Citation Nr: 1751287 Decision Date: 11/09/17 Archive Date: 11/17/17 DOCKET NO. 11-08 237 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). 2. Entitlement to an initial disability rating greater than 10 percent for diabetic sensory neuropathy of the right leg from April 8, 2009, and greater than 20 percent from May 14, 2014. 3. Entitlement to an initial disability rating greater than 10 percent for diabetic sensory neuropathy of the left leg from April 8, 2009, and greater than 20 percent from May 14, 2014. 4. Entitlement to a disability rating greater than 20 percent for diabetes mellitus type II. 5. Entitlement to an initial disability rating greater than 40 percent from April 8, 2009, for atheromatous disease of the right leg and to a compensable disability rating from July 1, 2014. 6. Entitlement to an initial disability rating greater than 40 percent from April 8, 2009 for atheromatous disease of the left leg and to a compensable disability rating from July 1, 2014. 7. Entitlement to service connection for heart disease, to include as due to herbicide agent exposure during service ATTORNEY FOR THE BOARD Heather J. Harter, Counsel INTRODUCTION The Veteran served on active duty from August 1967 to March 1969. He was awarded the Vietnam Campaign Medal in relation to his service in Vietnam, among other service medals and decorations. This matter comes before the Board of Veterans' Appeals (Board) from RO decisions of November 2009, February 2010, July 2011, and June 2014. The Board recharacterized the disability involving the Veteran's venous disease to more accurately reflect the medical evidence of record and to more precisely describe the Veteran's service-connected disability. Therefore, the issues certified to the Board as involving peripheral vascular disease have been recharacterized as atheromatous disease herein. The issue of entitlement to service connection for heart disease is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's combined disability rating has been 80 percent since April 8, 2009, and he is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 2. Separate disability ratings are warranted for diabetic sensory neuropathy of the femoral nerves and the sciatic nerves of both legs. 3. The Veteran's diabetic sensory neuropathy is analogous to no more than mild incomplete paralysis of the sciatic nerves of both legs for the entire period on appeal. 4. The Veteran's diabetic sensory neuropathy also results in moderate incomplete paralysis of the femoral nerves of both legs beginning May 14, 2014. 5. The Veteran's diabetes mellitus requires insulin and a restricted diet or oral hypoglycemic agents, but his physicians have not regulated his activities. 6. Throughout the appeal period, the Veteran's atheromatous disease affecting both legs did not result in claudication on walking more than 100 yards and diminished peripheral pulses or an ankle/brachial index of 0.9 or less. CONCLUSIONS OF LAW 1. A TDIU is warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). 2. Initial disability ratings higher than 10 percent for diabetic sensory neuropathy affecting the sciatic nerves in each leg are not warranted throughout the appeal period. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.7, 4.10, 4.14, 4.20, 4.31, 4.124a, Diagnostic Code 8520 (2017). 3. Beginning May 14, 2014, but not before, separate disability ratings of 20 percent, but not higher, for diabetic sensory neuropathy affecting the femoral nerves in each leg are warranted (in addition to separate ratings for sciatic nerves). 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.7, 4.10, 4.14, 4.20, 4.31, 4.124a, Diagnostic Code 8626 (2017). 4. A disability rating greater than 20 percent for diabetes mellitus is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.7, 4.10, 4.119, Diagnostic Code 7913 (2017). 5. Initial disability ratings greater than 40 percent from April 8, 2009, for atheromatous disease of both legs, and compensable disability ratings from July 1, 2014, are not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.7, 4.10, 4.20, 4.31, 4.104, Diagnostic Code 7114 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters The Veteran contends that higher disability ratings are warranted for each of the disabilities on appeal. He asserts that he is unable to maintain employment due to his service-connected disabilities and that he retired from his previous job on account of his service-connected disabilities. In a February 2017 written statement addressed to the Committees on Veterans Affairs of the United States Senate and the United States House of Representatives, the Veteran states he believes the VA has lost his records. He does not provide any details regarding when or which records he believes were lost, or indeed, any basis for his belief that records were lost. Because a complete record is the foundation for a well-informed adjudication, the Board has carefully reviewed the Veteran's electronic claims files for any indication of missing records. We have found no such indication. Rather, his file appears to be complete, as it contains the type and number of records which would be expected in a case such as his. His file contains his service records, personnel and medical; and records pertaining to his post-service educational benefits. The file it also contains recent medical records and VA examination reports obtained in connection with his current appeal. Lastly, his file contains all the administrative documentation which is expected, to include all RO decision-making and rating documents, and all notification letters; as well as the Veteran's own written correspondence over the years since his discharge from service. The Board therefore concludes that the Veteran must have been mistaken as to his assertion that VA had lost his records. The Board will therefore proceed to review his appeal is it stands. No other issues with the duty to notify or duty to assist have been raised and none are apparent upon Board review. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The Board thoroughly reviewed all the evidence in the Veteran's VA files. In every decision, the Board must provide a statement of the reasons or bases for its determination, adequate to enable an appellant to understand the precise basis for the Board's decision, as well as to facilitate review by the Court. 38 U.S.C. § 7104(d)(1); see Allday v. Brown, 7 Vet. App. 517, 527 (1995). Although the entire record must be reviewed by the Board, the Court has repeatedly found that the Board is not required to discuss, in detail, every piece of evidence. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (rejecting the notion that the Veterans Claims Assistance Act mandates that the Board discuss all evidence). Rather, the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake, infra. Claim for a TDIU Total disability ratings for compensation based on individual unemployability may be assigned when the combined schedular rating for the service-connected disabilities is less than 100 percent and when it is found that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age, provided that, if there is only one such disability, this disability is ratable at 60 percent or more, or if there are two or more disabilities, there is at least one disability ratable at 40 percent or more and additional disabilities to bring the combined rating to 70 percent or more. Alternatively, a total disability rating for compensation based on unemployability may be assigned to a veteran who is unable to secure and follow a substantially gainful occupation by reason of his/her service-connected disabilities. The Veteran's employment history, educational and vocational attainment as well as his particular physical disabilities are to be considered in making a determination on unemployability. 38 C.F.R. §§ 3.340, 3.341, 4.16. The Veteran's combined disability rating has been 80 percent since April 2009. He therefore meets the schedular criteria set forth at 38 C.F.R. § 4.16. The Veteran worked for Puerto Rico's tax office for many years, retiring in 2009. He has credibly asserted that even though he had worked enough years to support his retirement based upon seniority, he retired sooner than he would have liked due to his service-connected disabilities. His service connected disabilities include vascular and sensory impairment in both legs, diabetic nephropathy with hypertension, and diabetic retinopathy. In other words, multiple body systems are impacted by his service-connected diabetes. He takes medications multiple times a day and monitors his blood sugar. For these reasons, an award of a TDIU is warranted in this case. According the Veteran every benefit of the doubt under the law, he is unemployable due to service-connected disabilities. The appeal is therefore granted. Pertinent Laws and Regulations Governing Increased Rating Claims Disability evaluations are assigned to reflect levels of current disability. The appropriate rating is determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In evaluating claims for increased ratings, we must evaluate the Veteran's condition with a critical eye toward the lack of usefulness of the body or system in question. 38 C.F.R. § 4.10. In evaluating claims for increased ratings, we must evaluate the veteran's condition with a critical eye toward the lack of usefulness of the body or system in question. 38 C.F.R. § 4.10. A disability of the musculoskeletal system is measured by the effect on ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Weakness is as important as limitation of motion in assigning the most accurate disability rating. 38 C.F.R. § 4.40. Although § 4.40 does not require a separate rating for pain, it does provide guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. The Board has a special obligation to provide a statement of reasons or bases pertaining to § 4.40 in rating cases involving pain. Spurgeon v. Brown, 10 Vet. App. 194 (1997). When a disability not specifically provided for in the rating schedule is encountered, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. In every instance where the minimum schedular evaluation requires residuals and the schedule does not provide a no-percent evaluation, a no-percent evaluation will be assigned when the required residuals are not shown. 38 C.F.R. § 4.31. Diabetic sensory neuropathy affecting the lower extremities The rating criteria under 38 C.F.R § 4.124a, DC 8520 evaluate neurologic impairment of the sciatic nerve. DCs 8520, 8620, and 8720 provide ratings for paralysis, neuritis, and neuralgia of the sciatic nerve, respectively. Neuritis and neuralgia are rated as incomplete paralysis. Disability ratings of 10, 20, 40, and 60 are warranted, respectively, for mild, moderate, moderately severe, and severe (with marked muscular atrophy) incomplete paralysis of the sciatic nerve. A disability rating of 80 percent is warranted for complete paralysis of the sciatic nerve: the foot dangles and drops, no active movement possible of muscles below the knee, flexion of the knee weakened or lost. 38 C.F.R. § 4.124a. Under Diagnostic Code 8526, mild incomplete paralysis of the anterior crural (femoral) nerve, as well as neuritis (8626) and neuralgia (8726) of that nerve, warrants a 10 percent rating. Moderate incomplete paralysis is assigned a 20 percent rating. Severe incomplete paralysis of the femoral nerve warrants a 30 percent rating. With complete paralysis of the femoral nerve, which warrants a 40 percent rating, there is paralysis of the quadriceps extensor muscles. 38 C.F.R. § 4.124a. 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. Peripheral neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at time excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123. The term "incomplete paralysis" indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis given with each nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve 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. The Board notes that words such as mild, moderate, and severe 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. According to the report of a May 2009 VA examination for diabetes, the Veteran had peripheral neuropathic symptoms in the legs and plantar areas. The May 2009 VA examination of the peripheral nerves reflects that the Veteran had decreased sensation to vibration, pain and light touch. Reflexes and motor strength of the lower extremities was normal. The examiner concluded that the Veteran's clinical symptoms and neurological signs were compatible with a mild diabetic sensory neuropathy only limited to the lower extremities. While paralysis per se was not present, neuralgia and neuritis were present. According to the report of a May 2014 VA examination, the Veteran had mild intermittent pain, mild paresthesias and/or dysesthesias, and moderate numbness in both legs. He also had cramps in his legs, mostly at night. He had normal muscle strength in both legs, but absent reflexes at the knee and ankle. He had decreased sensation to light touch in the ankle and lower leg, and no sensation to light touch in his feet and toes. He had decreased position sense in his legs as well. He had no sensation to vibration in his legs. He had trophic changes consisting of shiny pretibials, loss of hair and loss of pigmentation. The examiner identified mild incomplete paralysis of the sciatic nerve affecting both legs, and moderate incomplete paralysis of the femoral nerve affecting both legs. It is this identification which the RO relied upon in assigning a higher disability rating under the provisions of Diagnostic Code 8626 for sensory neuropathy affecting the femoral nerve. Service connection for diabetic sensory neuropathy of both legs was granted effective April 8, 2009, the date of claim for increase. A 10 percent disability rating for sensory neuropathy affecting the sciatic nerve was assigned to each leg at that time under Diagnostic Code 8599-8520, based upon decreased sense of vibration, decreased pain sensation and decreased light touch sensation. In the narrative summary of the June 2014 rating decision, the RO indicated that it had changed the Veteran's diagnostic code for diabetic sensory neuropathy from 8520 to 8626 to warrant the separate increases from 10 to 20 percent for diabetic sensory neuropathy of each lower extremity. Indeed, the May 2014 VA examination reflected findings of moderate impairment of the femoral nerves. The Board observes however that the June 2014 rating code sheet reflects one increase from 10 to 20 percent for diabetic neuropathy of the right lower extremity under DC 8620 which as noted pertains to neuritis or neuralgia of the sciatic nerve, and one increase from 10 to 20 percent for diabetic neuropathy of the left lower extremity under DC 8626 which as noted pertains to neuritis or neuralgia of the femoral nerve. The Board assumes that the code sheet was in error in that the separate increases to 20 percent for femoral nerve impairment were intended to apply to both the right and left legs (rather than the right leg assigned under the sciatic nerve code and the left assigned under the femoral code). Thus, on remand, the RO will be given an opportunity to correct these errors. At any rate, the medical evidence clearly shows that the Veteran's diabetes has resulted in mild peripheral neuropathy in the right and left legs throughout the entire appeal period. This finding is supportive of separate 10 percent ratings for diabetic neuropathy of the right and left lower extremities under Diagnostic Code 8520 (or 8620 for neuritis or neuralgia). Even higher separate ratings are however not warranted as the Veteran's sciatic nerve impairment has been shown to be no worse than mild in nature. See May 2009 and May 2014 VA examination reports. Nonetheless, although the sciatic nerve impairment has remained unchanged as evidenced by the May 2014 VA finding of only mild sciatic nerve involvement, the Veteran's diabetes is shown to now affect the femoral nerves in each lower extremity. In this regard, the May 2014 VA findings reflect that the Veteran has moderate impairment of the femoral nerve in each lower extremity. As such, the criteria for separate 20 percent ratings are warranted under Diagnostic Code 8626 effective May 14, 2014. Even higher ratings are not warranted as no more than moderate impairment of the femoral nerves is demonstrated. Notably, the two different nerve distributions identified by the May 2014 examiner as affected by diabetic neuropathy constitute separate and distinct manifestations of the disability. As such, assigning separate ratings under the provisions of Diagnostic Code 8520 (sciatic nerve) and DC 8626 (femoral nerve) does not violate the rule against pyramiding in this case. 38 C.F.R. § 4.14. The Board therefore holds that separate disability ratings are warranted for diabetic sensory neuropathy of the sciatic nerve and the femoral nerve for the dates reflected above. Diabetes mellitus Service connection for diabetes mellitus was granted effective in March 2004 based upon the legal presumption that it was caused by exposure to herbicides in Vietnam. A 20 percent disability rating was assigned at that time and has been in effect ever since. Diabetes mellitus (also called Diabetes Type II) is evaluated under 38 C.F.R. § 4.119, Diagnostic Code 7913. A 10 percent rating is warranted for diabetes mellitus that is manageable by a restricted diet only. A 20 percent rating is warranted where insulin and restricted diet, or; use of oral hypoglycemic agent and restricted diet is required. A 40 percent rating is warranted where insulin, restricted diet, and regulation of activities is required. A 60 percent rating is warranted for 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. A 100 percent rating is warranted for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulations of activities (avoidance of strenuous occupational and recreational 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 evaluated. 38 C.F.R. § 4.119, DC 7913. Note (1) to Diagnostic Code 7913 provides that compensable complications of diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent rating under Diagnostic Code 7913. Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. The criteria for rating diabetes mellitus are conjunctive, meaning that each element of the criteria is needed to meet the requirements for the specified evaluation. Camacho v. Nicholson, 21 Vet. App. 360 (2007); see also Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision means that all of the conditions listed in the provision must be met). Because the entire Veteran's service-connected disabilities are secondary to, or complications of, his diabetes; his diabetes-related disability rating has risen dramatically since 2004, as he developed separately-rated complications including nephropathy, hypertension, diabetic retinopathy, erectile dysfunction, atheromatous disease, and diabetic sensory neuropathy. In this decision, the Board has granted a TDIU based upon all of the various impacts of the Veteran's diabetes complications. However, as explained above, the complications of diabetes are rated separately. Therefore, applying the facts of the Veteran's medical situation to the criteria set forth in Diagnostic Code 7913, a disability rating greater than 20 percent is not warranted. The Veteran's medical records show that he requires insulin and a restricted diet or oral hypoglycemic agents and a restricted diet. There is no indication that he requires regulation of his activities, as would be required for the next higher disability rating of 40 percent. Rather, according to his VA medical records, he is encouraged to exercise and he reports that he does exercise regularly. Therefore, the preponderance of the evidence is against the assignment of a disability rating greater than 20 percent for diabetes mellitus. Atheromatous disease (previously characterized as peripheral vascular disease) Service connection for peripheral vascular disease secondary to diabetes was granted effective in April 2009. A 40 percent disability rating was assigned for claudication on walking and trophic changes. Following a May 2014 VA examination which provided greater information as to the nature of the Veteran's peripheral vascular disease, the RO reduced the disability rating to 0 percent, or noncompensable, finding that the disabling symptoms of the Veteran's peripheral vascular disease were not caused by diabetes. The explanation was that the Veteran has two types of peripheral vascular disease, atheromatous disease, and peripheral venous insufficiency. Only the atheromatous disease was caused by the diabetes. Furthermore, the peripheral venous insufficiency accounted for the symptoms upon which the previous 40 percent disability rating had been based. Although this more precise view of the medical evidence resulted in reducing the disability ratings assigned to atheromatous disease affecting both legs, because of other adjustments in the Veteran's disability rating made at the same time, in particular, the assignment of a 60 percent disability rating for diabetic nephropathy with hypertension, the Veteran's overall combined disability rating of 80 percent remained the same. Therefore, no additional procedural steps to protect the Veteran's combined disability rating were necessary. See 38 C.F.R. § 3.105(e). In any case, the Board's grant of a TDIU herein, will result in a 100 percent disability rating throughout the time period at issue here. Therefore, as it stands, the Veteran is seeking a disability rating greater than 40 percent from April 2009 for atheromatous disease of each leg and a disability rating greater than 0 percent from July 2014. It is worth noting that he has not specifically requested restoration of the 40 percent or specifically disagreed with the reduction. He is however, presumed under law to be seeking the highest ratings available. The Veteran's service-connected atheromatous disease is rated by analogy to the criteria for arteriosclerosis obliterans under 38 C.F.R. § 4.104, Diagnostic Code 7114. This Diagnostic Code provides for a 100 percent disability rating when there is ischemic limb pain at rest, and; either deep ischemic ulcers or ankle/brachial index of 0.4 or less. A 60 percent disability rating is provided for claudication on walking less than 25 yards on a level grade at two miles per hour, and either persistent coldness or the extremity or ankle/brachial index of 0.5 or less. A 40 percent disability rating is provided for claudication on walking between 25 and 100 yards on a level grade at two miles per hour, and; trophic changes (thin skin, absence of hair, dystrophic nails) or ankle/brachial index of 0.7 or less. A 20 percent rating is assigned for claudication on walking more than 100 yards, and; diminished peripheral pulses or ankle/brachial index of 0.9 or less. The ankle/brachial index is the ratio of the systolic blood pressure at the ankle (determined by Doppler study) divided by the simultaneous brachial artery systolic blood pressure. The normal index is 1.0 or greater. Each leg is evaluated separately and combined under 38 C.F.R. § 4.25, using the bilateral factor at 38 C.F.R. § 4.26. 38 C.F.R. § 4.104. At no point during the appeal period is the Veteran's atheromatous disease shown to result in claudication on walking more than 100 yards and diminished peripheral pulses or ankle/brachial index of 0.9 or less. Rather, although the Veteran reported claudication in both legs on walking, he had a negative exercise tolerance test and walked for nearly five minutes without any restriction in April 2010. His ankle/brachial index was measured at 1.06 bilaterally in April 2010. Furthermore, a VA examination has attributed the Veteran's reported symptoms of claudication to nonservice-connected bilateral peripheral venous insufficiency. In other words, when symptoms from the non-service-connected bilateral peripheral venous insufficiency, which also affects the legs, are removed from the equation, symptoms from the Veteran's atheromatous disease do not meet the criteria for a compensable disability rating. Therefore, a disability rating greater than 40 percent from April 2009 for peripheral vascular disease of each leg and a disability rating greater than 0 percent from July 2014 are denied. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER A TDIU is granted, subject to the laws and regulations governing the award of monetary benefits. Throughout the entirety of the appeal period, initial disability ratings greater than 10 percent for diabetic sensory neuropathy affecting the sciatic nerve in each leg under DC 8520 are denied. Beginning May 14, 2014, but not before, separate disability of 20 percent, but not higher, for diabetic sensory neuropathy affecting the femoral nerves in each leg under DC 8626 are warranted. A disability rating greater than 20 percent for diabetes mellitus is denied. Initial disability ratings greater than 40 percent from April 8, 2009, for atheromatous disease of each leg, and compensable disability ratings from July 1, 2014, are denied. REMAND Further development is necessary prior to analyzing the merits of the service connection claim for heart disease. As the Veteran continues to receive VA healthcare, his VA medical records should be updated for the file. Additionally, it appears that he may receive some private medical care as well. If he wishes the VA to consider these medical records in support of his remaining appeal, he is encouraged to work with the RO to obtain these records for VA review. The Veteran underwent extensive medical testing in 2010 aimed at determining whether he had a cardiac disability, in light of his documented hypertension, diabetes, nephrologic disease, and high cholesterol. No cardiac diagnosis was identified. However, the Veteran submitted a statement in April 2009, which purports to list his current medical diagnoses including coronary artery disease. See April 2009 submission purportedly from Dr. Ortiz. Any VA medical records are deemed to be constructively of record in proceedings before the Board and should be obtained prior to further review of the claims file. Bell v. Derwinski, 2 Vet. App. 611 (1992). The most recent VA treatment records available to adjudicators are dated in 2014. Prior to a complete review of the Veteran's claim for service connection for heart disease, his recent VA medical records should be obtained. Many of the 2010 tests were ordered and interpreted by a private cardiologist. If the Veteran continues to receive any non-VA medical care, to include cardiologic evaluation and treatment, he is encouraged to release records of such treatment to VA for review by adjudicators. Accordingly, the case is REMANDED for the following action: 1. Issue a corrective rating code sheet reflecting the current ratings assigned herein for diabetic peripheral neuropathy of the sciatic and femoral nerves of each lower extremity. 2. Obtain all records of VA medical treatment afforded to the Veteran subsequent to June 2014 at the VA Caribbean Healthcare System, The Arecibo Community Based Outpatient Clinic and all related clinics for inclusion in the file. 3. After securing the necessary release from the Veteran, obtain all identified private medical records reflecting treatment for heart disease since 2010. 4. Then, afford the Veteran a VA cardiology examination to identify any currently-shown cardiac disease. The claims folder, including all records received pursuant to the above requests, must be made available to the examiner for review before the examination. All tests and studies deemed helpful by the examiner should be conducted in conjunction with the examination. The examiner is asked to: (a) Indicate all heart disabilities currently shown. *In doing so, specifically indicate whether the Veteran is currently diagnosed with coronary artery disease. If not, reconcile such finding with a statement received in April 2009, which is purportedly authored by Dr. Ortiz and lists coronary artery disease as one of the Veteran's medical problems. (b) For any currently shown heart disease, aside from coronary artery disease, provide an opinion as to whether it had its onset during active service or is otherwise related to it or a service connected disability. A complete rationale should be provided. 5. After the development requested above has been completed to the extent possible, the RO should again review the record. If the benefit sought on appeal remains denied, the Veteran, and his representative, should he choose to designate one, should be furnished a supplemental statement of the case and given the opportunity to respond thereto. 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 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. B. MAYS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs