Citation Nr: 1753476 Decision Date: 11/21/17 Archive Date: 12/01/17 DOCKET NO. 10-25 989 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for bilateral hearing loss disability. 2. Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus, type II. 3. Entitlement to service connection for an eye disability, to include refractive error and benign senile cataracts and as secondary to diabetes mellitus, type II. 4. Entitlement to service connection for a kidney disability, to include bilateral renal cortical cysts and as secondary to diabetes mellitus, type II. 5. Entitlement to a compensable rating for atheromatous aorta ("heart disability") for the period of June 10, 2008, to May 31, 2016. 6. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left lower extremity. 7. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right lower extremity. 8. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left upper extremity. 9. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right upper extremity. 10. Entitlement to a rating in excess of 20 percent for diabetes mellitus, type II with erectile dysfunction and atherosclerotic aorta. 11. Entitlement to an initial compensable rating for hepatomegaly (fatty liver disease). 12. Entitlement to an increased rating for posttraumatic stress disorder (PTSD), currently evaluated as 30 percent disabling from June 30, 2006, and as 50 percent disabling from September 23, 2010. 13. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities. ATTORNEY FOR THE BOARD K. Kovarovic, Associate Counsel INTRODUCTION The Veteran had active military service from February 1961 to February 1963 and October 1964 to September 1966. These matters come before the Board of Veterans' Appeals (Board) from several rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. They were subsequently remanded by the Board in August 2016 to schedule the Veteran for his requested videoconference hearing. See Stegall v. West, 11 Vet. App. 268 (1998). However, the Veteran withdrew his hearing request in November 2016. See 38 C.F.R. § 20.704(d) (2017). Thus, these matters have been returned to the Board for appellate consideration. Briefly, the Board notes that an April 2017 rating decision denied entitlement to automobile or adaptive equipment. The Veteran submitted a timely Notice of Disagreement (NOD) in May 2017. 38 C.F.R. § 20.202 (2017). As development for this claim is still ongoing, the Board declines to assert jurisdiction over the matter at this time. The following issues have been raised by the record but have not yet been adjudicated by the Agency of Original Jurisdiction (AOJ): (1) Entitlement to service connection for a left knee disability (raised in an October 2015 lay statement); and (2) entitlement to a temporary total evaluation for convalescence for psychiatric hospitalization from October 5, 2015 to November 13, 2015 (raised in November 2015 and November 2016 lay statements). 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) (2017). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900 (c) (2017). The Veteran's hypertension, eye, kidney, PTSD, and TDIU claims are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The most competent and probative evidence of record fails to demonstrate that it is at least as likely as not that the Veteran's bilateral hearing loss was incurred in or is otherwise etiologically related to service, to include conceded noise exposure. 2. From June 10, 2008, to April 25, 2012, the Veteran's atheromatous aorta resulted in a workload of 8.8 METs with symptoms of fatigue, dyspnea, and dizziness requiring continuous medication. 3. From April 26, 2012, to May 31, 2016, the Veteran's atheromatous aorta was asymptomatic. 4. From June 10, 2008, to January 29, 2017, the Veteran's peripheral neuropathies of the left and right lower extremities were productive of mild incomplete paralysis. 5. Beginning January 30, 2017, the Veteran's peripheral neuropathies of the left and right lower extremities were productive of moderate incomplete paralysis. 6. From June 10, 2008, to January 29, 2017, the Veteran's peripheral neuropathies of the left and right upper extremities were productive of mild incomplete paralysis. 7. From June 10, 2008, to January 29, 2017, the Veteran's peripheral neuropathies of the left and right upper extremities were productive of moderate incomplete paralysis. 8. Throughout the entire rating period on appeal, the Veteran's diabetes mellitus required treatment with insulin and a restricted diet, but not the regulation of activities. 9. Throughout the entire rating period on appeal, the Veteran's hepatomegaly was nonsymptomatic. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2017). 2. From June 10, 2008, to April 25, 2012, the criteria for a rating of 10 percent, but no higher, for atheromatous aorta have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.20, 4.130, Diagnostic Code 7005 (2017). 3. From April 26, 2012, to May 31, 2016, the criteria for a compensable disability rating for atheromatous aorta have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 7005 (2017). 4. From June 10, 2008, to January 29, 2017, the criteria for a disability rating in excess of 10 percent for peripheral neuropathy of the left and right lower extremities have not been met. 38 U.S.C. §§ 1155 (2012); 38 C.F.R. §§ 4.7, 4.124(a), Diagnostic Code 8520 (2017). 5. Beginning January 30, 2017, the criteria for a 20 percent disability rating, but no higher, for peripheral neuropathy of the left and right lower extremities have been met. 38 U.S.C. §§ 1155 (2012); 38 C.F.R. §§ 4.7, 4.124(a), Diagnostic Code 8520 (2017). 6. From June 10, 2008, to January 29, 2017, the criteria for a disability rating in excess of 10 percent for peripheral neuropathy of the left and right upper extremities have not been met. 38 U.S.C. §§ 1155 (2012); 38 C.F.R. §§ 4.7, 4.20, 4.124(a), Diagnostic Code 8515 (2017). 7. Beginning January 30, 2017, the criteria for a 20 percent disability rating, but no higher, for peripheral neuropathy of the left upper extremity have been met. 38 U.S.C. §§ 1155 (2012); 38 C.F.R. §§ 4.7, 4.20, 4.124(a), Diagnostic Code 8515 (2017). 8. Beginning January 30, 2017, the criteria for a 30 percent disability rating, but no higher, for peripheral neuropathy of the right upper extremity have been met. 38 U.S.C. §§ 1155 (2012); 38 C.F.R. §§ 4.7, 4.124(a), Diagnostic Code 8515 (2017). 9. Throughout the entire rating period on appeal, the criteria for a disability rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C. §§ 1155 (2012); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 7913 (2017). 10. Throughout the entire rating period on appeal, the criteria for a compensable disability rating for hepatomegaly have not been met. 38 U.S.C. §§ 1155 (2012); 38 C.F.R. §§ 4.7, 4.114, Diagnostic Code 7345 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection The Board first turns to the Veteran's service connection claims. During VA examination in May 2012, the Veteran's audiometric results were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 25 30 50 55 LEFT 20 25 30 40 45 The Veteran further registered a speech recognition score of 88 for the right ear and 92 for the left ear. Thus, the Veteran has clearly demonstrated a hearing loss disability for VA purposes during the rating period on appeal. See 38 C.F.R. § 3.385 (2017). The Board further finds evidence of noise exposure during service. The Veteran's Certificate of Release or Discharge from Active Duty (DD-214) denotes his Military Occupational Specialty (MOS) as an Indirect Fire Infantryman (11C10), which has a high probability of in-service exposure to hazardous noise. As such, VA concedes that the Veteran was exposed to hazardous noise during his military service. However, the Board does not find that the Veteran's current hearing loss is causally related to the in-service noise exposure. To that end, the May 2012 VA examiner opined that it was less likely than not that the Veteran's disability was incurred in or caused by his military service. In doing so, the examiner acknowledged the Veteran's history of in-service noise exposure. However, the examiner also noted that the Veteran demonstrated normal hearing on his September 1966 exit examination. Further, the examiner reported that it is well-established that exposure to high levels of noise causes either immediate hearing loss (as in cases of noise or acoustic trauma), or progressive hearing deficits (during prolonged periods of exposure). Here, the Veteran did not complain of hearing loss for approximately 50 years following his exit from service. At present, his audiometric results indicated mild to severe hearing loss affecting mostly the higher frequencies for both ears. However, retroactive hearing effect is not expected after years of being exposed to noise, and other factors, such as the natural aging process, may be contributing causes for the current sensorineural hearing loss. The Board affords significant probative value to the May 2012 opinion, which is based upon a detailed rationale assessing the Veteran's history of noise exposure, nature and onset of his current hearing loss, and additional contributing factors. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Thus, in light of the above and in the absence of a contrary medical opinion from the record, the Board concludes that no nexus exists in this case. In reaching this conclusion, the Board does not disregard the Veteran's assertion that such a nexus is present. However, without appropriate medical training and expertise, which he has not demonstrated, the Veteran is not competent to provide an opinion regarding etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Jones v. West, 12 Vet. App. 383, 385 (1999) (where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). Thus, the Board defers to the competent medical opinion of record in assessing the validity of the Veteran's claim. Further, there is no evidence of record showing the Veteran to have bilateral hearing loss disability for VA purposes to a compensable degree within one year of his separation from active service. Therefore, presumptive service connection for a chronic disability is not applicable in this case. Further, the Board acknowledges that a complete copy of the Veteran's service treatment records (STRs) has not yet been associated with the claims file. However, the Veteran has made no allegations of in-service symptoms of, or treatment for, bilateral hearing loss. Instead, the Veteran first complained of bilateral hearing loss approximately 50 years following his exit from service. Thus, the Board finds that the absence of STRs from the record constitutes a harmless error with regard to this claim, such that a determination on the merits may be made at this time. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). As there is no competent medical evidence of record to support the Veteran's claim, the preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. Accordingly, entitlement to service connection for bilateral hearing loss is not warranted. See 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Heart Disability The Board first turns to the Veteran's heart disability. Procedurally, the Board notes that a noncompensable initial rating was awarded for atheromatous aorta, effective June 10, 2008. However, that award was severed in a March 2016 rating decision, effective May 31, 2016, upon the RO's conclusion that the Veteran's condition did not qualify as a heart disability. Instead, the condition was reclassified under the Veteran's service-connected diabetes mellitus, type II, with erectile dysfunction and atherosclerotic (atheromatous) aorta at that time. Thus, the Board will now consider only the period of June 10, 2008, to May 31, 2016, during which the Veteran was in receipt of separate benefits for a heart disability. The Veteran first underwent VA heart examination in July 2008. A cardiovascular stress test was performed at that time, resulting in a maximum workload of 8.8 METs. Exercise was stopped due to fatigue, though no chest pain was observed. The Veteran assessed his symptoms as weekly fatigue, dyspnea upon moderate exertion, and monthly dizziness. Angina and syncope were explicitly denied, and no reports of cardiac hypertrophy or dilatation were made. However, the Veteran required the use of continuous medication to assist with managing his symptoms. The Veteran next underwent VA examination in April 2012, during which an interview-based stress test was performed. At that time, the Veteran denied experiencing symptoms with any level of physical activity, to include dyspnea, fatigue, angina, dizziness, and syncope. Although an exercise stress test was also performed, the examiner concluded that the METs level limitation was not due solely to the Veteran's heart disability, such that the limitation was impossible to accurately estimate. Thus, the examiner concluded that the Veteran's atheromatous aorta was asymptomatic. VA and private treatment records spanning the rating period on appeal denote no reports of, or treatment for, a heart disability. During that time, the Veteran consistently denied reports of fatigue and dizziness. References to additional symptoms such as syncope or angina are absent from the record. The Board finds that staged ratings are appropriate in this case. First, the Board finds that a rating of 10 percent is warranted for the period of June 10, 2008, to April 25, 2012. The July 2008 VA examination documents the Veteran's workload of 8.8 METs with fatigue. Additional symptoms of moderate dyspnea and dizziness were reported at that time, such that the Veteran required the use of continuous medication to assist with managing his symptoms. Reports of more severe symptoms, such as cardiac hypertrophy or dilatation, are absent from the record. Said disability picture best corresponds with the criteria for a 10 percent disability rating. 38 C.F.R. § 4.130, Diagnostic Code 7005 (2017). However, the April 2012 VA examiner documented a marked improvement of the Veteran's condition. At that time, the Veteran denied any cardiac symptoms upon physical exertion. The VA examiner thus concluded that any METs limitation were due to a combination of factors and not solely to the Veteran's heart condition. As such, the examiner classified the Veteran's condition as asymptomatic at that time. Said conclusion is supported by the additional evidence of record, to include VA and private treatment records which explicitly denounce the existence of such symptoms as fatigue or dizziness. Thus, the Board finds that a noncompensable rating is warranted for the period of April 26, 2012, to May 31, 2016. 38 C.F.R. § 4.130, Diagnostic Code 7005 (2017). Peripheral Neuropathy of the Lower Extremities The Veteran first underwent VA examination in July 2008. At that time, the Veteran reported a history of numbness and pain in his legs, accompanied by cramps and paresthesias. All muscles and nerves in the lower extremities were affected, without resulting in motor function impairment. Decreased sensory function was observed in the 4th and 5th toes bilaterally. Gait and balance was described as normal. Nerve dysfunction and neuritis were present, but paralysis and neuralgia were explicitly denied. As such, the Veteran experienced moderate limitations pertaining to chores, shopping, and traveling, and severe limitations pertaining to exercise. The Veteran next underwent VA examination in October 2009. Ongoing numbness and paresthesias were reported at that time, which the Veteran treated with medication. All muscles and nerves in the lower extremities were affected, without resulting in motor function impairment. Decreased sensory function was observed in the toetips bilaterally. Gait and balance