Citation Nr: 18153506 Decision Date: 11/28/18 Archive Date: 11/27/18 DOCKET NO. 16-33 790 DATE: November 28, 2018 ORDER Entitlement to a 30 percent evaluation, but not higher, for service-connected residuals of right thumb injury, to include numbness associated with strain of lateral ligament of metacarpophalangeal joint of the right thumb (claimed as residuals of right thumb injury), is granted. Entitlement to special monthly compensation (SMC) on the basis of the need for the regular aid and attendance is granted. Entitlement to an effective date of September 25, 2006, for the grant of entitlement to a total disability rating based on individual unemployability (TDIU) is granted. Entitlement to an effective date of September 25, 2006, for the grant of basic eligibility for Dependents’ Educational Assistance (DEA) is granted. REMANDED Entitlement to an evaluation in excess of 30 percent for left upper extremity peripheral neuropathy associated with type II diabetes mellitus with erectile dysfunction is remanded. Entitlement to an evaluation in excess of 40 percent for right upper extremity peripheral neuropathy associated with type II diabetes mellitus with erectile dysfunction is remanded. FINDINGS OF FACT 1. The Veteran’s service-connected residuals of right thumb injury, to include numbness associated with strain of lateral ligament of metacarpophalangeal joint of the right thumb, has been characterized by moderate, incomplete paralysis with pain and numbness. 2. The Veteran’s service-connected disabilities result in functional impairment that cause him to be in need of regular aid and attendance of another person because he is not able prepare his own meals and requires assistance in bathing and tending to hygiene. 3. It was factually ascertainable that the Veteran was unable to obtain or maintain substantially gainful employment due to his service-connected disabilities as of September 25, 2006. 4. The Veteran’s claim for basic eligibility to DEA benefits is derived from his claim for TDIU and thus, both awards must share the same effective date of September 25, 2006. CONCLUSIONS OF LAW 1. The criteria for a 30 percent evaluation, but no higher, for service-connected residuals of right thumb injury, to include numbness associated with strain of lateral ligament of metacarpophalangeal joint of the right thumb, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.124a, Diagnostic Code 8515 (2017). 2. The criteria for special monthly compensation on the basis of the need for the regular aid and attendance of another person have been met. 38 U.S.C. §§ 1114(l), 5107 (2012); 38 C.F.R. §§ 3.102, 3.350(b), 3.352(a) (2017). 3. The criteria for an effective date of September 25, 2006, but no earlier, for entitlement to TDIU have been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.155, 3.400, 4.16 (2017). 4. The criteria for an effective date of September 25, 2006, but no earlier, for entitlement to basic eligibility for DEA have been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.155, 3.400, 3.807, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1966 to June 1969. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. “Staged” ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). 1. Right thumb injury, to include numbness associated with strain of lateral ligament of metacarpophalangeal joint of the right thumb (right thumb numbness) By way of history, in an October 2013 Board decision, the Board bifurcated service connection for residuals of right thumb strain and service connection for right thumb numbness to include right-side carpal tunnel syndrome. The October 2013 Board decision granted service connection for a right thumb strain and denied service connection for right thumb numbness, to include right-side carpal tunnel syndrome. In a March 2014 Joint Motion for Remand, the Board’s October 2013 denial of entitlement to service connection for right thumb numbness was vacated and remanded. In November 2014 and February 2016, the Board remanded the issue of service connection for right thumb numbness. A July 2016 rating decision granted service connection for residuals of right thumb injury, to include numbness and assigned a 10 percent evaluation, from September 25, 2006, to April 29, 2013. The rating decision discontinued the 10 percent evaluation and included it with the evaluation of peripheral neuropathy, right upper extremity (which includes the evaluation of the right median nerve), effective April 30, 2013. The Veteran filed an August 2016 notice of disagreement (NOD) with the July 2016 rating decision and contends that a higher rating is warranted. The Veteran’s right thumb numbness is currently rated as 10 percent disabling under Diagnostic Code 8515. Diagnostic Code 8515 pertains to paralysis of the median nerve. 38 C.F.R. § 4.124a. Initially, the Board observes that the record reflects that the Veteran is right-handed. Pursuant to diagnostic Code 8515 for the dominant (right) upper extremity, a 30 percent evaluation is warranted when there is moderate incomplete paralysis. 38 C.F.R. § 4.124a, Diagnostic Code 8515. A 40 percent evaluation is warranted when there is severe incomplete paralysis. The Board notes that the term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The words “slight,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. It should also be noted that use of terminology such as “severe” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Turning to the evidence of record during the relevant period, upon November 2007 VA examination, the Veteran reported strength diminution and normal dexterity. He reported flare-ups of the joint of the thumb affecting the hand that occurred twice per week. The Veteran reported the severity, frequency, duration of the flare-ups as moderate to mild with duration lasting hours. There were no obvious precipitating or alleviating factors. He reported that flare-ups have not caused any limitation of motion or functional impairment. Physical examination revealed the thumb was morphologically normal. The report indicated that no joints are ankylosed and normal position of functioning was noted. Between the tips of the thumb and the fingers, the proximal transverse crease of the palm were normal and no gaps existed. Physical examination revealed normal strength for pushing, pulling and twisting, with normal dexterity of the thumb. Further, radiographic imaging has been normal. At his May 2009 DRO hearing, the Veteran testified that he had a reduced ability to lift and grab with his thumb and he reported constant pain. Upon June 2009 VA neurological examination, the Veteran had reduced sensation to pinprick on the right thumb on the palmar aspect and also right thenar area corresponding to right median nerve distribution. The Veteran was diagnosed with right-sided carpal tunnel syndrome minimal residual after surgery and left-sided carpal tunnel syndrome mild in degree. The report indicated the carpal tunnel syndrome also explained numbness in the right thumb in the distribution of the right median nerve. An April 2011 VA EMG consult note indicated the Veteran reported focal pain at the right MCP joint of the thumb, which appeared mildly swollen. He had a history of carpal tunnel syndrome with release on the right in 1998 and right ulnar nerve transposition in 1998. The VA neurologist concluded that there were findings of neuropathy in the right median and ulnar nerves and these findings are most compatible with mild peripheral neuropathy or perhaps residual from prior entrapment neuropathies. The VA neurologist stated, though a mild superimposed carpal tunnel syndrome could not be completely excluded in the presence of the neuropathy, he clinically does not describe intermittent numbness in the right hand. Based on these findings, including reduced pinprick sensation, mild to moderate flare-ups, and numbness in the right thumb, the Board finds that a 30 percent rating, but no higher, rating for right thumb numbness is warranted for the entire period on appeal. However, a 40 percent evaluation is not more nearly approximated at any time during the appeal period. Significantly, physical examination revealed normal strength for pushing, pulling and twisting, with normal dexterity of the thumb. See November 2007 VA examination. Further, the Veteran’s carpal tunnel syndrome has been characterized as mild and he has reported no more than moderate symptom severity during flare-ups. See April 2011 VA EMG consult note. As such, the Board finds that the evidence does not more nearly approximate the symptoms contemplated by a 40 percent evaluation. Thus, the Board finds that the criteria for a disability rating of 30 percent for the right thumb for the entire period on appeal is warranted. However, the Veteran’s disability picture does not more nearly approximate the criteria for a 40 percent rating at any time during the appeal period. See Gilbert v. Derwinski, 1 Vet. App 49, 55-57 (1990); 38 C.F.R. § 3.102. 2. SMC The Veteran filed a July 2016 claim for SMC. See July 2016 VA Form 21-2680. SMC is warranted when a veteran is so helpless as to be in need of regular aid and attendance. 38 U.S.C. § 1114(l) (2012); 38 C.F.R. § 3.350(b) (2017). The following will be accorded consideration in determining the need for regular aid and attendance: inability of veteran to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid; inability of veteran to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352(a). It is not required that all of the disabling conditions enumerated in this paragraph be found to exist, nor is it necessary that there be a constant need for aid and attendance. Id. However, entitlement requires at least one of the above enumerated factors be present. Turco v. Brown, 9 Vet. App. 222, 224-5 (1996). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be granted to the claimant. 38 U.S.C.§ 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on the merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Veteran is service-connected for the following disabilities: PTSD and major depressive disorder, rated 50 percent disabling from September 25, 2006, and 70 percent disabling from June 5, 2015; right upper extremity diabetic peripheral neuropathy, rated 40 percent disabling from April 30, 2013; left upper extremity diabetic peripheral neuropathy, rated 30 percent disabling from April 30, 2013; type II diabetes mellitus with erectile dysfunction, rated 20 percent from September 25, 2006; strain of lateral ligament of metacarpophalangeal joint of the right thumb, rated 10 percent disabling from September 25, 2006; tinnitus, rated 10 percent disabling from September 25, 2006; residuals of right thumb injury, to include numbness associated with strain of lateral ligament of metacarpophalangeal joint of the right thumb, rated 30 percent disabling from September 25, 2006, to April 30, 2013; right lower extremity diabetic peripheral neuropathy (sciatic nerve), rated 10 percent disabling from April 30, 2013; left lower extremity diabetic peripheral neuropathy (sciatic nerve), rated 10 percent disabling from April 30, 2013; right lower extremity diabetic peripheral neuropathy (femoral nerve), rated 10 percent disabling from April 30, 2013; left lower extremity diabetic peripheral neuropathy (femoral nerve), rated 10 percent disabling from April 30, 2013; bilateral hearing loss, rated noncompensable from September 25, 2006; and left arm residuals of mosquito bite, rated noncompensable from September 25, 2006. Further, the Veteran has been in receipt of a total disability rating based on individual unemployability (TDIU) due to his service-connected disabilities. See September 2015 DRO decision. The evidence of record demonstrates that the Veteran’s service-connected disabilities cause the need for regular aid and attendance. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The most recent evidence addressing the Veteran’s disability is found in the July 2016 private report by Dr. K.T. addressing aid and attendance. In a July 2016 private examination report for permanent need for regular aid and attendance, Dr. K.T. indicated that the Veteran’s diabetic peripheral neuropathy restricted his activities/functions. Specifically, she indicated that the Veteran is not able prepare his own meals because his neuropathy causes him to feel unsafe when using cooking instruments. The Veteran needs assistance in bathing and tending to his other hygiene needs because he is unable to tolerate activities requiring prolonged standing. He requires medication management because he forgets to take his medicine. The Veteran uses a wheelchair, as needed. Dr. K.T. described the restrictions of each upper extremity as the Veteran’s carpal tunnel syndrome makes the prolonged use of his hands uncomfortable and he also has neuropathy. Dr. K.T. indicated that on account of the Veteran’s bilateral lower extremity weakness, he requires the use of a wheelchair often, for traveling long distance. She indicated that the Veteran is continent, has intermittent dizziness, needs supervision, and needs help from his family. She described the circumstances in which the Veteran is able to leave his home as leaving his house with able family members at least once a month for doctors’ visits and errands. She noted that the Veteran required a wheelchair for locomotion. In an April 2018 Affidavit, the Veteran reported that due to his service-connected disabilities, he required aid and attendance from his wife to bathe, prepare meals, and take his medication. He reported that he uses a walker and cane and he must sit on a bench in the shower. Similarly, in an April 2018 Affidavit, the Veteran’s wife, V.C., indicated that she has been the Veteran’s primary caretaker. She reported that due to his service-connected disabilities, she spends every day, morning to night, helping the Veteran. She reported that a typical day begins with helping him get out of bed and then helping him shower. She must help him into the shower where he sits so he does not fall. She helps him wash his body and when he is done, she helps him dry off and get dressed. She has to cut up his food and feed him because shaking in his hands prevents his eating. She also has to help him take his medication. She reported that the Veteran falls two to three times per week because of weakness in his legs. Sometimes she has to get help to assist with getting him up and back into his wheelchair. His wife reported that she can rarely leave home because of the risk of the Veteran falling. She indicated that the veteran requires her hands-on help, every day. The Board finds the May 2016 aid and attendance examination report and April 2018 Affidavits to be of probative value. They provide information regarding the details of the Veteran’s medical history and impacts of his service-connected disabilities on his daily functioning. In sum, the evidence is clear that the Veteran is unable to dress or undress himself, bathe himself, is unable cook/feed himself, and requires regular assistance. It is also clear that he needs protection from hazards or dangers incident to his daily environment. See 38 C.F.R. § 3.352. With resolution of all reasonable doubt in the Veteran’s favor, the Board finds that, collectively, such evidence indicates that the Veteran is so helpless as to be in need of regular aid and attendance of another person because of the manifestations of his service-connected disabilities. As such, the claim is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Effective Date It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” 38 C.F.R. §§ 3.340(a)(1), 4.15. “Substantially gainful employment” is that employment “which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides.” Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). “Marginal employment shall not be considered substantially gainful employment.” 38 C.F.R. § 4.16(a). A total disability rating for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and the combined rating must be 70 percent or more. 38 C.F.R. § 4.16(a). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims held that a claim for TDIU due to service-connected disabilities is part and parcel of an increased rating claim when such claim is reasonably raised by the record. The statutory guidelines for the determination of an effective date of an award are set forth in 38 U.S.C. § 5110. Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after a final disallowance, or a claim for increase will be the date of receipt of the claim, or the date entitlement arose, whichever is the latter. 38 C.F.R. § 3.400. In cases involving an increased disability rating, if an increase in disability occurred within one year prior to the claim, the increase is effective as of the date the increase was “factually ascertainable.” If the increase occurred more than one year prior to the claim, the increase is effective the date of claim. If the increase occurred after the date of claim, the effective date is the date of increase. 38 U.S.C. § 5110(b)(2); Harper v. Brown, 10 Vet. App. 125 (1997); 38 C.F.R. 3.400(o); VAOPGCPREC 12-98 (1998). In making this determination, the Board must consider all of the evidence, including that received prior to previous final decisions. Hazan v. Gober, 10 Vet. App. 511 (1997). DEA benefits may be paid to dependents of a veteran who has a service-connected disability that is rated permanent and total. 38 U.S.C. §§ 3500, 3501; 38 C.F.R. §§ 3.807(a), 21.3021. A total disability may be assigned where a veteran’s service-connected disabilities are rated 100 percent disabling under the rating schedule, or if the veteran is unemployable due to service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341. 3. TDIU A September 2015 Decision Review Officer (DRO) Decision granted entitlement to TDIU, effective April 30, 2013. See September 2015 DRO decision. First, the Board finds that under Rice, the Veteran’s TDIU appeal is part and parcel of the Veteran’s appeal for increased disability ratings for his service-connected disabilities, to include his bilateral upper extremity peripheral neuropathy and his right thumb injury with numbness associated with strain of lateral ligament of metacarpophalangeal joint of the right thumb (right thumb numbness). See February 2014 and July 2016 rating decisions; see also DAV’s June 2015 Third Party Correspondence. Second, the Veteran is service-connected for the following disabilities: PTSD and major depressive disorder, rated 50 percent disabling from September 25, 2006, and 70 percent disabling from June 5, 2015; right upper extremity diabetic peripheral neuropathy, rated 40 percent disabling from April 30, 2013; left upper extremity diabetic peripheral neuropathy, rated 30 percent disabling from April 30, 2013; type II diabetes mellitus with erectile dysfunction, rated 20 percent from September 25, 2006; strain of lateral ligament of metacarpophalangeal joint of the right thumb, rated 10 percent disabling from September 25, 2006; tinnitus, rated 10 percent disabling from September 25, 2006; residuals of right thumb injury, to include numbness associated with strain of lateral ligament of metacarpophalangeal joint of the right thumb, rated 30 percent disabling from September 25, 2006, to April 30, 2013; right lower extremity diabetic peripheral neuropathy (sciatic nerve), rated 10 percent disabling from April 30, 2013; left lower extremity diabetic peripheral neuropathy (sciatic nerve), rated 10 percent disabling from April 30, 2013; right lower extremity diabetic peripheral neuropathy (femoral nerve), rated 10 percent disabling from April 30, 2013; left lower extremity diabetic peripheral neuropathy (femoral nerve), rated 10 percent disabling from April 30, 2013; bilateral hearing loss, rated noncompensable from September 25, 2006; and left arm residuals of mosquito bite, rated noncompensable from September 25, 2006. The Veteran’s combined rating has exceeded 70 percent since September 25, 2006. Thus, he has met the schedular criteria for TDIU. See 38 C.F.R. § 4.16(a). Accordingly, the question currently before the Board is when during the appeal period it was factually ascertainable that the Veteran was unable to obtain or maintain substantially gainful employment due to service-connected disabilities. The Board finds the totality of the evidence of record indicates it was factually ascertainable the Veteran was unable to obtain or maintain substantially gainful employment due to his service-connected disabilities, in combination, as of September 25, 2006. The evidence of record indicates the Veteran has not worked since 2004, when he retired because he could no longer handle the stress his service-connected disabilities were causing him. See June 2015 VA Form 21-8490. The Veteran has high school diploma with approximately two years of college, but did not earn a degree. See July 2015 private employability evaluation. His past relevant work experience is that of a supervisor and claims processor. Id. At his May 2009 DRO hearing, the Veteran testified that his PTSD, residual of a right thumb injury, residuals of a mosquito bite to the left forearm, and hearing loss have become worse. He testified that he had a reduced ability to lift and grab with his thumb. He also reported constant pain. A June 2009 VA neurological examination report indicated while the Veteran was previously working for the unemployment office, he had numbness of his right thumb. The examiner determined the Veteran had residual carpal tunnel syndrome on right side of where he had an operation in the past. Upon August 2009 VA audiological examination, the Veteran reported hearing difficulties in all settings and stated that the ringing in his ears is so distracting that it affects his concentration. Upon November 2009 VA PTSD examination, the Veteran had thought content that was marked by themes of hopelessness, helplessness, and worthlessness; he had difficulty with goal directed thinking; his insight was poor and he understood little of his symptoms and psychological problem; and he had poor impulse control, marked by anger outbursts. The examiner indicated that the Veteran’s prognosis was poor and he was not expected to improve significantly within the next six to 12 months. The examiner opined that regarding his ability to carry out employment functions, specifically the effect that his service-connected disabilities have on his ability to engage in substantially gainful employment, the Veteran is currently unable to function in occupational settings, including general employment settings and sedentary employment. An April 2011 VA EMG consult note indicated findings of neuropathy in the right median and ulnar nerves and these findings were most compatible with mild peripheral neuropathy or perhaps residual from prior entrapment neuropathies. In a July 2015 private employability evaluation, vocational rehabilitation consultant, E.H., indicated that the Veteran has high school diploma with approximately two years of college, but did not earn a degree. His past relevant work experience is that of a supervisor and claims processor. Ms. E.H. indicated that the Veteran’s symptoms of PTSD increased under stressful work conditions and he took early retirement in 2003. She stated that the Veteran’s service-connected PTSD symptoms impaired his special, occupational, and cognitive functioning as of September 25, 2006, including flashbacks, intrusive thoughts, anger, irritability, difficulty concentrating, anxiety, anhedonia, feelings of hopelessness/helplessness/worthlessness, depressed mood, and social withdrawal. Ms. E.H. determined that the Veteran has been unable to perform his past work as a supervisor and claims processor, and would also be unable to perform any other type of work for which he would be qualified based on his work background and training. She determined it is more likely than not that the Veteran has been unable to secure and follow a substantially gainful occupation since September 25, 2006, when service-connection for PTSD was established. She stated that since September 2006, the Veteran has only become more disabled with the progression of his physical impairments. Accordingly, the Board finds the totality of the evidence of record indicates the Veteran’s physical and psychiatric limitations due to his service-connected disabilities, when considered with the Veteran’s education and work history, combined to render the Veteran unable to obtain and maintain a substantially gainful occupation. Therefore, the Board finds entitlement to TDIU was factually ascertainable as of September 25, 2006, the effective date for the grant of service connection for PTSD and major depressive disorder, type II diabetes mellitus with erectile dysfunction, strain of lateral ligament of metacarpophalangeal joint of the right thumb, tinnitus, residuals of right thumb injury, to include numbness associated with strain of lateral ligament of metacarpophalangeal joint of the right thumb, bilateral hearing loss, left arm residuals of mosquito bite, and the date in which Ms. E.H. opined the Veteran was rendered unemployable due to his service-connected disabilities. Therefore, given the totality of the evidence, the Board finds the criteria for an effective date of September 25, 2006, but no earlier, for entitlement to TDIU have been met. 4. DEA In this case, a September 2015 DRO decision granted entitlement to basic eligibility to Dependents’ Educational Assistance (DEA), effective April 30, 2013, the date of the grant of TDIU. Based on the Board’s award of an earlier effective date of September 25, 2006, for TDIU, and because the effective date for DEA benefits was directly related to a finding that the Veteran had a total disability that was permanent in nature by virtue of his TDIU rating, the Veteran is also entitled to an earlier effective date of September 25, 2006, for eligibility for DEA benefits. Accordingly, given the totality of the evidence, the Board finds the criteria for an effective date of September 25, 2006, but no earlier, for entitlement to basic eligibility for DEA have been met. REASONS FOR REMAND Bilateral upper extremity peripheral neuropathy associated with type II diabetes mellitus The evidence suggests a material worsening of the Veteran’s bilateral upper extremity peripheral neuropathy symptoms since his last VA examination in June 2016; therefore, new examination to determine the current severity of the Veteran’s bilateral upper extremity peripheral neuropathy is needed. See 38 C.F.R. §§ 3.326, 3.327; Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). In this regard, it is noted that since the July 2016 VA examination, subsequent evidence reveals that the Veteran cannot cook for himself and the Veteran’s wife cuts up his food and feeds him because of the neuropathy in his hands. See April 2018 Affidavits. The matters are REMANDED for the following action: 1. Obtain outstanding relevant VA treatment records and associate them with the claims file. 2. Then, schedule the Veteran for a VA examination to determine the nature and severity of his peripheral neuropathy of the bilateral upper extremities. The examiner must review the claims file. All testing must be completed. The examiner should specifically state the affected nerve(s) and impairment level (e.g., mild, moderate, moderately severe, severe), and describe all symptoms related to bilateral upper extremity peripheral neuropathy. The examiner is requested to provide a complete rationale for any opinion expressed, based on the examiner’s clinical experience, medical expertise, and established medical principles. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. (CONTINUED ON NEXT PAGE) 3. Then, readjudicate the Veteran’s claims on appeal. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided a supplemental statement of the case. Allow an appropriate period of time for response. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Schick, Associate Counsel