Citation Nr: 19165514 Decision Date: 08/22/19 Archive Date: 08/22/19 DOCKET NO. 18-38 309 0DATE: August 22, 2019 ORDER The application to reopen the previously denied claim of entitlement to service connection for hypertension is granted. The application to reopen the previously denied claim of entitlement to service connection for bilateral hearing loss is granted. The application to reopen the previously denied claim of entitlement to service connection for tinnitus is granted. The application to reopen the previously denied claim of entitlement to service connection for erectile dysfunction is granted. Entitlement to service connection for bilateral hearing loss is granted. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for upper extremity peripheral neuropathy due to exposure to Agent Orange is granted. Entitlement to a rating higher than 20 percent for right and left lower extremity peripheral neuropathy of the sciatic nerve is denied. Restoration of a 10 percent rating for both right and left lower extremity peripheral neuropathy of the femoral nerve is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an effective date earlier than November 21, 2015 for the award of a 20 percent rating for right and left lower extremity peripheral neuropathy of the sciatic nerve is denied. Entitlement to an increased rating higher than 20 percent for type 2 diabetes mellitus (DMII) is denied. Entitlement to an effective date earlier than June 12, 2012 for the award of a 20 percent rating for DMII is denied. Entitlement to a total disability rating due to individual unemployability (TDIU) is granted, subject to the laws and regulations controlling the award of monetary benefits. REMANDED Entitlement to service connection for bilateral low-tension glaucoma and cataracts (eye disability) secondary to service connected DMII is remanded. Entitlement to service connection for hypertension, to include as due to exposure to Agent Orange is remanded. Entitlement to service connection for a urinary tract infection is remanded. Entitlement to service connection for gout is remanded. Entitlement to service connection for erectile dysfunction is remanded. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. FINDINGS OF FACT 1. In an April 2011 decision, the Regional Office (RO), inter alia, denied the Veteran’s claim for entitlement to service connection for hypertension; the Veteran did not timely initiate an appeal of that decision or submit new and material evidence within one year of notification. 2. Evidence added to the record since the April 2011 decision relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim. 3. In a March 2012 decision, the RO denied the Veteran’s claim for entitlement to service connection for bilateral hearing loss and tinnitus; the Veteran did not timely perfect an appeal of that decision or submit new and material evidence within one year of notification. 4. Evidence added to the record since the March 2012 decision relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim. 5. In an August 2013 decision, the RO denied the Veteran’s claim for entitlement to service connection for erectile dysfunction; the Veteran did not timely initiate an appeal of that decision or submit new and material evidence within one year of notification. 6. Evidence added to the record since the August 2013 decision relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim. 7. The evidence is at least evenly balanced as to whether the Veteran’s bilateral hearing loss is related to noise exposure during service. 8. The evidence is at least evenly balanced as to whether the Veteran’s tinnitus is related to noise exposure during service. 9. The evidence is at least evenly balanced as to whether the Veteran’s upper extremity peripheral neuropathy was caused by exposure to Agent Orange in service. 10. The Veteran’s right and left lower extremity peripheral neuropathy of the sciatic nerve symptomatology does not more nearly approximate at least moderately severe incomplete paralysis. 11. The reduction in the disability rating from 10 percent to noncompensable was not based on improvement in the Veteran’s ability to function under the ordinary conditions of life. 12. The Veteran filed a November 2015 application for a rating increase for his service connected right and left lower extremity peripheral neuropathy of the femoral nerve; there was no claim, formal or informal, filed after the April 2011 denial of the claim for service connection for right toe numbness, which became final when the Veteran did not appeal or submit new and material evidence within the one-year appeal period. 13. The Veteran’s DMII has not required regulation of activities. 14. The Veteran filed a June 2015 application for a rating increase for his service connected DMII and VA received no communication from the Veteran or his attorney that constitutes a formal claim or may be construed as an informal claim for a rating increase for DMII prior to June 2015. 15. The evidence is at least evenly balanced as to whether the Veteran’s service-connected disabilities preclude him from being able to secure or follow substantially gainful employment. CONCLUSIONS OF LAW 1. The April 2011 RO decision that denied service connection for hypertension is final. 38 U.S.C. § 7105(c); 38 C.F.R. § § 3.156(b), 20.1103. 2. The criteria for reopening a claim of entitlement to service connection for hypertension have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 3. The March 2012 RO decision that denied service connection for bilateral hearing loss and tinnitus is final. 38 U.S.C. § 7105(c); 38 C.F.R. § § 3.156(b), 20.1103. 4. The criteria for reopening a claim of entitlement to service connection for bilateral hearing loss and tinnitus have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 5. The August 2013 RO decision that denied service connection for erectile dysfunction is final. 38 U.S.C. § 7105(c); 38 C.F.R. § § 3.156(b), 20.1103. 6. The criteria for reopening a claim of entitlement to service connection for erectile dysfunction have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 7. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for bilateral hearing loss have been met. 38 U.S.C. § § 1110, 5107; 38 C.F.R. § § 3.6, 3.102, 3.303. 8. Resolving reasonable doubt in favor of the Veteran, the criteria for entitlement to service connection for tinnitus have been met. 38 U.S.C. § § 1110, 5107; 38 C.F.R. § § 3.102, 3.303, 3.304. 9. Resolving reasonable doubt in favor of the Veteran, the criteria for entitlement to service connection for upper extremity peripheral neuropathy have been met. 38 U.S.C. § § 1110, 5107; 38 C.F.R. § § 3.102, 3.303, 3.304. 10. The criteria for a rating higher than 20 percent for sciatic peripheral neuropathy of both the right and left lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code (DC) 8520. 11. The reduction of the disability rating for right and left lower extremity peripheral neuropathy of the femoral nerve from 10 percent to noncompensable was not proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.105(e), 3.344. 12. The criteria for an effective date prior to November 21, 2015, for the 20 percent evaluation for the Veteran’s right and left lower extremity peripheral neuropathy of the sciatic nerve are not met. 38 U.S.C. §§ 5101, 5103, 5107, 5110; 38 C.F.R. §§ 3.102, 3.114, 3.151, 3.155, 3.159, 3.400. 13. The criteria for a rating higher than 20 percent for DMII have not all been met. 38 U.S.C. § § 1155, 5107; 38 C.F.R. § § 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.119, DC 7913. 14. The criteria for an effective date prior to June 12, 2012 for the 20 percent evaluation for the Veteran’s DMII are not met. 38 U.S.C. §§ 5101, 5103, 5107, 5110; 38 C.F.R. §§ 3.102, 3.114, 3.151, 3.155, 3.159, 3.400. 15. With reasonable doubt resolved in favor of the Veteran, the criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1965 to October 1968. This case comes before the Board of Veterans’ Appeals (Board) on appeal of an April 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida which denied service connection for antisocial traits (claimed as stress anxiety disorder and PTSD), and upper extremity peripheral neuropathy, granted service connection for left and right lower extremity sciatic nerve peripheral neuropathy evaluating each as 10 percent disabling effective May 5, 2015, continued its denial of service connection for hearing loss and tinnitus, continued its denial of service connection for erectile dysfunction secondary to DMII, and granted service connection for right and left lower extremity femoral nerve peripheral neuropathy evaluating each as 10 percent disabling effective May 5, 2015; an April 2016 rating decision which granted a rating increase for left and right lower extremity sciatic peripheral neuropathy, proposed a decrease to 0 percent for right and left lower extremity peripheral neuropathy, and continued its denial of service connection for erectile dysfunction; and a September 2016 rating decision which continued its 20 percent rating for DMII, and left and right lower extremity sciatic peripheral neuropathy, decreased its rating for left and right lower extremity femoral nerve peripheral neuropathy to 0 percent, and denied service connection for gout, glaucoma, UTI, and hypertension. In May 2015 and September 2016, the Veteran filed notice of disagreements with the service connection denials, the ratings assigned, and with the effective dates for left and right lower sciatic and femoral nerve peripheral neuropathy. The Veteran was issued a statement of the case in June 2018, March 2019 and April 2019, and perfected his appeals in July 2018, April 2019, and May 2019. In September 2016, the Veteran filed a notice of disagreement regarding, among other things, the effective date of his bilateral lower extremity peripheral neuropathy of the femoral nerve, however the RO has yet to issue a statement of the case specifically addressing this issue. See 38 C.F.R. § 19.9 (c), codifying Manlincon v. West, 12 Vet. App. 238 (1999) (in cases before the Board in which a claimant has timely filed a notice of disagreement with a determination of the Agency of Original Jurisdiction (AOJ) on a claim, but the record reflects that the AOJ has not subsequently granted the claim in full and has not furnished the claimant with a statement of the case, the Board shall remand the claim to the AOJ with instructions to prepare and issue a statement of the case). Although the regulation requires remand with instructions to prepare a statement of the case, given that the RO is developing the claim in anticipation of issuance of a statement of the case, the Board will allow it to do so and not remand the claim at this time. New and Material In an April 2011 rating decision, the RO denied, inter alia, the Veteran’s claim of entitlement to service connection for hypertension secondary to DMII as the Veteran’s hypertension predated his DMII, tinnitus, and denied reopening the service connection claim for bilateral hearing loss. The Veteran did not file a timely appeal or submit new and material evidence within a year of the rating decision as to the hypertension claim, thus, the April 2011 rating decision became final. In October 2011, the Veteran submitted additional evidence regarding his bilateral hearing loss disability, and in a March 2012 rating decision the RO denied the Veteran’s service connection claims for bilateral hearing loss and tinnitus. The Veteran submitted a notice of disagreement with the service connection denial for bilateral hearing loss in April 2012, and in May 2014 was issued a statement of the case. The Veteran failed to timely perfect his appeal after receipt of the statement of the case, thus the RO closed the case and the decision became final. 38 U.S.C. § 7105 (c); 38 C.F.R. § 20.1103. In an August 2013 rating decision, the RO denied the Veteran’s claim of entitlement to service connection for erectile dysfunction secondary to DMII, finding the disability more likely due to the Veteran’s hypertension. The Veteran did not file a timely appeal or submit new and material evidence within a year of the rating decision, thus the August 2013 rating decision became final. The Board notes that to the extent that the RO appears to have adjudicated the claim involving the Veteran’s bilateral hearing loss on the merits as indicated by a June 2018 statement of the case, regardless of the RO’s actions, the Board must still determine whether new and material evidence has been received. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (reopening after a prior unappealed RO denial); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Generally, a claim which has been denied in an unappealed Agency of Original Jurisdiction (AOJ) decision is final and may not thereafter be reopened and allowed. 38 U.S.C.§ 7105 (c); 38 C.F.R. § 20.1100. One exception to this rule is that a previously denied claim may be reopened by submission of new and material evidence. 38 U.S.C. § 5108; 38 C.F.R.§ 3.156. New and material evidence cannot be cumulative or redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary’s duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. At the time of the April 2011 rating decision, evidence relevant to the service connection claim for hypertension included service treatment records, and a March 2011 VA examination. Evidence received since includes a statement from the Veteran regarding the etiology of his hypertension, noting his exposure to Agent Orange. At the time of the March 2012 rating decision, evidence relevant to the service connection claim for bilateral hearing loss included an October 2011 private audiogram, service treatment records, a statement from the Veteran regarding his in-service acoustic noise exposure, statements from family, VA treatment records, and a February 2012 VA examination report. Evidence received since includes a May 2014 letter from the Veteran’s ear, nose, and throat physician, private treatment records, and an April 2015 VA examination report. At the time of the August 2013 rating decision, evidence relevant to the service connection claim for erectile dysfunction included VA treatment records and service treatment records. Evidence received since includes a statement from the Veteran relaying an opinion from his private physician. This evidence regarding the service connection claims for hypertension, erectile dysfunction, bilateral hearing loss, and tinnitus is not redundant of the record and raises a reasonable possibility of substantiating the claims as the Veteran’s statements provide evidence of a new theory of entitlement for his hypertension, and he has provided new opinions regarding the etiology of his erectile dysfunction, bilateral hearing loss, and tinnitus. The evidence is thus new and material, and the service connection claims for hypertension, erectile dysfunction, bilateral hearing loss, and tinnitus are reopened. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including hypertension and organic diseases of the nervous system such as sensorineural hearing loss and tinnitus, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. § § 1101, 1112, 1113 (2012); 38 C.F.R. § § 3.307, 3.309(a) (2017); Fountain v. McDonald, 27 Vet. App. 258 (2015) (including tinnitus within the category of organic diseases of the nervous system for which presumptive service connection is provided under 38 C.F.R. § 3.309(a)). Service connection is warranted for disability that is proximately due to, the result of, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310 (a),(b). If a veteran was exposed to an herbicide agent, such as Agent Orange, during active service, service connection will be presumed for certain diseases which are listed at 38 C.F.R. § 3.309 (e), if the requirements of 38 C.F.R. § 3.307 (a) are met, even if there is no record of such disease during service. 38 U.S.C. § 1116(f); 38 C.F.R. §§ 3.307(a) (6) (iii), 3.309(e). For purposes of establishing service connection for a disability resulting from exposure to an herbicide agent, a veteran who, during active military, navel, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during service. 38 U.S.C. § 1116 (f). The Veteran’s DD-214 notes his military occupational specialty was as an electrician and that he is a recipient of the Vietnam Service Medal and the Vietnam Campaign Medal. A note included on the Veteran’s DD-214 indicates the Veteran served in Vietnam from May 1967 to June 1968. Therefore, the Veteran has established that he is a Vietnam veteran and thus is presumed to have been exposed to an herbicide agent. Bilateral hearing loss and tinnitus The Veteran contends that he suffers from bilateral hearing loss and tinnitus as a result of acoustic noise exposure from howitzer cannons during service, and an infection caused by microscopic snails in the water in which he showered. He stated that although his military occupational specialty was as an electrician, he also made courier runs to various locations such as Red Beach, Da Nang, Gong Ha, and Khe Sahn and was exposed to a lot of noise at various times. A hearing loss disability is defined for VA compensation purposes with regard to audiological testing involving pure-tone frequency thresholds and speech discrimination criteria. 38 C.F.R. § 3.385. For purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hertz (Hz) is 40 decibels (dB) or greater; or when the auditory thresholds for at least three of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hz are 26 dB or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. Id. A July 2010 audiological consult report indicated that the Veteran reported difficulty hearing in groups, on the telephone, in the presence of background noise, and hearing the television. He reported a history of military noise exposure from aircraft, explosions, and gunfire. The Veteran reported a history of imbalance and periodic tinnitus in the right ear. A March 2011 VA examination report noted that the Veteran complained of hearing loss, worse in the right ear with tinnitus which occurs 1 to 2 times a month, lasting 15 to 20 seconds. The audiologist noted that the examination results were not suitable for rating purposes. The audiologist noted that the Veteran’s tinnitus is inconsistent with the more recurrent and pervasive tinnitus typically associated with noise exposure, and that the Veteran reported onset of tinnitus decades after separation from service. Therefore, the audiologist opined that the Veteran’s tinnitus was not caused by and is not a result of military noise exposure. An October 2011 private audiological examination report noted that pure tone air and bone conduction testing revealed a relatively flat, mild to moderate sensorineural hearing loss in the left ear, and a relatively flat, moderate to moderately-severe sensorineural loss in the right ear. The October 2011 private audiological examination noted pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 55 55 60 70 70 LEFT 45 40 35 50 55 The audiologist stated that based on the case history, the Veteran’s hearing loss was of a degree and pattern associated with intense noise exposure and was more likely than not due to his military related intense noise exposure. A November 2011 letter from the Veteran’s wife indicated that the Veteran’s hearing has worsened since his late thirties and is especially noticeable on his right side. Additional letters from the Veteran’s children also attested to his hearing loss noting that they have to repeat themselves and that the Veteran needs to turn up the television to hear it. On the authorized audiological evaluation in February 2012, pure tone thresholds, in decibels, were not valid for rating purposes. The audiologist noted that despite repeated reinstruction and retesting, pure tone averages, which were in the moderately severe hearing loss range in the right ear and moderate range in the left ear, were not in agreement with speech reception thresholds which were in the mild hearing loss range bilaterally. The audiologist stated that she was unable to provide an opinion on hearing loss due to the poor reliability of the test results. The audiological examination report noted that the Veteran reported having ringing in his ears 3 to 4 times a month, lasting 15 to 20 years. The Veteran stated he has had it since service. The audiologist opined that the Veteran’s tinnitus was less likely than not (less than a 50 percent probability) caused by or a result of military noise exposure. A May 2014 audiologist’s letter indicated that the Veteran had a confirmed diagnosis of bilateral hearing loss and tinnitus with military noise exposure. The physician referenced the Institute of Medicine’s 2006 Noise and Military Service: Implications for Hearing Loss and Tinnitus and concluded that with regard to noise-induced tinnitus, specific parameters of hazardous noise exposure have not been defined, but noise levels associated with hearing loss are also likely to be associated with tinnitus. The audiologist provided the Veteran with an examination and noted pure tone thresholds, in dBs, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 40 35 30 45 45 LEFT 40 35 30 45 60 The audiologist opined that after consulting the Institute of Medicine report and assessing the claims file including the audiology report, it is more likely than not that the Veteran’s hearing loss and tinnitus was caused by, the result of, or aggravated by his military noise acoustic trauma. In April 2015, the Veteran was afforded a VA examination for hearing loss and tinnitus. The audiologist noted poor inter-test reliability and stated that the Veteran’s responses to behavioral audiometry testing were unreliable and invalid. The audiologist also noted that the word recognition score is not appropriate for the Veteran because of language difficulties, cognitive problems, inconsistent word recognition scores, etc, that make combined use of pure-tone average and word recognition scores inappropriate. The audiologist opined that the Veteran’s hearing loss was not at least as likely as not (50 percent probability or greater) caused by or a result of an event in military service. The audiologist stated that the results from the evaluation were unreliable and invalid. She stated that there was no evidence of middle or outer ear pathology and there is nothing to support service connection for hearing loss and tinnitus, referencing the Institute of Medicine’s Noise and Military Service: Implications for Hearing Loss and Tinnitus to support her opinion. The Board finds the Veteran has a current bilateral hearing loss disability for VA purposes as the May 2014 audiological examination indicates one auditory threshold at 40 dB or greater in at least one of the frequencies. Tinnitus is a disability capable of lay observation. The Veteran has offered competent, credible evidence that he experiences tinnitus, and the above audiological examinations and statements confirm an in-service injury or event, and a current bilateral hearing loss disability. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) (“ringing in the ears is capable of lay observation”). The remaining issue is whether there is a nexus between the current bilateral hearing loss and tinnitus, and the in-service noise exposure. For the following reasons, the evidence is at least evenly balanced as to whether the Veteran’s current bilateral hearing loss disability and tinnitus are related to in-service noise exposure. While the March 2011 and April 2015 audiologist opined that the Veteran’s bilateral hearing loss and tinnitus were not caused by or related to in-service noise exposure, October 2011 and May 2014 audiologists opined to the contrary, providing a thorough rationale to support their conclusions, thus their opinions are afforded significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The evidence is thus at least evenly balanced as to whether the Veteran’s bilateral hearing loss and tinnitus are related to his in-service noise exposure. As the reasonable doubt created by the relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for bilateral hearing loss and tinnitus is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Upper extremity peripheral neuropathy The Veteran contends that the suffers from upper extremity peripheral neuropathy which was caused by his service connected DMII, or alternately by exposure to Agent Orange in service. A May 2015 disability benefits questionnaire (DBQ) noted that the Veteran did not have an upper extremity diabetic peripheral neuropathy. The examiner noted that there was no pain apparent in the upper extremities, nor any evidence of paresthesias and/or dysesthesias, or numbness in the upper extremities. The Veteran also exhibited normal strength in his upper extremities. July 2015 private treatment notes indicate the Veteran stated that he has arm problems which bother him constantly which he described as achy, burning, a numbness and tingly. He stated that his arm problem stems from being exposed to Agent Orange in Vietnam and indicated that he has had his arm problem for over 12 years. The Veteran also described achy, burning, numbness, and tingling in his left and right hands which he stated bother him constantly. The examination report noted diagnoses of numbness, muscle spasm, and idiopathic progressive polyneuropathy. The private examiner noted that DMII is clinically proven to cause sensory fiber neuropathies in the hands and feet, as well as sensory peripheral neuropathies of the legs and feet. The examiner stated that these symptoms are the ones the Veteran is experiencing and are consistent with him serving in Vietnam and being exposed to Agent Orange and opined that the Veteran’s peripheral neuropathy and symptoms are more likely than not a result of his service related exposure. The evidence is thus at least in equipoise as to whether the Veteran’s peripheral neuropathy of the upper extremities was caused by exposure to Agent Orange in service. While the May 2015 examination report indicated that the Veteran did not have upper extremity peripheral neuropathy, a private examiner diagnosed the Veteran with progressive polyneuropathy, and the Veteran competently described his symptoms which included tingling and numbness. The Board notes the Veteran is competent to report his observable symptoms. Jandreau v. Nicholson, 492 F. 3d 1372, 1377, n.4 (Fed. Cir. 2007). The private examiner opined that the Veteran’s peripheral neuropathy was more likely than not a result of his service related exposure to Agent Orange and provided a thorough rationale to support his opinion, thus his opinion is afforded significant probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for peripheral neuropathy of the upper extremities is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. § § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staged” ratings. Hart v. Mansfield, 21 Vet. App. 505 (2008). Bilateral Lower Extremity Peripheral Neuropathy The Veteran stated that he struggles with severe peripheral neuropathy as he cannot stand from a squat and struggles to get up from a chair. He also indicated that he has difficulty standing for long periods of time, walking far, or engaging in physical activities. The Veteran’s right and left lower extremity sciatic peripheral neuropathy is currently rated 20 percent disabling from November 21, 2015 under DC 8520. The Board notes that the RO assigned a 10 percent rating for the Veteran’s right and left lower sciatic peripheral neuropathy effective May 5, 2015 in a May 2015 rating decision based on the evidence provided by a May 2015 DBQ which will be addressed below. The Veteran submitted a claim for a rating increase in November 2015 which was granted in an April 2016 rating decision wherein the RO evaluated the Veteran’s right and left lower extremity sciatic nerve peripheral neuropathy as 20 percent disabling from March 22, 2016, creating a staged rating. In a March 2019 rating decision, the RO assigned a November 21, 2015 effective date for the 20 percent rating for the Veteran’s right and left lower extremity sciatic nerve peripheral neuropathy, the date of the Veteran’s claim for a rating increase. Under DC 8520, a 20 percent rating is assigned for moderate incomplete paralysis of the sciatic nerve; a 40 percent rating is assigned for moderately severe incomplete paralysis; a 60 percent rating is assigned for severe incomplete paralysis, with marked muscular atrophy; and an 80 percent rating is assigned for complete paralysis of the sciatic nerve, where the foot dangles and drops, and there is no active movement possible of muscles below the knee, flexion of knee weakened, or (very rarely), lost. Neither the Rating Schedule nor the regulations provide definitions for descriptive words such as “mild,” “moderate,” “moderately severe,” and “severe.” Rather than applying a mechanical formula, the Board must instead evaluate all the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. December 2009 private treatment notes indicate no evidence of deep venous vein thrombosis, and the left lower extremity is otherwise acoustically unremarkable. A May 2015 DBQ noted that the Veteran developed what feels like needles and pins in both feet which is aggravated by prolonged standing and walking. The examination report noted no constant pain in the right and left upper extremities, mild constant pain in the right and left lower extremities, no intermittent pain in the right and left upper extremities, mild intermittent pain in the right and left lower extremities, no paresthesias and or dysesthesias in the right and left upper extremities, mild paresthesias and/or dysesthesias in the right and left lower extremities, no numbness in the right and left upper extremities, and mild numbness in the right and left lower extremities. Decreased position sense was noted in the right and left lower extremities, and there was no vibration sensation in the right and left lower extremities. The examination report noted that the Veteran did have trophic changes attributable to diabetic peripheral neuropathy, specifically bilateral feet with smooth shiny skin and loss of hair. The examination report noted mild incomplete paralysis of the left and right sciatic nerves, and mild incomplete paralysis of the left and right femoral nerves. The Veteran complained of a mass under his right 2nd digit metacarpophalangeal joint that at times becomes painful, but he denied any recent trauma or injury to his right foot. He admitted to having numbness, tingling, and burning sensations to his bilateral feet. The examiner noted that the Veteran’s diabetic peripheral neuropathy impacts his ability to work as prolonged standing and walking causes bilateral foot burning pain with numbness and tingling. A March 2016 DBQ noted that the Veteran reported continuous numbness of the right and left foot with pain (worse on the right side) which is most severe at night when he is trying to sleep. The examination report noted mild constant pain in the left and right lower extremities, moderate intermittent pain in the right lower extremities, paresthesias and/or dysesthesias which was moderate in the right lower extremity and mild in the left lower extremity, and moderate numbness in the right and left lower extremities. Position sense was noted as decreased in the right lower extremity, vibration sensation was absent in both the right and left lower extremities, and cold sensation was decreased in the right and left lower extremities. The examination report noted moderate incomplete paralysis of the right and left sciatic nerve, normal right and left femoral nerves, and the examiner noted that the Veteran’s diabetic peripheral neuropathy impacted his ability to work as the Veteran was unable to climb into trailers, use the clutch repetitively, or stand for long periods of time. The examining physician stated that there was no evidence of femoral nerve involvement and that the symptoms and findings are distal to his calves. Based on the foregoing, the Board finds that a rating higher than 20 percent for the Veteran’s right and left lower extremity peripheral neuropathy of the sciatic nerve is not warranted. The evidence of record does not indicate that the Veteran’s right and left peripheral neuropathy of the sciatic nerve more nearly approximated at least moderately severe incomplete paralysis. The May 2015 and March 2016 examiners each described the Veteran’s peripheral neuropathy as primarily mild and at most moderate, and while the March 2016 examiner noted decreased position sense in the right lower extremity, decreased cold sensation and no vibration sensation in both lower extremities, the examiner reported moderate incomplete paralysis of the sciatic nerves. While the examiners’ characterization of the level of impairment caused by the peripheral neuropathy is not binding on the Board, in this case the characterizations are consistent with the evidence of record. The examination reports do not indicate, and there is no evidence within the claims file which suggests that the Veteran’s right and left lower extremity sciatic peripheral neuropathy symptomatology more nearly approximated at least moderately severe incomplete paralysis of the sciatic nerve. Accordingly, the weight of the evidence demonstrates that the Veteran’s right and left lower extremity radiculopathy symptomatology has not more nearly approximated moderately severe incomplete paralysis of the sciatic nerve, as is required for a 40 percent rating. Therefore, a disability rating higher than 20 percent peripheral neuropathy of both the right and left lower extremities with sciatic nerve involvement is not warranted. As the preponderance of the evidence is against any higher rating, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. The Veteran contends that his right and left lower extremity peripheral neuropathy of the femoral nerve symptomatology warrants a compensable rating and thus seeks restoration of the 10 percent disability rating previously assigned under DC 8526. Under DC 8526, mild incomplete paralysis of the anterior crural (femoral) nerve, as well as neuritis (8626) and neuralgia (8726) of that nerve, warrants a 10 percent rating. Moderate incomplete paralysis of the femoral nerve warrants a 20 percent rating. Severe incomplete paralysis of the femoral nerve warrants a 30 percent rating. With complete paralysis of the femoral nerve, which warrants a 40 percent rating, there is paralysis of the quadriceps extensor muscles. 38 C.F.R. § 4.124a. There is no question that a disability rating may be reduced; however, the circumstances under which rating reductions can occur are specifically limited and carefully circumscribed by VA regulations. Dofflemyer v. Derwinski, 2 Vet. App. 277, 280 (1992). In any rating reduction case, it must be ascertained, based upon a review of the entire recorded history of the condition, whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations. 38 C.F.R. § 3.344 (a). Moreover, not only must it be determined that an improvement in a disability has actually occurred, but also that any improvement in a disability reflects an improvement in a veteran’s ability to function under the ordinary conditions of life and work. Id.; Brown v. Brown, 5 Vet. App. 413, 420-22 (1993). This is true even for ratings such as this one that were in effect for fewer than 5 years. The burden of proof is on VA to establish that a reduction is warranted by a preponderance of the evidence. The Court has stated that both decisions by the RO and by the Board that do not apply the provisions of 38 C.F.R. § 3.344, when applicable, are void ab initio and will be set aside as not in accordance with the law. Kitchens v. Brown, 7 Vet. App. 320 (1995). Where a rating reduction was made without observance of law, the reduction must be vacated, and the prior rating restored. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In light of the above previously discussed examination reports for peripheral neuropathy, the Board finds that the reduction in the disability rating for the Veteran’s right and left lower extremity peripheral neuropathy of the femoral nerve was not proper. Overall, the evidence does not reflect that there was any improvement in the Veteran’s ability to function under the ordinary conditions of life and work considering his right and left lower extremity peripheral neuropathy of the femoral nerve at the time of the September 2016 reduction. The May 2015 examination report noted mild paresthesias and/or dysesthesias in the right and left lower extremities, mild numbness in the right and left lower extremities, decreased position sense, and no vibration sensation in the right and left lower extremities. The examiner noted mild incomplete paralysis of the left and right femoral nerves. While the March 2016 examiner noted normal femoral nerves finding no evidence of femoral nerve involvement, the examination report indicated that the Veteran continued suffer from pain, paresthesias and/or dysesthesias, and numbness in the right and left lower extremities. Considering the temporal proximity of the May 2015 and March 2016 examination reports, it is reasonable to conclude the functional impact of the Veteran’s right and left lower extremity peripheral neuropathy of the femoral nerve has not improved to the point where a rating reduction would be warranted based on improvement in the Veteran’s ability to function under the ordinary conditions of life and work. For the foregoing reasons, the reduction in the disability rating for the Veteran’s right and left lower extremity peripheral neuropathy of the femoral nerve was not proper. This renders the reduction from 10 percent to noncompensable void ab initio. Accordingly, under these circumstances, restoration of the previously assigned 10 percent rating for the Veteran’s right and left lower extremity peripheral neuropathy of the femoral nerve is warranted. The Veteran contends that the 20 percent ratings for his bilateral peripheral neuropathy symptomatology of the sciatic nerves warrant an earlier effective date than November 21, 2015. 38 U.S.C. § 5110 (a) provides that, unless specifically provided otherwise, the effective date of an award of disability compensation is set in accordance with the facts found, but cannot “be earlier than the date of receipt of application therefor.” 38 U.S.C. § 5110 (a). If a previously denied claim is later reopened and granted based on the submission of new and material evidence, the effective date of benefits will ordinarily be the date that the claimant filed the application to reopen or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(q)(2). Generally, “absent a showing of clear and unmistakable error, [a veteran] cannot receive disability payments for a time frame earlier than the application date of his claim to reopen, even with new evidence supporting an earlier disability date.” Leonard v. Nicholson, 405 F.3d 1333, 1337 (Fed. Cir. 2005). VA amended its adjudication regulations on March 24, 2015, to require that all claims governed by VA’s adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. See 79 Fed. Reg. 57660 (Sept. 25, 2014) (codified at 38 C.F.R. §§ 19.23-19.24). The amendments, however, are only effective for claims and appeals filed on or after March 24, 2015. As the claim in this case was filed prior to that date, the amendments are not applicable and the law and regulations in effect prior to March 24, 2015, will be applied in this case. Under the prior, applicable, regulations, any communication or action, indicating intent to apply for one or more benefits under laws administered by VA, from a claimant or her representative, may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155 (a) (in effect prior to March 24, 2015). In the instant case, the Veteran’s claim for service connection for right foot numbness was denied in an April 2011 rating decision. The Veteran did not file a notice of disagreement or submit additional evidence within one year of the rating decision, thus the decision became final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.156(b), 20.1103. In a May 2015 rating decision, the RO considered the Veteran’s May 2015 examination report as new and material evidence and granted the Veteran’s claim for service connection for bilateral lower extremity peripheral neuropathy of the femoral and sciatic nerves, evaluating each as 10 percent disabling effective May 5, 2015. In November 21, 2015, the Veteran filed a claim for a rating increase for his bilateral lower extremity peripheral neuropathy of the femoral and sciatic nerves. In a March 2019 rating decision, the RO granted a rating increase for bilateral lower extremity peripheral neuropathy of the sciatic nerves, evaluating it as 20 percent disabling from November 21, 2015. While the Veteran has contended that he should receive an earlier effective date than November 21, 2015, he has not argued, and the evidence does not suggest, that a formal or informal claim was submitted at an earlier date. In addition, the Veteran has not alleged clear and unmistakable error in a prior rating decision. Therefore, considering the above-cited legal authority, the Board finds that an effective date earlier than November 21, 2015 for the Veteran’s 20 percent rating for bilateral lower extremity peripheral neuropathy of the sciatic nerves is not warranted. Based on the foregoing, the Board finds that the November 21, 2015 date is the proper effective date for the 20 percent rating for the Veteran’s bilateral lower extremity peripheral neuropathy of the sciatic nerves, thus the Veteran’s appeal for an earlier effective date must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. As to consideration of referral for an extraschedular rating, the Veteran has not contended, and the evidence does not reflect, that he has experienced symptoms outside of those listed in the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017); see also Spellers v. Wilkie, 30 Vet. App. 211, 218 (2018) (“when considering the first Thun element in the context of the evaluation of a neurological condition, one must assess not only whether symptoms are contemplated by the particular DC under which the condition is rated, here, DC 8520, but also whether they are contemplated in the language of the preface to the neurologic and convulsive disorders DCs, that is, in § 4.120. Given the broad nature of that provision, finding symptoms not contemplated by its ‘impairment of motor, sensory or mental function’ language presents quite a challenge”). DMII The Veteran contends that his DMII symptomatology warrants higher than a 20 percent disability rating. The Veteran’s DMII is currently rated 20 percent disabling under DC 7913. Under DC 7913, a 20 percent rating is warranted where the diabetes requires insulin and a restricted diet; or, hypoglycemic agent and a restricted diet. A 40 percent rating is warranted for diabetes requiring insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted for diabetes requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted for diabetes requiring more than one daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Within the criteria for a 100 percent rating, “regulation of activities” is defined as “avoidance of strenuous occupational and recreational activities.” This definition also applies to the “regulation of activities” criterion for a 40 percent rating under DC 7913. Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). Moreover, medical evidence is required to support this criterion for a 40 percent rating. Id. at 364. In addition, although VA regulations generally provide that symptoms need only more nearly approximate the criteria for a higher rating to warrant such a rating, see 38 C.F.R. § § 4.7, 4.21, those regulations do not apply where, as here, the conjunction “and” is used and the criteria are successive, with the criteria for the lower ratings encompassed within those for higher ratings. Id. at 366; Tatum v. Shinseki, 23 Vet. App. 152, 155-56 (2009). A July 2016 DBQ noted that Veteran has had a diagnosis of DMII since 1998. The examination report indicated that the Veteran’s DMII was managed by a restricted diet and that he was prescribed oral hypoglycemic agents. The Veteran’s DMII did not require regulation of activities, and the Veteran visited his diabetic care provider for episodes of ketoacidosis and hypoglycemia less than 2 times per month. The Veteran did not require hospitalization over the past 12 months for episodes of hypoglycemic reactions or ketoacidosis, and the Veteran had not suffered unintentional weight loss or loss of strength due to DMII. The examination report noted that the Veteran’s DMII impacted his ability to work as it caused fatigue with physical exertion. Based on the foregoing, the Board finds that a rating higher than 20 percent is not warranted at any time throughout the appeal. The above reflects that there is no evidence of regulation of activities as required for a rating higher than 20 percent under DC 7913. There is no indication that any physician advised the Veteran to regulate his activities due to his DMII, and the July 2016 examination report notes that the Veteran’s DMII was treated with oral hypoglycemic agents and a restricted diet, but not regulation of activities. As this is the only medical opinion to specifically address the question indicated that the Veteran did not have to regulate his activities due to his DMII and there is no evidence inconsistent with this opinion, the weight of the evidence is against a finding that the Veteran’s DMII required regulation of activities. As noted, while lay evidence must be considered as part of all claims, medical evidence is required to support the regulation of activities criterion for a 40 percent rating for diabetes. Moreover, while the Veteran may contend that his DMII had worsened, he has not indicated that his DMII has worsened to the point that he requires regulation of activities. Thus, there is no indication that there was any worsening that could result in a higher rating under the applicable diagnostic code. Copeland v. McDonald, 27 Vet. App. 333, 337 (2015) (“[W]hen a condition is specifically listed in the Schedule, it may not be rated by analogy”). A retrospective medical opinion as to whether there was any worsening from the time of the most recent July 2016 examination is not warranted. See Chotta v. Peake, 22 Vet. App. at 85 (explaining that VA’s duty to obtain a medical examination, including a retrospective examination, “applies only once the evidence has met the minimal threshold of indicating the existence of a medical question”); Shoffner v. Principi, 16 Vet. App. 208, 213 (2002) (acknowledging that the Secretary has “the discretion to determine how much development is necessary” to decide a claim). As the higher ratings all require regulation of activities, and there is no argument or evidence of ketoacidosis or hypoglycemic reactions requiring hospitalizations or visits to a diabetic care provider at least twice a month, the preponderance of the evidence is against a rating higher than 20 percent for the Veteran’s DMII throughout the appeal period. The benefit of the doubt doctrine is thus not for application in this regard. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. The Veteran also contends that an effective date earlier than June 12, 2012 is warranted for his service connected DMII. The Veteran’s claim for service connection for DMII was granted in an April 2011 rating decision, evaluating it as 10 percent disabling effective November 18, 2010. In June 2012, the Veteran filed a claim for a rating increase for his DMII, and in an October 2012 rating decision, the RO granted an increase evaluating the Veteran’s DMII as 20 percent disabling effective June 12, 2012. While the Veteran has contended that he should receive an earlier effective date than June 12, 2012, he has not argued, and the evidence does not suggest, that a formal or informal claim was submitted at an earlier date. In addition, the Veteran has not alleged clear and unmistakable error in a prior rating decision. Therefore, considering the above-cited legal authority, the Board finds that an effective date earlier than June 12, 2012 for the Veteran’s 20 percent rating for DMII is not warranted. Based on the foregoing, the Board finds that the June 12, 2012 date of the Veteran’s 20 percent rating for DMII is the proper effective date for the award, thus the Veteran’s appeal for an earlier effective date must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. As to consideration of referral for an extraschedular rating, the Veteran has not contended, and the evidence does not reflect, that he has experienced symptoms outside of those listed in the rating criteria. Doucette, 28 Vet. App. 366, 369-70. TDIU The Veteran contends that he was forced to retire from his job as a truck driver due to his service connected disabilities. Although a formal claim for a TDIU has not been filed, the issue of entitlement to a TDIU is a potential part of a ratings claim when such claim is expressly raised by the Veteran or reasonably raised by the record. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). Here, the Veteran has provided evidence that he is unemployable due to his service connected disabilities, thus the issue of entitlement to a TDIU has been raised as part and parcel of the increased rating claims. VA’s Adjudication Manual, M21-1, IV.ii.2.F.2.b provides that if the issue of entitlement to a TDIU is raised and the Veteran fails to complete and return the formal TDIU application form (VA Form 21-8940), VA must decide on the issue of TDIU based on the available evidence of record. While the Adjudication Manual is not binding on the Board, DAV v. Sec’y of Veterans Affairs, 859 F.3d 1072, 1077 (Fed. Cir. 2017) (“The M21-1 Manual is binding on neither the agency nor tribunals”), the Board “is required to discuss any relevant provisions contained in the M21-1 as part of its duty to provide adequate reasons or bases.” Overton v. Wilkie, 30 Vet. App. 257, 264 (2018). In this case, the record contains sufficient evidence to conclude that the Veteran is unemployed and unemployable due to his service connected disabilities. A remand for the Veteran to complete a VA Form 21-8940 is therefore not necessary. A TDIU is provided where the combined schedular evaluation for service-connected disabilities is less than total, or 100 percent. 38 C.F.R. § 4.16 (a). VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the veteran is precluded from obtaining or maintaining any gainful employment, due to his or her service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. Under 38 C.F.R. § 4.16 (a), if there is only one such disability, it must be rated at 60 percent or more to qualify for benefits based on individual unemployability. If there are two or more such disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16 (a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § § 4.16 (a). The central inquiry is, “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran’s level of education, special training, and previous work experience, but it may not be given to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. See Van Hoose, 4 Vet. App. at 363. “A high rating in itself is a recognition that the impairment makes it difficult to obtain or keep employment.” Id. The ultimate question, however, is “whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment.” Id. Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16 (a). Marginal employment generally shall be deemed to exist when a veteran’s earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Id. Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Id. In light of the decision herein, the Veteran is currently rated for the following disabilities: DMII, 20 percent disabling from June 12, 2012; left and right lower extremity peripheral neuropathy of the sciatic nerve, both evaluated as 20 percent disabling from November 21, 2015; and right and left lower extremity peripheral neuropathy of the femoral nerve, both evaluated as 10 percent disabling from May 5, 2015. As such, the Veteran has a combined 60 percent disability rating, and as his disabilities arise from a common etiology, his exposure to Agent Orange in Vietnam, the Veteran meets the percentage requirements for a TDIU in accordance with 38 C.F.R. § 4.16 (a). The May 2015 examiner opined that the Veteran’s diabetic peripheral neuropathy impacts his ability to work as prolonged standing and walking causes bilateral foot burning pain with numbness and tingling, and the March 2016 examiner noted that the Veteran’s peripheral neuropathy made it so that the Veteran is unable to climb into trailers, use the clutch repetitively, or stand for long periods of time. The July 2016 examination report indicated that the Veteran’s DMII impacted the Veteran’s ability to work as it caused fatigue with physical exertion. Based on the foregoing, the Board finds that the evidence of record is at least in equipoise on the question of whether the service-connected disabilities preclude the Veteran from securing and following substantially gainful employment for which the Veteran would otherwise be qualified. The Veteran has indicated that he previously worked as a truck driver, but his peripheral neuropathy would preclude him from working in such a capacity as he is unable to walk or stand for any long period of time, and even climbing into trailers or using the clutch, a task absolutely necessary for a truck driver, would be unfeasible due to his service connected disabilities. The evidence is thus at least evenly balanced as to whether the Veteran’s service connected disabilities render him unable to secure or follow substantially gainful employment. Accordingly, entitlement to a TDIU is warranted. It appears that the Veteran stopped working due to his service connected disabilities in March 2010. However, the Board will not specify the effective date of the TDIU to allow the RO to do so in the first instance. See Urban v. Principi, 18 Vet. App. 143, 145 (2004) (per curiam order) (“To the extent that [the appellant] is arguing that the Board must assign, sua sponte, an effective date once it awards a rating of TDIU on appeal from an RO decision, such an argument is unavailing unless an NOD is then of record as to the downstream issue of an effective date for the assignment of that rating.”) REASONS FOR REMAND Eye disabilities The Veteran contends that he suffers from a bilateral eye disability due to his service connected DMII. The record contains diagnoses other than glaucoma and cataracts. Therefore, the Board has expanded the issue on appeal to include all eye disabilities consistent with the holding in Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran’s September 1968 medical examination report upon discharge was normal with no noted eye disability. A March 2011 VA examination report noted a diagnosis of refractive error and presbyopia which was not caused by or related to DMII, and glaucoma suspect in both eyes which was not caused by or a result of DMII. The examiner referenced medical literature review, medical record review, and clinical experience to support his opinion. The examiner also noted a diagnosis of trace cataracts, but was not able to opine whether cataracts were caused by or related to DMII. The examiner noted that cataract is a natural aging process of the lens that can progress at an increased rate with various system disorders including DMII without a means to distinguish between the two causes, therefore it would be speculative to report the etiology of the Veteran’s cataracts. A September 2012 VA examination report noted that the Veteran had diagnoses of conjunctivitis, cataracts, and tumors and neoplasms, and glaucoma. In a July 2016 DBQ, the examiner opined that the Veteran’s eye disabilities were less likely than not (less than a 50 percent probability) proximately due to or the result of the Veteran’s service connected DMII. The examiner stated that as to the Veteran’s cataracts, while the incidence of cataracts is higher in a diabetic population than a non-diabetic one, and the age of onset is earlier, cataracts are ubiquitous in an otherwise normal aging population. The examiner stated that a diabetic cataract is indistinguishable in appearance from a cataract of any other cause and that the only clue that they are caused by diabetes is an unusually young age of onset or a severity disproportionate to the age of the individual. The examiner noted that the Veteran’s cataracts are mild considering his age, thus they are less likely than not due to DMII. The July 2016 examiner also noted that a Collaborative Low-Tension Glaucoma Study Group found no association between DMII and low-tension glaucoma. The examiner therefore opined that it was less likely than not that the Veteran’s glaucoma is due to his DMII. The Board finds the aforementioned opinions inadequate as they fail to address whether the Veteran’s eye disabilities were aggravated by his service connected DMII. A medical opinion that does not specifically address aggravation is generally inadequate to decide a secondary service connection claim. El-Amin v. Shinseki, 26 Vet. App. 136 (2013). The March 2011 VA examination failed to address whether the Veteran’s cataracts were aggravated by his DMII, and the July 2016 opinion failed to address aggravation regarding the Veteran’s eye disabilities, and such cannot be inferred from the opinions. Consequently, a remand is warranted for an opinion that specifically addresses aggravation. Hypertension The Veteran contends that he suffers from hypertension which was caused by exposure to Agent Orange during service in Vietnam. March 2010 private treatment notes indicate a diagnosis of hypertension. An October 2010 Persian Gulf Registry Note noted blood pressure 154/93, indicated that Veteran was deployed to Vietnam from 1967 to 1968, and noted exposure to Agent Orange. The Registry Note indicated the Veteran reported that his hypertension was known since 1968 and that his general blood pressure runs 137/70 with medication. March 2011 VA examination notes indicate the Veteran reported a history of hypertension with a diagnosis in 1968. The examiner noted a current diagnosis of hypertension, but opined that it was not caused by or a result of his DMII. The examiner noted that the Veteran’s hypertension had its onset many years prior to the Veteran’s onset of DMII. The examiner also noted that the objective data did not support that the Veteran’s hypertension was worsened or increased by the Veteran’s DMII. The examination report noted that the Veteran is unemployed due to his arthritis and gout as he would not be able to pass his Department of Transportation physical as a truck driver. While the Veteran has reported that his hypertension was diagnosed in 1968, there is no objective evidence of treatment for or a diagnosis of hypertension within a year after discharge from service, thus service connection for hypertension as a chronic disease is not warranted. While the Veteran is competent to provide testimony or statements relating to symptoms or facts of events that he has observed and is within the realm of his personal knowledge, he is not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The record does not show, nor does the Veteran contend, that he has specialized education, training, or experience that would qualify him to render a diagnosis or render a medical opinion on this matter as it involves a complex medical issue that goes beyond a simple and immediately observable cause-and-effect relationship. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). While the March 2011 examiner opined that the Veteran’s hypertension was not caused by or a result of his service connected DMII, the examiner did not address the Veteran’s presumed exposure to Agent Orange. Recently, hypertension was moved from the “limited or suggestive” category to the category of “sufficient” evidence of an association. Veterans and Agent Orange: Update 11 (2018). However, hypertension has not yet been added to the list of diseases for which veterans exposed to Agent Orange are entitled to service connection on a presumptive basis. A remand is therefore warranted for an opinion as to whether the Veteran’s hypertension is related to his presumed Agent Orange exposure or, if hypertension is added to the list of diseases for which veterans exposed to Agent Orange are entitled to service connection on a presumptive basis, for the grant of service connection. Urinary tract infection The Veteran contends that he suffers from a urinary tract infection caused by service. December 1967 service treatment records note the Veteran was treated for urethritis. He complained of burning with urination and discharge. The Veteran’s September 1968 medical examination report upon discharge does not note any issues with his urinary tract. Gout The Veteran contends that his gout was caused by service. The Veteran’s September 1968 medical examination report upon discharge does not note any issues regarding gout. February 2010 private treatment records note that the Veteran was treated for gout, noting right elbow pain. A July 2010 audiological consult report noted that the Veteran stated that he first suffered from gout in 1980 and that it flares off and on. Erectile dysfunction The Veteran contends that his erectile dysfunction was caused by his service connected DMII. August 2012 VA treatment notes indicate the Veteran was treated for erectile dysfunction. In an October 2013 statement, the Veteran stated that he was told by his urologist that his erectile dysfunction “definitely could be related to DMII.” In this regard, the Court has held that lay evidence regarding what a medical professional told a lay person was specifically listed as an example of competent lay testimony in Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Therefore, the Veteran is competent to relate what physicians stated to him regarding a possible nexus. The Veteran’s July 2016 DBQ indicates that the Veteran does not have erectile dysfunction that is at least as likely as not due to his DMII. Unfortunately, the Board cannot make a fully-informed decision on the issues of entitlement to service connection for urinary tract infection and gout because no VA examiner has opined whether the Veteran currently has the disabilities, and if so, if they are etiologically related to service. VA must provide a medical examination or obtain a medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A (d)(2) (2012); 38 C.F.R. § 3.159 (c)(4)(i) (2018). The third prong, which requires that the evidence of record “indicate” that the claimed disability or symptoms “may be” associated with the established event, disease or injury, is a low threshold. McLendon, 20 Vet. App. at 83. The Veteran has provided competent lay evidence of a urinary tract infection and gout, evidence of in-service injuries or treatment, and indicated that the current symptoms may be associated with service. As the evidence is insufficient to make an informed decision on the claim, a remand for VA examinations is warranted. Additionally, the Board cannot make a fully-informed decision on the issue of service connection for erectile dysfunction because while the July 2016 examination report indicated the Veteran’s erectile dysfunction was not related to his service connected DMII, the examiner did not opine as to whether the Veteran’s ED was related to service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Therefore, a remand is necessary for a new VA examination. Psychiatric Disorder, to include PTSD The Veteran contends that he suffers from a psychiatric disability including stress anxiety disorder due to being stationed at Phu Bai, Vietnam as an electrician which he contends was a target for attack by the Viet Cong. There are particular requirements for establishing service connection for PTSD in 38 C.F.R. § 3.304 (f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Service connection for PTSD requires: (1) a medical diagnosis of PTSD utilizing the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM 5) criteria, in accordance with 38 C.F.R. § 4.125 (a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. See 38 C.F.R. § 3.304 (f). The Board notes that the DSM-IV has been recently updated with a Fifth Edition (DSM-5). VA has amended 38 C.F.R. § 4.125(a) to require the diagnosis to conform to DSM-5. The amendment applies to cases such as this one that were certified to the Board after to August 4, 2014. See Schedule for Rating Disabilities—Mental Disorders and Definition of Psychosis for Certain VA Purposes, 80 Fed. Reg. 14308 (Mar. 19, 2015). Under 38 C.F.R. § 3.304 (f)(3), if a stressor claimed by a veteran is related to the veteran’s fear of hostile, military, or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD, and the veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places and circumstances of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, “fear of hostile military or terrorist activity” means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. The Veteran’s September 1968 medical examination report upon discharge is normal with no indication that the Veteran was treated for any psychiatric disabilities. A July 2014 private behavioral health examination report noted that the Veteran served in Vietnam as a utility electrician and witnessed a lot of injuries, dismemberment and death from rocket and mortar attacks. The report indicated that the Veteran suffers from daily fears of confronting death due to attacks from the enemy. The psychiatrist diagnosed the Veteran with PTSD due to service in Vietnam. A March 2015 VA examination report indicated that the Veteran’s claimed psychiatric disability was less likely than not (less than a 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness as the examining psychologist noted that the Veteran did not currently have a mental disorder. The psychologist noted that the Veteran reported realistic anxiety and dysphoria in response to events that would normally evoke these symptoms. The psychologist also noted that the Veteran did not endorse any PTSD symptoms, and his difficulty engaging with others appears more a function of his antisocial traits than a mental disability. The examination report noted the Veteran’s 2 periods of incarceration which exemplified his antisocial traits and behavior. The psychologist noted the Veteran’s symptoms did not meet the diagnostic criteria for PTSD under DSM-5 criteria, and that the Veteran did not have a mental disorder that conforms with DSM-5 criteria. However, with regard to the July 2014 diagnosis by the private psychiatrist, “[m]edical professionals are presumed competent to do their job.” Schertz v. Shinseki, 26 Vet. App. 362, 369 (2013) (citing Sickels v. Shinseki, 643 F.3d 1362, 1366 (Fed. Cir. 2011) (applying presumption of regularity to medical examiners’ competence). Moreover, health professionals “are presumed to know the [applicable] DSM requirements applicable to their practice and to have taken them into account in providing a PTSD diagnosis.” Cohen v. Brown, 10 Vet. App. 128, 139, 140 (1997). A remand is warranted to reconcile these conflicting diagnoses. Moreover, the Veteran appears to have experienced fear of hostile military or terrorist activity as that term is defined in the applicable regulation. 38 C.F.R. § 3.304(f)(3). Although service connection for PTSD is warranted in certain circumstances without verification of a claimed stressor where a veteran has experienced fear of hostile military or terrorist activity, the criteria of the regulation are satisfied only if the diagnosis of PTSD be by a VA psychologist. The matters are REMANDED for the following action: 1. Request an opinion to determine the nature and etiology of the Veteran’s bilateral eye disabilities. The claims file must be sent to the examiner for review. The examiner should opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s bilateral eye disability was either (a) caused or (b) aggravated by a service-connected disability, to include the Veteran’s DMII. If aggravation is found, the baseline level of disability should be identified to the extent possible. 2. Schedule the Veteran for an examination with an appropriate physician to determine the nature and etiology of the Veteran’s hypertension. The physician must opine whether the Veteran’s hypertension is at least as likely as not (at least a 50 percent probability) related to service, to include as due to exposure to an herbicide agent. The physician must consider the recent 2018 hypertension was moved from the “limited or suggestive” category to the category of “sufficient” evidence of an association. Veterans and Agent Orange: Update 11 (2018). 3. Schedule the Veteran for an examination to determine the nature and etiology of any urinary tract infection. The examiner must opine whether any urinary tract infection is at least as likely as not (at least a 50 percent probability) related to service, to include the noted treatment for urethritis during service. 4. Schedule the Veteran for an examination to determine the nature and etiology of his gout. The examiner must opine whether the Veteran has gout that is at least as likely as not related service. 5. Schedule the Veteran for an examination to determine the nature and etiology of his erectile dysfunction. The examiner must opine whether the Veteran’s erectile dysfunction is at least as likely as not (at least a 50 percent probability) related to service, to include as due to exposure to Agent Orange during service. The examiner should also opine as to whether the erectile dysfunction is either (a) caused or (b) aggravated by the service connected DM. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be considered when formulating the requested opinion. 6. Request an opinion from a VA psychiatrist or psychologist as to the nature and etiology of any psychiatric disorder with which the Veteran has been diagnosed since approximately October 2013 when he filed his claim in this case. The claims file should be reviewed by the psychiatrist or psychologist. The psychiatrist or psychologist should indicate all diagnoses, specifically addressing the conflicting diagnoses of PTSD by the private psychiatrist in July 2014 and the finding of no PTSD by the VA examiner in March 2015. If PTSD is diagnosed, the psychiatrist or psychologist should indicate the stressor or stressors upon which the diagnosis is based. If any other psychiatric disorder is diagnosed, the psychiatrist or psychologist should indicate whether it is at least as likely as not related to service, to include the claims stressors. A complete rationale should accompany any opinion given. The Veteran is competent to report symptoms, treatment, and injuries, and these reports should be taken into account in formulating the requested opinion. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Maddox, Associate Counsel 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.