were normal. Nerve dysfunction, neuritis, and neuralgia were present, but paralysis was denied. As such, the Veteran experienced moderate limitations pertaining to shopping and traveling, and severe limitations pertaining to chores and exercise. The Veteran underwent subsequent VA examination in January 2017. Bilateral symptoms included moderate constant pain; moderate paresthesias and/or dysthesias; moderate numbness; and cramping, mostly nocturnal. Decreased sensation was observed in the ankles, lower legs, feet, and toes. The examiner thus classified the Veteran's disabilities as moderate and incomplete paralysis of the sciatic nerves. The Veteran most recently underwent VA examination in August 2017. At that time, the Veteran reported constant pain, episodes of numbness, and a tingling sensation of the lower extremities. Additional symptoms included moderate constant pain; moderate paresthesias and/or dysthesias; and moderate numbness. Decreased sensation was observed in the ankles, lower legs, feet, and toes. As such, the Veteran's disabilities were classified as moderate incomplete paralysis of the sciatic nerves. VA and private treatment records spanning the rating period on appeal record the Veteran's history of peripheral neuropathy and ongoing numbness. Those disabilities were generally well-controlled with the use of medication. In July 2008, mild, sensory motor, axonal peripheral neuropathy was reported. Again, the Board finds that staged ratings are warranted. For the period prior to January 30, 2017, the Veteran's disabilities were primarily productive of numbness, pain, and decreased sensory function. Although those symptoms caused some impairment of the Veteran's capacity to function, both the July 2008 and October 2009 VA examiners reported no paralysis as a result thereof. Instead, the Veteran presented with normal gait and balance, and the use of an assistive device was not reported at any time. Thus, the Board finds that the Veteran's disabilities are best embodied in the criteria for a 10 percent rating, as currently assigned. 38 C.F.R. § 4.124(a), Diagnostic Code 8520 (2017). However, the January 2017 VA examiner reported a worsening of the Veteran's disabilities, such that moderate constant pain, paresthesias/dysthesias, and numbness were reported. Said symptoms were productive of decreased sensory function, such that the January 2017 and August 2017 examiners both classified the Veteran's disabilities as resulting in moderate and incomplete paralysis. In deferring to the competent medical opinions of record, as supported by the Veteran's treatment records, the Board thus finds that ratings of 20 percent are warranted for the Veteran's disabilities, effective January 30, 2017. 38 C.F.R. § 4.124(a), Diagnostic Code 8520 (2017). The Board has considered assignment of ratings in excess of 20 percent beginning January 30, 2017. However, there is no indication from the record that the Veteran's lower extremity peripheral neuropathy was moderately-severe or worse during that period. Therefore, a rating in excess of 20 percent for either lower extremity is not warranted. 38 C.F.R. § 4.124(a), Diagnostic Code 8520 (2017). Peripheral Neuropathy of the Upper Extremities At the outset, the Board notes that a review of the record indicates that the Veteran's right upper extremity is dominant. The Veteran first underwent VA examination in July 2008, and reported numbness and pain accompanied by cramps and paresthesia of his hands at that time. All muscles and nerves in the upper extremities were affected, without resulting in motor function impairment. Normal sensory function was observed bilaterally. Nerve dysfunction and neuritis were present, but paralysis and neuralgia were explicitly denied. As such, the Veteran experienced moderate limitations pertaining to chores, shopping, and traveling; and severe limitations pertaining to exercise. The Veteran next underwent VA examination in October 2009. Ongoing numbness and paresthesias were reported at that time, such that the Veteran was unable to wield a machete or operate a power trimmer due to marked tremors and weakness of the arms and hands. All muscles and nerves in the upper extremities were affected, without resulting in motor function impairment. Decreased sensory function was observed bilaterally, and a twitch-like tremor was observed in the entire right forearm. Nerve dysfunction, neuritis, and neuralgia were present, but paralysis was explicitly denied. As such, the Veteran experienced moderate limitations pertaining to shopping and traveling, and severe limitations pertaining to chores and exercise. The Veteran underwent subsequent VA examination in January 2017. Symptoms reported bilaterally included moderate constant pain; mild paresthesias and/or dysthesias; and moderate numbness. Decreased sensation was observed in the hands and fingers. The examiner thus classified the Veteran's disabilities as moderate and incomplete paralysis of the median nerves. The Veteran most recently underwent VA examination in August 2017. At that time, the Veteran reported constant pain, episodes of numbness, and a tingling sensation of the upper extremities. Additional symptoms included moderate constant pain; mild paresthesias and/or dysthesias; and moderate numbness. Decreased sensation was observed in the hands and fingers. As such, the Veteran's disabilities were classified as moderate and incomplete paralysis of the median nerves. VA and private treatment records spanning the rating period on appeal record the Veteran's history of peripheral neuropathy and ongoing numbness. Those disabilities were generally well-controlled with the use of medication. In July 2008, mild, sensory motor, axonal peripheral neuropathy was reported. Once again, the Board finds that staged ratings are appropriate in this case. For the period prior to January 30, 2017, the Veteran's disabilities were primarily productive of numbness, pain, and decreased sensory function. However, both the July 2008 and October 2009 VA examiners reported no paralysis as a result thereof, and accompanying treatment records indicate that the Veteran's symptoms were generally well-controlled with the use of medication. As such, the Veteran experienced mild limitation of function as a result of his disability, which was classified by VA examiners as mild and incomplete paralysis. Accordingly, the Veteran's disabilities are properly embodied in the criteria for a 10 percent rating as currently assigned. 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2017). However, the January 2017 examiner reported a worsening of the Veteran's disabilities, such that moderate constant pain and numbness, and mild paresthesias/dyesthesias were reported at that time. Decreased sensation was also observed bilaterally, such that the Veteran's disabilities were classified as moderate and incomplete paralysis of the median nerves. Such a classification warrants a 30 percent rating for the Veteran's dominant upper extremity, and a 20 percent rating for his non-dominant upper extremity. 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2017). The Board has considered assignment of ratings in excess of 30 percent and 20 percent beginning January 30, 2017, for the right and left upper extremities respectively. However, there is no indication from the record that the Veteran's bilateral upper extremity peripheral neuropathy was severe in nature, or that he has complete paralysis of the median nerve. Therefore, a rating in excess of 30 percent for right upper extremity peripheral neuropathy and a rating in excess of 20 percent for left upper extremity peripheral neuropathy is not warranted. 38 C.F.R. § 4.124(a), Diagnostic Code 8515 (2017). Diabetes Mellitus The Veteran first underwent VA examination in February 2008. At that time, the Veteran denied a history of ketoacidosis or hypoglycemic reactions, or hospitalizations therefor. The Veteran maintained a restricted diet, but no restriction of activities was reported at that time. Further, the Veteran denied treatment via oral hypoglycemic agents or insulin. The Veteran next underwent VA examination in October 2009. Again, the Veteran denied a history of ketoacidosis or hypoglycemic reactions, or hospitalizations therefor. Further, no restriction of activities was noted. However, the Veteran reported a restricted, low-sugar diet and treatment with oral hypoglycemic agents or insulin at that time. Nonetheless, the VA examiner opined that the Veteran's disability did not cause any functional limitations. The Veteran subsequently underwent VA examination in April 2012, and reported ongoing treatment with oral hypoglycemic agents at that time. However, the Veteran did not require regulation of activities as part of his treatment plan. Further, the Veteran reported less than two incidents per month of ketoacidosis or hypoglycemic reactions, and no incidents requiring hospitalization in the prior year. Peripheral neuropathy, erectile dysfunction, and atherosclerotic aorta were reported as complications of the Veteran's disability. The Veteran most recently underwent VA examination in August 2017. At that time, the Veteran reported a treatment plan of oral hypoglycemic agents and a restricted diet. However, the Veteran did not require the regulation of activities. The Veteran additionally reported less than two visits per month to his physician for episodes of ketoacidosis or hypoglycemia, and no episodes of hospitalization in the prior year. Peripheral neuropathy, erectile dysfunction, and atherosclerotic aorta were reported as complications of the Veteran's disability. VA and private treatment records spanning the rating period on appeal record the Veteran's treatment plan of hypoglycemic agents and a restricted diet. Tolerated exercises were repeatedly instructed. Upon review of the above, the Board does not find that a disability rating in excess of 20 percent is warranted for the Veteran's diabetes mellitus at any time during the rating period on appeal. In this case, the Veteran may only be awarded an increased rating upon evidence that his diabetes requires treatment with insulin, a restricted diet, and regulation of activities. Each of these criteria must be met for the Veteran to be awarded an increased rating. However, the evidence of record clearly establishes that the Veteran's diabetes requires treatment only with insulin and a restricted diet. The Veteran has denied the regulation of activities during four VA examinations, and VA treatment records do not establish this as a prescribed treatment method at any time. Instead, the Veteran's treatment records commonly instruct the Veteran to engage in exercise as tolerated. Thus, the Veteran's disability picture is best embodied in the criteria for a 20 percent rating, as currently assigned. 38 C.F.R. § 4.71a, Diagnostic Code 7913 (2017). The Board notes that October 2015 and March 2016 rating decisions assessed the Veteran's erectile dysfunction and atheromatous aorta as due to his service-connected diabetes mellitus, such that the disabilities were combined at that time. The existence of those conditions do not qualify the Veteran for an increased rating per Diagnostic Code 7913, nor is the Veteran entitled to separate, compensable ratings for those conditions. See 38 C.F.R. §§ 4.7, 4.115b, Diagnostic Codes 7520-22 (2017); 38 C.F.R. § 4.130, Diagnostic Code 7005 (2017); see also VA examinations dated January 2017 (classifying the Veteran's atheromatous aorta as asymptomatic) and August 2018 (noting no penile deformity, removal of glans, or removal of penis). The Board further acknowledges that the Veteran presents with peripheral neuropathy of the upper and lower extremities as a result of his diabetes. However, the Veteran is currently in receipt of separate, compensable ratings for these disabilities, such that their further consideration in conjunction with the Veteran's diabetes claim would be in violation of 38 C.F.R. § 4.14 (2017). Finally, the Board acknowledges that the Veteran's claim for entitlement to service connection for hypertension, to include as secondary to his service-connected diabetes mellitus, remains in appellate status as set forth in the remand section below. As such, the Board is precluded from considering hypertension as a symptom of the Veteran's diabetes in assessing the increased rating claim. Hepatomegaly Finally, the Board turns to the Veteran's hepatomegaly claim. Digestive conditions are evaluated under one of the Diagnostic Codes listed in 38 C.F.R. § 4.114. A note to that section states that ratings under Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive, may not be combined with each other. Instead, a single evaluation is assigned under the Code which reflects the predominant disability. Where the overall severity of the disability picture warrants it, the next higher evaluation under the selected Code may be assigned. 38 C.F.R. § 4.114 (2017). Here, the Veteran's disability has been rated under Diagnostic Code 7345. The evidence of record pertaining to hepatomegaly is sparse, but instructive. In this regard, the Veteran underwent VA examinations in July 2008, October 2009, and August 2017. During all three examinations, the Veteran denied symptoms pertaining to hepatomegaly. Further, the Veteran reported no treatment, hospitalizations, or incapacitating episodes as a result of hepatomegaly. As such, the August 2017 examiner classified the Veteran's hepatomegaly as asymptomatic. VA and private treatment records seemingly support this assessment of the Veteran's disability picture. Although the Veteran's diagnostic history is occasionally recorded, notations of accompanying symptoms or treatment are absent from the record. As such, the Board concludes that the Veteran's hepatomegaly has been nonsymptomatic throughout the duration of this appeal. At no time has the Veteran reported symptoms related to this disability, or required treatment therefor. Moreover, none of the Veteran's VA or private treatment providers have recorded the existence of symptoms which would justify the assignment of a compensable disability rating at this time. Accordingly, the Veteran's claim is hereby denied. C.F.R. § 4.114, Diagnostic Code 7345 (2017). ORDER Entitlement to service connection for bilateral hearing loss is denied. From June 10, 2008, to April 25, 2012, entitlement to a rating of 10 percent, but no higher, for atheromatous aorta is granted. From April 26, 2012, to May 31, 2016, entitlement to a compensable rating for atheromatous aorta is denied. From June 10, 2008 to January 29, 2017, entitlement to a rating in excess of 10 percent for peripheral neuropathy of the left lower extremity is denied. From June 10, 2008 to January 29, 2017, entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right lower extremity is denied. Beginning January 30, 2017, entitlement to a rating of 20 percent, but no higher, for peripheral neuropathy of the left lower extremity is granted. Beginning January 30, 2017, entitlement to a rating of 20 percent, but no higher, for peripheral neuropathy of the right lower extremity is granted. From June 10, 2008 to January 29, 2017, entitlement to a rating in excess of 10 percent for peripheral neuropathy of the left upper extremity is denied. From June 10, 2008 to January 29, 2017, entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right upper extremity is denied. Beginning January 30, 2017, entitlement to a rating of 20 percent, but no higher, for peripheral neuropathy of the left upper extremity is granted. Beginning January 30, 2017, entitlement to a rating of 30 percent, but no higher, for peripheral neuropathy of the right upper extremity is granted. Entitlement to a rating in excess of 20 percent for diabetes mellitus is denied. Entitlement to a compensable rating for hepatomegaly is denied. REMAND Although the Board sincerely regrets the additional delay this may cause, further development is necessary prior to the adjudication of the Veteran's remaining claims. Hypertension, Eye, and Kidney Claims At the outset, the Board notes that complete copies of the Veteran's service personnel or treatment records have not been requested or otherwise obtained. As these records may contain pertinent information relating to the Veteran's hypertension, eye, and kidney claims, all reasonable efforts must be made to obtain them. 38 U.S.C. §§ 5100, 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (c) (2017). Further, the Veteran's claimed disabilities were assessed during VA examinations in July 2008. Although the VA eye and kidney examiners provided negative nexus opinions at that time, no rationales were offered in support thereof. Further, all of the examiners failed to address whether the Veteran's claimed disabilities were aggravated by his service-connected diabetes mellitus. Accordingly, a remand is now warranted such that adequate nexus opinions may be obtained. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (holding that findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under § 3.310(b)). PTSD Claim The Veteran has reported psychiatric hospitalization at the Bay Pines VA Hospital from October 5, 2015 to November 13, 2015. However, these records have not yet been requested or otherwise obtained. As said records are likely relevant to the Veteran's psychiatric claim, all reasonable efforts must now be made to obtain them. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159(c) (2) (2017). TDIU Claim Determination of the above claims will directly impact the Veteran's TDIU claim, as well, such that the issues are all inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (finding two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered); Holland v. Brown, 6 Vet. App. 443, 445-46 (1994). As such, remand of the above-mentioned claims necessitates remand of the TDIU claim, as well. Accordingly, the case is REMANDED for the following actions: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain and associate with the record complete military service personnel and treatment records for the Veteran for each period of active and reserve service. All actions to obtain the requested records should be fully documented in the record. If they cannot be located or no such records exist, the Veteran should be so notified in writing. 2. Obtain and associate with the record all VA treatment records for the Veteran from October 2015 to April 2016, to include any records pertaining to the Veteran's hospitalization at the Bay Pines VA Hospital from October to November 2015. All actions to obtain the requested records should be fully documented in the record. If they cannot be located or no such records exist, the Veteran should be so notified in writing. 3. Provide the Veteran with VA hypertension, eye, and kidney examinations to assess the nature and etiology of the claimed disabilities. The claims file and a copy of this remand must be made available for review, and the examination reports must reflect that review of the claims file occurred. All pertinent symptomatology and findings must be reported in detail. Any indicated special diagnostic tests that are deemed necessary for an accurate assessment must be conducted. Each examiner should elicit a complete history from the Veteran. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. Each examiner must address the following: i. Identify all pertinent disabilities (hypertension, eye, and kidney) demonstrated by the Veteran throughout the course of this appeal. ii. For each diagnosis identified, indicate whether it is at least as likely as not (50 percent probability or more) that the disability began in service, was caused by service, or is otherwise related to military service, to include in-service exposure to herbicide agents. iii. For each diagnosis identified, further indicate whether it is at least as likely as not (50 percent probability or more) that the disability was caused or aggravated by the Veteran's diabetes mellitus, type II, or the treatment thereof. In formulating the opinions, the examiners are advised that the term "at least as likely as not" does not mean "within the realm of possibility." Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. Aggravation is defined as a permanent worsening beyond the natural progression of the disease or disability. A detailed rationale supporting the examiner's opinion must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 4. If appropriate, refer the claim to VA's Director of Compensation Service for consideration of whether a TDIU on an extraschedular basis is warranted. Include a full statement as to the Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue. See 38 C.F.R. § 4.16(b) (2017). 5. Thereafter, readjudicate the remaining claims on appeal. If the benefits sought remain denied, provide a Supplemental Statement of the Case to the Veteran, and an appropriate period in which to respond. Then, return the appeal to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ Kristin Haddock Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs