Citation Nr: 1647275 Decision Date: 12/19/16 Archive Date: 12/30/16 DOCKET NO. 08-32 344 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to a rating in excess of 20 percent for type II diabetes mellitus. 2. Entitlement to an initial compensable rating for bilateral cataracts with right eye pseudophakia for the period from August 24, 2005, to June 9, 2008, and in excess of 30 percent for the period beginning June 10, 2008. 3. Entitlement to a rating in excess of 20 percent for right lower extremity peripheral neuropathy. 4. Entitlement to a rating in excess of 20 percent for left lower extremity peripheral neuropathy. 5. Entitlement to an effective date earlier than April 8, 2016, for a grant of service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J.Andrew Ahlberg, Counsel INTRODUCTION The Veteran served on active duty from October 1971 to March 1974. This case was previously before the Board of Veterans' Appeals (Board) on appeal from a January 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Fargo, North Dakota that denied a claim for an increased rating for diabetes; an October 2008 rating decision by the VA RO in St. Paul, Minnesota that granted service connection for pseudophakia of the right eye and a separate 30 percent combined rating for these manifestations and bilateral cataracts as secondary to diabetes (with the appeal based on disagreement with the propriety of this rating); and a January 2015 rating decision by the VA RO in St. Paul, Minnesota that assigned 20 percent ratings for peripheral neuropathy of the lower extremities. In October 2014, the Board remanded the appeal with respect to the matters of the compensation assigned for diabetes and bilateral cataracts with right eye pseudophakia. These claims, as well as the claims for service connection for hypertension and increased ratings for right and left lower extremity neuropathy, were also remanded by the Board in February 2016. Following development conducted pursuant to this remand, a June 2016 rating decision granted service connection for hypertension; as such, the appeal with respect to this matter has been resolved. The claims for increased ratings for right and left lower extremity neuropathy were remanded in February 2016 for the purpose of a completion of a statement of the case (SOC) pursuant to Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). Such was completed in February 2016, followed by receipt of a timely substantive appeal with respect to these issues in March 2016; as such, appeals with respect to these issues have been perfected to the Board. Id. In addition to paper claims files, this record includes Virtual VA (VVA) and Virtual Benefits Management System (VBMS) paperless claims files. The claim for an effective date earlier than April 8, 2016, for a grant of service connection for PTSD addressed in the REMAND portion of the decision below requires additional development and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Diabetes mellitus has not required the avoidance of strenuous occupational and recreational activities. 2. Prior to a VA examination conducted June 10, 2008, an intraocular lens in the right eye representative of a pseudophakia was not demonstrated; corrected central visual acuity has been measured to, at worst, 20/30 in the left eye and 20/20 in the right eye. 3. Right and left lower extremity peripheral neuropathy results in no more than moderate incomplete paralysis of either sciatic nerve. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for type II diabetes mellitus are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.119, Diagnostic Code (DC) 7913 (2016). 2. The criteria for an initial rating in excess of 0 percent for bilateral cataracts with right eye pseudophakia for the period from August 24, 2005, to June 9, 2008, and in excess of 30 percent for the period beginning June 10, 2008, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.400, 4.1, 4.2, 4.3, 4.7, 4.84a, DC 6029 (2007), 4.79, DC 6029 (2016). 3. The criteria for a rating in excess of 20 percent for right lower extremity peripheral neuropathy are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.124a, DC 8520 (2016). 4. The criteria for a rating in excess of 20 percent for left lower extremity peripheral neuropathy are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.124a, DC) 8520 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Duty to Assist/Standard of Review With respect to the matters herein decided, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Any due process concerns have been addressed by the Board with respect to the claims adjudicated below. When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the U.S. Court of Appeals for Veterans Claims (Court) held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. While the Veteran's entire history is reviewed when assigning a disability evaluation, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Court has since held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. A. Diabetes As noted above, the Veteran is currently in receipt of a 20 percent rating for the service-connected diabetes. Under DC 7913, a 20 percent disability rating is assigned for diabetes mellitus requiring insulin and restricted diet, or oral hypoglycemic agent and restricted diet. The next higher disability rating of 40 percent is assigned for diabetes mellitus requiring insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities). Diabetes mellitus requiring 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 warrants a 60 percent disability rating. A 100 percent disability rating is applicable for diabetes mellitus that requires more than one daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least three 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 rated. 38 C.F.R. § 4.119, DC 7913. The Board also observes that compensable complications of diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent disability rating. Noncompensable complications are considered part of the diabetic process under DC 7913. Note (1). Here, the Veteran is in receipt of separate ratings for the service-connected bilateral cataracts, peripheral neuropathy of the upper and lower extremities, as well as hypertension, all associated with the service-connected diabetes mellitus. Summarizing the pertinent evidence with the above criteria in mind, service connection for diabetes based on the Veteran's presumed exposure to Agent Orange during his Vietnam service was granted by a January 2002 rating decision at a disability rating of 10 percent. This rating was based on evidence to include a private clinical report dated in October 2001 noting that the Veteran's diabetes was treated with diet, exercise, and home glucose monitoring. Also then of record were reports from a December 2001 VA examination indicating the Veteran's diabetes was being managed by diet and did not require any restriction of activities. The 10 percent rating was continued until a January 2006 rating decision increased the rating to 20 percent following a November 2005 VA examination which indicated the Veteran's diabetes had progress to the point that medication was required. These examination reports continued to note that the Veteran's diabetes did not require the restriction of activities. The 20 percent rating has been continued until the present time. More recent pertinent evidence includes reports from a June 2008 VA examination that indicated the Veteran's diabetes was well controlled with medication (metformin and glipizide). A January 2015 VA examination indicated that the Veteran was treating his diabetes with a low carbohydrate diet, increased exercise, and the previously referenced diabetic medication. This examination again noted that the Veteran's diabetes did not require the restriction of activities, as did the reports from the most recent VA diabetes examination (the reports from which are contained in the VBMS file) conducted in April 2016. Applying the pertinent legal criteria to the facts set forth above, a rating in excess of 20 percent for diabetes-given that the criteria are listed in the conjunctive-is for assignment if management of this disability requires insulin, a restricted diet, and the regulation of activities. None of the VA examinations set forth above indicated the Veteran's diabetes required the regulation of activities (or, for that matter, insulin), and there is otherwise no indication in the record, to include VA outpatient treatment reported dated through April 15, 2016, that indicates that the Veteran's mellitus requires the regulation of activities as defined by regulation. As such, the criteria for a schedular rating in excess of 20 percent for diabetes mellitus are not met. 38 C.F.R. § 4.119, DC 7913. B. Bilateral Cataracts The Veteran's service-connected eye disability, evaluated as 30 percent disabling, is rated, by analogy, under 38 C.F.R. § 4.79, DC 6029. [In rating a disability that is not listed in the Ratings Schedule, it is permissible to rate that disability under a closely related disease or injury in which not only the functions affected, but the anatomical location and symptomatology are closely analogous. 38 C.F.R. § 4.20.] While this appeal was pending, the rating schedule for evaluating disabilities of the eyes was revised and amended. See 73 Fed. Reg. 66543-54 (Nov. 10, 2008). Diseases of the eye are now rated under a General Rating Formula, under 38 C.F.R. § 4.79. These changes took effect on December 10, 2008. VA's General Counsel hold that where a law or regulation changes during the pendency of an appeal, the Board should first determine which version of the law or regulation is more favorable to the Veteran. If the application of the revised regulation results in a higher rating, the effective date for the higher disability rating can be no earlier than the effective date of the change in the regulation. 38 U.S.C.A. § 5110 (g) (West 2014). Prior to the effective date of the change in the regulation, the Board may apply only the original version of the regulation. VAOGCPREC 3-2000. Under the criteria in effect prior to December 10, 2008, a 30 percent rating was assigned for either bilateral or unilateral aphakia. 38 C.F.R. §4.84a, DC 6029 (2007). The 30 percent rating prescribed for aphakia was a minimum rating to be applied to the unilateral or bilateral condition and was not to be combined with any other rating for impaired vision. When only one eye was aphakic, the eye having poorer corrected visual acuity will be rated on the basis of its acuity without correction. When both eyes were aphakic, both were rated on corrected vision. The corrected vision of one or both aphakic eyes was taken one step worse than the ascertained value, however, not better than 20/70 (6/21). 38 C.F.R. §4.84a, DC 6029, Note. Combined ratings for disabilities of the same eye were not to exceed the amount for total loss of vision of that eye unless there was an enucleation or a serious cosmetic defect added to the total loss of vision. 38 C.F.R. §§ 4.80, 4.84a, Diagnostic DC 6029 (2007). [The Board takes judicial notice that enucleation is the same as anatomical loss of an eye. See Dorland's Illustrated Medical Dictionary, 31st Edition, p. 635 ("enucleation" defined as "the removal of an organ, of a tumor, or of another body in such a way that it comes out clean and whole, like a nut from its shell. Used in connection with the eye, it denotes removal of the eyeball after the eye muscles and optic nerve have been severed.")] Under the current criteria, aphakia is rated under Diagnostic Code 6029, and is to be evaluated based on visual impairment. The resulting level of visual impairment is then elevated one step. The minimum rating for aphakia, either unilateral or bilateral, is 30 percent. 38 C.F.R. § 4.79, DC 6029 (2016). Under the former criteria, the severity of visual acuity loss is determined by applying the criteria set forth at 38 C.F.R. § 4.84a. Under these criteria, impairment of central visual acuity was evaluated from noncompensable to 100 percent based on the degree of the resulting impairment of visual acuity. 38 C.F.R. § 4.84a, DCs 6061 to 6079 (2007). A disability rating for visual impairment was based on the best distant vision obtainable after the best correction by glasses. 38 C.F.R. § 4.75 (2007). The percentage evaluation were found from Table V by intersecting the horizontal row appropriate for the Snellen index for one eye and the vertical column appropriate to the Snellen index of the other eye. 38 C.F.R. § 4.83a (2007). Under the former criteria, impairment of visual field was rated under 38 C.F.R. § 4.84a, DC 6080. Under the current criteria, the evaluation of visual impairment is based on impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. § 4.75(a) (2016). Under the current criteria, impairment of central visual acuity and impairment of visual fields are evaluated pursuant to 38 C.F.R. § 4.79, DCs 6061 through 6081 (2016). Measurement of the visual field will be made when there is disease of the optic nerve or when otherwise indicated. 38 C.F.R. §§ 4.76, 4.79, DC 6080 (2016). Historically, following a November 2005 VA eye examination that demonstrated cortical and nuclear sclerotic cataracts in both eyes that the examiner attributed to diabetes, a January 2006 rating decision amended the rating assigned for diabetes to include bilateral cataracts, and assigned a combined 20 percent rating for a disability characterized as "Diabetes Mellitus Type II with Bilateral Cataracts" under DCs 6028-7913. [Hyphenated Diagnostic Code numbers reflect the assignment of a rating under the first diagnostic Code number using the criteria of the second Diagnostic Code. See 38 C.F.R. § 4.27.] Pertinent findings from the November 2005 VA eye examination, as relevant to the rating criteria, included corrected near and far vision in each eye of 20/20 with no visual field defects. Thereafter, the pertinent evidence includes reports from a January 2007 VA eye examination that showed corrected vision to 20/20 and an assessment by the examiner that the Veteran's cataracts were not affecting the Veteran's vision. A June 2008 VA eye examination showed corrected vision to 20/20 in the right eye and 20/30 in the left eye with no visual field defects. Also demonstrated was a well-centered posterior chamber intraocular lens in the right eye. Based on the results from the June 2008 VA examination, the previously referenced October 2008 rating decision-characterizing the intraocular lens in the right eye showed at the June 2008 VA examination as a "pseuophakia"-granted service connection for pseuo[d]ophakia of the right eye and assigned a separate 30 percent combined rating for these manifestations and bilateral cataracts secondary to diabetes effective from June 10, 2008 (the date of the June 2008 VA examination reference above) by analogy to DC 6029 (2007). This rating has been continued until the present time. The most recent pertinent evidence includes reports from a January 2015 VA eye examination in which corrected distance and near vision was said to be "20/40 or better." There was no astigmatism or double vision and the examiner commented that there was "no decrease in visual acuity or other visual impairment" and also stated as follows: [The Veteran] now has bilateral posterior chamber intraocular lenses that are clean and well centered. [H]is visual acuities are excellent at 20/20 in each eye. He has no ocular complications that would result in visual field loss[,] therefore any deviation is strictly the result of anatomical variation. [The Veteran] has no ocular complications rendering him unable to secure or maintain substantially gainful employment and has no ocular complications impacting physical or sedentary employment. The April 2016 VA examination conducted to determine the severity of the Veteran's diabetes [the Board notes that the "Action Paragraphs" in the February 2016 remand did not request that the Veteran be afforded an eye examination] did not list visual problems as a complication of the Veteran's diabetes causing any impairment, and resulted in the conclusion that none of the complications of diabetes impacted his ability to work. The Board-particularly in light of the static nature of the Veteran's visual acuity shown in the record-finds that the clinical record is adequate to determine the proper rating for the service connected eye disability as the VA examinations that have been conducted reflect interviews with the Veteran, review of the record, and full examinations addressing the relevant rating criteria providing sufficient detail so as to allow the Board to make a fully informed determination with respect to proper rating to be assigned for the service connected eye disability. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Therefore, the Board finds no further examination or opinion to make this determination is necessary. Applying the pertinent criteria to the facts set forth above, as the intraocular lens in the right eye representative of psuedoaphakia was not shown in the record prior to the VA eye examination of June 9, 2008-and the November 2005 and January 2007 VA eye examinations measured corrected vision to 20/20 in each eye and demonstrated no other significant impairment resulting from any visual problems attributable to the service connected diabetes-a schedular 30 percent, or otherwise compensable, rating for the service connected eye disability prior to June 9, 2008, cannot be assigned. 38 C.F.R. §§ 3.400, 4.84a, DC 6029 (2007). As for a rating in excess of 30 percent for the period beginning June 9, 2008, given the June 2008 VA examination finding of corrected vision to 20/20 in the right eye and 20/30 in the left eye with no visual field defects and the January 2015 VA eye examination finding of bilateral visual acuity to 20/20 and assessment by the examiner that there was "no decrease in visual acuity or other visual impairment," the criteria for a schedular rating in excess of 30 percent for the service connected eye disability cannot be assigned under either the old or revised criteria codified at DC 6029 or any other potentially applicable diagnostic code. 38 C.F.R. § 4.84a, including DC 6029 (2007); 38 C.F.R. § 4.79, including DC 6029 (2016). C. Lower Extremity Peripheral Neuropathy The Veteran is in receipt of a 20 percent rating for each lower extremity and its associated peripheral neuropathy. Under DC 8520, a 20 percent rating is assigned for moderate incomplete paralysis of the sciatic nerve; a 40 percent rating is assigned for moderately severe incomplete paralysis; a 60 percent rating is assigned for severe incomplete paralysis, with marked muscular atrophy; and a maximum 80 percent rating is assigned for complete paralysis of the sciatic nerve; the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. See 38 C.F.R. § 4.124a, DC 8520. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, 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. Historically, a July 2008 rating decision granted service connection for left and right lower extremity peripheral neuropathy as secondary to diabetes, assigning two separate 10 percent ratings for such manifestations under DC 8520 effective from June 10, 2008. These ratings were principally based on findings from a June 10, 2008, VA peripheral nerves examination that included the opinion by the examiner that neuropathy of the lower extremities-characterized at this examination as resulting in "mild" disability-were most likely caused by or a result of diabetes mellitus. Thereafter [and following an October 2008 rating decision that assigned earlier effective dates of August 24, 2005, for left and right lower extremity peripheral neuropathy], the aforementioned January 2015 rating decision assigned 20 percent ratings for left and right lower extremity peripheral neuropathy effective from January 26, 2015, the date of a VA examination conducted on that day that demonstrated moderate peripheral neuropathy in the lower extremities. Moderate peripheral neuropathy in the lower extremities was also demonstrated at an April 2016 VA "Diabetic Sensory-Motor Peripheral Neuropathy" examination (the reports from which are contained in the VBMS file). The VA physician's assistant who conducted this examination found that the peripheral neuropathy in the lower extremities did not impact the Veteran's ability to work. Applying the pertinent criteria to the facts set forth above, ratings in excess of 20 percent for the service connected peripheral neuropathy in each lower extremity would require moderately severe incomplete paralysis. 38 C.F.R. § 4.124a, DC 8520. As set forth above, both the January 2015 and April 2016 VA examination demonstrated moderate peripheral neuropathy in the lower extremities. As such, the criteria for a schedular rating in excess of 20 percent for peripheral neuropathy of either lower extremity are not met. 38 C.F.R. §4.124a, DC 8520. D. Final Considerations The undersigned again notes that in addition to the VA examination reports, the VA outpatient treatment reports have been reviewed and considered. As with respect to the rating assigned for diabetes under DC 7913, these records do not demonstrate a degree of disability associated with the service connected eye disability or lower extremity neuropathy that differ any significant way-as relevant to the applicable rating criteria-from that shown by the VA examination reports discussed above. The undersigned also finds that additional compensation based on an additional staged rating or ratings for the manifestations addressed above is not warranted, as the Veteran's symptomatology associated with these manifestations has otherwise remained stable throughout the appeal. The Board has also contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected manifestations addressed above with the established criteria found in the rating schedule. While the Veteran has described the functional impairment he experiences as a result of these manifestations, the Board finds that such manifestations are fully addressed by the rating criteria applicable to the disabilities addressed above. These disabilities are fully addressed by the rating criteria, and in particular with respect to diabetes, a wide range of manifestations are contemplated by DC 7913. With respect to the service connected eye disability and lower extremity peripheral neuropathy, the applicable rating criteria contemplate any difficulties the Veteran has due to such manifestations. As such, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected disabilities addressed above, and that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Furthermore, the Board notes that under Johnson v. McDonald, 762 F3.d 1362 (2014), a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. In this case, even after affording the Veteran the benefit of the doubt under Mittleider v. West, 11 Vet. App. 181 (1998), there is no additional impairment that has not been attributed to a specific, rated disability. Accordingly, this is not an exceptional circumstance in which extra-schedular consideration may be required to compensate the Veteran for disability that can be attributed only to the combined effect of multiple conditions. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for total disability rating for compensation based on individual Unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of Unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, none of the VA examination reports have indicated that the manifestations at issue have impacted employment, and there is no evidence of record to suggest that the service-connected manifestations addressed above, either alone or in combination, render the Veteran unemployable. Therefore, a claim for a TDIU is not raised and need not be further addressed. In sum, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 20 percent for type II diabetes mellitus; a rating in excess of 0 percent for bilateral cataracts with right eye pseudophakia for the period from August 24, 2005, to June 9, 2008, and in excess of 30 percent for the period beginning June 10, 2008; and a rating in excess of 20 percent for right or left lower extremity peripheral neuropathy. As such, the benefit of the doubt doctrine is not applicable with respect to such matters, and a rating in excess of 20 percent for type II diabetes mellitus; a rating in excess of 0 percent for bilateral cataracts with right eye pseudophakia for the period from August 24, 2005, to June 9, 2008, or in excess of 30 percent for the period beginning June 10, 2008; and a rating in excess of 20 percent for right or left lower extremity peripheral neuropathy must be denied. Gilbert, supra; 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. ORDER A rating in excess of 20 percent for type II diabetes mellitus is denied. An initial rating in excess of 0 percent for bilateral cataracts with right eye pseudophakia for the period from August 24, 2005, to June 9, 2008, and in excess of 30 percent for the period beginning June 10, 2008, is denied. A rating in excess of 20 percent for right lower extremity peripheral neuropathy is denied. A rating in excess of 20 percent for left lower extremity peripheral neuropathy is denied. REMAND Following a September 2016 rating decision (contained in the VBMS file) that granted service connection for PTSD, the Veteran submitted a notice of disagreement (also contained in the VBMS file) in October 2016 with respect to the effective date assigned for this disability. Therefore, the AOJ will be requested below to complete an SOC addressing this issue. Manlincon, supra. The Board emphasizes, however, that to obtain appellate review of this issue, a perfected appeal must be filed. See 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 20.200, 20.201, 20.202 (2016). Accordingly, the case is REMANDED for the following action: Furnish to the Veteran and his representative an SOC with respect to the matter of entitlement to an effective date earlier than April 8, 2016, for a grant of service connection for PTSD, along with a VA Form 9, and afford them the appropriate opportunity to submit a substantive appeal perfecting an appeal as to this issue. The Veteran and his representative are hereby reminded that to obtain appellate review of this issue, a timely appeal must be perfected. The Board intimates no opinion as to the outcome of the remanded claim. The Veteran need take no action until so informed. 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). The remanded claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs