Citation Nr: 1751442 Decision Date: 11/09/17 Archive Date: 11/17/17 DOCKET NO. 11-08 497 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for a disability manifested by chest pain. 2. Entitlement to service connection for a disability manifested by difficulty breathing. 3. Entitlement to a compensable rating for a left ear hearing loss disability. 4. Entitlement to a rating in excess of 20 percent for diabetes mellitus (diabetes). 5. Entitlement to a compensable disability rating for diabetic nephropathy. 6. Entitlement to a rating in excess of 20 percent for prostatitis before January 12, 2011, to a rating in excess of 40 percent between January 12, 2011, and May 24, 2016, and to a rating in excess of 60 percent thereafter. 7. Entitlement to a compensable rating for right ureterolithiasis. 8. Entitlement to a compensable rating for xerosis. 9. Entitlement to ratings in excess of 10 percent for peripheral neuropathy of the bilateral femoral nerves. 10. Entitlement to an effective date earlier than May 11, 2015, for the awards of service connection for peripheral neuropathy of the bilateral femoral nerves. 11. Entitlement to a total disability rating based on individual unemployability as the result of service-connected disability (TDIU). REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD J.A. Flynn, Counsel INTRODUCTION The Veteran served on active duty from September 1961 to August 1963 and from September 1963 to September 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from four rating decisions of the VA RO. An October 2009 rating decision, in part, declined to reopen the Veteran's claim for service connection for disabilities manifested by chest pain and difficulty breathing, continued the existing 20 percent rating of the Veteran's diabetes, continued the existing 20 percent rating for prostatitis, and denied a TDIU. A June 2010 rating decision continued the existing noncompensable ratings for right ureterolithiasis and xerosis. A June 2015 rating decision granted service connection for peripheral neuropathy of the bilateral femoral nerves and assigned 10 percent ratings effective May 11, 2015. A July 2016 rating decision, effectuating a February 2016 decision of the Board, granted service connection for left ear hearing loss and assigned a noncompensable rating. This appeal has previously been before the Board, most recently in February 2016, when it remanded the Veteran's claims for additional development of the medical evidence. The Board finds that its remand instructions have been substantially complied with, and the Board will proceed in adjudicating the Veteran's claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that when the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In December 2016, the Veteran submitted claims for an increased rating for peripheral neuropathy of the bilateral sciatic nerves, an increased rating for diabetic retinopathy, and a petition to reopen a claim of entitlement to service connection for right ear hearing loss disability, but these claims have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2016). The issues of entitlement to service connection for a disability manifested by difficulty breathing, a compensable rating for a left ear hearing loss disability, a compensable rating for diabetic nephropathy, and a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran does not have a disability manifested by chest pain. 2. The Veteran's diabetes requires the use of insulin and the restriction of diet, but it does not require restriction of activities. 3. It is not factually ascertainable that the symptoms associated with the Veteran's peripheral neuropathy of the bilateral femoral nerves were of a severity associated with a compensable evaluation any earlier than May 11, 2015. 4. The Veteran's peripheral neuropathy of the bilateral femoral nerves is not manifested by symptoms approximating moderate incomplete paralysis of the femoral nerve. 5. Before January 12, 2011, the Veteran's prostatitis did not result in a) the use of an appliance or wearing absorbent materials that had to be changed at least two times a day; b) a daytime voiding interval less than one hour or awakening to void at least five times per night, c) obstructed voiding, or d) urinary tract infections (UTIs). 6. Since January 12, 2011, the Veteran's prostatitis has resulted in wearing absorbent materials that have to be changed more than four times a day, but it has not resulted in UTIs. 7. The Veteran's right ureterolithiasis has not resulted in any symptoms or residuals. 8. The Veteran's xerosis does not involve at least five percent of the exposed body area or total body area, does not require intermittent systemic therapy, does not result in disfigurement of the head, face, or neck, and does not result in scarring or any other functional impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for a disability manifested by chest pain have not been met. 38 U.S.C.A. §§ 5103, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309 (2016). 2. The criteria for a rating in excess of 20 percent for diabetes have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2016). 3. The criteria for an effective date earlier than May 11, 2015, for service connection for peripheral neuropathy of the bilateral femoral nerves have not been met. 38 U.S.C.A. §§ 5107, 5110 (West 2014); 38 C.F.R. §§ 3.400, 4.119, Diagnostic Code 7913, Note 1 (2016). 4. The criteria for ratings in excess of 10 percent for peripheral neuropathy of the bilateral femoral nerves have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.124a, Diagnostic Code 8526 (2016). 5. Before January 12, 2011, the criteria for a rating in excess of 20 percent for prostatitis have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Code 7527 (2016). 6. From January 12, 2011, to May 24, 2016, the criteria for a rating of 60 percent, but no greater, for prostatitis have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Code 7527 (2016). 7. Since May 24, 2016, the criteria for a rating in excess of 60 percent for prostatitis have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Code 7527 (2016). 8. The criteria for a compensable rating for right ureterolithiasis have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Code 7510 (2016). 9. The criteria for a compensable rating for xerosis have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.118, Diagnostic Code 7806 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has certain notice and assistance obligations to claimants. 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2016). In the instant case, the Veteran was provided with all appropriate notification in June 2009 and September 2009. The Veteran has not otherwise alleged or demonstrated any prejudice with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders/Simmons, 556 U.S. 396 (2009); see also Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (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 duty to assist argument). Thus, adjudication of the Veteran's claims at this time is warranted. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran's post-service medical treatment records have been obtained, to the extent they were both identified and available. The duty to assist also includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). More specifically, a VA examination must be conducted when the evidence of record does not reflect the current state of the Veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2016). To that end, when VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In this case, the Veteran was provided with an examination addressing his chest pain in May 2016. In August 2016, the Veteran indicated the examiner incorrectly noted that his only complaint was shortness of breath; the Veteran indicated that the examiner failed to note his complaint of chest pain. The Board has no reason to doubt that the May 2016 examiner accurately recorded the Veteran's responses in the examination report. Even if, however, the Board were to find that the Veteran indeed had chest pain at the time of the May 2016 examination, the Board notes that it is undisputed that the Veteran has complained of chest pain throughout the appeal; indeed, the examiner conceded that the Veteran suffered from chest pain when rendering an etiological opinion. Otherwise, the May 2016 examination report addressing the Veteran's chest pain, and the examinations addressing the Veteran's diabetes, his neuropathy, his prostatitis, his right ureterolithiasis, and his xerosis, indicate that the examiners reviewed the Veteran's claims file and past medical history, recorded his current complaints, conducted appropriate evaluations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board, therefore, concludes that these examination reports are adequate for the purpose of rendering a decision in the instant appeal. 38 C.F.R. § 4.2 (2016); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran requested the opportunity to participate in a hearing before the Board, but in October 2015, the Veteran withdrew his request for such a hearing. The Board finds that there is no indication that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Thus, the duties to notify and assist have been met, and the Board will proceed to a decision. Service Connection for a Disability Manifested by Chest Pain In general, service connection may be granted for disability or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2016). In order to establish service connection for a claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence, generally medical, of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). In the absence of proof of a present disability (and, if so, of a nexus between that disability and service), there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Furthermore, pain alone, without a diagnosed or identifiable underlying malady or condition, does not itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). Turning to the facts in this case, it is undisputed that the Veteran sought treatment for chest pain on many occasions in service. For example, in an April 1973 Report of Medical history, the Veteran reported experiencing occasional non-exertional pain or pressure in his chest. The Veteran complained of a four-day history of pain in his heart area in May 1974. An associated electrocardiogram was normal, and the Veteran was assessed with muscle spasm. An October 1975 chest x-ray was normal. The Veteran complained of chest pain in July 1976. A July 1976 chest x-ray showed clear lung fields, no pulmonary lesions, and a normal heart size. The Veteran was assessed with vague muscle-cramp pain by description with no disease found. The Veteran complained of chest pains in August 1977; a clinician noted at that time that the Veteran had been diagnosed with recurrent chest pain since 1971. An electrocardiogram was normal, and a chest x-ray was within normal limits. The Veteran was assessed with probable cardiospasm. The Veteran complained of several months of intermittent chest pain in August 1980. It was noted that the Veteran smoked, but he denied shortness of breath associated with his chest pain. It was noted that an electrocardiogram was within normal limits. The Veteran was assessed with non-cardiac chest pain and was reassured. In a May 1981 Report of Medical History, the Veteran indicated that he experienced pain or pressure in his chest and palpitation or pounding heart. The Veteran did not indicate whether or not he had experienced shortness of breath, and he did not know whether he had experienced heart trouble. In the Veteran's May 1981 separation examination, the Veteran's heart, lungs, and chest were noted to be normal, and an electrocardiogram was within normal limits. A May 1981 chest x-ray showed no significant radiographic abnormality. In July 1981, the Veteran complained of chest pains. While it is well-established that the Veteran complained of symptoms of chest pain in service, the question in this case is whether the evidence shows that the Veteran has been diagnosed with a chronic disability manifested by chest pain at any time since filing his claim for service connection in June 2009. In July 2009, the Veteran denied experiencing chest pain. In a July 2009 examination addressing the Veteran's diabetes, an examiner noted that the Veteran's cardiac status was acceptable, with a July 2009 chest x-ray showing a normal heart without evidence of congestive heart failure or cardiac malfunction. In August 2009, the Veteran complained of chest pain and dyspnea. Private cardiac testing indicated that the Veteran had a normal sinus rhythm with a first degree atrioventricular (AV) block, which, the Board notes, is an impairment of conduction of cardiac impulses from the atria to the ventricles. Dorland's Illustrated Medical Dictionary, 230 (31st ed. 2007). The impression was normal myocardial perfusion, wall motion, and ejection fraction. The Veteran had an appropriate hemodynamic response to intravenous adenosine and adjunct hand grip exercise with no chest pain and no ischemic electrocardiogram changes. A September 2009 chest x-ray showed a normal heart and pulmonary vessels. In a January 2010 private treatment record, the Veteran denied experiencing chest pains, palpitations, tachycardia, or orthopnea. Cardiovascular examination was normal. In February 2010, a clinician noted that previous cardiology assessments did not show significant evidence for coronary artery disease. In March 2010 and May 2010, the Veteran denied experiencing chest pain. In July 2010, the Veteran's cardiovascular system was noted to be normal. In January 2011, the Veteran complained of pressure in his left upper chest wall. A clinician noted that an August 2009 stress test showed no coronary artery disease. In July 2011, February 2012, August 2012, February 2013, August 2013, March 2014, September 2014, April 2015, December 2015, and May 2016, the Veteran had no chest pain or palpitation. The Veteran underwent a cardiac examination in May 2016, at which time the examiner noted that a routine electrocardiogram test showed that the Veteran had a first degree AV block. The examiner indicated that the AV block was an incidental finding that produced no current symptoms. The AV block would not be expected to produce any signs or symptoms unless it progressed, nor was it early indicator of heart disease. The AV block did not fall within the generally-accepted medical definition of ischemic heart disease. The examiner indicated that the etiology of the AV block was age. The examiner further found no underlying heart or lung disease causing the Veteran's chest pain, which the examiner found to be more likely musculoskeletal in nature. The May 2016 examiner found that the Veteran's complaint of chest pain with exertion was not due to a cardiac condition; the examiner indicated that the results of a cardiac stress test verified this. The Veteran's AV block would not result in the symptom of chest pain. Turning to an analysis of these facts, the Board finds that while the Veteran has occasionally complained of chest pain since filing his claim in June 2009, the Veteran has more often denied experiencing such pain. Additionally, despite undergoing a number of cardiac tests, clinicians have consistently failed to attribute the Veteran's complaints of chest pain to an underlying disability. Furthermore, to the extent that the Veteran has been noted to have an AV block, the May 2016 examiner opined, essentially, that such a finding is akin to a positive laboratory finding, which is not a disability for which service connection may be granted. VA does not generally grant service connection for symptoms alone, without an identified basis for those symptoms. In other words, service connection requires the presence of a disability, not symptoms unassociated with a disability. To the extent that the Veteran believes that he experiences symptoms of a disability manifested by chest pain, the Veteran is competent to testify as to readily-observable symptoms such as pain. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran, as a layperson, is not competent to report that any symptoms that he currently experiences rise to the level of a "disability" for VA purposes. Thus, while the Veteran may experience chest pain, his statements are not sufficient to establish the presence of a disability manifested by chest pain. The Board finds that the weight of the evidence of record is against a finding that the Veteran suffers from a disability manifested by chest pain. In sum, the Board concludes that the criteria for service connection for a disability manifested by chest pain have not been met, and the claim is denied. Increased Ratings Generally Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2016). Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2016). 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 (2016). Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2016). In general, when 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, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are appropriate for an increased rating claim, if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Separate disabilities arising from a single disease entity are to be rated separately. 38 C.F.R. § 4.25 (2016); see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Pyramiding-the evaluation of the same disability or the same manifestations of a disability under different diagnostic codes-is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2016). Increased Rating for Diabetes The Veteran contends that he is entitled to a rating in excess of 20 percent for diabetes. Under the Diagnostic Code applicable to diabetes, a 20 percent disability rating applies to diabetes requiring insulin and restricted diet, or use of an oral hypoglycemic agent and a restricted diet. A 40 percent disability rating applies to diabetes requiring insulin, restricted diet, and regulation of activities. A 60 percent disability rating applies to diabetes 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 applies to diabetes requiring 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, Diagnostic Code 7913 (2016). The phrase "regulation of activities" means that a veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2016). Additionally, the rating criteria contained in Diagnostic Code 7913 are conjunctive. In other words, the criteria for each higher disability rating include the criteria of each lower disability rating. If any criterion is not met at any particular level, the Veteran can only be rated at the level that does not require the missing component. Tatum v. Shinseki, 23 Vet. App. 152 (2009). In other words, each higher rating requires the elements of the lower rating. Turning to the facts in this case, throughout the period on appeal, the evidence of record, including VA examination reports and VA outpatient treatment records, shows that the Veteran has been prescribed insulin to maintain a satisfactory blood sugar level and that he has been placed on a restricted diet. At issue in this case, then, is whether the Veteran's diabetes requires the regulation of activities that is associated with a rating in excess of the currently-assigned 20 percent evaluation. The Board cannot find that the weight of the evidence supports such a finding. To the contrary, not only does the evidence not show that the Veteran's diabetes required the regulation of activities, but clinicians regularly advised the Veteran to increase his activity. For example, in March 2012, an endocrinologist encouraged the Veteran to engage in ongoing exercise. In March 2014, the Veteran was counseled regarding the importance of exercise. In September 2014, a clinician emphasized the importance of an exercise plan for the fall and winter. In a separate record from September 2014, the Veteran was counseled regarding the importance of regular exercise and physical activity. In April 2015, the Veteran was counseled regarding the importance of exercise. The Veteran underwent a VA examination in May 2016, at which time the examiner indicated that the Veteran's diabetes did not require regulation of activities. To the extent that clinicians have noted that the Veteran is limited from engaging in activity, clinicians have attributed this limitation to the Veteran's COPD, rather than to his diabetes. For example, in March 2011, a private clinician indicated that "because of [the Veteran's] advanced COPD, it is difficult for him to exercise in a regular aggressive fashion [due] to intermittent exacerbation of his lung disease". Thus, upon review of the record, the Board finds that the weight of the medical evidence of record does not support a finding that the Veteran's diabetes requires the restriction of activities. To the extent that the Veteran indeed believes that diabetes requires the regulation of activities, the Board notes that laypersons can attest to factual matters of which they have first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). While the Veteran is competent to report what he perceives through his senses, such as difficulty engaging in activities, he does not have medical training or expertise. Layno v. Brown, 6 Vet. App. 465 (1994). Thus, to the extent that the Veteran indeed believes that diabetes requires the regulation of activities, the Board assigns such beliefs little probative weight, because the weight of the evidence of record indicates that the Veteran has not been prescribed or advised to avoid strenuous occupational and recreational activities due to diabetes. The Board finds that whether the management of diabetes requires the restriction of activities or the avoidance of strenuous occupational and recreational activities is a decision that is medical in nature. The weight of the competent evidence of record shows that restriction of activities is not required due to diabetes. Therefore, the Board finds that a rating in excess of 20 percent for diabetes is not warranted. The Board acknowledges that compensable complications of diabetes are to be evaluated separately unless they are part of the criteria used to support a 100 percent disability evaluation, with noncompensable complications to be considered as part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1) (2016). In this case, clinicians have identified peripheral neuropathy, nephropathy, and retinopathy as the Veteran's diabetic complications. The Board's February 2016 decision adjudicated the claims for greater ratings for peripheral neuropathy of the sciatic nerve and retinopathy; consideration of the proper ratings for these complications is thus no longer before the Board. The Veteran has separately pursued a claim of entitlement to increased ratings for peripheral neuropathy of the bilateral femoral nerves, and the Board addresses those claims in the section that follows. The Board has separately remanded the diabetic complication of nephropathy for additional development of the medical evidence. Earlier Effective Date and Increased Rating for Peripheral Neuropathy of the Femoral Nerve The Veteran contends that he is entitled to ratings in excess of 10 percent for peripheral neuropathy of the bilateral femoral nerves, and he additionally contends that the award of service connection for this disability should be earlier than May 11, 2015. The Board will address both of these contentions together because they involve the same factual history. Turning to the facts in this case, the Veteran underwent a VA examination in September 2008, at which time the Veteran denied experiencing paresthesias, dysesthesias, or other symptoms associated with peripheral neuropathy. Strength testing was normal, and it was noted that the Veteran had hypersensitivity of the third toe of the right foot and diminished sensation to the fourth toe of the left foot. The Veteran filed his underlying claim of entitlement to a greater rating for diabetes in May 2009. The Veteran underwent a VA examination in July 2009, at which time the Veteran denied experiencing paresthesias, dysesthesias, or other symptoms of peripheral neuropathy. Strength testing was normal, and it was noted that the Veteran had diminished sensation to light touch of the bilateral lower extremities. The Veteran underwent a VA examination in May 2015, at which time the Veteran complained of sensations of pain and numbness in the bilateral thighs. The examiner found that the Veteran did not experience constant or intermittent pain, but had mild paresthesias, dysesthesias, and numbness in the bilateral lower extremities. Strength and reflex testing were normal. Vibration sensation was decreased in the lower extremities. No muscle atrophy or trophic changes were noted. The examiner found that the Veteran had mild incomplete paralysis of the bilateral femoral nerves. The Veteran underwent an additional VA examination in May 2016, at which time the Veteran complained of sensations of pain and numbness that felt as if they were progressing up his legs. Strength and reflex testing were normal. Light touch and monofilament testing was normal at the knees, thighs, ankles, lower legs, but decreased at the feet and toes. Position sense and vibration sensation were normal. No muscle atrophy or trophic changes were noted. While the examiner noted that the Veteran had mild incomplete paralysis of the sciatic nerve, the examiner found the Veteran's femoral nerves to be bilaterally normal. Turning first to the question of the appropriate effective date for the award of separate 10 percent ratings for neuropathy of the bilateral femoral nerves, as noted above, the rating criteria for diabetes indicate that compensable complications of diabetes are to be evaluated separately unless they are part of the criteria used to support a 100 percent disability evaluation, with noncompensable complications to be considered as part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1) (2016). Thus, the Board finds that the Veteran's May 14, 2009, statement that was treated as a claim for an increased rating for diabetes was a claim for an increased rating for all diabetic complications, including peripheral neuropathy of the bilateral femoral nerves. With a May 14, 2009, date of claim established, the Board notes that the appropriate effective date for the separate ratings for peripheral neuropathy of the bilateral femoral nerves depends on the date when it was factually ascertainable that the Veteran's disability underwent an increase. 38 C.F.R. § 3.400(o) (2016). In this case, the Board notes that the Veteran has been in receipt of separate 20 percent evaluations for peripheral neuropathy of the sciatic nerves (rather than femoral nerves) at all times relevant in this appeal. To the extent that previous examiners described neuropathic symptoms, such symptoms were attributed to the Veteran's sciatic nerve impairment. It was only at the time of the Veteran's May 11, 2015, VA examination that any clinician attributed additional impairment to the Veteran's femoral nerves. May 11, 2015, is thus the first date that an increase in the Veteran's femoral nerve disability was shown to have occurred. At no time before May 11, 2015 had the Veteran been diagnosed with a compensable disability of the femoral nerve. The Veteran has argued, for example in August 2015, that he is entitled to an earlier effective date for the award of service connection for peripheral neuropathy of the femoral nerve because the has experienced "severe pain, tenderness, instability, [and] numbness . . . in the left lower extremity since 3 Aug 2006". The Board, for several reasons, cannot grant an earlier effective date for peripheral neuropathy of the femoral nerve based on such statements alone. First, the Veteran is not competent to assess whether he experienced such symptoms specifically as the result of femoral nerve impairment, rather than, for example, his sciatic nerve impairment, which has been awarded a 20 percent rating at all times relevant to this appeal. The Board further finds the Veteran's contemporaneous statements of experiencing constant pain associated with the femoral nerve since 2006 to be at odds with statements that he made to clinicians in September 2008 and July 2009 denying such symptoms. Accordingly, the Board finds that the proper effective date for the award of a separate evaluation for the Veteran's bilateral femoral nerves is May 11, 2015, which is the first time that the evidence arguably showed a compensable impairment of the femoral nerve. With this effective date established, the Board will determine whether a greater rating of the Veteran's neuropathy of the femoral nerves is available since that time. Incomplete paralysis of the anterior crural (femoral) nerve warrants a 10 percent evaluation when mild, a 20 percent evaluation when moderate, and a 30 percent evaluation when severe. 38 C.F.R. § 4.124a, Diagnostic Code 8526 (2016). The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured 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. Complete paralysis of the anterior crural (femoral) nerve is rated 40 percent and contemplates paralysis of the quadriceps extensor muscles. 38 C.F.R. § 4.124a, Diagnostic Code 8526 (2016). The rating schedule does not define terms such as "mild," "moderate," or "severe." Instead, adjudicators must evaluate all of the evidence and render a decision that is equitable and just. 38 C.F.R. § 4.6 (2016). Upon review of the evidence of record, the Board cannot find that the Veteran's symptoms of peripheral neuropathy of the bilateral femoral nerves approximate symptoms of moderate incomplete paralysis or worse at any time, as would be required for a rating in excess of the currently-assigned 10 percent rating. The May 2015 examiner found that the Veteran's peripheral neuropathy of the bilateral femoral nerves was of a mild severity, and the May 2016 examiner found that the Veteran had no impairment of the bilateral femoral nerves at all. While the Board otherwise notes that the Veteran has complained of symptoms such as pain and numbness, such complaints themselves are insufficient to establish that the Veteran's symptoms have approximated incomplete moderate paralysis or worse at any time, particularly given the consistent findings of clinicians that the Veteran did not suffer from moderate symptoms or worse. In sum, the weight of the credible evidence demonstrates that the Veteran's peripheral neuropathy of the bilateral femoral nerves does not warrant ratings in excess of 10 percent at any time, and the Veteran's claims are therefore denied. Increased Rating for Prostatitis The Veteran's prostatitis is rated 20 percent disabling before January 12, 2011, 40 percent disabling between January 12, 2011, and May 24, 2016, and 60 percent disabling thereafter under Diagnostic Code 7527, applicable to prostate gland injuries. Prostate gland injury is rated on the basis of voiding dysfunction or UTI, whichever is predominant. 38 C.F.R. § 4.115b, Diagnostic Code 7527. Voiding dysfunctions are rated under the criteria applicable to urine leakage, urinary frequency, or obstructed voiding. Under the criteria applicable to urine leakage, a 20 percent rating applies with the wearing of absorbent materials that must be changed fewer than two times per day. A 40 percent rating applies with the wearing of absorbent materials that must be changed two to four times per day. A 60 percent rating applies with the use of an appliance or the wearing of absorbent materials that must be changed more than four times per day. 38 C.F.R. § 4.115(a) (2016). Under the criteria applicable to urinary frequency, a 20 percent rating applies with a daytime voiding interval between one and two hours, or; awakening to void three to four times per night. A 40 percent rating applies with a daytime voiding interval less than one hour, or; awakening to void five or more times per night. Id. Under the criteria applicable to obstructed voiding, a 30 percent rating applies to urinary retention requiring intermittent or continuous catheterization. Id. Under the criteria applicable to UTI, in pertinent part, a 30 percent evaluation is warranted when there is recurrent symptomatic infection requiring drainage or frequent hospitalization (greater than two times a year), or requiring continuous intensive management. If UTIs result in poor renal function, the disorder is rated as renal dysfunction. Id. In this case, however, the medical evidence consistently shows that the Veteran has not suffered from UTIs at any time since filing his claim. The Board will thus not further discuss an increased rating based on UTIs. Turning to the facts in this case, in a September 2008 examination, the Veteran stated that he urinated once every hour and a half to three hours during the day and every three to four hours at night. The Veteran had a decreased urine stream but no hesitancy. The Veteran reported experiencing occasional urinary incontinence once every two weeks, usually occurring when the Veteran had urinary urgency and could not get to the bathroom in time. The Veteran had no history of recurrent UTIs, renal colic, bladder stones, acute nephritis, or hospitalizations for urinary tract disease. The Veteran had no treatment with intermittent or continuous catheterizations, dilations, or drainage procedures. The Veteran had no special diet for genitourinary tract problems. The Veteran filed his claim of entitlement to an increased rating in May 2009. The Veteran underwent an examination in July 2009. The Veteran indicated that he urinated once every hour and a half to three hours during the day and every three to four hours at night. The Veteran had a decreased urine stream but no hesitancy. The Veteran reported having one episode of incontinence weekly, usually occurring when the Veteran had urinary urgency and could not get to the bathroom in time. The Veteran reported a history of recurrent UTIs. The Veteran had no history of renal colic, bladder stones, acute nephritis, or hospitalizations for urinary tract disease. The Veteran had no treatment with intermittent or continuous catheterizations, dilations, or drainage procedures. The Veteran had no special diet for genitourinary tract problems. In September 2009, a clinician noted that the Veteran experienced nocturia twice nightly. In December 2009, a clinician indicated that the Veteran experienced nocturia up to two times nightly. The Veteran did not experience incontinence. In January 2010, a clinician indicated that the Veteran did not experience dysuria, hematuria, nocturia, or polyuria. In a separate record from January 2010, however, a clinician noted that the Veteran reported having significant urinary urgency. In May 2010, the Veteran complained of problems with urinary trouble, mostly in the form of urinary incontinence. The Veteran underwent a VA examination in June 2010, at which time the examiner noted that the Veteran had no systemic symptoms as the result of genitourinary disease, no urinary symptoms, and no urinary leakage. The Veteran did not have a history of recurrent UTIs. The Veteran had a history of obstructed voiding, but such obstruction did not result in recurrent UTIs, catheterization, or dilations. The examiner noted that the Veteran's urinary incontinence had improved. In June 2010, a private clinician indicated that the Veteran experienced urge incontinence with a slow interrupted stream, and some incontinence. The Veteran experienced nocturia once nightly. Urinalysis was normal. In January 2011, the Veteran denied having problems with urination, a slow urinary stream, or nocturia. In January 2011, Dr. Knight, the Veteran's private urologist, indicated that the Veteran had urinary urge and urge incontinence that required him to wear an absorbent pad when he went out. In February 2011, the Veteran's private urologist indicated that the Veteran was "doing very well" four months following a transurethral resection of the prostate. The Veteran had a good urinary stream without hesitancy, intermittency, or significant nocturia. The Veteran had an associated overactive bladder with occasional urge and urge incontinence, but this was mild and controlled with pads that the Veteran wore only when he went out. In March 2011, the Veteran stated that he had to change absorbent materials at least six times during the day, and he had to wake in order to urinate five or more times a night. The Veteran indicated that he experienced recurrent UTIs. The Veteran underwent a VA examination in June 2011, at which time the Veteran reported having urinary leakage requiring him to change absorbent pads four to five times daily. The Veteran had no history of UTI. The examiner noted that the Veteran experienced urinary urgency and dribbling. The Veteran did not experience hesitancy or difficulty starting a stream, a weak or intermittent stream, dysuria, straining to urinate, hematuria, urine retention, urethral discharge, or renal colic. The Veteran had a daytime voiding interval every two to three hours, and he voided two to three times nightly. The Veteran experienced urinary leaking that required him to change absorbent materials more than four times daily. The Veteran did not have a history of UTI or obstructed voiding. The Veteran underwent an additional VA examination in October 2011, at which time the Veteran was noted to have urinary leakage requiring wearing absorbent material and changing such material two to four times daily. There was no history of UTI or obstructed voiding. There was no history of renal dysfunction, renal failure, acute nephritis, hydronephrosis, or cardiovascular symptoms. In May 2013, a clinician noted that the Veteran requested to receive additional absorbent materials. The Veteran reported that he used approximately five to six absorbent pads during the day and two to three a night. In June 2014, the Veteran stated that he needed to change absorbent pads at least four times a day and five times a night. In August 2015, the Veteran reported that he used four absorbent pads during the day and five absorbent pads a night. The Veteran underwent a VA examination in May 2016, at which time the examiner indicated that the Veteran had a voiding dysfunction resulting in urine leakage such that the Veteran had to change absorbent material more than four times daily. The Veteran's voiding dysfunction did not require the use of an appliance. The Veteran had a daytime voiding interval between two and three hours. The Veteran did not wake up to void at night, but he often had to change an absorbent pad two times nightly. The Veteran had no signs or symptoms associated with obstructed voiding. The Veteran did not have a history of recurrent symptomatic bladder or urethral infection. Gross kidney function was maintained. Upon review of these facts, the Board will first address whether a rating in excess of 20 percent is warranted before January 12, 2011. A rating in excess of 20 percent based on urine leakage requires wearing absorbent materials that must be changed at least two times per day. The evidence does not show such a degree of urinary leakage before January 12, 2011. In September 2008, the Veteran indicated that he experienced an episode of urge incontinence every two weeks. In July 2009, the Veteran reported that he experienced an episode of urge incontinence every week. In June 2010, an examiner indicated that the Veteran did not experience urinary leakage. The Board cannot find that the weight of the evidence supports a finding that the Veteran's urinary leakage required the changing of absorbent pads at least two times per day before January 12, 2011. A rating in excess of 20 percent based on urinary leakage is thus unavailable before January 12, 2011. A rating in excess of 20 percent based on urinary frequency before January 12, 2011, requires a daytime voiding interval less than one hour, or awakening to void at least five times nightly. In September 2008 and July 2009, the Veteran reported a daytime voiding interval of an hour and a half to three hours, and a nighttime voiding interval of three hours (which, the Board notes, does not equate to voiding five times total at night). In September 2009 and December 2009, clinicians noted that the Veteran experienced two episodes of nocturia nightly. Without a daytime voiding interval less than one hour, or awakening to void at least five times nightly, the Board finds that the Veteran's self-reported urinary frequency does not support a rating in excess of 20 percent before January 12, 2011. A rating greater than 20 percent is unavailable to the Veteran before January 12, 2011, based on urinary frequency. A rating in excess of 20 percent based on obstructed voiding before January 12, 2011, is unavailable because the evidence has not shown, nor has the Veteran alleged, that the Veteran had urinary retention requiring intermittent or continuous catheterization before January 12, 2011. Having determined that 20 percent is the proper rating before January 12, 2011, the Board will next consider whether the Veteran is entitled to a rating in excess of 40 percent at any time between January 12, 2011, and May 24, 2016. The Board finds that a 60 percent rating, which is the maximum rating based on urine leakage, is warranted during this time. A 60 percent rating requires changing absorbent materials more than four times per day, and the weight of the evidence supports a finding that the Veteran indeed had to change materials with this frequency during this time. For example, in March 2011, the Veteran indicated that he had to change absorbent materials at least six times during the day. In June 2011, an examiner indicated that the Veteran had to change absorbent materials four to five times daily. In May 2013, the Veteran requested an increase in his prescription for absorbent pads because he used five to six absorbent pads during the day and two to three at night. In June 2014, the Veteran stated that he needed to change absorbent pads at least four times a day and five times a night. In August 2015, the Veteran reported that he used four absorbent pads during the day and five absorbent pads a night. In May 2016, an examiner noted that the Veteran had to change absorbent material more than four times daily. Thus, affording the Veteran with the benefit of the doubt, the Board finds that a 60 percent rating is warranted from January 12, 2011, based on urine leakage. Having determined that 60 percent is warranted from January 12, 2011, the Board will next consider whether the Veteran is entitled to a rating in excess of 60 percent at any time since January 12, 2011. A 60 percent is the greatest available rating on the basis of voiding dysfunction. While a greater rating is potentially available based on UTIs, as noted above, the evidence does not show that the Veteran has suffered from UTIs at any time since January 12, 2011. While the Board has self-reported a history of UTIs, clinicians consistently found that the Veteran had not, in fact, suffered from UTIs at any time. A rating in excess of 60 percent is thus unavailable at any time since January 12, 2011. In sum, the criteria for a rating in excess of 20 percent for prostatitis have not been met before January 12, 2011. From January 12, 2011, the criteria for a 60 percent rating, but no, greater, for prostatitis have been met. Increased Rating for Right Ureterolithiasis The Veteran's right ureterolithiasis, or kidney stone disease of the right ureter, is rated 0 percent disabling. Ureterolithiasis is rated on the basis of hydronephrosis, except in the case of recurrent kidney stone formation requiring one or more of the following: diet therapy, drug therapy, or invasive or non-invasive procedures more than twice a year, in which case, the disability is rated as 30 percent disabling. 38 C.F.R. § 4.115b, Diagnostic Code 7510. Under the criteria applicable to hydronephrosis, a 10 percent rating applies to only an occasional attack of colic without infection or the need for catheter drainage. A 20 percent rating applies to frequent attacks of colic requiring catheter drainage. A maximum 30 percent rating applies to frequent attacks of colic with infection and impaired kidney function. Severe hydronephrosis is to be rated as renal dysfunction. 38 C.F.R. § 4.115b, Diagnostic Code 7509. Turning to the facts in this case, the Board finds that the weight of the medical evidence shows that the Veteran's right ureterolithiasis has been entirely asymptomatic since the Veteran filed his appeal. The Veteran underwent a VA examination in June 2010, at which time the examiner noted that the Veteran had a remote history of urinary tract stones during service, and the Veteran had not experienced a recurrence of such symptoms since that time. Treatment of these stones did not require a special diet, invasive procedures, or non-invasive procedures. There was no history of renal dysfunction or renal failure. During a June 2011 examination, the Veteran reported that he last experienced an episode of renal stones in 1978, which passed spontaneously and resolved without residuals. During an October 2011 examination, it was noted that the Veteran had a history of urinary tract stones, with the Veteran last experiencing a renal stone in in 1979, and that his renal stones had resolved. The Veteran's stones did not require a special diet, and the Veteran had not undergone any procedures in treatment of such condition during the past 12 months. The medical evidence thus consistently shows that the Veteran had a remote history of kidney stone disease of the right ureter that resulted in no residuals. With that said, the Board acknowledges that the Veteran has submitted statements indicating that he indeed had residuals of right ureterolithiasis. For example, in May 2013, the Veteran stated that his October 2010 transurethral resection of the prostate "proved that [he] experienced frequent attacks of colic or obstructions that exacerbated [his] right ureterolithiasis". The Board places little weight on the Veteran's assertions; no clinician has indicated, for example, that the Veteran's prostate surgery related in any way to kidney stones. Furthermore, as noted above, clinicians consistently found that the Veteran did not suffer from kidney stones at all. Thus, with clinicians consistently finding that the Veteran had a remote history of kidney stone disease of the right ureter that resulted in no residuals, a compensable rating of the Veteran's right ureterolithiasis is unavailable. Increased Rating for Xerosis The Veteran's xerosis is rated 0 percent disabling under Diagnostic Code 7806, applicable to dermatitis or eczema, which provides for the following ratings, in pertinent part: a 10 percent rating applies when at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas is affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than 6 weeks during the past 12-month period. A 30 percent rating applies when 20 percent to 40 percent of the entire body or the exposed areas is affected, or; when systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of 6 weeks or more, but not constantly, during a 12-month period. A 60 percent rating applies when more than 40 percent of the entire body or the exposed areas is affected, or; when constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs is required during a 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2016). Turning to the facts in this case, the Veteran filed a claim of entitlement to an increased rating in April 2010. The Veteran underwent a VA examination in June 2010, at which time the Veteran complained that his arms and legs were dry, and he used topical lotions daily. The Veteran had no systemic symptoms, and he had not received treatment for skin disease in the past 12 months. Upon physical examination, none of the Veteran's exposed areas were affected, and less than five percent of the Veteran's total body area was affected. The examiner noted mild dermographia (or red lines that appear following the scratching of the skin) over the shins, and the Veteran's examination was otherwise normal. The Veteran underwent an additional VA examination in October 2011, at which time the examiner found that the Veteran had not been diagnosed with a skin disability, and no skin condition was identified upon examination. The Veteran underwent an additional VA examination in May 2016, at which time the examiner diagnosed the Veteran with xerosis. The Veteran's xerosis affected none of his exposed body area and less than five percent of his total body area. The examiner indicated that the Veteran used other topical medications (later clarified to be Vaseline) constantly or nearly constantly to treat his xerosis. The Veteran controlled his xerosis by using Vaseline on his feet at night. Turning to an analysis of these facts, a compensable rating for the Veteran's xerosis requires the involvement of at least 5 percent of the exposed areas or the total body area. The June 2010 and May 2016 examiners could not find that the Veteran's xerosis involved such an area of skin, and no other clinician has made such a finding. The Veteran has treated his xerosis only with Vaseline lotion; the Veteran's xerosis has never required systemic therapy such as corticosteroids or other immunosuppressive drugs. Furthermore, the Veteran's xerosis has not resulted in disfigurement of the head, face, or neck, scarring, or other functional impairment. Thus, upon review of the evidence, the Board finds that a compensable rating of the Veteran's xerosis is unavailable. ORDER Service connection for a disability manifested by chest pain is denied. A rating in excess of 20 percent for diabetes is denied. An effective date earlier than May 11, 2015, for the awards of service connection for peripheral neuropathy of the bilateral femoral nerves is denied. Ratings in excess of 10 percent for peripheral neuropathy of the bilateral femoral nerves are denied. Before January 12, 2011, a rating in excess of 20 percent for prostatitis is denied. From January 12, 2011, to May 24, 2016, a rating of 60 percent, but no greater, for prostatitis is granted, subject to the laws and regulations governing the award of monetary benefits. Since May 24, 2016, a rating in excess of 60 percent for prostatitis is denied. A compensable rating for right ureterolithiasis is denied. A compensable rating for xerosis is denied. REMAND In February 2016, the Board remanded the Veteran's claim of entitlement to service connection for a breathing disorder, including shortness of breath, fatigue, and snoring, in order to provide the Veteran with an examination addressing the nature and etiology of all diagnosed respiratory disorders. While the Veteran underwent an examination in May 2016, the examiner addressed only the Veteran's chronic obstructive pulmonary disease (COPD), and not, for example, his diagnosed sleep apnea. Furthermore, with respect to the Veteran's COPD, while the examiner opined that the Veteran's in-service complaints of chest pain would not cause COPD, the examiner did not explain why such in-service complaints were not an early manifestation of COPD. Accordingly, the AOJ should obtain an additional opinion addressing the likely etiology of all of the Veteran's diagnosed breathing disorders, to include sleep apnea and COPD. With regard to the Veteran's claim of entitlement to a greater rating for diabetes, the record shows that the Veteran has the complication of diabetic nephropathy. While the Veteran underwent a renal examination in May 2016, this examination did not fully describe all of the manifestations of the Veteran's diabetic nephropathy. The examiner indicated that the Veteran had microalbuminuria, which the Board notes is a symptom associated with a compensable rating of renal dysfunction. After indicating that the Veteran had consistent microalbuminuria, the examiner made a seemingly contrary finding that the Veteran had no signs or symptoms due to renal dysfunction. Furthermore, the examiner did not discuss evidence of record suggesting that the Veteran had additional complications associated with renal dysfunction. For example, in September 2014, a clinician found that the Veteran was experiencing a "concerning escalation in proteinuria", and in December 2014, a clinician found that the Veteran experienced edema of the feet and ankles. Accordingly, the AOJ should obtain an additional opinion fully addressing the nature and severity of the Veteran's diabetic nephropathy. In February 2016, the Board granted service connection for left ear hearing loss; in a July 2016 rating decision effectuating this decision, the RO assigned a noncompensable rating effective August 20, 2008. In December 2016, the Veteran disagreed with this assigned rating. As yet, a statement of the case does not appear to have been issued, and it is therefore proper to remand the issue of entitlement to a compensable rating for left ear hearing loss, to ensure that the Veteran is provided with a statement of the case. Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). However, this issue should be returned to the Board after issuance of the statement of the case only if perfected by the filing of a timely substantive appeal. See Smallwood v. Brown, 10 Vet. App. 93, 97 (1997). The Veteran's claim of entitlement to a TDIU is inextricably intertwined with the Board's remand of the issue of entitlement to a compensable rating for diabetic nephropathy. A decision addressing the Veteran's claim of entitlement to a TDIU at this time would be premature. Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of any disability manifested by difficulty breathing, to include COPD and sleep apnea. After examining the Veteran, discussing the Veteran's history, reviewing the Veteran's claims file, and describing the nature of all disabilities resulting in difficulty breathing, to include COPD and sleep apnea, the examiner should address, with a complete rationale, whether it is at least as likely as not (that is, a 50 percent probability or greater) that such disability had an onset in service or is otherwise related to service. The examiner should explain why the Veteran's in-service complaints of symptoms such as chest pain are, or are not, an early manifestation of a disability resulting in difficulty breathing, to include COPD and sleep apnea. 2. Schedule the Veteran for a VA examination with a physician with expertise in treating kidney disease to determine the nature and severity of his diabetic nephropathy. The examiner should describe all of the current symptoms of renal dysfunction that the Veteran shows, to include whether the Veteran has shown symptoms such as microalbuminuria. The examiner should also address, with a full explanation, whether the edema that clinicians have noted in the Veteran's feet and ankles is a symptom of renal dysfunction. 3. Issue a statement of the case addressing the issue of entitlement to a compensable rating for a left ear hearing loss disability. The Veteran should be informed of the period of time within which he must file a substantive appeal to perfect an appeal of this issue to the Board. If a timely substantive appeal is not filed, the claims should not be certified to the Board. 4. Then, readjudicate the issues of entitlement to service connection for a disability manifested by difficulty breathing, a compensable rating for diabetic nephropathy, and a TDIU. If the benefits sought are not granted to the Veteran's satisfaction, furnish the Veteran and his representative a Supplemental Statement of the Case and afford the Veteran with an opportunity to respond. Thereafter, if in order, return the case to the Board for further appellate action. The Veteran has the right to submit additional evidence and argument on the matters that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ THOMAS H. O'SHAY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs