Citation Nr: 1815354 Decision Date: 03/16/18 Archive Date: 03/23/18 DOCKET NO. 14-25 377A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial evaluation in excess of 20 percent for diabetes mellitus with cataracts and erectile dysfunction. 2. Entitlement to an initial evaluation in excess of 20 percent for peripheral neuropathy of the right upper extremity, for the period prior to January 8, 2014. 3. Entitlement to an evaluation in excess of 30 percent for peripheral neuropathy of the right upper extremity, for the period from January 8, 2014. 4. Entitlement to an initial evaluation in excess of 20 percent for peripheral neuropathy of the left upper extremity. 5. Entitlement to an initial evaluation in excess of 20 percent for peripheral neuropathy of the right lower extremity. 6. Entitlement to an initial evaluation in excess of 20 percent for peripheral neuropathy of the left lower extremity. 7. Entitlement to an initial compensable evaluation for bilateral hearing loss, for the period prior to April 10, 2014. 8. Entitlement to a compensable evaluation for bilateral hearing loss, for the period from April 10, 2014. 9. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), unspecified anxiety disorder, and major depressive disorder. 10. Entitlement to service connection for a digestive disability, to include irritable bowel syndrome (IBS), claimed as diabetic enteropathy as secondary to diabetes mellitus. 11. Entitlement to service connection for polyuria, to include as secondary to diabetes mellitus. 12. Entitlement to service connection for skin cancer, to include as due to exposure to herbicide agents. 13. Entitlement to service connection for atrial fibrillation, to include as secondary to diabetes mellitus. 14. Entitlement to service connection for ischemic heart disease, to include as due to exposure to herbicide agents. 15. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance. WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. Gallagher, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1965 to September 1968. This appeal is before the Board of Veterans' Appeals (Board) from January 2010, December 2010, and December 2011 rating decisions of the abovementioned Department of Veterans Affairs (VA) Regional Office (RO). In November 2017, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge via videoconference. A transcript is included in the claims file. The Board notes that the Veteran appointed an attorney as his representative in December 2010. At his November 2017 hearing, the Veteran informed the Board that the attorney has retired and that he wished to proceed unrepresented. The attorney is no longer accredited to practice before the Board. The representation is therefore deemed terminated, and the Board recognizes the Veteran's decision to proceed unrepresented. The RO has certified two issues which are not included in the above list. The first, entitlement to a total disability rating based on individual unemployability as a result of service-connected disabilities (TDIU), has been granted in full for the period requested by the Veteran in a June 2014 rating decision. The second issue, service connection for a vision disability associated with diabetes mellitus, is incorporated and analyzed as part of his claim for an increased evaluation for diabetes mellitus with cataracts and erectile dysfunction. Neither issue was separately addressed in a statement of the case issued by the RO. To the extent that these issues remain before the Board, they are dismissed as moot and will not be addressed further in this decision. The issue of entitlement to a compensable evaluation for bilateral hearing loss, for the period from April 10, 2014, is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Diabetes mellitus is not productive of the requirement of regulation of activities; of episodes of ketoacidosis or hypoglycemic reactions requiring hospitalizations or at least twice a month visits to a diabetic care provider, plus complications not separately evaluated; or of cataracts causing visual field reduction or corrected distance vision of 20/50 or worse. 2. For the period prior to January 8, 2014, peripheral neuropathy of the right upper extremity was not productive of the equivalent of complete paralysis or moderate or severe incomplete paralysis of the lower radicular nerve group. 3. For the period from January 8, 2014, peripheral neuropathy of the right upper extremity was not productive of the equivalent of complete paralysis or severe incomplete paralysis of the median nerve. 4. Peripheral neuropathy of the left upper extremity was not productive of the equivalent of complete paralysis or severe incomplete paralysis of the median nerve, or the equivalent of complete paralysis or moderate or severe incomplete paralysis of all radicular nerve groups. 5. Peripheral neuropathy of the right lower extremity is productive of the equivalent of moderately severe incomplete paralysis of the sciatic nerve, but not the equivalent of severe incomplete paralysis or complete paralysis. 6. Peripheral neuropathy of the left lower extremity is productive of the equivalent of moderately severe incomplete paralysis of the sciatic nerve, but not the equivalent of severe incomplete paralysis or complete paralysis. 7. Prior to April 10, 2014, the Veteran manifested, at worst, Level I hearing in his right ear and Level I hearing in his left ear. 8. An acquired psychiatric disability, to include PTSD or an unspecified anxiety disorder but excluding major depressive disorder, is related to service. 9. A digestive disability is not related to service or to a service-connected disability. 10. Polyuria is not related to service or to a service-connected disability. 11. The Veteran does not have a current skin cancer disability. 12. Atrial fibrillation is not related to service or to a service-connected disability. 13. The Veteran does not have a current ischemic heart disease disability. 14. The Veteran is so helpless as to be in need of regular aid and attendance due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 20 percent for diabetes mellitus with cataracts and erectile dysfunction have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2017). 2. The criteria for an initial evaluation in excess of 20 percent for peripheral neuropathy of the right upper extremity, for the period prior to January 8, 2014, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8512 (2017). 3. The criteria for an evaluation in excess of 30 percent for peripheral neuropathy of the right upper extremity, for the period from January 8, 2014, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2017). 4. The criteria for an initial evaluation in excess of 20 percent for peripheral neuropathy of the left upper extremity have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.124a, Diagnostic Codes 8513, 8515 (2017). 5. The criteria for an initial evaluation of 40 percent, but not in excess thereof, for peripheral neuropathy of the right lower extremity have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2017). 6. The criteria for an initial evaluation of 40 percent, but not in excess thereof, for peripheral neuropathy of the left lower extremity have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2017). 7. The criteria for an initial compensable evaluation for bilateral hearing loss, for the period prior to April 10, 2014, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100 (2017). 8. The criteria for service connection for an acquired psychiatric disability, to include PTSD or an unspecified anxiety disorder but excluding major depressive disorder, have been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 9. The criteria for service connection for a digestive disability, to include IBS, claimed as diabetic enteropathy as secondary to diabetes mellitus, have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 10. The criteria for service connection for polyuria, to include as secondary to diabetes mellitus, have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 11. The criteria for service connection for skin cancer, to include as due to exposure to herbicide agents, have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 12. The criteria for service connection for atrial fibrillation, to include as secondary to diabetes mellitus, have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 13. The criteria for service connection for ischemic heart disease, to include as due to exposure to herbicide agents, have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 14. The criteria for SMC based on the need for aid and attendance have been met. 38 U.S.C. §§ 1114(l), 5107 (2012); 38 C.F.R. §§ 3.350(b), 3.352(a) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The Veteran has not raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). There is thus no prejudice to the Veteran in deciding this appeal. Increased Ratings Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. "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). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Diabetes Mellitus The Veteran seeks an increase to his rating for diabetes mellitus with cataracts and erectile dysfunction. Diabetes mellitus is evaluated under 38 C.F.R. § 4.119, Diagnostic Code 7913. The Veteran's current 20 percent rating is warranted for diabetes mellitus requiring insulin and restricted diet, or oral hypoglycemic agent and restricted diet. A higher rating of 40 percent is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. A 60 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and 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 evaluated. Separate ratings for cataracts are available under 38 C.F.R. § 4.79, Diagnostic Code 6027. Under this code, preoperative cataracts and postoperative cataracts with a replacement lens present are evaluated based on visual impairment. Postoperative cataracts without a replacement lens are to be evaluated as aphakia under Diagnostic Code 6029, which directs that the disability be evaluated based on visual impairment with the resulting level elevated by one step and with a minimum unilateral or bilateral evaluation of 30 percent. Generally, visual acuity is evaluated on the basis of corrected distance vision. 38 C.F.R. § 4.76. Compensable ratings for impaired visual acuity require evidence of corrected distance vision of 20/50 or worse. See 38 C.F.R. § 4.79. The Veteran underwent a VA examination in October 2007. He reported that he was diagnosed with diabetes around November 2003 and had been treated with oral agents since that time. He had been instructed to follow a restricted diet. He was not restricted in his ability to perform strenuous activity. There was no history of hospitalization, hypoglycemic reactions, or episodes of ketoacidosis. The Veteran underwent a VA optical examination in November 2017. The examiner found trace cataracts and blurred vision due to changing sugars, but no diabetic retinopathy. VA treatment records reflect that in February 2008 the Veteran was prescribed insulin. As of March 2008 he was taking insulin twice daily for his diabetes. In January 2009, his ophthalmologist diagnosed incipient cataracts, dry eye syndrome, and diabetes mellitus without retinopathy. In September 2008 his physician congratulated him on weight loss and improved control of diabetes. The Veteran underwent another VA examination in June 2009. He reported that his diabetes had worsened. Specifically, he stated that his medication had increased with the addition of insulin and an increase in oral medication use. He had been instructed to follow a restricted diet. He was not restricted in his ability to perform strenuous activity. There was no history of hospitalization, hypoglycemic reactions, or episodes of ketoacidosis. In his January 2011 notice of disagreement, the Veteran stated that his diabetes mellitus causes him severe restriction in activities of daily living. He also stated that he had retinopathy with cataracts due to his diabetes. The Veteran underwent another VA examination in July 2011. He was currently taking insulin about once per week and was otherwise on oral medication. He had been instructed to follow a restricted diet. He was not restricted in his ability to perform strenuous activity. There was no history of hospitalization. Episodes of hypoglycemic reactions or ketoacidosis were managed without visiting a diabetic care provider. The Veteran underwent a VA vision examination in August 2011. Corrected distance vision was 20/30 in the right eye and 20/25 in the left eye. He was diagnosed with cataracts related to diabetes. No diabetic retinopathy was found. In a January 2014 letter, the Veteran's treating VA physician's assistant reported that since March 2008 the Veteran has required insulin injections to control his diabetes. Since his November 2010 gastric bypass surgery, he had been able to control his diabetes through diet and the use of regular insulin. At his January 2014 RO hearing, the Veteran stated that he took insulin shots to treat his diabetes. He stated that he had restricted activities due to diabetes. The Veteran underwent another VA vision examination in March 2014. Corrected distance vision was 20/30 in both eyes. There were no visual field defects. He was diagnosed with bilateral preoperative cataracts. There was no aphakia or dislocation of the crystalline lens. There was no diabetic retinopathy. The Veteran underwent another VA examination in April 2014. He was currently taking insulin about twice per week and was otherwise on oral medication. He had been instructed to follow a restricted diet. He was not restricted in his ability to perform strenuous activity. There was no history of hospitalization. Episodes of hypoglycemic reactions or ketoacidosis were managed with less than two visits per month to a diabetic care provider. In a statement attached to his July 2014 substantive appeal, the Veteran's former representative stated that a 40 percent evaluation was warranted for his diabetes, and that the VA examination was not adequate. At his November 2017 hearing, the Veteran stated that he should be rated higher because he was taking insulin and was insulin-dependent. He reported that his activities could not be regulated because he did not have any activities to regulate, as he was wheelchair-bound. He stated that he did not see a diabetic care provider twice per month. The Board finds that a rating in excess of 20 percent is not warranted for the Veteran's diabetes mellitus. Higher ratings are available for the requirement of regulation of activities, or for episodes of ketoacidosis or hypoglycemic reactions requiring hospitalizations or at least twice a month visits to a diabetic care provider, plus complications not separately evaluated. The evidence weighs against such manifestations. Despite the Veteran's statements to the contrary, the evidence does not establish that the Veteran's activities are regulated. He may feel that his diabetes prevents him from engaging in activities, but there is no evidence in the record that his physicians have advised him to avoid strenuous activity because of his diabetes. Indeed, treatment records are replete with instructions for the Veteran to engage in more exercise, not less. Furthermore, while the Veteran has complications from diabetes not separately evaluated, including erectile dysfunction and cataracts, both medical records and his statements indicate that episodes of ketoacidosis or hypoglycemic reactions do not require hospitalizations or at least twice a month visits to a diabetic care provider. For these reasons, the Board finds that a rating in excess of 20 percent is not warranted for the Veteran's diabetes mellitus. The Board further finds that a separate evaluation is not warranted for the Veteran's cataracts associated with diabetes. Though the evidence establishes that these cataracts are related to his diabetes and are therefore part of the service-connected disability, a compensable evaluation is not warranted. Preoperative cataracts are compensable to the extent that they cause visual impairment. Compensable ratings for visual impairment require evidence of visual field reduction or corrected distance vision of 20/50 or worse. There is no evidence in the record of visual field reduction, and the Veteran's corrected distance vision has been consistently measured at no worse than 20/30. A separate compensable rating for cataracts is therefore not warranted. Peripheral Neuropathy The Veteran seeks increases to his ratings for peripheral neuropathy associated with diabetes mellitus. Prior to January 8, 2014, the Veteran's peripheral neuropathy of the right upper extremity was evaluated as paralysis of the lower radicular nerve group under 38 C.F.R. § 4.124a, Diagnostic Code 8512. Under this code, as applied to the dominant extremity, his rating of 20 percent was warranted for mild incomplete paralysis. A 40 percent rating is warranted for moderate incomplete paralysis. A 50 percent rating is warranted for severe incomplete paralysis. A 70 percent rating is warranted for complete paralysis. Complete paralysis of the lower radicular nerve group is present when all intrinsic muscles of the hand and some or all of the flexors of the wrist and fingers are paralyzed with substantial loss of use of the hand; when pronation is incomplete and defective, flexion of the index finger is absent and flexion of the middle finger is feeble, a fist cannot be made, and the index and middle fingers remain extended; when the distal phalanx of the thumb cannot be flexed, and opposition and abduction of the thumb at right angles to the palm are defective; when flexion of the wrist is weakened; and when there is pain with trophic disturbances. From January 8, 2014, the Veteran's peripheral neuropathy of the right upper extremity is evaluated as paralysis of the median nerve under 38 C.F.R. § 4.124a, Diagnostic Code 8515. Under this code, as applied to the dominant extremity, his current 30 percent rating is warranted for moderate incomplete paralysis. A 50 percent rating is warranted for severe incomplete paralysis. A 70 percent rating is warranted for complete paralysis. Complete paralysis of the median nerve is present when the hand is inclined to the ulnar side, the index and middle fingers are more extended than normally, there is considerable atrophy of the muscles of the thenar eminence, and the thumb is in the plane of the hand The Veteran's peripheral neuropathy of the left upper extremity is evaluated as paralysis of all radicular nerve groups under 38 C.F.R. § 4.124a, Diagnostic Code 8513. Under this code, as applied to the non-dominant extremity, his current rating of 20 percent is warranted for mild incomplete paralysis. A 30 percent rating is warranted for moderate incomplete paralysis. A 60 percent rating is warranted for severe incomplete paralysis. An 80 percent rating is warranted for complete paralysis. The Veteran's peripheral neuropathy of the lower extremities is evaluated as paralysis of the sciatic nerve under 38 C.F.R. § 4.124a, Diagnostic Code 8520. His current ratings of 20 percent are warranted for moderate incomplete paralysis. A 40 percent rating is warranted for moderately severe incomplete paralysis. A 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy. An 80 percent rating is warranted for complete paralysis. Complete paralysis of the sciatic nerve is productive of the foot dangling and dropping, with no active movement possible of the muscles below the knee, and with flexion of the knee weakened or (very rarely) lost. In rating the peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. At an October 2007 VA examination for diabetes mellitus, the examiner noted the presence of symptoms of diabetic neuropathy. Examination revealed decreased sensation to vibration, pain, and light touch over all areas of the body. There was no muscle atrophy present. Because the examiner opined that neuropathy was not related to diabetes, there was no analysis of its severity. VA treatment records reflect that in November 2007 the Veteran reported persistent burning, tingling, and numbness in all peripheral extremities. He was diagnosed with diabetic peripheral neuropathy. His medication for his neuropathy was increased in September 2008. At a June 2009 VA examination for diabetes, the Veteran was noted to have diabetic neuropathy, specifically numbness, paresthesia, and dysesthesia in both feet. Muscle strength and sensory function tests were normal. There was no muscle atrophy present. The examiner found that the sensory examination was essentially normal, with mild interference occurring from lower extremity edema. He was diagnosed with peripheral neuropathy. Paralysis was absent but neuritis and neuralgia were present. The examiner found that peripheral neuropathy had a significant effect on the Veteran's occupation through decreased mobility and pain. In a December 2010 statement, the Veteran reported that his peripheral neuropathy of the lower extremities made him wheelchair bound. In his January 2011 notice of disagreement, the Veteran stated that his peripheral neuropathy should be rated at 40 percent in each of his upper extremities and at 20 percent in each of his lower extremities. He stated that he had little to no feeling in his lower extremities and was thus in a wheelchair. The Veteran underwent a VA examination in July 2011. He reported neuropathy symptoms in all extremities. He was only able to walk about 50 feet due to exertional dyspnea and fatigue. Examination revealed numbness, paresthesia, and dysesthesia in both hands and feet. Reflexes in the upper extremities were normal. Ankle jerk reflexes were absent and knee jerk reflexes were hypoactive. Sensory response in the upper extremities was normal except for decreased light touch in the hands. Sensory response in the lower extremities was absent to vibration or light touch from the toes to the ankles, and position sense in the toes was decreased. Motor and muscle examination was normal. Imbalance was due to combined effects of morbid obesity, deconditioning, and neuropathy. Gait abnormality was due to morbid obesity and deconditioning. With both hands he was able to pick up a coin, unscrew the cap off a bottle, and replace it. He was able to uncap a ball point pen and make his initials. He was diagnosed with moderately severe peripheral sensory neuropathy of the lower extremities and mild peripheral sensory neuropathy of the upper extremities. Nerve dysfunction and neuralgia were present, paralysis and neuritis were absent. In a January 2014 letter, the Veteran's treating VA physician's assistant reported that although the Veteran's diabetes had come under control since his November 2010 gastric bypass surgery, his peripheral neuropathy had continued to progress and worsen. He had multiple falls due to the non-feeling in his lower extremities. He required an electronic wheelchair due to his peripheral neuropathy. At his January 2014 RO hearing, the Veteran reported that he used a wheelchair whenever leaving his house and walker inside his house. He reported no feeling from his knees down or in his hands up to his wrists. The Veteran underwent another VA examination in April 2014. He reported constant pain, mild in the upper extremities and moderate in the lower extremities. He reported mild intermittent pain in all extremities. He reported paresthesia or dysesthesia, moderate in the upper extremities and severe in the lower extremities. He reported severe numbness in all extremities. Muscle strength was 3/5 in the left upper extremity, normal in the right upper extremity, and 4/5 in the bilateral lower extremities. There was no muscle atrophy. Reflexes were decreased in the upper extremities and normal in the lower extremities. Light touch sensation was decreased in the bilateral hands, fingers, ankles, and lower legs, and absent in the feet and toes. Position sense was decreased in the upper extremities and absent in the lower extremities. Vibration sensation was normal in the upper extremities and decreased in the lower extremities. The examiner found that the Veteran had no evidence of paralysis, but evidence of marked sensory peripheral neuropathy in all extremities. In a May 2014 addendum, the examiner clarified that the Veteran exhibited moderate sensory neuropathy of the bilateral median and ulnar nerves in the upper extremities and moderate sensory neuropathy of the sural, medial, and lateral plantar and deep peroneal nerves in the bilateral lower extremities. In a statement received by VA in July 2014, the Veteran stated that he believed that his symptoms warranted a 50 percent rating in his right upper extremity and a 40 percent rating in each of his other extremities. In a statement attached to his July 2014 substantive appeal, the Veteran's former representative stated that a 50 percent evaluation was warranted for his peripheral neuropathy in the right upper extremity, and a 30 percent evaluation was warranted for peripheral neuropathy in each of the remaining extremities. The representative further stated that the VA examination was not adequate. At his November 2017 hearing, the Veteran reported that he had no feeling in his hands or his feet. He stated that he dropped stuff all the time. Prior to January 8, 2014, peripheral neuropathy in both of the Veteran's upper extremities was evaluated as analogous to paralysis of the radicular nerves under Diagnostic Codes 8512 and 8513. His 20 percent ratings were warranted for mild incomplete paralysis. Higher ratings for this period are available for complete paralysis or for moderate or severe incomplete paralysis. The evidence weighs against such manifestations. At his July 2011 VA examination, the Veteran was found to have decreased light touch sensation in the hands. Reflexes and muscle strength were normal. With both hands he was able to pick up a coin, unscrew the cap off a bottle, and replace it. He was able to uncap a ball point pen and make his initials. The examiner diagnosed mild sensory peripheral neuropathy in both upper extremities. The Board finds that the evidence for this period does not contradict the VA examiner's assessment. From January 8, 2014, peripheral neuropathy in the Veteran's right upper extremity is evaluated as analogous to paralysis of the median nerve under Diagnostic Code 8515. This change represents the more detailed evaluation of the July 2014 VA examiner and the localization of the Veteran's symptoms in his hands. His current 30 percent rating is warranted for moderate incomplete paralysis in the dominant extremity. Higher ratings are available for complete paralysis or for severe incomplete paralysis. The evidence weighs against manifestations of such severity. The July 2014 VA examiner found moderate sensory neuropathy, and the Board finds no evidence to contradict this finding. An evaluation in excess of 30 percent is therefore not warranted for this period. The Veteran's 20 percent rating for peripheral neuropathy of the left upper extremity was not altered for the period from January 8, 2014. The more detailed evaluation from the July 2014 VA examiner, however, applied to both upper extremities, as did the examiner's evaluation of the mild sensory neuropathy worsening to moderate sensory neuropathy. Indeed, nearly all the evidence for this period applies equally to both upper extremities. Thus, his Diagnostic Code should have likewise switched to 8515 with moderate severity. For a nondominant extremity, however, moderate incomplete paralysis of the median nerve warrants the Veteran's current 20 percent rating. As such, with no change to the Veteran's rating, no change was made to his Diagnostic Code either. The Board thus finds that an evaluation in excess of 20 percent is not warranted for peripheral neuropathy of the left upper extremity for this period, for the same reasons that an increased rating is not warranted for the right upper extremity. The Board further finds that evaluations of 40 percent are warranted for peripheral neuropathy in the Veteran's lower extremities. Such an evaluation is warranted for neuropathy equivalent to moderately severe incomplete paralysis of the sciatic nerve. As the July 2011 VA examiner characterized the Veteran's peripheral neuropathy as moderately severe, affording all benefit of the doubt to the Veteran the Board awards 40 percent evaluations for peripheral neuropathy in each of the lower extremities. Higher ratings are available for neuropathy equivalent to complete paralysis or to severe incomplete paralysis. The evidence weighs against such manifestations. His VA examiners have consistently evaluated his lower extremity neuropathy as moderate or moderately severe in nature, with the April 2014 VA examiner specifically referring to moderate sensory neuropathy. The Board recognizes that the evidence establishes absent sensation, diminished muscle strength, and diminished reflexes in the lower extremities and that the Veteran cannot ambulate on his own without the use of a wheelchair or a walker. Nevertheless, the Veteran also has vascular and musculoskeletal disabilities of the lower extremities which are not service-connected. The Board thus relies on the evaluations of the VA examiners to determine the extent to which the neuropathy and the neuropathy alone impairs the Veteran, and the examiners have evaluated the severity of the Veteran's neuropathy as no more than moderately severe. Ratings in excess of 40 percent are therefore not warranted. Hearing Loss The Veteran claims an initial compensable rating for bilateral hearing loss. In evaluating service-connected hearing loss, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. 38 C.F.R. § 4.85. Evaluations of bilateral hearing loss range from noncompensable to 100 percent based on an organic impairment of hearing acuity, as measured by controlled speech discrimination tests in conjunction with the average hearing threshold, as measured by puretone audiometric tests in the frequencies of 1000, 2000, 3000 and 4000 cycles per second. The rating schedule establishes 11 auditory acuity Levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. VA audiological evaluations are conducted using a controlled speech discrimination test together with the results of puretone audiometry tests. The vertical line in Table VI (printed in 38 C.F.R. § 4.85) represents nine categories of the percentage of discrimination based on a controlled speech discrimination test. The horizontal columns in Table VI represent 9 categories of decibel loss based on the puretone audiometry test. The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the vertical row appropriate for the percentage of discrimination and the horizontal column appropriate to the puretone decibel loss. The percentage evaluation is found from Table VII in 38 C.F.R. § 4.85 by intersecting the vertical column appropriate for the numeric designation for the ear having the better hearing acuity and the horizontal row appropriate for the numeric designation for the level for the ear having the poorer hearing acuity. For example, if the better ear had a numeric designation of Level V and the poorer ear had a numeric designation of Level VII the percentage evaluation is 30 percent. See 38 C.F.R. § 4.85. Regulations also provide that in cases of exceptional hearing loss, i.e., when the puretone threshold at each of the four specified frequencies (1000, 2000, 3000 and 4000 hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). The provisions of 38 C.F.R. § 4.86(b) further provide that when the puretone threshold is 30 decibels or less at 1000 hertz and 70 decibels or more at 2000, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or VIa, whichever results in the higher numeral. That numeral will then be evaluated to the next higher Roman numeral. The Veteran underwent a VA examination in July 2011. He reported difficulty understanding people and use of high volume on the television. He also reported difficulty on the phone. Pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 10 45 60 55 42.5 LEFT 15 35 35 45 32.5 Speech recognition scores were 92 percent in the right ear and 94 percent in the left ear. The examiner diagnosed sensorineural hearing loss, normal to moderately severe in the right ear and normal to moderate in the left ear. In his June 2012 notice of disagreement, the Veteran stated that his symptoms were most consistent with an evaluation of 10 percent. He stated that VA failed to provide him with an adequate examination. The Veteran underwent another VA examination in April 2014. He reported worsening hearing. Pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 15 50 70 65 50 LEFT 15 45 55 50 41.25 Speech recognition scores were 96 percent in both ears. He was diagnosed with normal to moderately severe bilateral sensorineural hearing loss. In a statement attached to his July 2014 substantive appeal, the Veteran's former representative stated that a 10 percent evaluation was warranted for his hearing loss, and that the VA examination was not adequate. At his November 2017 hearing, the Veteran stated that he should be rated higher because without his hearing aids he could not hear. He stated that his hearing had been tested a few months prior at a VA treatment facility. The Board finds that a compensable evaluation is not warranted for the Veteran's hearing loss for the period prior to April 10, 2014. Taking his most severe speech recognition scores of 92 percent in the right ear and 94 percent in the left ear, any average decibel threshold of 57 or less results in Level I hearing loss on Table VI. The Veteran's average decibel thresholds are no higher than 50. Under Table VII, no compensable evaluations are available without hearing loss measured at Level IV or higher in at least one ear. Moreover, there is no indication of audiological findings which would qualify as an exceptional pattern of hearing, as the Veteran at no point had thresholds of 55 decibels or more at each of the frequencies of 1000, 2000, 3000 and 4000 hertz or a threshold of 70 decibels or more at 2000 hertz. For these reasons, the Board finds that a compensable evaluation is not warranted for the Veteran's hearing loss for the period prior to April 10, 2014. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). For certain diseases with a relationship to herbicide agent exposure, such as ischemic heart disease, a presumption of service connection arises if the disease manifests to a degree of 10 percent or more following service in the Republic of Vietnam any time during the period from January 9, 1962 to May 7, 1975. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Acquired Psychiatric Disability The Veteran claims service connection for an acquired psychiatric disability, to include PTSD. Service connection for PTSD requires: (1) a diagnosis of the disorder made in accordance with the criteria of Diagnostic and Statistical Manual of Mental Disorders (DSM-5); (2) credible supporting evidence that the claimed in-service stressor occurred; and (3) a link established by medical evidence, between current symptoms and an in-service stressor. 38 C.F.R. §§ 3.304(f), 4.125(a). There are several avenues to document an in-service stressor, other than obtaining verification from the Joint Services Records Research Center (JSRRC) or other government records repository: an in-service PTSD diagnosis with lay testimony; combat service with lay testimony; prisoner of war status with lay testimony; lay evidence of personal assault with appropriate corroboration; and a stressor related to a veteran's fear of hostile military or terrorist activity, with appropriate medical evidence. 38 C.F.R. § 3.304(f). Lay evidence may establish an in-service stressor if the evidence establishes that a veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(f)(2). Service treatment records do not reflect any symptoms of or treatment for a mental health disability. The Veteran does not claim that his disability arose in service. VA treatment records reflect that in November 2007 the Veteran reported that he was depressed due to his weight and inability to move around. He declined counseling or medication. In September 2008 he underwent a psychological evaluation prior to a scheduled gastric bypass surgery. Although the surgery did not ultimately happen, the psychologist deemed the Veteran psychiatrically stable and did not diagnose any mental health disabilities. In January 2009 he reported that he had been having flashbacks to Vietnam. At a February 2009 psychology consultation he reported that he served in combat and routinely handled personal effects and dead bodies, seeing many gruesome sights while in Vietnam. He was diagnosed with chronic PTSD and recurrent moderate major depressive disorder. In March 2009 he continued treatment for PTSD and reported that his depression had caused him to gain weight. He began group therapy. Later in the month he reported panic attacks 2-3 times per week. He reported similar symptoms in June 2009. In August 2009, he stated that he still hears the gunfire, feels the shaking of the ground, and smells the burning flesh from an incident on July 17, 1967. He denied panic attacks. In an August 2009 statement, the Veteran described the stressors which caused his PTSD. He reported that from June to September of 1966 he served handling dead bodies in Vietnam. Specifically, he stated that he unloaded the corpses of Marines who had been killed in action and then loaded them onto flights to Saigon. He stated that he has had nightmares related to this duty. He also reported that the air base which he served at from June 1966 to August 1967 regularly came under attack. Finally, he stated that in 1966 a large commercial plane crashed in a village on the southern end of the air base, and he had to clean up the disaster area. VA treatment records reflect that in November 2009 the Veteran reported memory difficulties. He reported increased feelings of depression, poor sleep, increased mood swings, and acknowledged being discouraged. He stated that his depression medication was causing him to gain weight. His psychologist noted that the cause of the new short-term-memory complaints was likely an increase in depression and anxiety symptoms. The Veteran underwent a VA examination in December 2009. He reported depression manifesting as irritability, social isolation, emotional withdrawal, anhedonia, and increased appetite. The examiner determined that the Veteran did not meet the DSM-IV criteria for PTSD and diagnosed an anxiety disorder. The examiner opined that PTSD was not related to service but gave no opinion regarding his anxiety disorder. VA treatment records reflect that in December 2009 the Veteran reported panic attacks 2-3 times per week. In his January 2011 notice of disagreement, the Veteran stated that his stressors were verifiable, and that his claim should also include his anxiety and depression disorders. The Veteran underwent another VA examination in April 2014. After evaluating the Veteran under the DSM-5 criteria, the examiner concluded that he did not meet the criteria for a diagnosis of PTSD. The examiner diagnosed unspecified anxiety disorder and opined that it was at least as likely as not related to service. This opinion is based on the rationale that his symptoms appeared chronic in nature and were consistently reported to have begun in the period following Vietnam service. The examiner further diagnosed major depressive disorder with many contributing factors generally related to psychosocial stressors and not directly due to or currently aggravated by his service-connected medical conditions. At his November 2017 hearing, the Veteran stated that he had been diagnosed with and was treated for PTSD. The Board finds that the evidence is at least in equipoise as to whether an acquired psychiatric disability is related to service. VA treatment records show a significant history of treatment for the Veteran's diagnosis of PTSD. While two VA examiners found that the Veteran did not meet the criteria for PTSD under different iterations of the DSM, the December 2009 VA examiner gave no opinion regarding the Veteran's anxiety disorder and the April 2014 VA examiner opined that an unspecified anxiety disorder was related to service. Because the criteria for rating PTSD are identical to that for rating an unspecified anxiety disorder, the Board need not resolve the dispute in diagnoses among the medical experts. The Board notes, however, that the evidence weighs against a finding that major depressive disorder is related to service or service-connected disabilities, and service connection is therefore only established for the variable diagnosis of PTSD/anxiety disorder. For these reasons, the Board finds that the evidence is at least in equipoise as to whether PTSD or an anxiety disorder is related to service, and service connection is therefore granted. Digestive Disability The Veteran claims service connection for a digestive disability. In his December 2010 claim, he stated that he had constipation and diarrhea or diabetic enteropathy secondary to diabetes mellitus. Service treatment records do not reflect any symptoms of or treatment for a gastrointestinal disability. The Veteran does not claim that his disability arose in service. VA treatment records reflect that in August 2005 the Veteran reported diarrhea secondary to his diabetes medication. His physician discontinued the medication and prescribed another. The Veteran underwent a VA examination in July 2011. He reported intermittent diarrhea for about 7 years with symptoms every week or two. He reported severe, crampy, colicky intestinal pain in the middle abdominal area several times per month in 15-minute episodes. He reported flatulence. He denied nausea or vomiting. He stated that he did not recall being diagnosed with diabetic enteropathy or having had a gastric emptying test. X-rays were normal. He was diagnosed with IBS. The examiner explained that no diabetic enteropathy was found. The examiner also noted a diagnosis of gastroesophageal reflux disease (GERD). In his June 2012 notice of disagreement, the Veteran stated that the VA examination was not adequate and that his IBS was related to his service-connected disabilities. In a statement attached to his July 2014 substantive appeal, the Veteran's former representative stated that IBS was related to service and that the VA examination was not adequate. At his November 2017 hearing, the Veteran reported that he soils himself all the time and he does not know what causes it. He stated that his physician told him that it could have something do with his diabetes. The Board finds that the evidence weighs against a finding that a digestive disability is related to service or to a service-connected disability. While the Veteran's treating physician suggested in August 2005 that his diabetes medication was contributing to his diarrhea, he promptly changed medications. To the extent that diabetes medication contributed to IBS prior to this change in medication, this was more than 5 years prior to his claim and therefore cannot be considered a current disability. There is no medical evidence which relates a current digestive disability to service or to a service-connected disability. The only evidence of such a link is the Veteran's own speculative statements that it is caused by diabetes, but he provides no basis of knowledge, and in fact stated at his November 2017 hearing that he did not know what caused his digestive difficulties. For these reasons, the Board finds that the evidence weighs against a finding that a digestive disability is related to service or to a service-connected disability. Service connection is therefore denied. Polyuria The Veteran claims service connection for polyuria. In his December 2010 claim, he stated that he has frequent urination or polyuria secondary to diabetes mellitus. Service treatment records do not reflect any symptoms of or treatment for polyuria. The Veteran does not claim that his disability arose in service. At an October 2007 VA examination for diabetes mellitus, the examiner noted the presence of genitourinary symptoms related to diabetes. VA treatment records reflect that in August 2009 the Veteran presented to the emergency room with hematuria, incontinence, and burning with urination. He was diagnosed with a urinary tract infection. At a September 2009 follow-up, he reported that his hematuria had resolved. The Veteran underwent a VA examination in July 2011. He reported frequent urination and some dribbling. He stated that he was told that he had an enlarged prostate. He reported incontinence if he cannot get to a restroom fast enough. He was diagnosed with benign prostatic hyperplasia. The examiner opined that polyuria was not caused by or the result of diabetes. This opinion was based on the rationale that polyuria due to diabetes occurs in uncontrolled diabetics with grossly elevated glucose levels, but the Veteran's diabetes was stable with only mildly elevated levels. Furthermore, his renal function was within normal limits and he reported diagnosis of an enlarged prostate. In his June 2012 notice of disagreement, the Veteran stated that the VA examination was not adequate and that his polyuria was related to his service-connected disabilities. The Veteran underwent another VA examination in April 2014. He reported problems with a slow urinary stream and drippling. The examiner diagnosed benign prostatic hyperplasia and opined that it was less likely than not related to diabetes mellitus. This opinion is based on the rationale that while several medical studies have shown that there can be a higher incidence of benign prostatic hyperplasia in diabetic males compared to non-diabetic males, there is no evidence of a causal relationship between having diabetes and developing benign prostatic hyperplasia. The examiner further explained that the Veteran's urinary symptoms appeared prior to his diagnosis of diabetes. In a statement attached to his July 2014 substantive appeal, the Veteran's former representative stated that polyuria was related to service and that the VA examination was not adequate. At his November 2017 hearing, the Veteran reported that his problems with urination were bad. The Board finds that the evidence weighs against a finding that polyuria is related to service or to a service-connected disability. Two VA examiners provided probative and detailed opinions explaining why the Veteran's diabetes was not contributing to his polyuria, and further explaining that polyuria was likely caused by benign prostatic hyperplasia. The Veteran's treatment records do not contradict these opinions. Thus, while the October 2007 VA examiner noted without further explanation the presence of genitourinary symptoms related to diabetes, the Board finds that this referred to the Veteran's erectile dysfunction. The only other evidence suggesting a link between polyuria and service or a service-connected disability are the speculative statements of the Veteran and his former representative. The Board finds the VA examiners' opinions more probative as they are based on rationales and medical expertise. For these reasons, the Board finds that the evidence weighs against a finding that polyuria is related to service or to a service-connected disability. Service connection is therefore denied. Skin Cancer The Veteran claims service connection for skin cancer. In his December 2010 claim, he stated that he had skin cancer due to exposure to herbicide agents. Service treatment records do not reflect any symptoms of or treatment for skin cancer. The Veteran does not claim that his disability arose in service. In his June 2012 notice of disagreement, the Veteran stated that he had been diagnosed with skin cancer. At his January 2014 RO hearing, the Veteran reported that he had skin cancer all over his body, which he regularly got removed. In a statement attached to his July 2014 substantive appeal, the Veteran's former representative stated that he had been diagnosed with skin cancer that was related to service and that the VA examination was not adequate. At his November 2017 hearing, the Veteran reported that he had had a bunch of skin cancers removed from his arm. VA treatment records throughout the claims file reflect various dermatological diagnoses, including skin nodules and tinea, but no biopsies or diagnoses of cancer. The Board finds that the evidence weighs against a finding of a current skin cancer disability. While the Veteran has repeatedly stated that he has skin cancer, no such diagnosis is reflected in his treatment records. It is highly unlikely that such a serious diagnosis would go unmentioned in the countless prior medical histories in his VA treatment records. Furthermore, the Veteran has not provided any specific information on where and when he was treated for this claimed disability. Where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As such, the Board finds that the evidence weighs against a finding of a current disability and service connection must therefore be denied. Atrial Fibrillation and Ischemic Heart Disease The Veteran claims service connection for atrial fibrillation, to include as secondary to diabetes mellitus, and for ischemic heart disease, to include as due to exposure to herbicide agents. Service treatment records do not reflect any symptoms of or treatment for a disability of the heart. The Veteran does not claim that such a disability arose in service. VA treatment records reflect that in September 2005 the Veteran reported left sided chest pain. A myocardial perfusion scan showed no ischemia, and resting left ventricular systolic function was normal with an ejection fraction of 61 percent. At an October 2007 VA examination for diabetes mellitus, the examiner noted the presence of cardiac symptoms related to diabetes. Specifically, the examiner noted shortness of breath, fatigue, peripheral edema, and weakness. The examiner diagnosed hypertension and opined that it was less likely than not related to diabetes. This opinion was based on the rationale that the diagnosis of hypertension predated the diagnosis of diabetes. (The Veteran has since withdrawn his appeal of the issue of service connection for hypertension, and it is therefore outside the scope of this decision.) In his June 2008 claim, the Veteran stated that his doctor told him that his cardiac symptoms were related to his diabetes mellitus. VA treatment records reflect that in July 2008 the Veteran reported chest pain with exertion and some tightness. He denied any previous heart problems. An electrocardiogram showed atrial fibrillation. He was diagnosed as such and prescribed medication. In September 2008 his physician noted a history of atrial fibrillation, for which he took medication. An August 2010 chest x-ray as part of a bariatric evaluation for surgery showed mild cardiomegaly with bibasilar atelectasis. In September 2010 his physician found that angina and dyspnea on exertion were most probably related to morbid obesity and chronic pulmonary obstructive disease (COPD). The physician noted that there was no ischemia in 2005 and that reassessment was not possible due to the Veteran's weight. He was diagnosed with atrial fibrillation. The Veteran underwent a VA examination in November 2010. The examiner noted atrial fibrillation but found no ischemic heart disease. VA treatment records reflect that in July 2011 the Veteran reported nocturnal chest pain and left arm numbness. He underwent a significantly abnormal stress test showing significant potential ischemia. He therefore underwent cardiac catheterization. A stable chest x-ray showed streaky atelectasis and was unchanged from prior studies. Electrocardiography showed atrial fibrillation. The Veteran underwent another VA examination in July 2011. The examiner noted that he recently had a cardiac catheterization which showed normal ejection fraction and no significant coronary disease. The examiner diagnosed atrial fibrillation and no ischemic heart disease. The examiner opined that atrial fibrillation was not caused by or the result of diabetes. This opinion was based on the rationale that diabetes does not cause atrial fibrillation. In his June 2012 notice of disagreement, the Veteran stated that the VA examination was not adequate and that his atrial fibrillation was related to his service-connected disabilities. The Veteran underwent another VA examination in April 2014. The examiner found no evidence of ischemic heart disease. Private treatment records include an April 2014 electrocardiogram showing atrial fibrillation. In a statement attached to his July 2014 substantive appeal, the Veteran's former representative stated that atrial fibrillation and ischemic heart disease were related to service and that the VA examination was not adequate. At his November 2017 hearing, the Veteran reported that his heart skips a beat and that he has to take blood thinner. The Board finds that the evidence weighs against a finding that atrial fibrillation is related to service, to a service-connected disability, or to exposure to herbicide agents. There is no evidence that atrial fibrillation is directly related to service, and the only evidence that it is related to a service-connected disability is the Veteran's own statements relating it to diabetes. The Veteran has provided no basis of knowledge for this relationship, and the July 2011 VA examiner explained that diabetes does not cause such a disability. The Board finds the VA examiner's opinion more probative than the Veteran's speculative statements because it is based on medical expertise. Furthermore, atrial fibrillation is not among the disabilities for which VA recognizes a relationship with exposure to herbicide agents, see 38 C.F.R. § 3.309(e), and there is no evidence of such a relationship in the record. For these reasons, the Board finds that the evidence weighs against a finding that atrial fibrillation is related to service, to a service-connected disability, or to exposure to herbicide agents. Service connection for atrial fibrillation is therefore denied. The Board further finds that the evidence weighs against a finding of a current ischemic heart disease disability. While some treatment records note findings of possible ischemia, subsequent testing has always shown that the Veteran does not have ischemic heart disease. VA treatment records and multiple VA examinations have repeatedly found there to be no ischemic heart disease, and the Board finds these records more probative than the Veteran's baseless statements to the contrary. Where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As such, the Board finds that the evidence weighs against a finding of a current disability and service connection must therefore be denied. SMC The Veteran seeks SMC under 38 U.S.C. § 1114(l). Special monthly compensation provided by 38 U.S.C. § 1114(l) is payable for being so helpless as to be in need of regular aid and attendance due to service-connected disability or disabilities. 38 C.F.R. § 3.350(b). The following is accorded consideration in determining the need for regular aid and attendance: inability of claimant to dress or undress oneself, or to keep oneself ordinarily clean and presentable; inability to attend to the wants of nature; and incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment. It is not required that all of these disabling conditions be found to exist before a favorable rating may be made. The particular personal functions which a veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that a veteran is so helpless as to be in need of regular aid and attendance are based on the actual requirement of personal assistance from others. 38 C.F.R. § 3.352(a). VA treatment records reflect that in February 2009 the Veteran's social worker evaluated him as eligible for the VA pain homemaker/home health aide program, based on his reports that he lived alone and experienced difficulty with preparing meals, performing housework, and transportation. The social worker considered the Veteran homebound and noted dependence in bathing, dressing, toileting, and continence. In August 2009, he reported that his son and grandchildren had moved in with him. In a statement attached to his December 2010 claim, the Veteran reported that he was unable to walk because of his service-connected disabilities and required the use of a walker to move around his house. He stated that his neuropathy reduced his grip and he dropped things. He reported that he was able to prepare his own meals and feed himself but need assistance bathing his back, legs, and feet, and applying lotion. He stated that he sometimes need help dressing himself and avoided clothes with buttons. He reported that he had a nurse come to his home 3 days a week for a total of 5 hours per week to help strip his bed, clean his bathroom, wash his clothes, and bathe him. The nurse also checks his medication. He reported that his son helps him manage his finances. He reported that he stayed home unless he had a medical appointment and used his wheelchair to go outside for fresh air a couple of times per day. In June 2011 the Veteran submitted a form completed by a VA physician's assistant. The assistant reported that the Veteran is able to feed himself and prepare his own meals, though his nurse helps with some cooking. He needed assistance in bathing and tending to hygiene via a home health nurse who visited 3 times a week for a total of 6 hours per week. He did not require home nursing care or medication management and was able to manage his own finances. He had a lordotic stance and was in a motorized wheelchair. The assistant noted that diabetic neuropathy and left iliopsoas bursitis limited his mobility. He had a right shoulder injury but had full use of his left arm. He was unable to bend forward, and thus could not get his shoes on and had difficulty with pants. The assistant attributed this to degenerative changes of the lower back. He had bladder and bowel incontinence. He was able to drive himself. In his June 2012 notice of disagreement, the Veteran stated that the VA examination was not adequate and that he met the criteria for aid and attendance/housebound. The Veteran underwent a VA examination in April 2014. The examiner opined that the Veteran met the criteria for aid and attendance. This opinion was based on findings of severe diabetic peripheral neuropathy of all extremities with balance problems, high fall risk, morbid obesity, and lack of independent ambulation. At his November 2017 hearing, the Veteran reported that he is cared for by his daughter and a nurse who comes in 3 times per week for three hours each visit. The Board finds the evidence is at least in equipoise as to whether the Veteran is so helpless as to be in need of regular aid and attendance due to his service-connected disabilities. Both the Veteran's VA treating physician's assistant and the April 2014 VA examiner opined that the Veteran needs aid and attendance. Indeed, the Veteran has been receiving some in-home assistance from VA since being deemed eligible in February 2009. While it is true that the Veteran's need for aid and attendance comes from a combination of disabilities service-connected and otherwise, the Board finds probative multiple statements from treatment providers and VA examiners noting the significant impairment from the Veteran's peripheral neuropathy and its contribution to his need for a wheelchair and walker. For these reasons, the Board finds the evidence is at least in equipoise as to whether the Veteran is so helpless as to be in need of regular aid and attendance due to his service-connected disabilities. SMC based on the need for aid and attendance is therefore granted. ORDER An initial evaluation in excess of 20 percent for diabetes mellitus with cataracts and erectile dysfunction is denied. An initial evaluation in excess of 20 percent for peripheral neuropathy of the right upper extremity, for the period prior to January 8, 2014, is denied. An evaluation in excess of 30 percent for peripheral neuropathy of the right upper extremity, for the period from January 8, 2014, is denied. An initial evaluation in excess of 20 percent for peripheral neuropathy of the left upper extremity is denied. An initial evaluation of 40 percent, but not in excess thereof, for peripheral neuropathy of the right lower extremity is granted, subject to the laws and regulations governing the payment of VA benefits. An initial evaluation of 40 percent, but not in excess thereof, for peripheral neuropathy of the left lower extremity is granted, subject to the laws and regulations governing the payment of VA benefits. An initial compensable evaluation for bilateral hearing loss, for the period prior to April 10, 2014, is denied. Service connection for an acquired psychiatric disability, to include PTSD or an unspecified anxiety disorder, but excluding major depressive disorder, is granted. Service connection for a digestive disability, to include IBS, claimed as diabetic enteropathy as secondary to diabetes mellitus, is denied. Service connection for polyuria, to include as secondary to diabetes mellitus, is denied. Service connection for skin cancer, to include as due to exposure to herbicide agents, is denied. Service connection for atrial fibrillation, to include as secondary to diabetes mellitus, is denied. Service connection for ischemic heart disease, to include as due to exposure to herbicide agents, is denied. SMC based on the need for aid and attendance is granted, subject to the laws and regulations governing the payment of VA benefits. REMAND The Veteran's last VA audiological examination was on April 9, 2014. The Board has no record of any audiological treatment since that time. At his November 2017 hearing, the Veteran stated that he had had recently had his hearing tested at the Lakeland VA Medical Center, but provided no specific date other than a few months prior. VA must obtain and associate with the claims file any potentially relevant medical treatment or examination records at VA health-care facilities if the location of such records are known or reasonably identified. 38 U.S.C. § 5103A(c)(2); see Loving v. Nicholson, 19 Vet. App. 96, 102 (2005). As such, remand is necessary to obtain these records before a decision can be made for the period from April 10, 2014. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file any additional medical evidence that may have come into existence but has not been associated with the record, including VA treatment records from the San Juan VA Medical Center from February 2013 through July 2014. 2. After completing the above, and any other development deemed necessary (such as procurement of a VA audiological examination), readjudicate the appeal. If the benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran, and return the appeal to the Board. The appellant has the right to submit additional evidence and argument on the matter or 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.A. §§ 5109B, 7112 (West 2014). ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs