Citation Nr: 1617627 Decision Date: 05/03/16 Archive Date: 05/13/16 DOCKET NO. 09-31 047 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus. 2. Entitlement to a disability rating in excess of 20 percent for peripheral neuropathy of the right lower extremity. 3. Entitlement to a disability rating in excess of 20 percent for peripheral neuropathy of the left lower extremity. 4. Entitlement to disability ratings in excess of 10 percent for hypertension prior to October 12, 2011; and in excess of 60 percent for diabetic nephropathy with hypertension, for the period from October 12, 2011. 5. Entitlement to a compensable disability rating for hemorrhoids. 6. Entitlement to a compensable disability rating for erectile dysfunction. 7. Entitlement to a total disability rating based on individual unemployability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Mary C. Suffoletta, Counsel INTRODUCTION The Veteran served on active duty from January 1975 to April 1989, plus had prior unverified service. These matters come to the Board of Veterans' Appeals (Board) on appeal from an October 2008 decision and subsequent decisions of the RO that denied a TDIU; and thereby denied the underlying claims for increased ratings for diabetes mellitus, for peripheral neuropathy of each lower extremity, for hypertension, for diabetic nephropathy, for hemorrhoids, and for erectile dysfunction. The Veteran timely appealed. These are the only issues that have been perfected on appeal. In May 2010, the Veteran testified during a hearing before RO personnel. In August 2015, the Veteran withdrew his prior request for a Board hearing, in writing. Lastly, in addition to reviewing the Veteran's paper claims file, the Board has surveyed the contents of his electronic claims file. The issue of a compensable rating for hemorrhoids is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran and his representative when further action is required. FINDINGS OF FACT 1. The Veteran's diabetes mellitus has been treated with insulin and oral medications and a restricted diet, but has not required restriction or regulation of activities. 2. The Veteran's peripheral neuropathy of the right lower extremity has been manifested primarily by constant pain and sensory deficits of the right lower extremity equivalent to, at most, moderate incomplete paralysis of the sciatic nerve; motor weakness, muscle atrophy, or trophic changes equivalent to moderately severe incomplete paralysis of the sciatic nerve have not been demonstrated. 3. The Veteran's peripheral neuropathy of the left lower extremity has been manifested primarily by sensory deficits of the left lower extremity equivalent to, at most, moderate incomplete paralysis of the sciatic nerve; motor weakness, muscle atrophy, or trophic changes equivalent to moderately severe incomplete paralysis of the sciatic nerve have not been demonstrated. 4. For the rating period prior to October 12, 2011, the Veteran's hypertension has required medication for control; and has been manifested by systolic blood pressure of predominantly 160 or more. 5. For the rating period from October 12, 2011, the Veteran's diabetic nephropathy with hypertension has been manifested by a definite decrease in kidney function; persistent edema and albuminuria with BUN 40 to 80mg%, creatinine 4 to 8mg%, or generalized poor health characterized by lethargy or weakness or anorexia or weight loss or limitation of exertion are not demonstrated. 6. The Veteran's erectile dysfunction does not result in any deformity of the penis. 7. Service connection is in effect for tinea versicolor, rated as 60 percent disabling; for diabetic nephropathy with hypertension, rated as 60 percent disabling; for diabetes mellitus, rated as 20 percent disabling; for peripheral neuropathy of the right lower extremity and of the left lower extremity, each rated as 20 percent disabling; for diabetic retinopathy and vitreous heme, rated as 20 percent disabling; for a voiding dysfunction, rated as 10 percent disabling; and for hemorrhoids and for erectile dysfunction, each rated as 0 percent (noncompensable) disabling. The combined disability rating is 90 percent from April 9, 2008, and 100 percent from June 30, 2014. 8. The Veteran has not worked full-time since 2005; he reportedly has work experience as a real estate agent. 9. Prior to the award of the combined 100 percent evaluation, the combined effect of service-connected disabilities prevented the Veteran from obtaining or retaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for diabetes mellitus are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.119, Diagnostic Code 7913 (2015). 2. The criteria for a disability rating in excess of 20 percent for peripheral neuropathy of the right lower extremity are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.20, 4.27, 4.124a Diagnostic Codes 8520, 8620 (2015). 3. The criteria for a disability rating in excess of 20 percent for peripheral neuropathy of the left lower extremity are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.20, 4.27, 4.124a Diagnostic Codes 8520, 8620 (2015). 4. The criteria for a disability rating in excess of 10 percent for hypertension, for the period prior to October 12, 2011, are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.104, Diagnostic Code 7101 (2015). 5. The criteria for a disability rating in excess of 60 percent for diabetic nephropathy with hypertension, for the period from October 12, 2011, are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.115b, Diagnostic Code 7541 (2015). 6. The criteria for a compensable rating for erectile dysfunction are not met. 38 U.S.C.A. §§ 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.115b, Diagnostic Code 7522 (2015). 7. The criteria for TDIU are met (prior to the award of the combined 100 percent evaluation). 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.15, 4.16(b) (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist 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 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). VA should notify the Veteran of: (1) the evidence that is needed to substantiate the claim(s); (2) the evidence, if any, to be obtained by VA; and (3) the evidence, if any, to be provided by the claimant. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (codified at 38 C.F.R. Part 3). A decision by the United States Court of Appeals for the Federal Circuit has addressed the amount of notice required for increased rating claims, essentially stating that general notice is adequate and notice need not be tailored to each specific Veteran's case. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), rev'd sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Through April 2008 and May 2011 letters, the RO notified the Veteran of elements of an increased rating claim, and the evidence needed to establish each element. These documents served to provide notice of the information and evidence needed to substantiate the claims, including the process by which disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Defects as to the timeliness of the statutory and regulatory notice are rendered moot because each the Veteran's claims on appeal has been fully developed and re-adjudicated by an agency of original jurisdiction after notice was provided. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). There is no indication that any additional action is needed to comply with the duty to assist the Veteran. The RO has obtained copies of the service treatment records and outpatient treatment records, and has arranged for VA examinations in connection with the claims on appeal, reports of which are of record and are adequate for rating purposes. The Veteran has not identified, and the record does not otherwise indicate, any existing pertinent evidence that has not been obtained. Given these facts, it appears that all available records have been obtained. There is no further assistance that would be reasonably likely to assist the Veteran in substantiating the claims. 38 U.S.C.A. § 5103A(a)(2). II. Increased Ratings Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 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 (2015). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 4.3 (2015). The Veteran's entire history is reviewed when making disability evaluations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When a disability has undergone varying and distinct levels of severity during the appeal, it is appropriate to apply staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). On April 9, 2008, the Veteran filed a claim for a TDIU due to his diabetes mellitus and its complications. A. Diabetes Mellitus Service connection has been established for diabetes mellitus. The RO evaluated the Veteran's disability as 20 percent disabling under 38 C.F.R. § 4.119, Diagnostic Code 7913. Pursuant to Diagnostic Code 7913, a 20 percent rating is assigned for diabetes mellitus requiring insulin and restricted diet, or oral hypoglycemic agent and restricted diet. A rating of 40 percent is assigned for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent evaluation is for application when diabetes mellitus requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent evaluation requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least 3 hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2015). Pursuant to Diagnostic Code 7913, Note (1)-pertaining to diabetes mellitus-complications are rated as part of the diabetic process unless they are compensably disabling, in which case they are rated separately. In this case, the Veteran's complications have been evaluated separately and most are discussed in detail below; hence, they are not for consideration in the evaluation of his diabetes mellitus. 38 C.F.R. § 4.14. The Veteran's diabetic retinopathy, which has also been separately evaluated, is no longer in appellate status and is not addressed in this decision. Historically, the Veteran's diabetes mellitus had been controlled with oral medications and a restricted diet of no salt, low fat, and no concentrated sweets. VA records, dated in May 2008, show that the Veteran was taking insulin and oral medications for his diabetes mellitus. At the time he discussed his dietary intake and diet portion. The Veteran denied hypoglycemia or other problems with treatment. The report of a May 2008 VA (contract) examination reflects that the Veteran visited his physician four times yearly for his diabetes mellitus; and that treatment consisted of insulin administered once per day, and oral medications. The Veteran reportedly did not experience any functional impact from the condition. Following examination, the examiner opined that the Veteran's diabetes mellitus did not cause any restriction of activities. The report of a May 2012 VA (contract) examination reflects that the Veteran's diabetes mellitus is treated by restricted diet, oral hypoglycemic agents, and prescribed insulin. Regulation of activities is not part of the medical management of his diabetes mellitus. The Veteran visited his diabetic care provider less than two times per month, and reported no hospitalizations for episodes of ketoacidosis or hypoglycemic reactions over the past twelve months. He also attributed no progressive unintentional weight loss or strength to diabetes mellitus. Here, throughout the rating period, the evidence supports a finding that the Veteran's diabetes mellitus requires insulin, oral medications, and a restricted diet; and is against a finding that the Veteran's diabetes mellitus requires regulation of activities. Under these circumstances, the evidence is against awarding an evaluation in excess of 20 percent. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21 (2015). B. Peripheral Neuropathy of Each Lower Extremity As noted above, complications are rated as part of the diabetic process unless they are compensably disabling, in which case they are rated separately. Service connection has been established for peripheral neuropathy of the right and left lower extremities. The RO evaluated each lower extremity as 20 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code 8620, pertaining to neuritis of the sciatic nerve. The criteria for rating diseases of the peripheral nerves are based on paralysis, neuritis, or neuralgia. Because the evidence shows that the Veteran's lower extremities are functional, it is clear that the peripheral neuropathy does not produce complete paralysis. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a (Diseases of the Peripheral Nerves). Neuritis of a peripheral nerve, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain-at times excruciating-is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe incomplete paralysis. 38 C.F.R. § 4.123. Neuralgia of a peripheral nerve, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124 (with exceptions not relevant here). A 20 percent evaluation is warranted for moderate incomplete paralysis of the sciatic nerve of the lower extremity. A 40 percent evaluation is warranted for moderately severe incomplete paralysis of the sciatic nerve of the lower extremity. A 60 percent evaluation is warranted for severe incomplete paralysis of the sciatic nerve with marked muscular atrophy of the lower extremity. An 80 percent evaluation is warranted for complete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Complete paralysis of the sciatic nerve is indicated when the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Historically, the Veteran developed numbness in his feet, with an increasing sensation of cold at night in his feet. He had to get up and walk to relieve the symptoms. This gradually progressed to numbness in the lower legs, which was worse with walking; and the bottoms of his feet were numb. During a May 2008 VA examination, the Veteran reported progressive loss of strength in his legs and feet; and tingling and numbness in his legs and feet. He reported no leg pain after walking distances. There was no calf pain at rest, and he did not feel persistent coldness of the extremities. Neurological examination of the lower extremities revealed that motor function was within normal limits; sensory function was abnormal, with findings of decreased vibratory sense. Reflexes of both knee jerk and ankle jerk were 2+. The examiner opined that the Veteran's peripheral neuropathy was a complication of diabetes mellitus, and resulted in neuritis. Nerve conduction studies in April 2010 were abnormal, and revealed evidence of mixed peripheral polyneuropathy involving the lower and upper extremities. The report of an April 2012 VA examination reveals a history of numbness, cold feet, tingling, and loss of feeling in both lower extremities. Current symptoms included constant pain, paresthesias, and numbness of the right lower extremity-described as moderate; and paresthesias and numbness of the left lower extremity, described as moderate. Muscle strength testing was normal, and there was no muscle atrophy. Sensory examination of both lower extremities was decreased. There were no trophic changes. The examiner diagnosed diabetic peripheral neuropathy of both lower extremities, and specifically found no nerve dysfunction. Here, the objective evidence is against increased ratings for peripheral neuropathy of each lower extremity. Specifically, the evidence reveals peripheral neuropathy of each lower extremity manifested primarily by sensory disturbances that is characterized as moderate. This evidence warrants no more than the currently assigned 20 percent disability rating by analogy under Diagnostic Code 8520. No examiner has described moderately severe or severe manifestations of incomplete paralysis, or of muscle atrophy or organic changes in the Veteran's gait or otherwise due specifically to diabetic peripheral neuropathy throughout the rating period. While the Veteran is competent to describe coldness in his feet and some sensory deficit and pain in the lower extremities, the objective evidence on neurological testing weighs against the Veteran's lay reports as to the severity of symptoms. Hence, disability ratings greater than 20 percent for peripheral neuropathy of each lower extremity are not warranted. Lastly, a Veteran who, as the result of a service-connected disability, has suffered the anatomical loss or loss of use of both feet shall receive special monthly compensation (SMC) under the provisions of 38 U.S.C.A. § 1114(l). See 38 C.F.R. § 3.350(b). The term "loss of use" of a hand or foot is defined by 38 C.F.R. § 3.350(a)(2) and § 4.63 as that condition where no effective function remains other than that which would be equally well served by an amputation stump at the site of election below elbow or knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function, whether the acts of grasping, manipulation, etc., in the case of the hand, or balance, propulsion, etc., in the case of a foot, could be accomplished equally well by an amputation stump with prosthesis. In this case, the Board has considered whether the issue of entitlement to SMC based on loss of use of both feet is warranted. On close review of the evidence, the Board finds that the Veteran still retains function in his feet. He primarily indicates that the peripheral neuropathy has kept both feet cold nightly. Here, the April 2012 examiner found that functional impairment of the lower extremities was not so diminished that amputation with prosthesis would equally serve the Veteran. Again, the Board finds that the April 2012 examiner's opinion based on neurological testing is more probative than lay evidence as to functional loss of use of both feet. C. Hypertension, Prior to October 12, 2011 Service connection has been established for hypertension. The RO evaluated the Veteran's hypertension as 10 percent disabling prior to October 12, 2011, under 38 C.F.R. § 4.104, Diagnostic Code 7101, pertaining to hypertensive vascular disease. Pursuant to Diagnostic Code 7101, a 10 percent rating is assigned for essential hypertension when diastolic pressure is predominantly 100 or more, or; systolic pressure is predominantly 160 or more, or; as a minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is assigned for diastolic pressure that is predominantly 110 or more, or; systolic pressure that is predominantly 200 or more. A 40 percent rating is assigned for diastolic pressure that is predominantly 120 or more. A 60 percent rating is assigned where diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. Note (1) following Diagnostic Code 7101 provides that the term "hypertension" means the diastolic blood pressure is predominantly 90 millimeters or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 millimeters or greater with a diastolic blood pressure of less than 90 millimeters. Note (2) provides that hypertension due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, is to be evaluated as part of the condition causing it, rather than by a separate evaluation. Note (3) provides that hypertension is to be evaluated separately from hypertensive heart disease and other types of heart disease. 38 C.F.R. § 4.104, Diagnostic Code 7101, Notes. Historically, the Veteran was treated for high blood pressure and placed on medications in active service. Records show that his hypertension was well controlled in July 1989 and in November 1996. His medications were increased in August 1999. Records show fair control of hypertension with medication management in April 2001. Blood pressure readings taken in May 2008 were 144/85 and 140/82. The report of a May 2008 VA examination reflects a history of hypertension for 25 years, and that the Veteran took medications. Examination in May 2008 revealed elevated blood pressure readings of 167/97, 167/95, and 163/91. Additional blood pressure readings on separate days were not obtained. VA records, dated in June 2008, show that the Veteran's blood pressure reading was 114/74 and that the Veteran was compliant in taking medications. Blood pressure readings on three separate days in December 2010 were 115/72, 124/75, and 132/76; and on three separate days in January 2011 were 130/75, 127/76, and 142/77. Records show that the Veteran was continuing to monitor his blood pressure for the next few weeks. Specifically, throughout the rating period prior to October 12, 2011, the evidence reveals that the Veteran required continuous medication for control of hypertension; and that systolic blood readings were predominantly 160 or higher in May 2008. This evidence warrants a 10 percent, but no greater, disability rating prior to October 12, 2011. At no time prior to October 12, 2011, were diastolic blood readings predominantly 110 or more, or systolic pressure predominantly 200 or more, to warrant a disability rating in excess of 10 percent for hypertension. D. Diabetic Nephropathy with Hypertension, As of October 12, 2011 In this case, the Veteran also had reported an increase in his blood pressure medications; and reportedly he now had renal involvement. The Board finds the Veteran's statements to be credible. As of October 12, 2011, the RO evaluated the Veteran's diabetic nephropathy with hypertension as 60 percent disabling under 38 C.F.R. § 4.115b, Diagnostic Code 7101-7541, pertaining to renal involvement in diabetes mellitus. While a hyphenated diagnostic code generally reflects rating by analogy (see 38 C.F.R. §§ 4.20 and 4.27), here, the RO has considered both diagnostic codes, alternatively. Pursuant to Diagnostic Code 7541 involving renal dysfunction, a 60 percent rating is assigned when the Veteran experiences constant albuminuria with some edema; definite decrease in kidney function; or hypertension with diastolic pressure predominantly 120 or more. An 80 percent rating is assigned when the Veteran has persistent edema and albuminuria with BUN 40 to 80mg%; creatinine 4 to 8mg%; or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A maximum 100 percent rating is assigned when the Veteran requires regular dialysis or is precluded from more than sedentary activity from one of the following: BUN more than 80 mg%, creatinine more than 8 mg%, or markedly decreased function of kidney or other organ systems, especially cardiovascular. 38 C.F.R. § 4.115b, Diagnostic Code 7541. The report of an April 2012 VA (contract) examination reveals blood pressure readings of 129/87, 137/77, and 138/76; and reflects the results of diagnostic tests pertaining to kidney functioning. Urinalysis at the time was positive for trace proteinuria (albumin). Laboratory studies revealed BUN 30; creatinine was high at 1.56; and epidermal growth factor receptor was low at 47. The examiner included a diagnosis of nephrosclerosis, and noted that the condition began in 2012. There was evidence of neither renal dysfunction, nor recurrent symptomatic urinary tract infections nor kidney infections. VA records, dated in July 2014, show chronic kidney disease, Stage III, due to diabetes mellitus and hypertension. In this case, the Board finds that an increased disability rating is not warranted. Here, the evidence reflects no more than a definite decrease in kidney function. Persistent edema and albuminuria with BUN 40 to 80mg%; creatinine 4 to 8mg%; or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion due to diabetic nephropathy are not demonstrated. Moreover, when examined in April 2012, the VA (contract) examiner noted that the Veteran was not required to take medication for his kidney condition; and that there was no evidence of renal dysfunction, to include edema. Recent VA records do not reveal any contradictory findings. Under these circumstances, the evidence is against awarding an evaluation in excess of 60 percent for diabetic nephropathy with hypertension. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21 (2015). E. Erectile Dysfunction Service connection has been established for erectile dysfunction. The RO evaluated the Veteran's erectile dysfunction as 0 percent (noncompensable) disabling under 38 C.F.R. § 4.115b, Diagnostic Code 7522. Pursuant to Diagnostic Code 7522, a 20 percent disability rating is assigned for deformity of the penis, with loss of erectile power. 38 C.F.R. § 4.115b, Diagnostic Code 7522. Historically, the Veteran reported the gradual onset of erectile dysfunction in the early 1990's. The report of an April 2001 VA examination includes a diagnosis of erectile dysfunction, impotence, secondary to hypertension and diabetes mellitus. During a May 2008 VA (contract) examination, the Veteran reported being impotent, which began five years earlier. He reportedly could not achieve and maintain and erection. His treatment included medications for impotence. Examination of the penis and testicles revealed normal findings. The report of an April 2012 VA (contract) examination reflects that the Veteran took medication for erectile dysfunction, and was able to achieve an erection sufficient for penetration and ejaculation. Examination revealed a normal penis and normal testes. Epididymis was normal, and prostate was normal. Here, the evidence reflects that the Veteran has erectile dysfunction, and that he receives special monthly compensation for loss of use of a creative organ. In this case, the Veteran's erectile dysfunction is noncompensable under Diagnostic Code 7522 because there is no deformity shown. F. Extraschedular Consideration Finally, the potential application of 38 C.F.R. § 3.321(b)(1) has also been considered. See Thun v. Peake, 22 Vet. App. 111 (2008); Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for the service-connected disabilities are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disabilities with the established criteria found in the rating schedule for each disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria reasonably describe the Veteran's disability level and symptoms, then the Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluations are, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluations do not contemplate the Veteran's level of disability and symptomatology and are found inadequate, VA must determine whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-i.e., a determination of whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. Id. Here, the symptomatology and impairment caused by the Veteran's service-connected disabilities are specifically contemplated by the rating criteria. Specifically, he has diabetes mellitus and several severe complications. In this case, as shown above, any functional impairment is contemplated in the applicable rating criteria. There are no other ratable symptoms stemming from the disabilities. Thus, the Board finds that the rating criteria adequately cover his symptoms. In the absence of exceptional factors associated with the disabilities (i.e., no frequent hospitalizations, no interference with work), the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. As such, referral for consideration for an extraschedular evaluation is not warranted. See 38 C.F.R. § 3.321(b)(1); Thun v. Peake, 22 Vet. App. 111 (2008); Bagwell v. Brown, 8 Vet. App. 337, 339 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Finally, a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Johnson v. McDonald, 762 F.3d 1362 (2014). In this case, the Veteran has not alleged that his currently service-connected disabilities combine to result in additional disability or symptomatology that is not already contemplated by the rating criteria for each individual disability. Further, there is no medical evidence indicating that the Veteran's service-connected disabilities combine or interact in such a way as to result in further disabilities, functional impairment, or additional symptomatology not accounted for by the rating criteria applicable to each disability individually. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. III. TDIU Benefits Total disability ratings for compensation based upon individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. For the purpose of one 60 percent disability, or one 40 percent disability in combination, disabilities resulting from a common etiology or a single accident will be considered as one disability; and disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, will be considered as one disability. 38 C.F.R. §§ 3.340, 3.34l, 4.16(a). In determining whether the Veteran is entitled to TDIU, neither his non-service-connected disabilities nor his age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993); 38 C.F.R. § 3.341(a). As noted above, VA received the Veteran's claim for a TDIU in April 2008. In this case, the Veteran has completed four years of college education, and has had no additional education and training. He reportedly last worked as a real estate agent full-time in 2005. Service connection is currently in effect for tinea versicolor, rated as 60 percent disabling; for diabetic nephropathy with hypertension, rated as 60 percent disabling; for diabetes mellitus, rated as 20 percent disabling; for peripheral neuropathy of the right lower extremity and of the left lower extremity, each rated as 20 percent disabling; for diabetic retinopathy and vitreous heme, rated as 20 percent disabling; for a voiding dysfunction, rated as 10 percent disabling; and for hemorrhoids and for erectile dysfunction, each rated as 0 percent (noncompensable) disabling. The combined disability rating is 90 percent from April 9, 2008, and 100 percent from June 30, 2014. Hence, the Veteran meets the threshold percentage requirements for consideration of a TDIU. The remaining issue, then, is whether the Veteran's service-connected disabilities render him unable to obtain and retain substantially gainful employment. The sole fact that a Veteran is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363. In May 2008, the Office Manager at the real estate company where the Veteran worked as a subcontractor (and not as an employee), indicated that the Veteran earned $13,066.03 during the preceding twelve months; and that the number of hours the Veteran worked weekly had varied, and that the Veteran set his own work hours. In terms of functional impairment, a VA (contract) examiner in May 2008 opined that the Veteran's diabetes mellitus, hypertension, and tinea versicolor provided no functional impairment as far as performing physical and sedentary activities of employment. During a May 2008 VA (contract) eye examination, the Veteran reported that his diabetic retinopathy did not cause incapacitation; and that he did not experience any functional impairment from the condition. The examiner also found no functional impairment at the time. A Form 1099-MISC for tax year 2009, which was submitted by the Veteran in May 2010, reflects non-employee compensation of $4733.40. In May 2010, the Veteran testified that he had daily pain and circulation problems, and weakness in his lower extremities that made it difficult to show land for sale to potential buyers, and to walk long distances and climb stairs. Records received from the Social Security Administration in March 2012 reveal that the Veteran's work activity had not risen to the level of substantial gainful activity since April 2009. The Veteran's severe impairments at the time included loss of visual acuity, chronic pulmonary insufficiency, diabetes mellitus, and peripheral neuropathy in both lower extremities. In April 2012, a VA (contract) examiner opined that the Veteran's hypertension, diabetes mellitus, kidney condition, hemorrhoids, and erectile dysfunction did not impact his ability to work. Here, the Board finds that none of the VA (contract) examiners has described total occupational impairment due to the Veteran's service-connected disabilities. That is evidence that must be considered. The Veteran has asserted that he is unemployable due to his service-connected disabilities. To this extent, his statement is of probative value. Significantly, the Board finds that the Veteran's physical limitations due to diabetes mellitus and peripheral neuropathy of both lower extremities have been corroborated by his Social Security records. The record further reflects significant disability due to the skin disorder. The record also reflects a significant decrease in earnings, and his reports are credible. Here, the overall evidence demonstrates that the Veteran is unable to secure and follow any substantially gainful occupation by reason of his service-connected disabilities alone. In reaching this decision, the Board has resolved all doubt in favor of the Veteran. The Board also notes that this is a limited grant and raises another factor. Eventually, a 100 percent schedular evaluation was assigned based upon the combined disability. The award of TDIU is granted on combined disability, and such award shall terminate as of the date of the 100 percent schedular evaluation. Furthermore, because the TDIU is not based upon a single disability, the issue of SMC is not raised by the record. Specifically, the Veteran does not have a single 100 percent evaluation. ORDER An increased evaluation in excess of 20 percent for diabetes mellitus is denied. An increased evaluation in excess of 20 percent for peripheral neuropathy of the right lower extremity is denied. An increased evaluation in excess of 20 percent for peripheral neuropathy of the left lower extremity is denied. For the period prior to October 12, 2011, a disability rating in excess of 10 percent for hypertension is denied. For the period from October 12, 2011, a disability rating in excess of 60 percent for diabetic nephropathy with hypertension is denied. A compensable disability rating for erectile dysfunction is denied. The claim of entitlement to a TDIU is granted, in part. REMAND Hemorrhoids During an April 2012 VA (contract) examination, the Veteran reported current symptoms of bleeding and itching. Examination revealed small or moderate external hemorrhoids. VA records show an assessment of internal hemorrhoids in May 2012. At that time the Veteran denied any symptoms, and indicated that he was not on medication for hemorrhoids. Laboratory testing in November 2012 revealed anemia due to iron deficiency. Subsequent VA records show an assessment of anemia in April 2014. In light of the Veteran's complaints of bleeding and laboratory findings of anemia, the Board finds that a contemporaneous and thorough VA examination is required to clarify the nature and extent of the Veteran's service-connected disability. See Colayong v. West, 12 Vet. App. 524, 532 (1999); Goss v. Brown, 9 Vet. App. 109, 114 (1996). Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's outstanding VA treatment records, from November 2014 forward; and associate them with the Veteran's claims file. 2. Afford the Veteran an appropriate VA examination, for evaluation of the service-connected hemorrhoids. All appropriate tests should be conducted. The examiner should specify: (a) Whether the disability is manifested by large or thrombotic hemorrhoids, whether the hemorrhoids are irreducible, whether there is excessive or redundant tissue, or whether there is any indication that the service-connected disability is productive of frequent recurrences; (b) Whether there is evidence of current anemia; and (c) Specifically, with regard to findings of iron deficiency anemia in 2012 and in 2014, whether there is evidence of persistent bleeding with secondary anemia, or with fissures. These specific findings are needed to rate the Veteran's disability in accordance with the rating schedule. It is therefore important that the examiner furnish the requested information. 3. After ensuring that the requested actions are completed, re-adjudicate the claim on appeal. If the benefits sought are not fully granted, furnish a supplemental statement of the case (SSOC) and then return the claims file to the Board, if otherwise in order. No action is required of the Veteran and his representative until they are notified by the RO or VA's Appeals Management Center (AMC); however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2015). The Veteran has the right to submit additional evidence and argument on the matter that 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). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs