a left ankle disability. 20. Entitlement to service connection for a right ankle disability. 21. Entitlement to an initial disability rating in excess of 10 percent for small hiatal hernia, distal grade I reflux esophagitis, erosive gastritis. 22. Entitlement to service connection for bilateral hearing loss. ATTORNEY FOR THE BOARD M.W. Kreindler, Counsel INTRODUCTION The Veteran served on active duty from October 1968 to October 1970. These matters come to the Board of Veterans' Appeals (Board) from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In a June 2009 rating decision, service connection was established for diabetes mellitus, type II, rated 20 percent disabling, effective October 12, 2008, but the RO denied entitlement to service connection for neuropathy of the bilateral lower and upper extremities; denied entitlement to service connection for hypertension, and denied entitlement to service connection for an acquired psychiatric disability. In July 2009, the Veteran filed a notice of disagreement with regard to the denials of service connection for neuropathy, hypertension, and an acquired psychiatric disability. A statement of the case was issued in June 2010, and a substantive appeal was received in June 2010. In a December 2009 rating decision, the RO denied entitlement to service connection for a bilateral eye disability, erectile dysfunction, renal dysfunction, urinary incontinence, heart disability, fecal incontinence, and determined that while service connection was warranted for peripheral vascular (arterial) disease of the lower extremities as associated with his diabetes mellitus, compensable ratings were not warranted, thus this condition was included in the 20 percent rating for diabetes mellitus. A notice of disagreement was filed in December 2009, a statement of the case was issued in April 2011, and a substantive appeal was received in April 2011. In a February 2012 rating decision, the RO, in pertinent part, granted entitlement to small hiatal hernia, distal grade I reflux esophagitis, erosive gastritis, assigning a 10 percent disability rating, effective August 6, 2010; and, denied entitlement to service connection for low back, cervical spine, bilateral knee, bilateral ankle, and bilateral hearing loss disabilities. A notice of disagreement was filed in April 2012, a statement of the case was issued in August 2013, and a timely substantive appeal was received in November 2013. In an August 2013 rating decision, the RO granted entitlement to service connection for posttraumatic stress disorder (PTSD), assigning a 70 percent disability rating, effective October 1, 2008. In a February 2015 rating decision, the RO granted entitlement to service connection for erectile dysfunction, assigning a noncompensable rating, and entitlement to special monthly compensation due to loss of a creative organ, effective December 12, 2011; and, granted entitlement to peripheral neuropathy, right upper extremity 20%, peripheral neuropathy, left upper extremity 20%, peripheral neuropathy, right lower extremity 10%, peripheral neuropathy, left lower extremity 10% all effective September 7, 2012; peripheral neuropathy, right upper extremity 40%, peripheral neuropathy, left upper extremity 30%, peripheral neuropathy, right lower extremity 40%, peripheral neuropathy, left lower extremity 40%, all effective September 13, 2013; and, granted separate 40 percent ratings for peripheral vascular (arterial) disease of the bilateral lower extremities from September 13, 2013. The grant of service connection for PTSD, erectile dysfunction, and peripheral neuropathy of the bilateral upper and lower extremities constituted a full award of the benefits sought on appeal as to those issues. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Neither the Veteran nor his representative submitted a jurisdiction-conferring notice of disagreement as to the down-stream elements of effective date or compensation level within the applicable time period. Thus, those issues are not currently in appellate status. Id. The Board notes that for the period prior to September 7, 2012, the peripheral neuropathy, bilateral upper and lower extremities, issues remain on appeal. With regard to the peripheral vascular (arterial) disease ratings, although increased ratings were granted, the issues remain in appellate status, as the maximum schedular ratings have not been assigned and have not been assigned during the entire appeal period. AB v. Brown, 6 Vet. App. 35 (1993). In a December 2012 rating decision, the RO denied entitlement to an increased rating for diabetes mellitus. A notice of disagreement was filed in January 2013 and a statement of the case was issued in March 2015, but the Veteran did not submit a substantive appeal. The issues of entitlement to service connection for hypertension and an initial increased rating for small hiatal hernia are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's decreased visual acuity is due to refractive error and is not a disability for the purposes of entitlement to VA compensation benefits. 2. A bilateral eye disability was not manifested during service and is not otherwise related to the Veteran's active service, and is not otherwise caused by or aggravated by a service-connected disability. 3. Renal dysfunction is not shown. 4. Urinary incontinence is not shown. 5. A heart disability is not shown. 6. Fecal incontinence is not shown. 7. For the period from October 12, 2008, to September 7, 2012, the Veteran has peripheral neuropathy, left upper extremity, due to service-connected diabetes mellitus, type II, manifested by mild incomplete paralysis, which is wholly sensory. 8. For the period from October 12, 2008, to September 7, 2012, the Veteran has peripheral neuropathy, right upper extremity, due to service-connected diabetes mellitus, type II, manifested by mild incomplete paralysis, which is wholly sensory. 9. For the period from October 12, 2008, to September 7, 2012, the Veteran has peripheral neuropathy, left lower extremity, due to service-connected diabetes mellitus, type II, manifested by mild incomplete paralysis, which is wholly sensory. 10. For the period from October 12, 2008, to September 7, 2012, the Veteran has peripheral neuropathy, right lower extremity, due to service-connected diabetes mellitus, type II, manifested by mild incomplete paralysis, which is wholly sensory. 11. A low back disability was not manifested during service and is not otherwise related to the Veteran's active service. 12. A cervical spine disability is not shown. 13. A left knee disability is not shown. 14. A right knee disability is not shown. 15. A left ankle disability was not manifested during service and is not otherwise related to the Veteran's active service. 16. A right ankle disability is not shown. 17. The weight of the evidence is against a finding that bilateral hearing loss was manifested during the Veteran's period of active service; it did not manifest within a year of separation from service, and is not otherwise shown to be the result of a disease or injury during active service. 18. Prior to September 13, 2013, the Veteran's peripheral vascular disease of the left lower extremity has not resulted in claudication on walking more than 100 yards, nor diminished peripheral pulses or ankle/brachial index of 0.9 or less. 19. Prior to September 13, 2013, the Veteran's peripheral vascular disease of the right lower extremity has not resulted in claudication on walking more than 100 yards, nor diminished peripheral pulses or ankle/brachial index of 0.9 or less. 20. From September 13, 2013, the Veteran's peripheral vascular disease of the left lower extremity has not resulted in claudication on walking less than 25 yards on a level grade at 2 miles per hour, nor ankle/brachial index of 0.5 or less. 21. From September 13, 2013, the Veteran's peripheral vascular disease of the right lower extremity has not resulted in claudication on walking less than 25 yards on a level grade at 2 miles per hour, nor ankle/brachial index of 0.5 or less. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral eye disability have not been met. 38 U.S.C.A. § 1110, 5107 (West 2002); 38 C.F.R. § 3.303, 4.9 (2015). 2. The criteria for service connection for renal dysfunction have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2014); 38 C.F.R. § 3.303 (2015). 3. The criteria for service connection for urinary incontinence have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2014); 38 C.F.R. § 3.303 (2015). 4. The criteria for service connection for a heart disability have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2014); 38 C.F.R. § 3.303 (2015). 5. The criteria for service connection for fecal incontinence have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2014); 38 C.F.R. § 3.303 (2015). 6. Effective October 12, 2008 to September 6, 2012, the criteria for a separate 10 percent disability rating for peripheral neuropathy, left upper extremity, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8515 (2015). 7. Effective October 12, 2008 to September 6, 2012, the criteria for a separate 10 percent disability rating for peripheral neuropathy, right upper extremity, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8515 (2015). 8. Effective October 12, 2008 to September 6, 2012, the criteria for a separate 10 percent disability rating for peripheral neuropathy, left lower extremity, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8520 (2015). 9. Effective October 12, 2008 to September 6, 2012, the criteria for a separate 10 percent disability rating for peripheral neuropathy, right lower extremity, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8520 (2015). 10. The criteria for service connection for a low back disability have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 11. The criteria for service connection for a cervical spine disability have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 12. The criteria for service connection for a left knee disability have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 13. The criteria for service connection for a right knee disability have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 14. The criteria for service connection for a left ankle disability have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 15. The criteria for service connection for a right ankle disability have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 16. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 17. Prior to September 13, 2013, the criteria for a compensable rating for peripheral vascular disease of the left lower extremity have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7114 (2015). 18. Prior to September 13, 2013, the criteria for a compensable rating for peripheral vascular disease of the right lower extremity have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7114 (2015). 19. From September 13, 2013, the criteria for a disability rating in excess of 40 percent for peripheral vascular disease of the left lower extremity have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7114 (2015). 20. From September 13, 2013, the criteria for a disability rating in excess of 40 percent for peripheral vascular disease of the right lower extremity have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7114 (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. The Veteran was sent letters in October 2008 and July 2009 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. Such letters also informed the Veteran of the type of information and evidence needed to establish a disability rating and effective date. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. Accordingly, no further development is required with respect to the duty to notify. 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 bilateral eye, renal dysfunction, urinary incontinence, heart disability, fecal incontinence, peripheral neuropathy, upper and lower extremities, low back disability, cervical spine disability, bilateral knee disability, bilateral ankle disability, and bilateral hearing loss service connection claims, and peripheral vascular disease increased rating claims. The Veteran was afforded VA examinations in August 2009 and September 2013 regarding his eyes; August 2009 regarding his claimed renal dysfunction and urinary incontinence; September 2009 regarding his claimed heart disability; September 2009 regarding his claimed fecal incontinence; April 2009 and September 2013 regarding his peripheral neuropathy; and, March 2011 regarding his bilateral hearing loss claim which will all be discussed below. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran was not afforded VA examinations with regard to his claimed back, cervical spine, bilateral ankle, and bilateral knee disabilities, but as will be discussed below such are not required in this case. Id. The Veteran was afforded VA examinations in September 2009 and September 2013 regarding his peripheral vascular disease. The Virtual folder contains the Veteran's service treatment records and identified post-service treatment records. No additional evidence has been identified by the Veteran with regard to these disabilities. 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). Service connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). An award of service connection based solely on continuity of symptomatology only applies to the listed chronic disabilities in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (38 C.F.R. § 3.303(b). For veterans who have served 90 days or more on or after December 31, 1946, certain chronic diseases, such as arthritis, cardiovascular-renal disease, sensorineural hearing loss, or tinnitus (as an organic disease of the nervous system), are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). With chronic diseases shown as such in service, or within the presumptive period after service, so as to permit a finding of service connection, subsequent manifestation of the same chronic disease at any later date, however remote, are service connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The second and third Caluza elements may also be satisfied under 38 C.F.R. § 3.303(b), by the submission of (a) evidence that a condition was "noted" during service or during an applicable presumption period; (b) evidence showing post-service continuity of symptomatology; and (c) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-97 (1998) (overruled on other grounds). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established. This baseline is to be established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(b). The rating activity is to determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. Id. In adjudicating this claim, the Board must assess the Veteran's competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368- 69 (2005). In Barr v. Nicholson, 21 Vet. App. 303 (2007) (overruled on other grounds), the Court emphasized that lay testimony is competent if it pertains to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge. See also 38 C.F.R. § 3.159(a)(2) (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person). Bilateral eye disabilities For purposes of entitlement to benefits, the law provides that refractive errors of the eyes are developmental defects and not disease or injury within the meaning of applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9. In the absence of superimposed disease or injury, service connection may not be allowed for refractive error of the eyes. 38 C.F.R. §§ 3.303(c), 4.9; VAOPGCPREC 82-90, 55 Fed. Reg. 45711 (1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). The Veteran asserts that his current vision impairment and disabilities related to the eyes are due to his service-connected diabetes mellitus, type II. Service records do not reflect any disabilities related to the eyes. An August 2009 VA examination report reflects diagnoses of refractive error (myopia, astigmatism, presbyopia), mild dry eyes, bilateral senile cataracts, hypertensive retinopathy grade 1, and glaucoma suspect with no diabetic retinopathy observed. The examiner commented that the Veteran's loss of vision is caused by refractive error and his symptoms by the mild dry eyes. The examiner stated that his loss of vision, including cataracts, was not caused by or a result of diabetes mellitus. A September 2012 VA examination report to assess the Veteran's diabetes mellitus reflects that the examiner checked the box for diabetic retinopathy but provided no further comment. Moreover, no eye examination was conducted at that time. 09/07/2012 VBMS entry, VA Examination at 3. A September 2013 VA examination report reflects that the Veteran has loss of vision due to incipient nuclear sclerosis and refractive error (myopia, astigmatism, presbyopia) in both eyes. Dilated fundus examination did not show diabetic retinopathy. The examiner commented that there were no findings of diabetic retinopathy and the examiner noted that no VA evaluations reflected diabetic retinopathy. The examiner stated that the Veteran's loss of vision and open angle glaucoma are not secondary to diabetes mellitus. Likewise, review of VA treatment records does not reflect a diagnosis of diabetic retinopathy. 02/03/2015 Virtual VA entry, CAPRI at 35-37; 08/30/2012 Virtual VA entry, CAPRI at 5-6; 12/18/2012 Virtual VA entry, CAPRI at 17, 24, 28; and, 04/07/2011 VBMS entry, Medical Treatment Record-Government Facility at 86 Initially, the Board notes that the Veteran's diagnosed refractive error is a condition which is not a disease or injury within the meaning of the applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9. Thus, service connection must be denied for this disability as a matter of law. Sabonis v. Brown, 6 Vet. App. 426 (1994). While the Veteran asserts that he has an eye condition that is due to his service-connected diabetes mellitus, the objective medical evidence does not reflect a finding of diabetic retinopathy or any disability of the eye associated with his diabetes mellitus. While acknowledging that the September 2012 VA examiner checked the box for 'diabetic retinopathy,' such was not based on an eye examination, and eye examinations conducted by all of the other VA examiners for VA examination and evaluation purposes do not reflect any findings of diabetic retinopathy nor any findings that he has an eye condition due to his diabetes mellitus. Thus, the Board finds that the September 2012 VA examination lacks any probative value with regard to the eye diagnosis. Rather, he has undergone two VA examinations wherein VA examiners found no diabetic retinopathy nor any eye disability due to his diabetes mellitus. These examinations are probative as the findings were based on objective examination of the Veteran. There is otherwise no medical evidence to support a finding of an eye disability related to his diabetes mellitus. The record contains no competent medical evidence of a nexus between his eye disabilities and the Veteran's active service or his diabetes mellitus. The Board has given consideration to the assertions of the Veteran; while he is competent to attest to the symptomatology associated with his eyes, it would require medical expertise to say that any eye disability is due to his diabetes mellitus. He is not shown to possess the requisite medical expertise. The Board therefore concludes that the evidence is against a nexus between the Veteran's claimed eye disabilities and his service-connected diabetes mellitus. Renal dysfunction The Veteran asserts that he has renal dysfunction due to his diabetes mellitus. Service treatment records do not reflect any complaints or treatment of renal or kidney dysfunction. An August 2009 VA examination reflects that the Veteran does not have a renal condition; he had normal renal function. A September 2013 VA examination also reflect no findings of renal involvement related to diabetes mellitus. Treatment records do not reflect a renal condition. In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer, 3 Vet. App. at 225. In the absence of any competent evidence of renal dysfunction, the Board must conclude the Veteran does not currently suffer from such disability. Without competent evidence of a diagnosis of renal dysfunction, the Board must deny the Veteran's claim. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). The Board has considered the Veteran's general contention that he has this claimed disability due to his service-connected diabetes mellitus, but he is not competent to attest to a diagnosis as this requires medical expertise. Again, the medical records do not reflect a diagnosis of renal dysfunction. The Veteran's general contentions are outweighed by the lack of diagnosis or complaints reflected in the medical records. Absent a showing of a renal condition, service connection for this disability cannot be granted. Thus, the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim of service connection for renal dysfunction must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Urinary incontinence The Veteran asserts that he has urinary incontinence due to his diabetes mellitus. Service treatment records do not reflect any complaints or treatment of urinary incontinence. An August 2009 VA examination reflects that the Veteran does not have urinary incontinence. Treatment records do not reflect urinary incontinence. In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer, 3 Vet. App. at 225. In the absence of any competent evidence of urinary incontinence, the Board must conclude the Veteran does not currently suffer from such disability. Without competent evidence of a diagnosis of urinary incontinence, the Board must deny the Veteran's claim. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). Again, the medical records do not reflect a diagnosis of urinary incontinence due to diabetes mellitus or any other cause. The Board acknowledges that urinary incontinence is a condition that a lay person can observe, and thus the Veteran's lay statements could by themselves support the existence of symptomatology. Here, however, he has not provided detailed or specific statements on this claim; thus the best evidence of record is the notation in the examination report that there is no urinary incontinence. Moreover, even if incontinence was accepted as fact, the record lacks any showing of continuity back to service or competent evidence otherwise linking the disorder to service or to service-connected diabetes mellitus. The Veteran himself is not competent to attribute a diagnosis to service or to his diabetes, as this requires medical expertise. In sum, the Veteran's general contentions are outweighed by the lack of diagnosis or complaints reflected in the medical records. Absent a showing of urinary incontinence, service connection for this disability cannot be granted. Thus, the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim of service connection for urinary incontinence must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Heart disability The Veteran asserts that he has a heart disability. Service treatment records do not reflect any complaints or treatment of a cardiac disability. At a September 2009 VA examination, the Veteran reported that he did not know if he had a heart condition but reported a history of heart palpitations. He reported occasional chest oppression that last 10 minutes with associated shortness of breath without irradiation. On examination, there was no objective evidence of a heart condition. Treatment records do not reflect a heart condition. In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer, 3 Vet. App. at 225. In the absence of any competent evidence of a heart condition, the Board must conclude the Veteran does not currently suffer from such disability. Without competent evidence of a diagnosis of a heart condition, the Board must deny the Veteran's claim. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). The Board has considered the Veteran's general contention that he has this claimed disability due to service or due to his diabetes mellitus. The Veteran, however, is not competent to attest to a diagnosis as this requires medical expertise. Again, the medical records do not reflect a diagnosis of a heart condition. The Veteran's general contentions are outweighed by the lack of diagnosis or complaints reflected in the medical records. Absent a showing of a heart condition, service connection for this disability cannot be granted. Thus, the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim of service connection for a heart condition must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Fecal incontinence The Veteran asserts that he has fecal incontinence due to his diabetes mellitus. Service treatment records do not reflect any complaints or treatment of fecal incontinence. At a September 2009 VA examination, the Veteran reported that he had been noticing that with the urge to bowel movement he had small stool incontinence as well as upon standing from a chair. He denied waking up with involuntary bowel movement, and denied involuntary bowel movement. On objective examination, there was no finding of fecal incontinence. Treatment records do not otherwise reflect fecal incontinence. In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer, 3 Vet. App. at 225. In the absence of any competent evidence of fecal incontinence, the Board must conclude the Veteran does not currently suffer from such disability. Without competent evidence of a diagnosis of fecal incontinence, the Board must deny the Veteran's claim. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). The Board has considered the Veteran's general contention that he has this claimed disability due to his service-connected diabetes mellitus; however, he is not competent to attest to a diagnosis as this requires medical expertise. The examiner considered the Veteran's lay contentions but found no diagnosed condition. Again, the medical records do not reflect a diagnosis of fecal incontinence. The Veteran's general contentions are outweighed by the lack of diagnosis or complaints reflected in the medical records. Absent a showing of fecal incontinence, service connection for this disability cannot be granted. Thus, the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim of service connection for fecal incontinence must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Peripheral neuropathy, bilateral lower and upper extremities As detailed above, service connection was established for diabetes mellitus, type II, rated 20 percent disabling, effective October 12, 2008 but the RO denied entitlement to separate awards of service connection for neuropathy of the bilateral lower and upper extremities. Thereafter, ratings were assigned to peripheral neuropathy, right upper extremity, rated 20 percent disabling; peripheral neuropathy, left upper extremity, rated 20 percent disabling; peripheral neuropathy, right lower extremity, rated 10 percent disabling; peripheral neuropathy, left lower extremity, rated 10 percent disabling, all effective September 7, 2012. Effective September 13, 2013, the following ratings were assigned: peripheral neuropathy, right upper extremity, 40 percent disabling; peripheral neuropathy, left upper extremity, 30 percent disabling; peripheral neuropathy, right lower extremity, 40 percent disabling; and, peripheral neuropathy, left lower extremity, 40 percent disabling. The Board has determined that separate compensable ratings are warranted for the Veteran's peripheral neuropathy, bilateral lower and upper extremities, associated with his diabetes mellitus, type II, effective October 12, 2008, corresponding to the date that service connection was established. A December 2008 VA treatment record reflects complaints of tingling sensation in his feet. The examiner suspected diabetic neuropathy and Gabapentin was prescribed. 02/03/2015 Virtual VA entry, CAPRI at 35. An April 2009 VA examination report reflects complaints of neuropathy with a date of onset in 2007. The disorder was treated with Gabapentin. In both his upper and lower extremities, the Veteran complained of pin and needles and electric shock, painful cramps in toes. On objective sensory examination, the examiner noted decreased vibration, pain, sensation, and light touch. His peripheral nerves were affected. The examiner diagnosed clinical symptoms of mild peripheral neuropathy affecting the lower and upper extremities, most likely of diabetic origin. A June 2010 VA treatment record reflects complaints of moderate burning pain and electrical sensation in both plantar areas, toes, and posterior aspects of the legs. Neuropathy was assessed. 04/07/2011 VBMS entry, Medical Treatment Record - Government Facility at 76. A July 2012 VA treatment record reflects objective findings of decreased DTR patellar arches bilaterally. 12/18/2012 Virtual VA entry, CAPRI at 27-28. A September 2013 VA examination report reflects mild, intermittent pain in the extremities. The Veteran experienced mild paresthesia and/or dysthesia in the upper extremities and severe paresthesia and/or dysthesia in the lower extremities. He experienced moderate numbness in the upper extremities and severe numbness in the lower extremities. On light touch/monofilament testing, there was decreased sensation in the hands/fingers and the foot/toes. For the period prior to September 7, 2012, the Board finds that the evidence reflects that separate 10 percent ratings are warranted for a mild incomplete paralysis of the left and right upper extremities, specifically in contemplation of 38 C.F.R. § 4.124a, Diagnostic Code 8515 (median nerve) and 8615 (neuritis). The evidence of record prior to September 7, 2012 describes the neuropathy as wholly sensory and mild in nature. The April 2009 peripheral nerve reflex examination was essentially normal. Thus, 30 percent ratings are not warranted in contemplation of moderate incomplete paralysis. Thus the evidence reflects mild neuropathy affecting the right and left upper extremities, for which separate 10 percent ratings are to be assigned for the period from October 12, 2008, to September 7, 2012. For the period prior to September 7, 2012, the Board finds that the evidence reflects that separate 10 percent ratings are warranted for neuropathy of the left and right lower extremities, specifically in contemplation of 38 C.F.R. 4.124a, Diagnostic Code 8520 as analogous to impairment of the sciatic nerve. Under Diagnostic Code 8520, pertaining to paralysis of the sciatic nerve, mild incomplete paralysis warrants a 10 percent disability rating, moderate incomplete paralysis warrants a 20 percent disability rating, moderately severe incomplete paralysis warrants a 40 percent disability rating, and severe incomplete paralysis with marked muscular atrophy warrants a 60 percent disability rating. An 80 percent disability rating is warranted for complete paralysis, where the foot dangles and drops, there is no active movement possible of the muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. See 38 C.F.R. § 4.121a, Diagnostic Code 8520. Again, the Board finds that the evidence supports a 10 percent rating per leg for the peripheral neuropathy affecting the lower extremities under Diagnostic Code 8520 for this period. The findings from the April 2009 VA examination showed complaints of tingling bilateral lower extremities, and the examiner described the sensory loss on both the left and ride side as mild peripheral neuropathy. He had 2+ reflexes, and no evidence of more than mild pathology. Babinski reflex was normal. Thus the evidence reflects mild neuropathy affecting both legs, for which separate 10 percent ratings are to be assigned for the period from October 12, 2008, to September 7, 2012. Back, cervical spine, bilateral ankle, and bilateral knee disabilities The Veteran has claimed entitlement to service connection for low back, cervical spine, bilateral knee, and bilateral ankle disabilities due to service. See 08/06/2010 VBMS entry, VA 21-4138 Statement in Support of Claim and 04/18/2012 VBMS entry, Correspondence. These submissions do not contain any specifics as to his belief that these conditions are due to service. Service treatment records do not reflect treatment for any of these claimed disabilities. On a September 1970 Report of Medical History conducted for separation purposes, the Veteran checked the 'No' boxes for '"trick" or locked knee' and 'back trouble of any kind.' On a September 1970 Report of Medical Examination, the Veteran's 'spine, other musculoskeletal' and 'lower extremities' were clinically evaluated as normal. Post-service treatment records do not reflect any complaints or treatment related to the cervical spine, right ankle, and knees. A September 2003 VA treatment record reflects complaints related to the left ankle. Specifically, he denied any trauma but reported pain since early that morning. 08/30/2013 Virtual VA entry, CAPRI at 3. An April 2004 VA treatment record reflects initial complaints related to the back, specifically rule out back strain. Id. at 8. Subsequent records reflect treatment related to the low back. 02/03/2015 Virtual VA entry, CAPRI at 28; 08/30/2012 Virtual VA entry, CAPRI at 68; 04/07/11 VBMS entry, Medical Treatment Record-Government Facility at 38, 57-61, 93. The Veteran has made general assertions that these conditions are due to service, however, there is otherwise no evidence that these conditions manifested in service or are due to service. With regard to the back and left ankle, the Veteran sought treatment for these conditions over three decades after separation from service. In this regard, evidence of a prolonged period without medical complaint can be considered as a factor, along with other factors concerning the Veteran's health and medical treatment during and after military service. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Notwithstanding this, the Veteran has not offered any specific assertions as to why he believes that service connection is warranted for these claimed disabilities. The Veteran has not claimed any specific injuries or symptoms experienced during service. With regard to the claimed cervical spine, right ankle, and bilateral knee disabilities, in the absence of proof of current disabilities, there can be no valid claims. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer, 3 Vet. App. at 225. In the absence of any competent evidence of cervical spine, right ankle, and bilateral knee disabilities, the Board must conclude the Veteran does not currently suffer from such disabilities. Without competent evidence of diagnoses of cervical spine, right ankle, and bilateral knee disabilities, the Board must deny the Veteran's claims. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). It is noted that the RO did not provide a VA examiner to review the Virtual folders for a nexus opinion for these service connection claims but such is not required in order to make a final adjudication. McLendon v. Nicholson, 20 Vet. App. 79 (2006), states, that in disability compensation (service connection) claims, VA must provide a medical examination [for a nexus opinion, as applicable] when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. Simply stated, the standards of McLendon are not met in this case. There is no evidence to establish a link between his current back and left ankle conditions, as such conditions were diagnosed decades after separation from service. As detailed above, cervical spine, right ankle, and bilateral knee disabilities have not been diagnosed. As the evidence does not establish that the Veteran suffered "an event, injury or disease in service," with regard to any of these claimed disabilities, it is not necessary to obtain a VA medical opinion with regard to etiology. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). In other words, absent such evidence, the Board finds that it is unnecessary to require the Veteran to report for a VA medical examination or to ask a medical expert to review the record because any examination report or medical opinion could not provide competent evidence of the incurrence of these claimed disabilities in service. Moreover, given the absence of any competent evidence of the claimed back and left ankle disabilities until many years after service, any current opinions provided at this point would be no more than speculative. See 38 C.F.R. § 3.102 (a finding of service connection may not be based on a resort to speculation or even remote possibility). The Board has considered the Veteran's general contention that he has these claimed disabilities due to service. He has not offered any specific statements regarding any observable symptomatology related to the cervical spine, right ankle, and bilateral knee disabilities, and is otherwise not competent to attest to diagnoses as this requires medical expertise. Likewise, the Veteran's assertions reflected in the post-service records pertaining to the back and left ankle do not contain any lay assertions of an in-service injury, and he is not competent to relate these conditions to service. Again, the medical records do not reflect diagnoses of cervical spine, right ankle, and bilateral knee disabilities. Medical diagnoses related to the back and left ankle are documented decades after separation from service. The Veteran's general contentions are outweighed by the clinical findings documented many years after separation from service, and the lack of diagnoses or complaints reflected in the medical records. Absent a showing of cervical spine, right ankle, and bilateral knee disabilities, service connection for these disabilities cannot be granted. Moreover, absent any credible evidence supporting a connection between his current back and left ankle disabilities and service, service connection for these disabilities cannot be granted. Thus, the preponderance of the evidence is against the claims, the benefit-of-the-doubt doctrine does not apply, and the claims of service connection for back, left ankle, right ankle, cervical spine, right knee, and left knee disabilities must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Bilateral hearing loss Hearing loss is considered to be a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition thresholds using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The United States Court of Veterans Appeals (Court) has indicated that the threshold for normal hearing is between 0 and 20 decibels and that higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 159 (1993). The Veteran's DD Form 214 reflects that he served in the Republic of Vietnam as a combat engineer. In September 1970, the Veteran complained of hearing loss. Three audiograms were done which showed hearing loss, however, findings were inconsistent. Repeat testing showed normal hearing after encouragement. Reports of Medical Examinations conducted in January 1980 and July 1987 reflect normal hearing. On a July 1987 Report of Medical History, the Veteran checked the 'No' box for hearing loss. 08/09/2014 VBMS entry, STR-Medical. In March 2011, the Veteran underwent a VA examination. The examiner noted review of the service treatment records noting normal hearing on examinations in July 1968, September 17, 1970, January 1980, and July 1987. A September 3, 1970 examination showed mild to severe hearing loss. A September 4, 1970 examination showed mild to moderately severe loss in the right ear and moderate and moderately severe loss in the left ear. The Veteran claimed one and a half years of in-service noise exposure and denied post-service occupational and recreational exposure. The examiner diagnosed hearing within normal limits from 500 to 3000 Hertz with mild sensorineural hearing loss at 4000 Hertz; and, hearing within normal limits from 5000 to 2000 Hertz with mild to moderate sensorineural hearing loss from 3000 to 4000 Hertz. The examiner stated that it is well known that prolongated exposure to noise of high intensity and short duration, such as the military type, could cause permanent damage in the inner structures of the ear, resulting in irreversible hearing loss. On the other hand, this could be caused by the normal aging process. Even though the audiologic exams show hearing loss in service records in two examinations prior to service separation, normal hearing was shown in the next three audiologic evaluations. These evaluations include an audiogram performed a few days after the two examinations showing hearing loss. In addition, inconsistency in the Veteran's response was noted in the examinations showing hearing loss. The examiner stated that since the Veteran is 62 years old and normal hearing is shown in the last pre-separation examination and the evaluations in January 1980 and July 1987 it is less likely as not related to the acoustic trauma and diagnosed hearing while in service. In September 2012, the Veteran underwent a VA examination wherein the examiner diagnosed sensorineural hearing loss. The examiner commented that the claims folder was not available and only had access to VA treatment records. The examiner noted that VA audiological evaluations showed mild hearing loss at the higher frequencies in the right ear and mild to moderate hearing loss in the left ear, since October 2002 to March 2011. However, there are no significant changes when compared with the March 2011 evaluation. While the record establishes that the Veteran had noise exposure in service and has a current hearing loss disability, the outcome of the appeals turns on whether the hearing loss is related to the noise exposure or other disease or injury in service. As detailed above, while service treatment records do reflect complaints of hearing loss and objective findings of hearing loss in 1970, subsequent testing does not show any hearing loss. Moreover, there is no post-service evidence of hearing loss until in or about 2002, thus many years after separation from active service and when in-service hearing loss was shown. With respect to negative evidence, the fact that there was no record of any complaint, let alone treatment, involving the Veteran's condition for many years is significant. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that it was proper to consider the veteran's entire medical history, including a lengthy period of absence of complaints). In March 2011, the Veteran underwent a VA audiological examination wherein the examiner acknowledged the Veteran's in-service hearing problems and audiological findings, but noted that subsequent examinations showed normal hearing. Even considering his in-service noise exposure and hearing problems, the examiner opined that his current hearing loss is not due to service. The March 2011 VA examiner considered the Veteran's in-service noise exposure, his in-service hearing loss, his post-service lay contentions, and objective findings, concluding that his hearing loss is not due to his in-service noise exposure. The March 2011 opinion was supported by a thorough analysis in consideration of the lay evidence and objective evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295. 304 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board has given consideration to the lay evidence from the Veteran pertaining to his hearing loss symptoms. The Veteran, however, is not capable of diagnosing hearing loss as such requires appropriate audiometric testing. While the Veteran is competent to attest to any hearing problems during and since service, after in-service hearing loss was shown, audiometric testing showed normal hearing. The Veteran does not have the requisite medical expertise to find that this disability is due to service. His opinion in this regard is not competent. In light of the Veteran's assertions of noise exposure and VA conceding noise exposure, and in light of the in-service problems, a medical opinion was sought, which was negative. The medical evidence and opinion outweighs the lay contentions of the Veteran. Moreover, while hearing loss is a chronic disease subject to special presumptive provisions, there is no evidence of manifestation within one year of active service. Therefore, in this case service connection cannot be established through the chronic disease presumption or lay statements of continuity of symptomatology. See Walker, 708 F.3d at 1331; 38 C.F.R. §§ 3.307, 3.309. The March 2011 VA examiner's opinion is the most probative evidence of record as to the question of nexus. As the most probative evidence is against the claim of service connection for hearing loss, reasonable doubt does not arise and the claim is denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Increased ratings 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. Peripheral vascular (arterial) disease, bilateral lower extremities, prior to September 13, 2013 Peripheral vascular disease is evaluated pursuant to Diagnostic Code 7114. This code provision provides a 20 percent disability rating if evidence shows claudication on walking more than 100 yards, and diminished peripheral pulses or an ankle/brachial index (ABI) of 0.9 or less. The next higher rating of 40 percent disability rating is assigned if there is claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour, and; trophic changes (thin skin, absence of hair, dystrophic nails) or ABI of 0.7 or less. A 60 percent disability rating requires claudication on walking less than 25 yards on a level grade at 2 miles per hour, and; either persistent coldness of the extremity or ABI of 0.5 or less. A 100 percent disability rating is warranted for ischemic limb pain at rest, and; either deep ischemic ulcers or ABI of 0.4 or less. Note 1 to Diagnostic Code 7114 provides that the ABI is the ratio of the systolic blood pressure at the ankle (determined by Doppler study) divided by the simultaneous brachial artery systolic blood pressure. The normal index is 1.0 or greater. 38 C.F.R. § 4.104, DC 7114 (2015). In September 2009, the Veteran underwent a VA examination to assess the nature and etiology of his peripheral vascular disease. At that time, he reported that he had been developing episodes of electrical sensation of the feet, calf, and toes. He also reported leg cramps while sleeping. He denied cramps while walking. He denied any claudication and denied any pain at rest. On objective examination, there was distal hair loss of the legs and his skin was cold to touch but there were no trophic changes or color changes or ulcers. The examiner diagnosed peripherovascular artery disease. While the September 2009 examiner determined that this condition was due to his diabetes mellitus, the objective findings and subjective complaints do not support findings of claudication nor diminished peripheral pulses or ankle brachial index of .9 or less. Thus, compensable ratings are not warranted for peripheral vascular disease for the period prior to September 13, 2013. There are no treatment records during this period which would support a higher rating. The Board notes that, per this decision, for such period, separate ratings are in effect for his peripheral neuropathy affecting the lower extremities. Peripheral vascular (arterial) disease, bilateral lower extremities, from September 13, 2013 In September 2013, the Veteran underwent a VA examination to assess his peripheral vascular disease wherein the examiner determined that his condition was manifested by claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour and manifested by persistent coldness of the extremity, diminished peripheral pulses, and trophic changes. Based on such objective findings, disability ratings in excess of 40 percent are not warranted as claudication on walking less than 25 yards on a level grade at 2 miles per hour was not shown. The examiner was unable to test the ankle/brachial index as calcifications were scattered in both legs. There are no treatment records which would support a higher rating. The Board notes that separate ratings are also in effect for his peripheral neuropathy affecting the lower extremities. The Board must also determine whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluations are adequate. An evaluation in excess of those assigned is provided for certain manifestations of the disability in question, but the medical evidence reflects that the manifestations are not present in this case. Additionally, the diagnostic criteria adequately describes the severity and symptomatology of the various aspects of the Veteran's disorder. The Veteran has not alleged during the appeal period that such evaluations are inadequate for distinct symptomatology nor has he stated that such symptomatology is additionally exceptional in some way or manifests itself in an otherwise unusual disability picture. The Board finds that diagnostic criteria is adequate for the service-connected disability. Indeed, there is no indication that the Veteran experiences symptoms that are outside the range of that contemplated by the relevant diagnostic codes. Accordingly, referral for extraschedular consideration is not for application here. A total disability rating due to individual unemployability (TDIU) has been established effective October 1, 2008, which contemplates the entire period contemplated by this appeal. ORDER Entitlement to service connection for a bilateral eye disability is denied. Entitlement to service connection for renal dysfunction is denied. Entitlement to service connection for urinary incontinence is denied. Entitlement to service connection for a heart disability is denied. Entitlement to service connection for fecal incontinence is denied. Entitlement to a compensable disability rating for peripheral vascular (arterial) disease, right lower extremity, for the period prior to September 13, 2013 is denied. Entitlement to a compensable disability rating for peripheral vascular (arterial) disease, left lower extremity, for the period prior to September 13, 2013 is denied. Entitlement to a disability rating in excess of 40 percent for peripheral vascular (arterial) disease, right lower extremity, for the period from September 13, 2013 is denied. Entitlement to a disability rating in excess of 40 percent for peripheral vascular (arterial) disease, left lower extremity, for the period from September 13, 2013 is denied. For the period from October 12, 2008, to September 7, 2012, a 10 percent disability rating for peripheral neuropathy, right upper extremity, is granted. For the period from October 12, 2008, to September 7, 2012, a 10 percent disability rating for peripheral neuropathy, left upper extremity, is granted. For the period from October 12, 2008, to September 7, 2012, a 10 percent disability rating for peripheral neuropathy, right lower extremity, is granted. For the period from October 12, 2008, to September 7, 2012, a 10 percent disability rating for peripheral neuropathy, left lower extremity, is granted. Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a cervical spine disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left ankle disability is denied. Entitlement to service connection for a right ankle disability is denied. Entitlement to service connection for bilateral hearing loss is denied. REMAND Hypertension The Veteran asserts that his hypertension is due to or aggravated by his service-connected diabetes mellitus and PTSD. An April 2009 VA examination report reflects that the Veteran has hypertension and indicated 'No' it is not a complication of diabetes. The rationale was that there was no microalbuminuria nor retinopathy on examination. With regard to whether the Veteran's hypertension is worsened or increased by his diabetes mellitus, the examiner stated 'No.' 04/21/2009 VBMS entry, VA Examination at 7. In September 2013, the Veteran underwent a VA examination. The examiner stated that the blood pressure chart shows no evidence of high blood pressure aggravation. 09/16/2013 VBMS entry, Medical Treatment Record - Government Facility at 14. Such opinions do not contain an appropriate rationale, and do not address any claimed relationship between his hypertension and PTSD. Thus, remand is necessary to obtain appropriate opinions. Small hiatal hernia, distal grade I reflux esophagitis, erosive gastritis In February 2011, the Veteran underwent a VA examination to assess the nature and etiology of his claimed gastric condition and service connection was established for small hiatal hernia, distal grade I reflux esophagitis, erosive gastritis, rated 10 percent disabling. The Veteran continues to seek treatment for gastritis. 02/03/2015 Virtual VA entry, CAPRI at 83. In light of the fact that the Veteran asserts that a higher rating is warranted and that such examination was conducted over five years prior, the Veteran should be afforded a new VA examination to assess the severity of his condition. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995)). Accordingly, the case is REMANDED for the following actions: 1. Associate with the Virtual folders updated treatment records for the period from January 29, 2015. 2. Request that a VA physician with appropriate expertise review the Virtual folders to determine the etiology of his claimed hypertension. The examiner should respond to the following: a) Please state whether hypertension is at least as likely as not (50 percent or greater probability) caused by diabetes mellitus, type II. b) Please state whether hypertension 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, type II?. 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 hypertension is at least as likely as not (50 percent or greater probability) caused by PTSD. d) Please state whether hypertension 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 PTSD? 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. An examination should be scheduled only if deemed necessary by the VA examiner. 3. Schedule the Veteran for VA examination to determine the current severity of his service-connected hiatal hernia. The Virtual folder should be made available to the examiner(s) for review and all necessary testing should be conducted. All indicated studies and diagnostic testing should be performed. The examination report should clearly address whether the veteran has recurrent epigastric distress with dysphagia; pyrosis; regurgitation; substernal or arm or shoulder pain; pain; vomiting; material weight loss; hematemesis; melena; anemia; or, any other symptom combinations productive of severe impairment of health. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so. 4. After completion of the above, review the expanded record and readjudicate the service connection and increased rating issue. If either benefit sought is not granted in full, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The Veteran has 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