Citation Nr: 1626745 Decision Date: 07/05/16 Archive Date: 07/14/16 DOCKET NO. 13-01 879 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to an initial disability rating in excess of 10 percent for peripheral neuropathy of the right lower extremity. 2. Entitlement to an initial disability rating in excess of 10 percent for peripheral neuropathy of the left lower extremity. 3. Entitlement to an initial disability rating in excess of 30 percent for coronary artery disease, status post stent placement. REPRESENTATION Veteran represented by: Michael T. Sullivan, Attorney ATTORNEY FOR THE BOARD S. Delhauer, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1966 to June 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2010 and March 2011 rating decisions by the VA Regional Office (RO) in New York, New York. In the March 2011 rating decision, the RO granted a 30 percent disability rating for coronary artery disease, effective September 25, 2009. As the Veteran has not been granted the maximum benefit allowed for the entire appeal period, the claim is still active. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In a February 2015 decision, the Board denied the Veteran's claims of entitlement to service connection for a right ear hearing loss disability, and denied entitlement to increased disability ratings for left ear hearing loss, bilateral tinnitus, and open-angle glaucoma. The Board remanded the Veteran's claims of entitlement to increased disability ratings for peripheral neuropathy of the right and left lower extremities and for coronary artery disease for further development. In an October 2010 written statement, the Veteran indicated he currently suffers from side effects due to medication prescribed for his service-connected coronary artery disease. See also November 2010 Veteran statement. The Veteran has not clearly indicated any specific side effects, or that he wishes to pursue any claims of entitlement to service connection for such side effects. Therefore, the Board will not refer any claims to the Agency of Original Jurisdiction (AOJ) at this time, but notes the Veteran is free to file such claims at a future date if he desires. The issue of entitlement to an increased initial disability rating for coronary artery disease is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. Prior to January 18, 2013, the Veteran's peripheral neuropathy of the right and left lower extremities was manifested by mild incomplete paralysis of the sciatic nerves. 2. From January 18, 2013, the Veteran's peripheral neuropathy of the right and left lower extremities was manifested by moderate incomplete paralysis of the sciatic nerves. 3. The Veteran's peripheral neuropathy of the right and left lower extremities does not present an exceptional or unusual disability picture. CONCLUSIONS OF LAW 1. Prior to January 18, 2013, the criteria for an initial disability rating in excess of 10 percent for peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8520 (2015). 2. Prior to January 18, 2013, the criteria for an initial disability rating in excess of 10 percent for peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8520 (2015). 3. Beginning January 18, 2013, the criteria for a disability rating of 20 percent, but no higher, for peripheral neuropathy of the right lower extremity have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8520 (2015). 4. Beginning January 18, 2013, the criteria for a disability rating of 20 percent, but no higher, for peripheral neuropathy of the left lower extremity have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8520 (2015). 5. Application of the extraschedular rating provisions is not warranted in this case. 38 C.F.R. § 3.321(b) (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. VA's duty to notify was satisfied by a letter in October 2010. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the claims for bilateral lower extremity peripheral neuropathy. Lay statements, VA treatment records, and identified private treatment records have been associated with the evidence of record. The Veteran was afforded a VA examination in January 2013. The January 2013 VA examination report is thorough, and discusses the clinical findings and the Veteran's reported history and symptoms as necessary to rate the disabilities under the applicable rating criteria. This examination report also discuss the functional impact of the Veteran's peripheral neuropathy of the bilateral lower extremities on the ordinary conditions of his daily life, including his ability to work. Based on the examination and the absence of evidence of worsening symptomatology since the examination, the Board concludes the January 2013 examination report in this case is adequate upon which to base a decision. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). In the February 2015 remand, the Board instructed the AOJ to contact the Veteran and his representative and ask him to identify any pertinent VA or private treatment records regarding his service-connected coronary artery disease, and to obtain any identified private or VA treatment records. The AOJ was then instructed to readjudicate the claims in light of all the evidence of record, including that associated with the evidentiary record since the December 2012 statement of the case. In a February 2015 letter to the Veteran and his representative, the AOJ asked the Veteran to send any treatment records pertinent to his claimed conditions, or to complete and return the enclosed forms if the Veteran wanted VA to try and obtain any doctor, hospital, or medical reports on his behalf. Further, the February 2015 letter asked the Veteran to identify any VA treatment. In a March 2015 response, the Veteran indicated he had no other information or evidence to give VA. VA treatment records from the Northport VA Medical Center dated through December 2015 have been associated with the evidentiary record. Given the February 2015 letter to the Veteran, the March 2015 response from the Veteran, the association of updated VA treatment records with the evidentiary record, and the subsequent readjudication of the claims in February 2016, the Board finds that there has been substantial compliance with its remand directives with regard to the claims for peripheral neuropathy of the bilateral lower extremities. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Thus, with respect to the Veteran's claims, there is no additional development that needs to be undertaken or evidence that needs to be obtained. Rating Principles A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's peripheral neuropathy of the right and left lower extremities is currently rated as 10 percent disabling under Diagnostic Code 8520, paralysis of the sciatic nerve. Under Diagnostic Code 8520, a 10 percent evaluation is warranted for mild incomplete paralysis of the sciatic nerve. A 20 percent rating requires evidence of moderate incomplete paralysis of the sciatic nerve. A 40 percent rating requires evidence of moderately severe incomplete paralysis of the sciatic nerve. A 60 percent rating requires evidence of severe incomplete paralysis with marked muscular atrophy. An 80 percent rating requires evidence of complete paralysis. When there is complete paralysis, the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C.A. § 7104; 38 C.F.R. §§ 4.2, 4.6. Analysis In the March 2011 rating decision, the RO granted entitlement to service connection for peripheral neuropathy of the right lower extremity, rated as 10 percent disabling, and entitlement to service connection for peripheral neuropathy of the left lower extremity, rated as 10 percent disabling, with both awards effective April 28, 2010. In the April 2011 notice of disagreement, the Veteran disagreed with the initial ratings assigned. Upon a March 2010 VA primary care visit, the Veteran complained of numbness/tingling in his lower extremities, right greater than left, for six months. Later in March 2010, the Veteran underwent a medical herbicide registry examination with a VA primary care physician. The Veteran complained of right leg tingling, numbness, and sharp pain. The physician noted the Veteran had a neurology examination pending to evaluate him for diabetic neuropathy. In April 2010, the Veteran underwent nerve conduction studies and electromyogram (EMG) testing with VA physical medicine and rehabilitation. The Veteran complained of numbness and tingling, and stated he felt a worsening of symptoms in his right lower extremity. Upon sensory examination, the Veteran had decreased sensation to light touch in the right lower extremity. Motor nerve and sensory nerve conduction studies showed evidence of sensory axonal peripheral neuropathy of the lower extremities. Upon VA podiatry visits in May, June, and July 2010, the Veteran's protective sensation in both feet was found to be grossly intact to light touch with monofilament testing. In August 2010, the Veteran underwent a VA examination regarding his diabetes mellitus, type II. In a January 2011 addendum to that report, the VA examiner confirmed the Veteran has peripheral neuropathy of the lower extremities. Upon a November 2010 VA podiatry visit, the Veteran denied any cramping, numbing, burning, or tingling in the legs. Upon examination, the Veteran had intact sensation measured with a monofilament to all digits bilaterally, and sharp, dull, and proprioceptive sensations were intact bilaterally. The VA podiatrist assessed diabetes mellitus with neuropathy. In a November 2010 written statement, the Veteran reported that he wakes up in the middle of the night to severe leg cramps and both his legs tingling, so he would have to get up and walk around. The Veteran stated that recently he was experiencing pain in his legs when he was on his feet for long periods of time, and that he would experience "electrical shocks" in his legs sometimes. The Veteran stated that while standing, he would just fall to one side until he caught himself and would attempt to stand up straight. The Veteran stated he had noticed a worsening of his symptoms in the past few months. See also September 2011 Veteran statement. Upon a July 2011 VA podiatry visit, the Veteran reported tingling in both of his feet. Upon examination, the Veteran had intact sensation measured with a monofilament to all digits bilaterally, and sharp, dull, and proprioceptive sensations were intact bilaterally. The podiatrist noted the Veteran showed early stages of peripheral neuropathy in both feet. In September 2011, the Veteran was afforded a VA examination regarding his diabetes mellitus, type II. The Veteran reported that due to his diabetic peripheral neuropathy, he was unable to deal with taking public transportation to work because it became difficult due to his symptoms from the peripheral neuropathy. The Veteran reported being retired since 2001. Upon a September 2011 VA general medical examination, the Veteran reported symptoms of intermittent numbness/tingling of the feet and lower calves, as well as intermittent cramps and a burning sensation. The Veteran stated he has some difficulty with balance and sitting or standing for prolonged periods of time. A sensory examination revealed impairment to light touch of the lower extremities; sensation of the feet was impaired bilaterally. The VA examiner diagnosed diabetic peripheral neuropathy of the bilateral lower extremities, and stated the functional impairments due to this diagnosis were difficulty maintaining balance, inability to sit or stand for prolonged periods of time, and intermittent numbness/tingling and cramps. Upon January, March, and November 2012 VA podiatry visits, the Veteran reported tingling in both of his feet. Upon examination, the Veteran had intact sensation measured with a monofilament to all digits bilaterally, and sharp, dull, and proprioceptive sensations were intact bilaterally. The podiatrist noted the Veteran showed early stages of peripheral neuropathy in both feet, and assessed diabetes mellitus with peripheral neuropathy. In January 2013, the Veteran was afforded a VA diabetic sensory-motor peripheral neuropathy examination. Upon examination, the Veteran had moderate intermittent pain (usually dull), paresthesias and/or dysesthesias, and numbness in both the right and left lower extremities. The Veteran had normal strength in knee extension, knee flexion, ankle plantar flexion, and ankle dorsiflexion bilaterally. The Veteran's deep tendon reflexes were normal in the bilateral knees and ankles. Light touch/monofilament testing revealed decreased sensation in the ankle/lower leg and foot/toes bilaterally. No muscle atrophy or trophic changes were present. The January 2013 VA examiner assessed lower extremity diabetic peripheral neuropathy affecting the sciatic nerves of both the right and left lower extremities, and assessed the severity as moderate incomplete paralysis of the sciatic nerves bilaterally. Upon a June 2013 VA podiatry visit, the Veteran had diminished sensation measured with a monofilament to all digits bilaterally. Upon an October 2013 VA podiatry visit, the Veteran had diminished hair growth on his feet. Upon neurological examination, burning and tingling were present bilaterally, and vibratory sensation was reduced bilaterally; numbness, light touch, position sense, monofilament, and deep tendon were deferred bilaterally. Upon May, November, and December 2014 VA podiatry visits, the Veteran's sensation was found to be present and intact to both feet. Neurological examination revealed burning and tingling present bilaterally, and vibratory sensation reduced bilaterally; numbness, light touch, position sense, monofilament, and deep tendon were deferred bilaterally. Upon two VA podiatry visits in June 2015, the Veteran had decreased epicentric sensation measured with a monofilament to the bilateral feet. Upon careful review of the evidence of record, the Board finds that prior to January 18, 2013, the preponderance of the evidence is against granting an initial disability rating in excess of 10 percent for peripheral neuropathy of the right or left lower extremities. First, the Board finds the medical evidence of record indicates that the Veteran's symptoms more nearly approximated mild incomplete paralysis of the sciatic nerves of both legs. Although April 2010 EMG testing found evidence of sensory axonal peripheral neuropathy of the lower extremities, it did not indicate the severity of such peripheral neuropathy. Further, although the September 2011 VA general medical examination revealed impaired light touch of the lower extremities and impaired sensation of the feet bilaterally, the examiner did not indicate the level of severity of the Veteran's impaired sensation. Although VA podiatrists assessed early stages of peripheral neuropathy in both of the Veteran's feet during this time period, upon examination, the Veteran repeatedly had intact sensation measured with a monofilament to all digits bilaterally, and sharp, dull, and proprioceptive sensations were intact bilaterally. See November 2012 VA podiatry note; March 2012 VA podiatry note; January 2012 VA podiatry note; July 2011 VA podiatry note; November 2010 VA podiatry note; July 2010 VA podiatry note; June 2010 VA podiatry note; May 2010 VA podiatry note. The Veteran is competent and credible to report what he feels, such as the severity of the pain, numbness, and tingling in his feet and legs. Accordingly, the Board finds that his statements are credible as to the matter of frequency and severity of his symptoms in his right and left legs and feet. See Layno v. Brown, 6 Vet. App. 465, 469 (1994); 38 C.F.R. § 3.159(a)(2). Notably, as discussed above, the Veteran has consistently reported that he experienced intermittent numbness, tingling, and at times sharp pain in his right and left legs and feet during this time period. See, e.g., November 2012 VA podiatry note; March 2012 VA podiatry note; January 2012 VA podiatry note; September 2011 VA general medical examination; September 2011 Veteran statement; July 2011 VA podiatry note; November 2010 Veteran statement; April 2010 VA physical medicine and rehabilitation note; March 2010 VA primary care notes. Further, the Veteran has reported that these symptoms impacted the function of his legs and feet, as well as interrupting his sleep. See, e.g., September 2011 VA general medical examination; September 2011 VA diabetes mellitus examination; September 2011 Veteran statement; November 2010 Veteran statement. However, the Board finds the objective medical testing of record repeatedly showing intact sensation but the beginnings of bilateral peripheral neuropathy carries more probative value as it was performed by a VA examiner with knowledge of the full severity of symptomatology possible with regard to evaluating this disability. Accordingly, considering the lay and medical evidence of record, the Board finds that prior to January 18, 2013, the Veteran's reports of intermittent numbness, tingling, at times sharp pain in his lower legs and feet, combined with the repeated findings of VA podiatrists of intact sensation but early stages of bilateral peripheral neuropathy, more nearly approximates mild incomplete paralysis of the sciatic nerves of the right and left lower extremities. Accordingly, under Diagnostic Code 8520, the Board finds the preponderance of the evidence is against granting a disability rating in excess of 10 percent for peripheral neuropathy of either the right or left lower extremity prior to January 18, 2013. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Next, upon careful review of the evidence of record, the Board finds that beginning January 18, 2013, the totality of the evidence of record more nearly approximates moderate incomplete paralysis of the right and left sciatic nerves and accordingly, 20 percent disability ratings for peripheral neuropathy of the right and left lower extremities are warranted. Upon the January 2013 VA diabetic sensory-motor peripheral neuropathy examination, the Veteran had moderate intermittent pain (usually dull), paresthesias and/or dysesthesias, and numbness in both the right and left lower extremities. Light touch/monofilament testing revealed decreased sensation in the ankle/lower leg and foot/toes bilaterally. However, the Veteran had normal strength in knee extension, knee flexion, ankle plantar flexion, and ankle dorsiflexion bilaterally. The Veteran's deep tendon reflexes were also normal in the bilateral knees and ankles, and no muscle atrophy or trophic changes were present. Accordingly, the January 2013 VA examiner opined that the Veteran experienced moderate incomplete paralysis of the right and left sciatic nerves. The Veteran's VA podiatry visits also support a finding of moderate incomplete paralysis, as diminished sensation was measured with a monofilament to all digits bilaterally in June 2013 and again in June 2015. In October 2013, May 2014, November 2014, and December 2014, burning and tingling were present bilaterally, and vibratory sensation was reduced bilaterally. In October 2013, it was noted the Veteran had diminished hair growth on his feet. Accordingly, the Board finds the evidence of record indicates that as of January 18, 2013, it was factually ascertainable that the Veteran experienced moderate intermittent pain (usually dull), paresthesias and/or dysesthesias, and numbness in both the right and left lower extremities, with decreased sensation in both lower legs and feet. However, the Veteran's normal muscle strength, deep tendon reflexes, and lack of muscle atrophy indicate the Veteran's bilateral peripheral neuropathy of the lower extremities more nearly approximates moderate incomplete paralysis of the sciatic nerves. Accordingly, under Diagnostic Code 8520, a 20 percent disability rating for peripheral neuropathy of the right lower extremity and a 20 percent disability rating for peripheral neuropathy of the left lower extremity are warranted. 38 C.F.R. § 4.124a, Diagnostic Code 8520. The Board has also considered the application of other diagnostic codes to determine whether a higher rating may be warranted for the Veteran's disabilities, but finds no other codes are applicable based upon the evidence. The Diagnostic Codes for the Diseases of the Peripheral Nerves are separated out into the specific nerve affected. Here, the January 2013 VA examiner determined that the Veteran's service-connected disabilities affected only the sciatic nerves of the right and left lower extremities. Thus, only Diagnostic Code 8520 is applicable to the Veteran's claims. 38 C.F.R. § 4.124a. Extraschedular Considerations The Board has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. While the Board does not have authority to grant an extraschedular rating in the first instance, the Board does have the authority to decide whether the claim should be referred to the VA Director of Compensation for consideration of an extraschedular rating. 38 C.F.R. § 3.321(b)(1). The governing norm for an extraschedular rating is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or necessitated frequent periods of hospitalization so as to render the regular schedular standards impractical. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for the service-connected disability is inadequate. There must be a comparison between the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111 (2008). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology pertaining to his service-connected peripheral neuropathy of the right and left lower extremities. The Veteran's peripheral neuropathy is manifested by tingling, numbness, burning, and pain in his bilateral lower legs and feet. The ratings assigned contemplate these impairments, as well as how they affect the function of his lower extremities. The Board observes that the Veteran reported that his service-connected peripheral neuropathy of the bilateral lower extremities sometimes interrupts his sleep. To the extent the Veteran is asserting that his bilateral lower extremities have caused a sleep related disorder, he is free to file a claim for such. For these reasons, the disability picture is contemplated by the Rating Schedule, and the assigned schedular ratings are, therefore, adequate. Consequently, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). Under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), 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. Notably, the Veteran is also service connected for coronary artery disease, status post stent placement; right upper extremity peripheral neuropathy and carpal tunnel syndrome; left upper extremity peripheral neuropathy and carpal tunnel syndrome; diabetes mellitus, type II, with erectile dysfunction and hypertension; bilateral tinnitus; left ear hearing loss disability; and open-angle glaucoma. Neither the Veteran nor his representative has indicated any specific service-connected disabilities which are not captured by the schedular evaluations of the Veteran's individual service-connected conditions. After applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), the Board finds there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. 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. Total Disability Based Upon Individual Unemployability Lastly, in the case of Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims held, in substance, that every claim for an increased evaluation includes a claim for a total disability rating based on individual unemployability (TDIU) where the Veteran claims that his service-connected disabilities prevent him from working. Here, the September 2011 VA general medical examination report indicated the Veteran's peripheral neuropathy of the bilateral lower extremities would prevent him from obtaining and maintaining both physical and sedentary employment. However, in a March 2012 rating decision, the RO granted entitlement to a TDIU effective April 28, 2010. Again, the grants of entitlement to service connection for peripheral neuropathy of the right and left lower extremities were effective April 28, 2010. See March 2011 rating decision. Accordingly, as the Veteran has been granted entitlement to a TDIU for the entire appeal period currently before the Board, the Board finds that here, the issue of entitlement to a TDIU is moot. ORDER Prior to January 18, 2013, entitlement to an initial disability rating in excess of 10 percent for peripheral neuropathy of the right lower extremity is denied. Prior to January 18, 2013, entitlement to an initial disability rating in excess of 10 percent for peripheral neuropathy of the left lower extremity is denied. From January 18, 2013, entitlement to a disability rating of 20 percent, but no higher, for peripheral neuropathy of the right lower extremity is granted. From January 18, 2013, entitlement to a disability rating of 20 percent, but no higher, for peripheral neuropathy of the left lower extremity is granted. REMAND Beginning in November 2014, the Veteran's VA treatment records indicate congestive heart failure has been diagnosed as well as his service-connected coronary artery disease. See November 2015 VA primary care note (diagnosis of "CHF/CAD"); May 2015 VA primary care note; November 2014 VA primary care note. The Veteran was last afforded a VA ischemic heart disease examination in December 2010. Where a veteran asserts that a disability has worsened since his last VA examination, and the last examination is too remote to constitute a contemporaneous examination, a new examination is required. See 38 U.S.C.A. § 5103A(d) (West 2014); 38 C.F.R. § 3.159(c)(4) (2015); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Green v. Derwinski, 1 Vet. App. 121 (1991). Accordingly, on remand the AOJ should afford the Veteran a new VA examination to determine the current manifestations and severity of his service-connected coronary artery disease. The Veteran's VA treatment records indicate the Veteran continues to receive treatment from a private cardiologist, Dr. R.S. See, e.g., November 2015 VA primary care note. As a remand is necessary to provide an examination, on remand, the AOJ should again undertake appropriate development to obtain the Veteran's relevant private treatment records dated since October 2009. Accordingly, the case is REMANDED for the following action: 1. The AOJ should ask the Veteran to identify all private treatment related to his heart disability. The AOJ should undertake appropriate development to obtain all of the Veteran's outstanding private treatment records, to include from Dr. R.S. dated from October 2009 to the present. The Veteran's assistance should be requested as needed. All obtained records should be associated with the evidentiary record. The AOJ must perform all necessary follow-up indicated. If the Veteran's records are not available, the AOJ should make a formal finding of unavailability, advise the Veteran and his representative of the status of his records, and give the Veteran the opportunity to obtain his records on his own. 2. The AOJ should obtain all outstanding VA treatment records from November 2015 to the present. All obtained records should be associated with the evidentiary record. 3. After the above development has been completed, and after any records obtained have been associated with the evidentiary record, the Veteran should be afforded a VA examination with an appropriate examiner to determine the current severity of his service-connected coronary artery disease. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place. A complete history should be elicited directly from the Veteran, and any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. The examiner should specifically address the diagnoses of congestive heart failure as well as coronary artery disease. 4. After the above development has been completed, readjudicate the claim. If the benefit sought remains denied, provide the Veteran and his representative with a supplemental statement of the case, and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ S. HENEKS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs