Citation Nr: 19181404 Decision Date: 10/25/19 Archive Date: 10/25/19 DOCKET NO. 05-26 726 Represented by: Kathy Lieberman, Attorney DATE: October 25, 2019 ORDER Entitlement to an initial disability rating greater than 10 percent for gastroesophageal reflux disease (GERD) is denied. Entitlement to a disability rating greater than 10 percent from September 1, 2010 through March 30, 2011, and from October 1, 2011 for thrombosis, transient ischemic attack (TIA), or cerebral infarct is denied. Entitlement to a disability rating greater than 50 percent for peripheral neuropathy of the right upper extremity is denied. Entitlement to a disability rating greater than 40 percent for peripheral neuropathy of the left upper extremity is denied. Entitlement to special monthly compensation (SMC) based upon being housebound (HB) is granted. REMANDED Entitlement to a disability rating greater than 20 percent for diabetes mellitus, type II is remanded. Entitlement to service connection for arterial hypertension is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to April 2, 2012, is remanded. FINDINGS OF FACT 1. The Veteran’s GERD is manifested by pyrosis, regurgitation and substernal pain but is not manifested by material weight loss, hematemesis, melena or anemia and is not productive of considerable impairment of health. 2. The Veteran is right handed, and the service-connected radiculopathy of the right upper extremity is productive of sensory and motor impairment but is not productive of more than severe neuropathy. 3. The service-connected radiculopathy of the left upper extremity is productive of sensory and motor impairment but is not productive of more than severe neuropathy. 4. The Veteran has been assigned a 100 percent rating for six months following a cerebral event on February 26, 2010 and for six months following a cerebral event on March 30, 2011, and he has not had another cerebral event since then. 5. The Veteran has been assigned a 100 percent schedular rating with additional service-connected disabilities independently ratable at 60 percent or more from February 26, 2010 to August 31, 2010, and from March 30, 2011, to September 30, 2011, and since the assignment of a 100 percent schedular rating for prostate cancer effective March 18, 2016. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating higher than 10 percent for GERD are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 4.114, Diagnostic Code 7346 (2018). 2. The criteria for a disability rating higher than 50 percent for peripheral neuropathy of the right upper extremity are not met. 38 U.S.C. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.41, 4.45, 4.59, 4.124a, Diagnostic Code 8515 (2018). 3. The criteria for a disability rating higher than 40 percent for peripheral neuropathy of the left upper extremity are not met. 38 U.S.C. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.41, 4.45, 4.59, 4.124a, Diagnostic Code 8515 (2018). 4. The criteria for a disability rating higher than 10 percent from September 1, 2010 through March 30, 2011, and from October 1, 2011 for thrombosis, TIA, or cerebral infarction are not met. 38 U.S.C. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, Diagnostic Code 8008 (2018). 5. The criteria for SMC based upon being HB are met. 38 U.S.C. § 1114(s) (2002); 38 C.F.R. § 3.350(i) (2918). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the Army from March 1969 to October 1970. As shown on his DD 214 Discharge papers, he had one year of foreign service. His military decorations include the Vietnam Service Medal, the Combat Infantry Badge, the “ARCOM” Vietnam Campaign Medal, two overseas bars, the National Defense Service Medal, the M-16 Marksman badge, and the M-60 Marksman badge. He served in Vietnam from October 3, 1969 to October 5, 1970. His DD 214 lists his military occupational specialty as “InfindirFireCrwm.” This case has a long procedural history which must be set forth below. A March 2004 rating decision granted service connection for diabetes mellitus, type II, premised upon inservice herbicide exposure in Vietnam, and assigned an initial 20 percent rating, all effective November 12, 2003 (date of receipt of claim). An October 2004 rating decision granted service connection for diabetic peripheral neuropathy of each upper extremity with each rated 10 percent from April 20, 2004 (date of receipt of claim). Service connection was denied for PTSD, irritable bowel syndrome (IBS), and arterial hypertension. This appeal originally stemmed from a July 2005 rating decision which confirmed and continued the abovementioned ratings for diabetes mellitus, type II, and the 10 percent ratings for diabetic peripheral neuropathy of each upper extremity. A February 2006 rating decision granted service connection for erectile dysfunction, rated noncompensable because it is compensated by special monthly compensation (SMC) based on loss of use of a creative organ, which was granted, all effective October 27, 2005. A March 20, 2008 decision of the Board of Veterans’ Appeals (Board) denied ratings in excess of 20 percent for service-connected diabetes mellitus, type II, and 10 percent for diabetic peripheral neuropathy of each upper extremity. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court) which by Order in July 2008, and pursuant to a Joint Motion for Remand (JMR) vacated that Board decision and remanded the case to obtain VA treatment records of 2007 and 2008, pursuant to the holding in Bell Derwinski, 2 Vet. App. 611 (1992) (per curiam). An August 2008 rating decision denied service connection for an anxiety disorder, not otherwise specified (NOS) (claimed as a nervous condition) and confirmed and continued the denial of service connection for arterial hypertension. In November 2008 the Board remanded the claims addressed in the March 2008 Board decision for compliance with the instructions in the JMR. A December 2011 rating decision granted service connection for GERD, secondary to medication for service-connected disabilities, which was assigned an initial 10 percent rating from November 24, 2010. Service connection was denied for diabetic peripheral neuropathy of each lower extremity, and the prior denial of service connection for arterial hypertension was confirmed and continued. A February 2012 rating decision denied service connection for ischemic heart disease (IHD), claimed as due to inservice herbicide exposure, and confirmed and continued the noncompensable rating for service-connected erectile dysfunction. VA Form 21-8940, Application for Increased Compensation Based on Unemployability, was received on April 2, 2012. An April 11, 2012 rating decision denied service connection for depression, previously claimed as an anxiety disorder, NOS, and also denied service connection for PTSD. That rating decision increased the 10 percent ratings for upper extremity diabetic peripheral neuropathies to 30 percent for the right upper extremity and 20 percent for the left upper extremity, effective May 26, 2009 (date of VA examination). This increased the combined disability rating of 20 percent from November 12, 2003; and 40 percent (including the bilateral factor) from April 20, 2004; to 60 percent (including the bilateral factor) effective May 26, 2009. A November 2014 rating decision granted service connection for thrombosis, TIA (transient ischemic attack) or cerebral infarction and under Diagnostic Code (DC) 8008 assigned a 100 percent rating from February 26, 2010 (date of VA hospital admission), and thereafter a 10 percent rating was assigned from September 1, 2010. That rating also granted SMC based upon being HB from February 26, 2010, to September 1, 2010. Thus, there was a combined rating of 100 percent from February 26, 2010; 60 percent (including the bilateral factor) from September 1, 2010; and 70 percent (including the bilateral factor) from November 24, 2010. That rating decision also granted SMC under 38 U.S.C. § 1114(k) and 38 C.F.R. § 3.350(i) on account of Thrombosis, TIA or cerebral infarction rated 100 percent and additional service-connected disabilities independently ratable at 60 percent or more from February 26, 2010 to August 31, 2010. A March 2015 rating decision denied service connection for tinnitus and for a sensorineural hearing loss. A December 31, 2015 rating decision granted increases from 30 percent and 20 percent for diabetic peripheral neuropathies of, respectively, the right and left upper extremities to, respectively, 50 percent and 40 percent, both effective May 22, 2014 (date of VA examination); and also granted a TDIU rating and basic eligibility to Dependents’ Educational Assistance (DEA) both effective April 2, 2012. A May 2016 rating decision increased the 10 percent rating for thrombosis, TIA or cerebral infarction, rated 10 percent, to 100 percent effective March 30, 2011 (for six months following date of private hospital admission for a diagnosed cerebrovascular accident (CVA)); and a 10 percent schedular rating was reassigned effective October 1, 2011. That rating decision also granted SMC based on HB criteria from March 30, 2011, to September 30, 2011 (due to service-connected thrombosis, TIA or cerebral infarction, rated 100 percent and other service-connected disorders independently ratable at 60 percent or more). A July 2016 rating decision granted service connection for prostate cancer, due to inservice herbicide exposure, which was rated 100 percent disabling since March 18, 2016, and granted SMC based on HB criteria from March 18, 2016. A February 15, 2017, Board decision reopened claims for service connection for an acquired psychiatric disorder, to include PTSD and depression (because an examiner had indicated that serious medical conditions could exacerbate a depressive disorder), as well as for hypertension (because of submitted medical literature suggesting that hypertension appeared to be associated clinically with diabetes as a syndrome). Entitlement to an effective date for service connection for GERD prior to November 24, 2010 was denied. The Board also granted increases for the diabetic peripheral neuropathies of the right and left upper extremities based on severe neuropathy, to, respectively, 50 percent and 40 percent, throughout the course of the appeal. However, the appeal was to continue because these ratings were not the maximum assignable under the VA Schedule for Rating Disabilities. The Board remanded claims for de novo adjudication of service connection for an acquired psychiatric disorder, to include PTSD and depression; hypertension; and service connection for diabetic peripheral neuropathy of the right and the left lower extremities. Also remanded were claims for an initial rating in excess of 20 percent for diabetes mellitus, type II, with erectile dysfunction; an initial rating in excess of 10 percent for GERD; and a TDIU rating prior to April 2, 2012. A claim for an initial schedular rating in excess of 10 percent for thrombosis, TIA or cerebral infarction was remanded, pursuant to the holding in Manlincon v. West, 12 Vet. App. 238 (1999). It was found that the claim for a TDIU rating prior to April 2, 2012 was part and parcel of the increased rating claims, citing Rice v. Shinseki, 22 Vet. App. 447 (2009). An August 2017 rating decision confirmed and continued the 100 percent rating for prostate cancer. It also granted SMC under 38 U.S.C. § 1114(s) and 38 C.F.R. § 3.350(i) on account of prostate cancer rated 100 percent and other service-connected disorders independently ratable at 60 percent or more from March 18, 2016. A March 2018 Board decision remanded claims for service connection for arterial hypertension, tinnitus, and an acquired psychiatric disorder, to include PTSD and depression, as well as diabetic peripheral neuropathy of each lower extremity. Claims for ratings greater than 10 percent for GERD, 20 percent for diabetes, 40 percent for peripheral neuropathy of the left upper extremity, 50 percent for peripheral neuropathy of the right upper extremity, and a rating greater than 10 percent from September 1, 2010 through March 30, 2011 and from October 1, 2011 for thrombosis, TIA or cerebral infarction were remanded. The claim for a TDIU rating prior to April 2, 2012 was also remanded. The March 2018 Board decision noted that the RO had not yet effectuated the grants of increased ratings for diabetic peripheral neuropathy of each upper extremity, rated 50 percent for the right and 40 percent for the left upper extremity. It was further noted that claims of service connection for (a) thromboangiitis obliterans, (b) amputation of his right fifth toe, and (c) sleep apnea have been raised by statements in February and May 2016 but not adjudicated by RO and, so, they were referred to RO under 38 C.F.R. § 19.9(b). A July 2018 rating decision effectuated the Board grants of a 50 percent rating for diabetic peripheral neuropathy of the right upper extremity and a 40 percent rating for diabetic peripheral neuropathy of the left upper extremity, both effective April 20, 2004. A September 2018 rating decision denied service connection for right fifth toe amputation and for sleep apnea. Email from the Veteran’s attorney of June 10, 2019, reported that an October 1, 2018 RO notification letter was received stating that service connection was denied for right fifth toe amputation and sleep apnea but the copy of the decision attached to the letter was of July 2018 effectuating grants of increased ratings for diabetic peripheral neuropathy of each upper extremity. It was requested that a copy of the rating decision denying service connection for right fifth toe amputation and sleep apnea be provide to the attorney. However, it does not appear that the Veteran’s attorney was ever provided a copy of the September 2018 rating decision denying service connection for right fifth toe amputation and for sleep apnea. Accordingly, proper notice of that rating decision has not been accomplished. The RO should, as requested, provide the Veteran’s attorney a copy of the September 2018 rating decision and of the Veteran’s appellate rights. A May 18, 2019 Statement of the Case (SOC) addressed entitlement to a rating in excess of 10 percent for thrombosis, TIA or cerebral infarction, and also addressed entitlement to SMC based on HB criteria, which was granted from March 30, 2011 to September 30, 2011. A July 8, 2019 rating decision granted service connection for tinnitus, which was assigned an initial rating of 10 percent from December 3, 2014; and granted service connection for diabetic peripheral neuropathy of each lower extremity, with each rated 10 percent from July 20, 2017, and 20 percent from October 16, 2018. That rating decision also affirmed that SMC under 38 U.S.C. § 1114(s) and 38 C.F.R. § 3.350(i) had been granted from February 26, 2010 to August 31, 2010; and from March 30, 3011 to September 30, 2011 (when he had 100 percent ratings under DC 8008 following his two cerebral events); and granted SMC under 38 U.S.C. § 1114(s) and 38 C.F.R. § 3.350(i) from March 18, 2016 (effective date of a grant of a 100 percent rating for prostate cancer). During this appeal, the Veteran’s attorney has raised additional claims which have not been addressed by the RO. These appears to include service connection for thromboangiitis obliterans, insomnia, and chronic constipation; a temporary total rating based on convalescence (38 C.F.R. § 4.30) from September 7, 2011 (date of right carpal tunnel release surgery, until he finished physical therapy on December 15, 2011; as well as SMC based on the need for regular aid and attendance (A&A) of another. In this regard, as to claims received on or after March 24, 2015, VA regulations have replaced the previously informal/formal claims process with a standardized and more formal process so that a complete application on a prescribed VA From is required for all claims. See 79 Fed.Reg. at 57, 663-64; see also 38 C.F.R. § 3.155(d). An “intent to file a claim” may be filed pending completion of the prescribed form for “complete claims,” either orally or on a prescribed VA Form for that purpose. 38 C.F.R. § 3.155(b). However, a claimant who wishes to file a claim but does not communicate that desire orally or on a prescribed VA Form (on paper or electronically) is not considered to have filed a claim. 38 C.F.R. § 3.150(a). Rather, the person is considered to have requested an application form. Id. The Board’s practice of referring claims reasonably raised by the record but not adjudicated by the AOJ under 38 C.F.R. § 19.9(b) was not altered during the recent rule making. See 79 Fed.Reg.57660 (Sept. 24, 2014) (codified in 38 C.F.R. Parts 3, 19, and 20 (2015). Thus, the matters addressed by the attorney have not been submitted, as required, by use of the appropriate application form. See 38 C.F.R. §§ 3.150(a) and 3.155(a). These matters are referred to the RO for appropriate action, i.e., either clarification of whether there is an intention to file such claims and, if so, to forwarded to the Veteran or his attorney the appropriate forms by which such claims may be formally filed. Background Of record is a report of an examination for service induction in June 1969 and reflects a normal psychiatric status, although the recorded blood pressure was illegible. However, this military service clinical record pertains to a soldier who is not the Veteran. A March 21, 1970 service clinical record noted that a complaint of dizziness, and a blood pressure reading, taken while sitting, was 138\86. There was a notation that the patient was to return to the clinic for a blood pressure check in 2 weeks if he remained symptomatic. However, the military service clinical record pertains to a soldier who is not the Veteran. An August 7, 1970, clinical record noted that the Veteran’s chief complaint was having a nervous condition. He needed to see a Medical Officer. He had previously had nervousness and depression relative to the military. The impression was an adjustment reaction. He was given Librium. He was to see the Chaplain and return to the clinic as needed. A December 26, 1970, service clinical record noted a blood pressure reading of 130\82, and a complaint of aching all over. The patient seemed apprehensive. The impression was a question of an anxiety reaction. He was given Valium. However, the military service clinical record also pertains to a soldier who is not the Veteran. There is of record a record of an examination for separation, dated in August 1971, revealing a normal psychiatric status, and blood pressure of 128\78. However, the military service clinical record also pertains to a soldier who is not the Veteran. The Veteran initially applied for VA education or training benefits in 1972. In VA Form 21-526, received on November 12, 2003, the Veteran claimed service connection for diabetes mellitus. VA outpatient treatment (VAOPT) records reflect treatment for diabetes in 2003 with Metformin and Sulindac. A December 2003 VAOPT record shows that his blood pressure was 130/80, and an examination did not detect any cataracts. The diagnoses included a refractive error. On VA examination in February 2004 the Veteran reported that he had been diagnosed as having diabetes only 5 to 6 months earlier when he was seen due to polyuria, polydipsia, and polyphagia. He had been taking 5 mgs of Glucotrol daily. He denied a history of ketoacidosis or unexplained weight loss. He reported having intestinal diverticulosis which had been diagnosed after a colonoscopy. He reported having cataracts, and that a private ophthalmologist had prescribed bifocal lenses. He was currently working as a boilers repairman’s assistant for the Puerto Rico Water Resources Authority and had so worked for 17 years. His occupational history included work as an insurance salesman for 1 ½ years, as a console operator for Union Carbide for 14 years, and as an electrician’s assistant for an unspecified period of time. On physical examination three blood pressure readings were 136/90, 130/88, and 134/90. Nutritionally, he was overweight but well developed. He was right handed. Neurologically, he had hypoactive knee jerks but no sensory or motor deficit. Psychiatrically, he was alert, coherent, relevant, cooperative, and well oriented. The diagnoses include diabetes type II, intestinal diverticulosis, and exogenous obesity. In VA Form 21-4138, Statement in Support of Claim, received on April 2, 2004, the Veteran claimed service connection for, in part, PTSD, peripheral neuropathy, and high blood pressure. On VA examination for hypertension of July 23, 2004, the Veteran’s records were reviewed, and it was noted that when he had his first routine VA outpatient visit for diabetes, he was found to be hypertensive. A work-up to determine if the hypertension was secondary to diabetes was negative, and specifically because microalbuminuria tests were negative in November 2003, ruling out the diagnosis of diabetic nephropathy, which was the only acceptable etiologic link between the two conditions. The diagnoses were diabetes mellitus secondary to Agent Orange, and arterial hypertension, not proximately due to diabetes mellitus. On VA peripheral nerve examination in August 2004 the Veteran indicated that he tried to follow a sugar-free diet and that he did not exercise. He complained of cramps in his hands. He was independent in all activity of daily life and self-care. Sensory examination was normal as to pain, touch vibration, and position sense. He had normal motor power, normal grip, normal tone, and no involuntary movement, atrophy or fasciculations. Deep tendon reflexes were normal at 2+ throughout. He had normal coordination in the upper extremities. The diagnosis was that there was electrodiagnostic evidence of carpal tunnel syndrome (CTS) in both upper extremities, as least as likely as not associated with diabetes mellitus, and no evidence of neuropathy in the lower extremities. At the time of a private nerve conduction study in September 2004 the Veteran complained of pain, cramps, and numbness in all extremities. The study showed no evidence of neuropathy of the lower extremities but severe bilateral CTS, with the right side being worse than the left. On VA examination for PTSD in October 2004 the Veteran’s records were reviewed, and he had not had any psychiatric prescriptions at any VA facility. He had been employed at “AEE” as a general helper for 15 years. He had attended college, taken courses in accounting, management, and other things but had not completed his Bachelors’ degree. He had worked for Union Carbide after service for 13 years until beginning his current employment. During service his military occupational specialty had been an indirect fireman. He had not been wounded and did not report any stressors. Despite having diabetes had had gained some weight and ate the same as before. He desired to retire soon. No abnormality was noted on a mental status examination, and the diagnosis was that he did not have any psychiatric disorder and he did not meet the criteria for a diagnosis of PTSD. The Veteran’s claim for an increased rating for diabetes mellitus was received on October 7, 2004. VAOPT records show that on repeated evaluations in 2004 and 2005 no evidence of cataracts was found. In February 2004 an ophthalmological evaluation found that the Veteran had a refractive error of the eyes but no retinopathy. In March 2004 it was noted that he did not exercise but he received exercise counseling. In November 2004 he was given a prescription for lenses (glasses) for a diagnosed refractive error. At the time of a diabetic evaluation in March 2005 it was reported that a mood disorder screening was positive and the Veteran was instructed about the signs and symptoms of depression. He was instructed in the benefits of exercising. VAOPT records show that in March 2005 an examination of the Veteran's extremities found no evidence of clubbing, cyanosis or edema. These records also indicate no skin discoloration, trauma, ulcers or callus. Musculoskeletal examination found his range of motion was intact, and that he had adequate muscle tone and no deformities. A neurologic examination found no gross motor or sensory deficits. A November 2005 VAOPT record shows that the Veteran reported having frequent nightmares, and he complained of nervousness and hearing voices. He complained of a past experience (which was not described) which caused nightmares and which he avoided thinking about. He also reported being guarded, watchful and easily startled as well as numbness or detachment from others. A screening for PTSD was positive. On physical examination his muscle tone was adequate, and he had no gross motor or sensory deficit. The relevant assessment was “anxiety/depressive disorder.” On VA examination in February 2006 an examiner noted that the Veteran's treatment for diabetes mellitus included insulin, glyburide, rosiglitazone, simvastatin and paroxetine. On examination his blood pressure was 160/90. The diagnosis was erectile dysfunction, most likely secondary to service-connected diabetes mellitus. VAOPT records show that the Veteran was given a PTSD evaluation in February 2006 at which time he reported having sleep disturbance, and he occasionally heard the voice of his mother calling his name. He reported having lost a friend who had been killed in action. He reported having witnessed the death of comrades, one of them having stepped on a booby trap. His infantry company had come under frequent enemy attacks. He was now employed working for “Energy Power.” VAOPT records show that in May 2006 it was reported that when seen by a physician in February 2006 the Veteran had been given a provisional diagnosis of PTSD, and prescribed Mirtazapine. It was noted that he had multiple medical conditions which impacted his functioning, including diabetes, neuropathy, herniated discs, and median nerve “paralysis.” His multiple somatic complaints had a negative impact at work, with supervisors asking if he was “OK.” On mental status examination he reported that sometimes at night he heard his name being called but he had no other overt psychotic symptoms. He felt depressed. It was noted that he presented with depressive symptoms and possible PTSD. The diagnosis was major depression, and PTSD was to be ruled out. He was advised to lose weight and to limit his drinking (of alcohol) to a minimum. An April 2, 2007, VA Primary Care Follow-Up record shows that after a physical examination, which found no gross motor or sensory deficit, and laboratory studies were done, the Veteran’s diagnoses were controlled diabetes mellitus, type II; and chronic back pain. His treatment plan was to include “avoid weight lifting or back bend.” On VA psychiatric examination in February 2008, to determine if the Veteran had PTSD, the Veteran’s records were reviewed. It was reported that he had previously been seen in February 2004 to consider whether he had PTSD but no specific mental disorder had been found. He was seen by a psychiatrist for the first time at a VA facility in February 2006 and the diagnostic impression had been PTSD but when seen later that year the primary diagnosis had been a major depressive disorder, and PTSD was to be ruled out. He had not been seen again for psychiatric purposes. At the current evaluation the Veteran reported that he would awaken at night because he believed he heard someone calling him. When awaking he sometimes felt as if he were back “in the field.” He currently had a stressful situation at work. He spoke of the stresses of modern life and having children. He denied alcohol and substance abuse. He reported that in Vietnam a fellow soldier at his side had been killed during an enemy attack. It was reported that after service he had worked for 15 years for Union Carbide as a petrochemical operator. He had completed a Bachelor’s degree in accounting, computers, and management. After working at Union Carbide, he had worked as an insurance salesman for about a year, and for a short time as an electrician’s assistant. He had worked full-time for the electrical energy authority from 1987 to the present. He reported that he was not physically active. On mental status examination he had no hallucinations. The examiner reported that the Veteran did not fulfill the diagnostic criteria for PTSD, and his history did not reflect any behavioral, cognitive, social, affective or somatic changes due to his Vietnam experiences. The diagnosis was an anxiety disorder, not otherwise specified (NOS). In a June 2008 addendum to the February 2008 VA psychiatric examination it was reported that the November 2005 PTSD screening note which was positive, alone, did not support or establish a diagnosis of PTSD. The examination in February 2008 took into consideration all the elements required and the diagnosis established was made in accordance to DSM-IV diagnostic criteria for PTSD but that condition (PTSD) was not found to be present. Thus, the established diagnosis of an anxiety disorder, NOS, was correct and confirmed by a thorough review of the medical evidence and in compliance with diagnostic criteria. The Veteran had no other mental disorder. In another addendum, of August 19, 2008, to the February 2008 VA psychiatric examination it was reported that after reviewing the service treatment records (STRs) there was no relationship between to two inservice clinical notations, in August 1970 of an adjustment reaction, and December 1970 of an anxiety reaction, and his present condition of an anxiety disorder, NOS. The rationale was that the word “reaction” implied it was a response to an acute situation or problem which by definition was transitory and not permanent; whereas the a “disorder” implied a series of symptoms that complied with certain diagnostic criteria to establish a specific diagnosis. As stated earlier, the Veteran had never requested, sought or received any further psychiatric treatment after military service until 2006 when, as previously explained, he was seen on three occasions but never seen again. After military service he had worked, studied in his educational pursuits, and married and now had a successful career. There was no relationship to be established since there had not been any continuity of treatment or manifestations of symptoms to “establish such condition (nexus) with those mentioned instances in military service.” The February 2008 psychiatric examination as well as the addendums in June and August 2008 were all rendered by the same VA physician. Placed into VBMS on April 12, 2012, was a handwritten note from the VA clinical psychologist that conducted the February 2008 VA psychiatric examination, which states that the “military service health records” of a completely different person had been mistakenly place in the “C-folder” of the Veteran in this case. “Unfortunately, information from [these incorrectly filed record] was used in C & P Medical opinion dated 08/19/2008.” An October 2008 VAOPT record of a Psychiatric Consultation shows that the Veteran requested an evaluation due to anxiety. He reported that since 1998 he had struggled with episodes of anxiety, which occurred mostly at night, but the episodes were occurring more frequently now. It was noted that he had back pain, neuropathy of the median nerve, diabetes, and hypertension. He had difficulty doing physical work due to pain in the cervical and lumbar spinal segments. He worked for an “electric utility company (AEE)” as a mechanic and repairman. After a mental status examination the diagnosis was a panic disorder without agoraphobia. Depression, NOS, was to be ruled out. He was prescribed medication for anxiety and insomnia. A February 10, 2009, Progress Note from the Office of Dr. O. Ortega shows that the Veteran had uncontrolled diabetes and consequently had severe diabetic neuropathy which was being treated, with some improvement, with medication. This prevented him from being able to stand or sit for long periods of time. It was recommended that he have a cardiovascular consultation because he was at risk for developing peripheral vascular disease. On VA examination on May 26, 2009 for diabetes it was reported that the Veteran was using insulin and Metformin, orally, for diabetes. He followed a diabetic diet, and he did not exercise. He reported having fatigue, numbness in his legs and hands, blurred vision, and nocturia. He reported that his condition had progressively worsened. There were no side effects of his treatment. He denied any episodes of hypoglycemic reactions or ketoacidosis. He had a history of diabetes since 2003 and hypertension since 2003. He had been instructed to follow a restricted or special diet. He was not restricted in his ability to perform strenuous activity. He had paresthesia, loss of sensation, and pain in his legs and hands. He had erectile dysfunction due to diabetes. He weighed 224 pounds and had not had any weight change. On physical examination he had normal temperature, color and pulsations of each upper and lower extremity and no trophic changes. There was sensory loss to soft touch but no motor loss, and deep tendon reflexes were normal throughout. There were no cataracts. There was no diagnosis of visual impairment or kidney disease due to diabetes. He had erectile dysfunction and diabetic neuropathy due to diabetes. He had hypertension which was not a complication of diabetes because no microalbuminuria was present. He was not employed, having retired as an electrical technician in 2009 due to spinal canal stenosis. The effect of his diabetes on daily activities was that it prevented exercise and sports, and mildly impaired him as to performing chores, shopping, recreation, traveling, and driving. On VA peripheral nerve examination on May 26, 2009 the Veteran was noted to have a medical history of paresthesias, loss of sensation, and pain. On physical examination, hand grip and pincer grasp were weakened, with muscle strength rated as 3 out of 5 (no movement against resistance). Sensory function report showed decreased vibration, pain, and light touch. Reflex testing showed bilateral bicep, tricep, and brachioradialis reflexes at +1. There was no muscle atrophy, abnormal muscle tone or bulk, or tremors, tics, or other abnormal movements. The diagnosis was diabetic peripheral neuropathy of the upper extremities, now with motor component. The effect on his usual daily activities was to prevent participation in sports; severe as to exercising; moderate as to chores; mild as to shopping, recreation, and traveling. Of record is a report of hospital admission of February 25, 2010 for “stroke in evolution.” A June 2010 VAOPT record reflects that the Veteran reported taste sense changes, slow gastric emptying, and heartburn. The Veteran’s application to reopen the claim for service connection for arterial hypertension was received on February 9, 2011. Records of the Damas Hospital reflect, as translated, that he was seen on March 28, 2011 for medication reconciliation. Received on December 17, 2015, were record of the Veteran’s hospitalization at the Damas Hospital to which he was admitted on March 30, 2011, because of a transient ischemic attack (TIA). It was noted that he had had an old CVA one year earlier. A private April 13, 2011 brain scan revealed lacunar infarcts in the centrum semiovale, bilaterally, the right thalmus and left pons of unknown age; and small vessel ischemic changes to the posterior horn of the lateral ventricle. On VA neurology examination on May 21, 2011 it was reported that the Veteran complained of chronic numbness of both hands of gradual onset but with progressive worsening. It found that the Veteran’s median and ulnar nerves were affected. It was reported that he had had a cerebrovascular accident (CVA) several years ago and now had right hemiparesis. On physical examination, reflex and sensory testing produced the same results as the May 2009 VA examination. Motor testing revealed that elbow flexion and extension, wrist flexion and extension, finger flexion and abduction, and thumb opposition were each rated as 5 (indicating active movement against full resistance) on the left side and 4 (indicating active movement against some resistance) on the right side. It was noted that a June 2010 nerve conduction study had characterized the neuropathies as moderate to severe right median wrist neuropathy, worse in the sensory nerve, asymptomatic; and moderate left carpal tunnel syndrome, symptomatic. It was noted that he had retired in 2009 due to lumbar pain. The occupational effects of the neuropathies were decreased manual dexterity, decreased strength, and pain. The effects on usual daily activities were noted as unable to cook, drive, or do the dishes due to loss of strength in hands. On VA examination for diabetes on June 7, 2011, the Veteran reported that his peripheral neuropathy had caused pain which affected his sleep pattern, and that he continued to take insulin twice daily. He reported that due to a CVA two years ago he had residual weakness of the extremities of his left side. He also reported having had another stroke two month ago with residual right sided hemiparesis, for which had had undergone VA hospitalization in April 2011. Hypertension had been diagnosed in 2003. He had not had episodes of hypoglycemic reactions or ketoacidosis. He had been instructed to follow a restricted or special diet. He was not restricted in his ability to perform strenuous activities. He denied symptoms of visual disorders, neurovascular disease, diabetic nephropathy, and gastrointestinal (GI) disorders. On examination the Veteran did not have cataracts. Reflexes were 2+ throughout. In each upper extremity he had no dysesthesias, and had normal sensation to vibration, position sense, light touch, and pain. Motor strength was 5, indicating active movement against full resistance, throughout. He had normal muscle tone and no muscle atrophy. The examiner reported that the Veteran did not have diabetic complications of visual impairment. However, it was reported that of other potential diabetic complications found he had kidney disease, consisting of early diabetic nephropathy, which was a complication of his diabetes in light of the duration of the diabetes. There were no effects of his diabetes or diabetic complications as to functionality in his usual occupation or usual daily activities. It was reported that he had retired in 2009 due to physical problems caused by diabetes. The Veteran underwent a right carpal tunnel release surgery in September 2011. On VA GI examination on December 28, 2011, an examiner opined, after reviewing the record and conducting a physical examination that the Veteran had GERD which was at least as likely as not due to having taken medication since 2009, Gabapentin for peripheral neuropathy and Vardenafil for erectile dysfunction, for complications of service-connected diabetes. The Veteran reported that these medications caused heart burn and gastric reflux. He took Ranitidine for his GI symptoms. The examiner reported that the Veteran’s symptoms were pyrosis (heartburn), reflux, substernal arm or shoulder pain, and sleep disturbance caused by esophageal reflux four or more times a year. The symptoms that the Veteran did not have were persistent or even infrequent epigastric distress, dysphagia, regurgitation, anemia, weight loss, nausea, vomiting, hematemesis, and melena. A laboratory test had revealed that his hematocrit and hemoglobin levels were within normal limits. The examiner reported that the GI condition did not impact the Veteran’s ability to work. The Veteran’s application to reopen his claim for service connection for PTSD was received on January 17, 2012, in which he also claimed service connection for depression secondary to his service-connected conditions. On VA examination for heart disease of January 31, 2012, the Veteran’s claim file was reviewed. The examiner opined that the Veteran’s hypertensive heart disease was less likely as not proximately due to or the result of the Veteran’s service-connected diabetes. The rationale was that the diagnosis of this disease was based on evidence of mild concentric left ventricular hypertrophy (LVH) by an echocardiogram in 2010. This hypertensive heart disease was secondary to chronic longstanding arterial hypertension. By the time he was found to have mild concentric LVH there was no evidence of significant microalbuminuria yet. Thus, the hypertension and hypertensive heart disease were not caused or aggravated by the service-connected diabetes. The examiner reported that there was no evidence of significant microalbuminuria or nephropathy until 2011. His hypertensive heart disease did not qualify as being within the generally accepted medical definition of ischemic heart disease. Received on April 2, 2012, was VA Form 21-8940, Application for Increased Compensation Based on Unemployability, in which the Veteran reported that his disability had affected his full-time employment, he had become too disabled to work, and had last worked in August 2008. His occupation that year was plant repairs for Energia Electrica, in Puerto Rico, where he had worked since 1988. He had 4 years of college education. On VA psychiatric examination of April 2, 2012, the Veteran’s records were reviewed. It was noted that he had been deployed to Vietnam as an infantryman and had been awarded the Combat Infantry Badge. He had been present at the time of the death of a friend in a combat fire fight in Vietnam. After service he had obtained a Bachelor’s degree in Business Administration, majoring in accounting and management. After service he had worked for Union Carbide as a petrochemical operator until about 1984 or 1985, and then worked for National Insurance Company selling insurance, following which he had worked in Puerto Rico for Electrical Energy Company until 2008 when he had to quit due to his medical conditions. The Veteran denied any referral or need for psychiatric services during his military service. He had first been seen by VA for psychiatric service in December 2005, and he was last seen in January 2012 with diagnoses of a panic disorder without agoraphobia, and depression, NOS. He had taken medication for depression, anxiety, and insomnia. On the formal psychiatric examination the Veteran was found to meet Criterion A, an event adequate to support a diagnosis of PTSD which was related to fear of hostile military activity. However, he did not meet any additional criterion for a diagnosis of PTSD. The Veteran was observed to ambulate with a one-point cane. He could manage his financial affairs. After a mental status examination, which noted that he had chronic sleep impairment, the examiner found that the Veteran did not meet the criteria for a diagnosis of PTSD, and he had only one psychiatric disorder which was a depressive disorder, NOS. In rendering opinions, the examiner observed that the service medical records referenced in an August 2008 VA examination were actually the records of a completely different Veteran and, so, were disregarded by the examiner. The examiner opined that the Veteran did not meet the criteria for a diagnosis of PTSD, and noted that the Veteran was first seen by a psychiatrist in February 2006 and while at that time PTSD was to be diagnostically ruled out, he was later diagnosed with a major depressive disorder. His visits to VA psychiatric service had been sporadic, and he had not had consistent complaints of or treatment for PTSD-related symptoms. With respect to the Veteran’s service-connected disabilities, which were diabetes mellitus, GERD, peripheral neuropathy of each upper extremity, and erectile dysfunction, it was opined that the Veteran’s depressive disorder, was less likely than not proximately due to or the result of his service-connected conditions. The examiner reported that the Veteran had many serious medical conditions which could exacerbate a depressive disorder. It was noted that the Veteran reported that his main concern was the future and well-being of his two youngest children. Two psychiatric interventions, in December 2009 and September 2011, mentioned complaints of neuropathic pain but the examiner indicated that the pain was apparently under control with medication. Due to the inconsistency with which the Veteran had pursued psychiatric interventions for depression and the paucity of evidence relating his depression to his service-connected conditions, it was opined that the Veteran’s depression was not related to his service-connected disabilities. Of record is VA Form 21-0781, Statement in Support of Claim for PTSD, dated April 5, 2012. As translated from Spanish, it was reported that on October 20, 1969 in Vietnam a fellow soldier was shot and killed in combat and upon being shot fell on the Veteran’s shoulder. The Veteran had been frightened and scared. In another incident in Vietnam in January 1970 a fellow soldier had stepped on a land mine and been blown up, in front of the Veteran. Received in November 2012 was an article of the Journal of the American Society of Nephrology entitled “Prevention and Treatment of Diabetic Renal Disease in Type 2 Diabetes: The BENEDICT Study.” The abstract of that article states that diabetic nephropathy was the leading cause of end-stage renal failure in Western countries. A number of factors played a part in the development of diabetic nephropathy and among them hypertension and proteinuria were the most important. In the early stages of diabetic nephropathy, when there was microalbuminuria and an increase in blood pressure, there was no loss of filtrate and patients responded well to prophylactic measures. Microalbuminuria was considered to be an early marker for diabetic nephropathy. The BENEDICT study had shown that diabetic nephropathy could be prevented by ACE inhibitor therapy. On May 22, 2014, the Veteran was afforded VA examinations for his service-connected GERD; diabetes mellitus, type II; erectile dysfunction; and upper extremity diabetic peripheral neuropathy. At that time his claim files and VA electronic records were reviewed. With respect to GERD, the Veteran complained of persistently recurrent daily epigastric pain, 6 on a pain scale of 10, with heartburn/reflux and monthly exacerbations associated with nausea lasting 2 days not relieved by daily constant use of medications. He denied having anemia, weight loss, vomiting, hematemesis, or melena. Upon examination he had mild epigastric (i.e. substernal) tenderness. Due to his GERD he had symptoms productive of considerable impairment of health, pyrosis, reflux, substernal pain, and nausea with the frequency of nausea being 4 or more times per year with an average duration of episodes of nausea of 1 to 9 days. The Veteran did not have an esophageal stricture, spasm of esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus. The examiner opined that the Veteran’s GERD did not impact his ability to work. On VA examination for diabetes of May 22, 2014, the examiner reported that the Veteran’s diabetes required one or more injections of insulin per day and was managed by a restricted diet. He did not require regulation of activities as part of medical management of diabetes mellitus. He visited his diabetic care provider less than 2 times per month for episodes of ketoacidosis or episodes of hypoglycemia. He had not been hospitalized in the past 12 months for episodes of ketoacidosis or episodes of hypoglycemia. He had not had any progressive unintentional weight loss or loss of strength due to diabetes. He had erectile dysfunction and a stroke as a complication for diabetes. The examiner opined that the diabetes and its complications impacted his ability to work. On examination of the Veteran’s genitourinary system, for erectile dysfunction, it was reported that the Veteran did not have any renal dysfunction due to erectile dysfunction and no voiding dysfunction. On VA diabetic peripheral neuropathy examination of May 22, 2014, the Veteran complained of constant severe pain, of 7 on a scale of 10, difficulty with handgrip, and severe tingling and numbness which were not relieved with medication. He was right handed. The Veteran had severe constant pain, paresthesias and/or dysesthesias, and numbness of each upper extremity. He had 4/5 (less than normal) strength but no muscle atrophy, although deep tendon reflexes were absent throughout both upper extremities. Sensations to light touch, position sense, and vibratory sense were decreased in both upper extremities, but not absent. He had trophic changes of loss of extremity hair, and shiny and smooth skin. The examiner reported that the Veteran had incomplete paralysis of the median and radial nerves of each upper extremity, which impacted his ability to work. The examiner opined that the Veteran was not able to perform all of his daily living activities. It was opined that his service-connected conditions might produce severe impairment for a sustained gainful occupation, and render him unemployable. It was felt that he was not able to obtain, perform and secure a job. On VA central nervous system (CNS) examination of May 22, 2014, the Veteran’s records were reviewed. It was reported that the diagnosis was thrombosis, TIA, or cerebral infarction with the date of diagnosis having been March 4, 2010. It was reported that he had had a cerebrovascular accident (CVA) in March 2010 with left sided involvement due to occlusion of the right internal capsule and thalamus. He required continuous medication for diabetes and hypertension to control his condition. On physical examination the Veteran did not have any pharynx and/or larynx and/or swallowing condition. He had sleep disturbance due to insomnia and also due to sleep apnea which required the use of a breathing assistance device such as continuous positive airway pressure (CPAP) machine. He had chronic constipation but did not have any voiding dysfunction causing urine leakage, urinary frequency, obstructed voiding or use of an appliance. He did not have a history of recurrent symptomatic urinary tract infections. He had erectile dysfunction. Neurologically, his speech was normal. His gait was abnormal, being wide based, short-stepped and slightly hemiparetic. Strength was 4/5, less than normal, throughout both upper and both lower extremities, which was characterized as mild weakness but there was no muscle atrophy. Deep tendon reflexes were absent throughout both upper and both lower extremities. He did not have any depression or cognitive impairment attributable to a CNS disease. He constantly used a cane as an ambulatory aid. It was noted that a February 26, 2010 brain MRI had revealed an acute infarction of posterior limb of right internal capsule/right thalamus with small vessel and ischemic changes and old lacunar infarcts. It was opined that his CNS disorder impacted his ability to work due to generalized weakness and clumsiness in his movements due to the CNS changes. The examiner opined that the two CVA's reported by Veteran were more likely than not precipitated by the accelerated degeneration of the vessels observed in diabetic patients. Also, his right hemiparesis was not overshadowing the symptoms of the peripheral neuropathy in the right upper extremity, and the weakness in his upper extremities could be considered as symmetrical for most purposes. VAOPT records include a November 1, 2012, record notation included “[d]iabetes with Renal Manifestations.” Also a September 26, 2014, record notation that the Veteran had “[d]iabetes with Renal Manifestations.” He also complained of continuous pain in his right arm and his legs. He continued to have anxiety and depression, and continued to struggle with his physical conditions. A November 22, 2014, rating decision granted service connection for thrombosis, TIA, or cerebral infarct which was evaluated as 100 percent disabling from February 26, 2010, with a 10 percent schedular rating assigned effective September 1, 2010; and granted SMC based on housebound criteria being met from February 26, 2010 to September 1, 2010. On March 13, 2015, the Veteran underwent amputation of the right 5th toe at a VA facility due to melanoma. The Veteran was admitted to a VA medical facility on March 10, 2016, and discharged on March 16, 2016, due to sepsis secondary to Bacteremia, status post prostatic biopsy on March 8, 2016. On VA CNS examination of May 10, 2016, the Veteran’s records were reviewed. It was reported that the diagnosis was thrombosis, TIA, or cerebral infarction. He required continuous medication for diabetes and hypertension to control his condition. On physical examination the Veteran did not have any pharynx and/or larynx and/or swallowing condition. He had sleep disturbance due to insomnia and also due to sleep apnea which required the use of a breathing assistance device such as continuous positive airway pressure (CPAP) machine. He had chronic constipation but did not have any voiding dysfunction causing urine leakage, urinary frequency, obstructed voiding or use of an appliance. He did not have a history of recurrent symptomatic urinary tract infections. He had erectile dysfunction, the etiology of which was his prostate cancer, hypertension, and peripheral neuropathy. Neurologically, his speech was normal. His gait was abnormal, being wide based, and slightly hemiparetic requiring constant use of a one-point cane. Strength was 4/5, less than normal, throughout both upper and both lower extremities, which was characterized as mild weakness but there was no muscle atrophy. Deep tendon reflexes were absent throughout both upper and both lower extremities. He did not have any depression or cognitive impairment attributable to a CNS disease. It was opined that his CNS disorder impacted his ability to work due to loss of dexterity and endurance due to his CNS condition. On May 26, 2016, a VA physician rendered an opinion, after reviewing the records, that the Veteran did not have a diagnosis of thromboangiitis obliterans. Available VA clinical documents failed to show that he had been diagnosed with thromboangiitis obliterans. Thromboangiitis obliterans, also known as Buerger's disease, was a nonatherosclerotic, segmental, inflammatory disease that most commonly affected the small to medium-sized arteries and veins of the extremities where occlusive peripheral vascular disease could be seen. Thromboangiitis obliterans was not known to be caused by or secondary to diabetes mellitus II. Medical literature review did not show that diabetes mellitus caused or was a risk factor in the development of Thromboangiitis obliterans. Moreover, the Veteran did not have peripheral vascular disease. Available VA clinical documents included a lower extremity arterial duplex from April 13, 2011, that showed normal arterial circulation. There was also a lower extremity arterial duplex from July 6, 2011 that showed no arterial abnormalities. On VA genitourinary examination on June 8, 2016, the Veteran’s records were reviewed. It was noted that active adenocarcinoma of the Veteran’s prostate had been diagnosed by biopsy on March 8, 2016. He was to eventually have radiotherapy but currently his regimen was watchful waiting. He denied all urinary symptoms. He reported having erectile dysfunction due to diabetes which was treated with Viagra with good results. The etiology of his erectile dysfunction was multi-factorial, including age, diabetes, and medications. He did not have any renal dysfunction due to his prostate condition. It was reported that his prostate cancer did not affect his ability to work. A July 11, 2016, rating decision granted service connection for prostate cancer which was assigned an initial disability rating of 100 percent, all effective March 18, 2016. Also, SMC based on housebound criteria was granted under 38 U.S.C. § 1114(s) and 38 C.F.R. § 3.350(i) from March 18, 2016, due to prostate cancer rated 100 percent disabling and other service-connected disorders independently ratable at 60 percent or more. On VA examination on August 15, 2016, the Veteran reported that he had had amputation of the 5th toe of the right foot in 2015 due to melanoma, and it was opined that this was less likely than not due to his diabetes because it was due to melanoma and while there were several risk factor for melanoma, diabetes mellitus was not a risk factor for melanoma. In November 2016 the Veteran submitted a treatise, Arterial Hypertension in diabetes mellitus: from theory to clinical practice, that indicated that hypertension and type II diabetes appear to be associated clinically as a syndrome. Diabetics had a much higher rate of hypertension than the general public. Arterial hypertension was clearly related to nephropathy in those with diabetes. In November 2016, the Veteran's representative alleged that medical literature indicates that hypertension can increase in severity as a result of coexisting diabetes. The Veteran was seen at a VA emergency clinic on December 12, 2016 due to an adverse reaction to oral contrast material given for a pelvic CT scan regarding workup for an enlarged inguinal node in the right leg. On December 16, 2016, the Veteran underwent VA outpatient surgical removal of inguinal lymph nodes. A December 29, 2016, pathology report reflects that as to the right inguinal lymph nodes there was malignant epitheloid neoplasm, compatible with melanoma in matted lymph nodes. He was subsequently seen on January 18, 2017 for re-evaluation because of seroma accumulation and what appeared to be a fungal rash. VAOPT records include a December 26, 2016 clinical record which states that in addition to hypertension, the Veteran had diabetes with renal manifestations, and that he had chronic kidney disease, stage 1, due to diabetes. The Veteran underwent VA hospitalization from February 21st to February 24th, 2017. The chief diagnoses were acral melanoma, receiving chemotherapy, and acute thrombosis of the right limb. On VA hypertension examination of July 20, 2017, the Veteran’s electronic folder and medical records were reviewed. The Veteran reported that he had been diagnosed with hypertension by a VA physician some years ago. He had been started on hypertensive medication in January 2008 and with continued medication his blood pressure was under good control. After a physical examination, the examiner reported that available documents in the Veteran’s electronic claim file and electronic VA medical records did not show that hypertension was diagnosed during service or within one year thereafter. it was opined that the hypertension did not have its onset during service, having begun many years after service, and was not otherwise related to military service. The examiner observed that hypertension was not among the diseases presumptively related to herbicide exposure. As to any relationship between hypertension and inservice herbicide exposure based on the National Academy of Sciences Veterans and Agent Orange, updated on 2014, although the Update stated that there was suggestive evidence to link hypertension to Agent Orange exposure, there was limited evidence that it caused or aggravated it. It also stated that additional research was warranted. The Update stated that "The conclusions are related to associations between exposure and outcomes in human populations, not to the likelihood that any individual's health problem is associated with or caused by the chemicals in question." The examiner stated that “[f]urther evaluation of available medical literature such as the medical textbook publications Harrison's Principles of Internal Medicine, 19e and Current Medical Diagnosis & Treatment 2016 in addition to online current medical reference, UpToDate.com fail to show that exposure to Agent Orange causes, aggravates or is a risk factor to develop hypertension. They do not suggest either that Agent Orange exposure causes or aggravates hypertension.” The examiner also stated that it was less likely than not that hypertension was proximately due to or the result of the service-connected diabetes. As to this, the examiner commented that a review of VA records disclosed that urinary microalbumin levels had been normal, and there was no evidence of diabetic nephropathy. In the absence of diabetic nephropathy or diabetic renal disease, hypertension could not be attributed to diabetes. Rather, the etiology of the Veteran’s hypertension was likely due to the aging process and family factors. With respect to aggravation of hypertension by the service-connected diabetes, the examiner reported that there was no baseline level of aggravation because aggravation of hypertension had not occurred, having been well controlled with medication. A review of VA records disclosed that urinary microalbumin levels had been normal (as listed by that examiner in a contemporaneous VA diabetes examination), and there was no evidence of diabetic nephropathy. In the absence of diabetic nephropathy or diabetic renal disease, hypertension could not be attributed to diabetes and not aggravated by diabetes. On VA examination of July 20, 2017, for diabetes mellitus, the Veteran’s electronic folder and medical records were reviewed. It was noted that the Veteran required more than one injection of insulin per day. It was stated that there was no requirement of regulation of activities as part of medical management of diabetes mellitus. The Veteran visited his diabetic care provider less than 2 times per month for episodes of ketoacidosis and episodes of hypoglycemia. He had not been hospitalized for episodes of ketoacidosis and episodes of hypoglycemia. He had not had any progressive unintentional weight loss and loss of strength attributable due to diabetes. He had diabetic complications of diabetic peripheral neuropathy, erectile dysfunction, a stroke (CVA) and GERD (due to medications for diabetic peripheral neuropathy). The examiner (who also conducted the contemporaneous VA hypertension examination) stated that there was no evidence of diabetic nephropathy and in the absence thereof hypertension could not be attributed to diabetes and was not aggravated by diabetes. On VA GI examination of July 20, 2017, the Veteran’s electronic folder and medical records were reviewed. The Veteran reported that he continued to have acidity that rose up to his throat, and not infrequently awakened him from sleep. It was reported that he required continuous medication for his GERD. His signs and symptoms of GERD were: infrequent episodes of epigastric distress; pyrosis; reflux; sleep disturbance caused by esophageal reflux 4 or more times per year with an average duration of less than one day; nausea 3 times per year with an average duration of less than one day; vomiting 2 times per year with an average duration of less than one day. The examiner opined that the GERD did not impact the Veteran’s ability to work. He was able to obtain and maintain a financially gainful job without restrictions because the GERD did not cause any functional, i.e., occupational, disability. On VA CNS examination of July 20, 2017, the Veteran’s electronic folder and medical records were reviewed. It was reported that due to his past thrombosis, TIA, or cerebral infarction he continued to receive VA follow-up care and took medication which was an anticoagulant. The Veteran reported having persistent weakness in all four extremities, more so in his left upper extremity. He also complained of poor balance, stating that he had fallen a few times. On examination he did not have any pharynx and/or larynx and/or swallowing conditions, any respiratory conditions, functional impairment of the bowel, or any voiding dysfunction conditions. He had sleep apnea which required the use of a CPAP device. His erectile dysfunction was due to diabetes. His speech was normal. His gait was antalgic, and the examiner reported that the Veteran had more than one medical condition contributing to the abnormal gait (diabetic peripheral neuropathy). His poor balance was due to weakness in his legs as a sequela of past CVA. The Veteran’s muscle strength was 4/5, less than normal, in both upper and both lower extremities but there was no muscle atrophy. Deep tendon reflexes were decreased, at 1+, throughout all extremities expect for being normal at both knees. The examiner summarized, stating that the Veteran had moderate muscle weakness of both upper extremities and mild muscle weakness in both lower extremities. The were no mental health manifestations due to the CNS or treatment therefore. The Veteran constantly used a cane as an ambulatory aid to prevent falls. The examiner reported that the CNS condition impacted the Veteran’s ability to work because he had lost dexterity and endurance due to his CNS condition. Based solely on his CNS condition he was able to obtain and maintain a financially gainful job with the restriction that it was a sedentary desk-type job only. Due to weakness in the hands and legs, he had lost dexterity and endurance, and had limitations to perform in a job that required prolonged standing, walking or carrying heavy things or operating dangerous tools or equipment, or driving vehicles. On VA genitourinary examination of July 20, 2017, the Veteran’s electronic folder and medical records were reviewed. the Veteran reported that the efficiency of his erections had worsened to the extent that now even Viagra did not allow for satisfactory sexual relations. On examination it was reported that the Veteran could not achieve penetration and ejaculation with medication. It was opined that based solely on his erectile dysfunction he was able to obtain and maintain a financially gainful job without restriction because his erectile dysfunction did not cause any functional, i.e., occupational disability. On VA psychiatric examination of July 20, 2017, by a VA psychiatrist the Veteran’s electronic folder and medical records were reviewed. The examiner rendered a diagnosis of a generalized anxiety disorder, which was the Veteran’s only psychiatric disability. Also, it was opined that the Veteran did not meet the criteria under the Diagnostic and Statistical Manual (DSM) V for PTSD. It was reported that he had retired in 2006 after 20 years of employment as an electric repair technician. He continued to receive VA psychotherapy and pharmacotherapy. The Veteran reported that during service he had seen many wounded soldiers and the examiner noted that the Veteran’s stressor was related to a fear of hostile military activity, which met criterion A for PTSD. However, it was also reported that the Veteran did not meet the other criteria for PTSD. His symptoms were a depressed mood, anxiety, chronic sleep impairment, and disturbance of motivation and mood. On mental status examination the Veteran’s thought processes were coherent and logical and there was no looseness of association or signs of disorganized speech. His recent, remote, and immediate memory were preserved. The examiner reported that the Veteran’s military service and his trauma had not impaired his marital relations, parenting performance, or his social or occupational functioning. There was no change in his functional status or quality of life due to trauma exposure. The examiner opined that the Veteran’s generalized anxiety disorder was not incurred in or caused by inservice injury, event or illness. It was also opined that he did not meet the criteria for a diagnosis of PTSD because he did not meet the criteria for PTSD of persistent re-experiencing the traumatic event, avoiding reminders of the trauma, increased anxiety and emotional arousal. The examiner reported that there was no evidence of psychiatric complaints, findings or treatment during military service or within one year after service discharge. The Veteran had first sought treatment almost 38 years after service discharge and, thus there was no temporal relationship between his neuropsychiatric disorder, which was a generalized anxiety disorder, and his military service. As to there having been other diagnoses in the past, the examiner reported that the Veteran’s past diagnoses had a common root; which was that the past diagnoses were all anxiety related diagnoses. It was reported that the different past diagnoses had been subject to change based on the criteria in the DSM. The examiner listed many of the past diagnoses, covering the time from 2006 to 2016. The examiner also opined that the Veteran’s generalized anxiety disorder was not due to, i.e., not secondary to or associated in any way, to his service-connected disabilities of diabetes because he had not sought psychiatric care until 2006, almost 11 years after he developed diabetes. His generalized anxiety disorder and his diabetes were in different time frames, of different etiology, different pathophysiology, and different anatomical systems, with no relation of one with the other. With respect to aggravation, the Veteran’s generalized anxiety disorder had followed a natural course and had not been aggravated beyond that natural path due to his service-connected conditions. Rather, his generalized anxiety disorder had had a very mild course without any crises or hospitalizations. His generalized anxiety disorder had had the same pattern shown in those individuals without the Veteran’s service-connected disabilities. Subsequently, in June 2019 the VA psychiatrist that conducted the July 20, 2017, examination opined that the Veteran’s generalized anxiety disorder had followed its’ natural course and had not been aggravated beyond it natural pathy or beyond the regular course due to the service-connected disabilities of diabetes, peripheral neuropathy of the upper extremities, GERD, and thrombosis, TIA and cerebral infarction. It was again reported that the Veteran’s generalized anxiety disorder had had a very mild course without any hospitalizations or emotional crises. He had shown improvement due to conventional medication and therapy, and no special measures had been required. It was again opined that his generalized anxiety disorder had had the same pattern shown in those individuals without the Veteran’s service-connected disabilities. On VA genitourinary examination on August 22, 2017, it was reported that the Veteran’s prostate cancer was active. He had had radiation therapy. It was reported that due to prostate cancer and radiotherapy the Veteran had voiding dysfunction consisting of urinary leakage but which did not require wearing absorbent material or use of an appliance but urinary frequency of daytime voiding interval of less than one hour and nighttime awakening to void 5 times or more, as well as slow urinary stream. Because of erectile dysfunction he was unable to achieve an erection sufficient for penetration and ejaculation even with medication. His prostate cancer had not caused any renal dysfunction. As to the impact of his prostate cancer on his ability to work he would need nearby toileting facilities. An April 3, 2018 VA imaging study revealed that the Veteran had an enlarged heterogeneous hypoechoic lesion at the (right) inguinal region which was felt to represent known metastatic lymphadenopathy from known melanoma. An April 4, 2018 VAOPT record reflects that the Veteran had a clinical history of right acral melanoma, status post (SP) surgery [right 5th toe amputation] with recurrence at the right inguinal area. On VA examination of June 25, 2019, for evaluation of diabetic peripheral neuropathy the Veteran’s electronic folder and medical records were reviewed. It was reported that the Veteran had moderate diabetic peripheral neuropathy of all extremities with respect to constant pain, which was intermittently severe, and as to paresthesias and/or dysesthesias, as well as numbness. He had normal strength, at 5/5, at all joints of the upper and lower extremities except for less than normal strength, at 4/5, in plantar flexion and dorsiflexion of both ankles and bilateral grip strength and pinch strength (thumb to index fingers). There was no muscle atrophy. Deep tendon reflexes were decreased, being 1+, throughout, but absent at the ankles. Sensation to light touch was decreased throughout except for being normal at the shoulders and the inner and outer areas of the forearms. Sensation to position, vibration, and cold was decreased throughout. There were trophic changes consisting of loss of body hair and shiny skin in the pretibial lower one-thirds of both lower extremities. The examiner reported that the radial nerves were normal but there was mild incomplete paralysis of both median and both ulnar nerves. The Veteran had mild incomplete paralysis of the right and left sciatic nerves. The examiner stated that the impact of the diabetic peripheral neuropathy was a loss of endurance and stamina, with limitation as to constant use of the hands and feet in repetitive work or lifting. He was limited in standing, walking and sitting for prolonged periods of time. He had poor dexterity of his hand, and poor balance when walking due to peripheral neuropathy. It was opined that he was limited to a sedentary lifestyle. On VA audiology examination of June 25, 2019, the Veteran’s electronic folder and medical records were reviewed. After audiometric testing, the Veteran was found to have a bilateral sensorineural hearing loss. It was noted that the Veteran reported having to frequently ask people to repeat themselves, and having to raise the volume of a television too high. He also reported having tinnitus which was a bothersome noise at night or when it was quiet. The examiner opined that the tinnitus was at least as likely as not etiologically related to his service-connected thrombosis, TIA or cerebral infarction. Rating Principles 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. A higher rating is assigned if a disorder more nearly approximates the criteria therefore but not all disorders will show all the findings specified for a particular disability rating, especially with the more fully described grades of disabilities but coordination of ratings with functional impairment is required. 38 C.F.R. §§ 4.7, 4.21. 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). Separate evaluations may be assigned for separate periods of time based on the facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). A higher rating may not be denied on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). An initial disability rating higher than 10 percent for GERD Because there is no specific Diagnostic Code (DC) for rating GERD, service-connected GERD may be rated analogously by use of a “built-up” DC as a hiatal hernia under DC 7346. A disorder not listed in the rating schedule may be rated as if it were a closely related disease or injury, when (1) the functions affected, (1) the anatomical localization, and (3) symptoms are closely analogous. See generally 38 C.F.R. §§ 4.20, 4.27; see also Lendenmann v. Principi, 3 Vet. App. 345, 351 (1992); Archer v. Principi, 3 Vet. App. 433 (1992). Gastroesophageal reflux is the “reverse flow of material from stomach to esophagus.” Cox v. Brown, 5 Vet. App. 95, 97 (1993). Gastroesophageal reflux is the most disabling manifestation of a hiatal hernia. 76 Fed. Reg. 39160, 39174 (Jul. 5, 2011). Accordingly, the evaluation for GERD is most appropriately determined by the application of the schedular criteria for evaluating a hiatal hernia. 38 C.F.R. § 4.114, DC 7346 provides that a minimum 10 percent rating is warranted for a hiatal hernia when there are two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is warranted when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. The criteria for a 60 percent rating are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.112 provides that minor weight loss means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. Substantial weight loss means a loss of greater than 20 percent of the individual's baseline weight, sustained for three months or longer. “Hematemesis is vomiting of blood.” Vega v. Shinseki, No. 10-3483, slip op. (U.S. Vet. App. March 13, 2012); 2012 WL 803299; (nonprecendential memorandum decision) (citing DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 831 (32d ed. 2011)). “Melena is ‘the passage of dark-colored feces stained with blood pigments or with altered blood’.” Gilmore v. Shinseki, No. 10-2085 (U.S. Vet. App. Sept. 29, 2011); Slip Copy, 2011 WL 4489187 (Table); (nonprecendential memorandum decision) (citing DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1126 (32d ed. 2012)).“’Pyrosis’ is defined as ‘[s]ubsternal pain or burning sensation, usually associated with regurgitation of acid-peptic gastric juice into the esophagus.’ STEDMAN'S MEDICAL DICTIONARY 1494 (27th ed.2000).” Melendez-Pimentel v. Peake, slip op. (U.S. Vet. App. September 2, 2008) (non-precedential Memorandum decision) (Slip Copy, 2008 WL 4118042 ( Vet. App. )). “’Dysphagia’ is ‘difficulty in swallowing’.” Silimon v. Shinseki, No. 12–0668, slip op. (U.S. Vet. App. Jan. 17, 2013) 2013 WL 174423 ( Vet. App. ) (citing DORLAND’s at 579). It is neither shown nor contended that the Veteran has ever had material weight loss, hematemesis, melena or any anemia. In asserting that a rating greater than 10 percent is warranted for the Veteran’s GERD, a number of his symptoms have been addressed. The characteristic symptoms are not recited in the criteria for a 10 percent rating, which requires two or more symptoms recited in the criteria for a 30 percent rating, including pyrosis, regurgitation (which is also called reflux) and substernal arm or shoulder pain. Other symptoms are listed in the criteria for a 60 percent rating. Because a 10 percent rating is warranted for two or more symptoms listed for a 30 percent rating, it is argued that because the Veteran has more than two symptoms, a 30 percent rating should be assigned. However, the primary prerequisite for a 30 percent rating is that the Veteran’s symptomatology of GERD be productive of considerable impairment. Here, the VA examiners in 2011, 2014, and 2017 all found that the Veteran’s GERD was not productive of considerable impairment of health. The Board reaches this conclusion because the 2011 VA examiner reported that it did not impact the Veteran’s ability to work; the 2014 VA examiner also found that it did not impact the Veteran’s ability to work; and, also, the 2017 VA examiner found that it did not cause any function, i.e., occupational, disability. Accordingly, the Board finds that the preponderance of the evidence establishes that the Veteran’s GERD is manifested at least in part by pyrosis, regurgitation, and substernal pain but is not productive of at least considerable impairment of health and, so, does not warrant an evaluation in excess of 10 percent. A disability rating higher than 50 percent for peripheral neuropathy of the right upper extremity Under 38 C.F.R. § 4.124a, the schedules for rating diseases of the cranial and peripheral nerves include alternate DCs for paralysis, neuritis, and neuralgia of each nerve. See 38 C.F.R. § 4.124a, DCs 8205 to 8730 (2013). The DCs for paralysis of a nerve allow for multiple levels of incomplete paralysis, as well as complete paralysis. However, the ratings available for neuritis and neuralgia of the same nerves can be limited to less than the maximum ratings available for paralysis. In rating peripheral neuropathy attention is given to sensory or motor impairment as well as trophic changes (described at 38 C.F.R. § 4.104, DC 7115"). Peripheral neuropathy which is wholly sensory is mild or, at most, moderate. With dull and intermittent pain in a typical nerve distribution, it is at most moderate. With no organic changes it is moderate or, if of the sciatic nerve, moderately severe. 38 C.F.R. § 4.20. Neuralgia of a peripheral nerve of a lower extremity can receive a maximum rating of moderate incomplete paralysis. 38 C.F.R. § 4.124. Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, can receive a maximum rating of severe, incomplete paralysis. 38 C.F.R. § 4.123. Peripheral nerves ratings are for unilateral involvement; when bilateral, combine with application of the bilateral factor. 38 C.F.R. §§ 4.123, 4.124, 4.124a. Median nerve neurological manifestations are rated under Diagnostic Code 8515, 8615, or 8715 as, respectively, paralysis, neuritis or neuralgia of the median nerve. Under DC 8515, severe incomplete paralysis of the median nerve of the major upper extremity is rated as 50 percent disabling, and severe incomplete paralysis of the minor upper extremity is rated as 40 percent disabling. Complete paralysis of the median nerve is rated as 70 percent disabling for the major extremity and 60 percent disabling for the minor extremity. Complete paralysis is identified by symptoms such as the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. The term "incomplete paralysis" used in reference to evaluation of peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 U.S.C. § 4.124a. The terms "mild," "moderate," and "severe" are not defined in the Schedule. 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. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. 38 C.F.R. § 4.69. VA examination reports indicate that the Veteran is right handed, thus, for rating purposes, his right upper extremity is considered the major extremity and his left upper extremity is considered the minor extremity. See 38 C.F.R. § 4.124a, DC 8515. Since the grants of service connection for peripheral neuropathy of each upper extremity, made effective in4 for peripheral neuropathy of each upper extremity, made effective in April 2004, there is evidence of additional neurologic impairment due to the Veteran’s past stroke, being productive of hemiparesis. However, the current ratings for severe neuropathy of each upper extremity encompass both the neurologic manifestations due to diabetic peripheral neuropathy and neurologic manifestations due to any hemiparesis. It is undisputed and the evidence has shown that the Veteran is right handed and, so, his right upper extremity is his major extremity. The repeated examinations in this case have shown that the neurologic manifestations impact both sensory and motor functions. The examinations have shown that the muscle strength in the right upper extremity has never been less than 3/5, no movement against resistance, as found on VA examination in May 2009, but later examinations have shown that it is not less than 4/5 which is less than normal strength and is not as severe as having no move against resistance. Moreover, he has never had any muscular atrophy. Reviewing all the characteristic manifestations of complete paralysis, as set forth in DC 8515, the Veteran has pain and he also had trophic disturbances. However, the trophic disturbances have been described by examiners as affecting the Veteran’s lower extremities, and not described as affecting his upper extremities. He has weakness of pinching of the thumb and index fingers and wrist strength. However, as to the other criteria characteristic of complete paralysis he has never had ulnar inclination of the hand; greater than normal extension of the index and middle fingers; any atrophy, much less the required considerable atrophy, the thenar eminence; the thumb in the plane of the hand (ape hand); incomplete and defective pronation; absence of flexion of index finger and feeble flexion of middle finger; an inability to make a fist; continued or remaining extension of the index and middle fingers; and an inability to flex the distal phalanx of thumb. The Board has considered the Veteran’s statements that the severity of his right upper extremity. However, a reasonable inference can be made that if he had the degree of functional impairment which is characteristic of complete paralysis it would be expected that he would need a brace or splint for his wrist and that he would have some muscle atrophy, or trophic changes of the upper extremity but there is virtually no evidence of any of these findings. Accordingly, the Board finds that the preponderance of the evidence establishes that the Veteran’s right upper extremity neuropathy is manifested by both sensory and motor impairment but is not productive of more than severe functional impairment and does not warrant an initial evaluation in excess of 50 percent. A disability rating higher than 40 percent for peripheral neuropathy of the left upper extremity It is undisputed that the Veteran’s left upper extremity is his minor extremity. The impairment of the neuropathy of each upper extremity has been essentially the same. As with the right upper extremity, repeated examinations have shown impairment of both sensory and motor functions. The examinations have shown that the muscle strength in the left upper extremity has never been less than 3/5, no movement against resistance, as found on VA examination in May 2009, but later examinations have shown that it is not less than 4/5 which is less than normal strength and is not as severe as having no move against resistance. Moreover, he has never had any muscular atrophy. Reviewing all the characteristic manifestations of complete paralysis, as set forth in DC 8515, the Veteran has pain and he also had trophic disturbances. However, the trophic disturbances have been described by examiners as affecting the Veteran’s lower extremities, and not described as affecting his upper extremities. He has weakness of pinching of the thumb and index fingers and wrist strength. However, as to the other criteria characteristic of complete paralysis he has never had ulnar inclination of the hand; greater than normal extension of the index and middle fingers; any atrophy, much less the required considerable atrophy, the thenar eminence; the thumb in the plane of the hand (ape hand); incomplete and defective pronation; absence of flexion of index finger and feeble flexion of middle finger; an inability to make a fist; continued or remaining extension of the index and middle fingers; and an inability to flex the distal phalanx of thumb. The Board has considered the Veteran’s statements that the severity of his left upper extremity. However, a reasonable inference can be made that if he had the degree of functional impairment which is characteristic of complete paralysis it would be expected that he would need a brace or splint for his wrist and that he would have some muscle atrophy, or trophic changes of the upper extremity but there is virtually no evidence of any of these findings. Accordingly, the Board finds that the preponderance of the evidence establishes that the Veteran’s left upper extremity neuropathy is manifested by both sensory and motor impairment but is not productive of more than severe functional impairment and does not warrant an initial evaluation in excess of 40 percent. A disability rating higher than 10 percent from September 1, 2010 through March 30, 2011, and from October 1, 2011 for thrombosis, TIA, or cerebral infarction Under DC 8008 thrombosis of a blood vessel of the brain is rated 100 percent disabling for six (6) months, and thereafter is rated on the basis of residuals with a minimum rating of 10 percent. A November 22, 2014, rating decision granted service connection for thrombosis, TIA or cerebral infarction is granted with an evaluation of 100 percent effective February 26, 2010, day of informal claim based on VA Discharge Summary dated March 4, 2010. The 100 percent rating was assigned under DC 8008 for six months following the date of thrombosis on February 26, 2010. Thus, a minimum 10 percent evaluation was assigned from September 1, 2010. Service connection for thrombosis, TIA or cerebral infarction has been established as related to the service-connected disability of diabetes mellitus type II with erectile dysfunction. An evaluation of 100 percent is assigned from February 26, 2010, day of informal claim based on VA Discharge Summary dated March 4, 2010 (San Juan VAMC.) A 100 percent evaluation was assigned throughout six months following the date of thrombosis on February 26, 2010. A minimum 10 percent evaluation is assigned from September 1, 2010. A higher evaluation of 100 percent is not warranted in the absence of recently active disease. Subsequently, the Veteran appealed the November 2014 rating decision and submitted private medical evidence from Damas Hospital revealing that he had had another stroke on March 30, 2011. Following a May 10, 2016, VA examination an additional period of temporary 100 percent evaluation for six months from March 30, 2011 to October 1, 2011, and a 10 percent rating was assigned thereafter. In a July 2019 VA Form 9, it was alleged that treatment records in April 2011 revealed that the Veteran had had another CVA. However, these records appear to actually reference the cerebral event which the Veteran suffered on March 30, 2011. Stated in simpler terms, the Veteran was assigned 100 percent evaluations under DC 8008 following each of the two cerebral events, the first in February 2010, and the second in March 2011. As stated previously, to the extent that the Veteran now has any neuropathy of any extremity due to any thrombosis, TIA or cerebral infarction, these are assigned separate disability ratings. Because he has not had a third cerebral event another 100 percent rating under DC 8008 is not warranted. SMC based upon HB Governing law and regulations provide that SMC under 38 U.S.C. § 1114(s) and 38 C.F.R. § 3.350(i) is payable where the veteran has a single service-connected disability rated as 100 percent and, (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. This requirement is met when the veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. In other words, the requirements for compensation for SMC under 38 U.S.C. § 1114(s) and 38 C.F.R. § 3.350(i) are in the alternative. That is, if the Veteran meets the criteria under 38 C.F.R. § 3.350(i)(1) of a service-connected disability rated 100 percent disabling with other disabilities, separate and distinct, rated 60 percent disabling; or, under 38 C.F.R. § 3.350(i)(2) is permanently housebound by reason of service-connected disability or disabilities, such that he is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises. Here, the Veteran has met the requirements under 38 C.F.R. § 3.350(i)(1). In fact, as shown by the July 2019 rating decision, the RO has already assigned SMC under 38 C.F.R. § 3.350(i)(1) from February 26, 2010 to August 31, 2010, and from March 301, to September 30, 2011, and since the assignment of a 100 percent schedular rating for prostate cancer effective March 18, 2016. It is not alleged that the Veteran is entitled to SMC under 38 U.S.C. § 1114(s) and 38 C.F.R. § 3.350(i) for any other period of time. Thus, the factual question of whether the Veteran is actually housebound, for SMC compensation under 38 C.F.R. § 3.350(i)(2), is moot because he already meets the criteria for compensation under 38 C.F.R. § 3.350(i) under the alternative criteria set forth at 38 C.F.R. § 3.350(i)(1). REASONS FOR REMAND Service Records As made clear in the April 2012 handwritten note from the VA clinical psychologist that conducted the February 2008 VA psychiatric examination, and rendered addendums in June and August 2008, the “military service health records” of a completely different person had been mistakenly place in the “C-folder” of the Veteran in this case. In reviewing the STRs of records, there are a few clinical records which do not bear an indication of the name or serial identification number of the servicemember being treated for evaluated. Otherwise, virtually all of the STRs of record belong to one servicemember, who is not the Veteran, because the records reflect a servicemember with a different name and/or a service identification number different from the Veteran in this case. In other words, it appears that none of the Veteran’s STRs have been obtained and associated with his VA electronic claim file. The Board notes that it is not contended that the Veteran ever sought or received treatment for either hypertension or psychiatric disability. Nevertheless, there are medical opinions of record stating that neither disability was incurred during service and, so, at least presumably relied upon erroneous service records in reaching those opinions. Moreover, any blood pressure readings during service could be relevant to the claim for service connection for hypertension, as could any complaints in any medical history questionnaire adjunct to the Veteran’s examination for service discharge. This must be rectified. The STRs of the individual servicemember which are erroneously contained in the Veteran’s VA electronic file should be removed. The appropriate steps should be undertaken to locate and obtain the Veteran’s STRs and associate the same with the Veteran’s VA electronic claim file. If the Veteran’s STRs cannot be located, there should be a formal finding in writing reciting the steps undertaken and an explanation for a finding that either the STRs no longer exist or that further steps to obtain them would be futile. The Veteran and his representative should be provided copies of any such formal findings. Service connection for arterial hypertension In correspondence of August 6, 2019, the Veteran’s attorney noted that the July 2017 VA medical opinion had acknowledged the National Academy of Sciences earlier statement of limited or suggestive evidence of a relationship between herbicide exposure and the development of hypertension but, nevertheless, had opined that it was less likely than not that hypertension was related to military service, or caused or aggravated by service-connected diabetes. However, since the July 2017 VA medical opinion the National Academy of Sciences in 2018 had changed the classification from limited or suggestive evidence of a relationship to “sufficient” evidence of an association. In this regard, the duty to assist requires VA to provide a medical opinion when the evidence “indicates” that there “may” be a nexus between the in-service injury and current disability. See McLendon v. Nicholson, 20 Vet. App. 79, 83 2996). Accordingly, after the Veteran’s STRs have been obtained, if possible, the case should be returned to the examiner that conducted the July 2017 VA examination and rendered a negative medical opinion. The examiner should be requested to opine whether, in light of any STRs of the Veteran which are received or in light of the National Academy of Sciences 2018 changed of the classification from limited or suggestive evidence of a relationship to “sufficient” evidence of an association warrants changing the examiner’s opine as to whether hypertension was incurred during service or is due to the Veteran’s conceded inservice herbicide exposure. Service connection for an acquired psychiatric disorder, to include PTSD and depression A July 2017 VA examiner opined that although the Veteran had an adequate combat-related stressor, the Veteran did not meet the other criteria for a diagnosis of PTSD. Also, it was opined that the Veteran’s current generalized anxiety disorder was not secondary to or associated with his then service-connected disabilities. However, since then by a July 2018 rating decision effectuating a February 2017 Board decision, the ratings for the service-connected peripheral neuropathy of each upper extremity were increased by granting a 50 percent rating for right upper extremity peripheral neuropathy and a 40 percent rating for left upper extremity peripheral neuropathy throughout the entire appeal period. Also, a March 2018 Board decision granted service connection for peripheral neuropathy of each lower extremity, which was effectuated by a July 2019 rating decision. Accordingly, after the Veteran’s STRs have been obtained, if possible, the case should be returned to the examiner that conducted the July 2017 VA examination and rendered a negative medical opinion. The examiner should be requested to opine whether, in light of any STRs of the Veteran which are received or in light of the grants of higher disability ratings for peripheral neuropathy of each upper extremity and/or grants of service connection for peripheral neuropathy of each lower extremity warrants changing the examiner’s opine as to whether a psychiatric disability was incurred during service or is due to or aggravated by the Veteran’s service-connected disabilities. A disability rating higher than 20 percent for diabetes mellitus, type II The criteria for 40 percent under DC 7913 are insulin dependence, restricted diet, and regulation of activities. It has been held that competent medical evidence is required to establish “regulation of activities,” namely, avoidance of strenuous occupational and recreational activities, for a 40 percent rating under DC 7913. Camacho v. Nicholson, 21 Vet. App. 360, 364 (2007). Nevertheless, in the February 2017 Board remand of this claim it was specifically requested that an examiner opine as to whether the Veteran's physical impairments would preclude him from physical activity in such a way that the prescription of regulation of activities to treat diabetes mellitus type II would be unnecessary. In other words, was the Veteran's diabetes mellitus type II of such severity that it would typically be treated with a regulation of activities. However, the July 2017 VA examination merely reported that there was no requirement of regulation of activities as part of the Veteran’s management of his diabetes. This response does not directly address with Board’s concern as stated in the February 2017 remand. See generally Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the case should be returned to the July 2017 examiner, or if not available another clinician, who should be requested to directly respond to the query set forth in the February 2017 Board remand. A TDIU rating prior to April 2, 2012 Any grant of service connection, with assignments of disability ratings and effective dates, could potentially impact upon the effective date for a TDIU rating. Thus, at this time, the Board may not adjudicate the claim for a TDIU rating prior to April 2, 2012. Additionally, although the Veteran’s attorney has stated that the appeal initiated from a claim filed in 2004, there is ample evidence that the Veteran had full-time gainful employment until he retired sometime between 2006 and 2009. The Veteran has reported that he retired from full-time employment in Puerto Rico. He reported in his VA Form 21-8940 received on April 2, 2012 (the current effective date for his TDIU rating) that he had become too disabled to work, and had last worked in August 2008. His occupation that year was plant repairs for Energia Electrica, in Puerto Rico, where he had worked since 1988. The Board is aware that there was no response to the RO’s attempts to obtain information from his last employer as to the Veteran’s inclusive dates of employment. Thus, the Veteran should be requested to provided copies of his “W-2” forms for the inclusive years from 2006 to 2009, and any other information verifying when he formally retired from full-time gainful employment. The matters are REMANDED for the following action: 1. Take the appropriate steps to remove from the Veteran’s VA electronic claim file the STRs which belong to a servicemember that is not the Veteran. 2. Take the appropriate steps to locate and obtain the Veteran’s STRs and associate the same with the Veteran’s VA electronic claim file. If the Veteran’s STRs cannot be located, there should be a formal finding in writing reciting the steps undertaken and an explanation for a finding that either the STRs no longer exist or that further steps to obtain them would be futile. The Veteran and his representative should be provided copies of any such formal findings. 3. The Veteran should be requested to provided copies of his “W-2” forms for the inclusive years from 2006 to 2009, and any other information verifying when he formally retired from full-time gainful employment. 4. After obtaining the Veteran’s STRs, if possible, return the case to the VA examiner that conducted the July 2017 VA examination for hypertension. Since it is undisputed that the Veteran now has hypertension, for which he has taken medication, the matter of whether an additional in-person examination should be conducted if left to the discretion of the July 2017 examiner. If the clinician that conducted the July 2017 examination is not available, the matter addressed in this remand should be addressed by another clinician. The clinician should be requested to opine whether, in light of any STRs of the Veteran which are received or in light of the National Academy of Sciences 2018 changed of the classification from limited or suggestive evidence of a relationship to “sufficient” evidence of an association warrants changing the 2017 opinion as to whether hypertension was incurred during service or is due to the Veteran’s conceded inservice herbicide exposure. 5. After obtaining the Veteran’s STRs, if possible, return the case to the VA examiner that conducted the July 2017 VA examination for psychiatric disability. Since it is undisputed that the Veteran now has a psychiatric disability, the matter of whether an additional in-person examination should be conducted if left to the discretion of the July 2017 examiner. If the clinician that conducted the July 2017 examination is not available, the matter addressed in this remand should be addressed by another clinician. The clinician should be requested to opine whether, in light of any STRs of the Veteran which are received or in light of the grants of higher disability ratings for peripheral neuropathy of each upper extremity and/or grants of service connection for peripheral neuropathy of each lower extremity warrants changing the examiner’s opine as to whether a psychiatric disability was incurred during service or is due to or aggravated by the Veteran’s service-connected disabilities. 6. Return the case to the VA examiner that conducted the July 2017 VA examination for diabetes. If the clinician that conducted the July 2017 examination is not available, the matter addressed in this remand should be addressed by another clinician. The matter of whether an additional in-person examination should be conducted if left to the opining clinician. The clinician should be requested to opine whether (a) the Veteran's physical impairments would preclude him from physical activity in such a way that the prescription of regulation of activities to treat diabetes mellitus type II would be unnecessary; or (b) the Veteran's diabetes mellitus type II of such severity that it would typically be treated with a regulation of activities. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.