Citation Nr: 21001545 Decision Date: 01/08/21 Archive Date: 01/08/21 DOCKET NO. 19-31 555 DATE: January 8, 2021 ORDER 1. New and material evidence having been received, the claim of service connection for sleep apnea is reopened. 2. From September 23, 2014 to April 14, 2015, a 50 percent rating, but no higher, for posttraumatic stress disorder (PTSD) with major depressive disorder (MDD), is granted, subject to the applicable laws and regulations governing the payment of monetary benefits. 3. Since April 15, 2015, exclusive of the period of a temporary total rating from August 27, 2015 to September 30, 2015, a rating in excess of 70 percent for PTSD with MDD is denied. 4. An effective date prior to April 15, 2015 for service connection for diabetes mellitus, type 2, is denied. 5. An effective date of September 29, 2016 for service connection for right upper extremity peripheral neuropathy is granted, subject to the applicable laws and regulations governing the payment of monetary benefits. 6. An effective date of September 29, 2016 for service connection for left upper extremity peripheral neuropathy is granted, subject to the applicable laws and regulations governing the payment of monetary benefits. REMANDED 1. A rating in excess of 30 percent for pancreatitis. 2. An initial rating in excess of 20 percent for diabetes mellitus, type 2. 3. A rating in excess of 10 percent for right lower extremity sciatic nerve peripheral neuropathy. 4. A rating in excess of 10 percent for left lower extremity sciatic nerve peripheral neuropathy. 5. A rating in excess of 10 percent for right lower extremity femoral nerve peripheral neuropathy. 6. A rating in excess of 10 percent for left lower extremity femoral nerve peripheral neuropathy. 7. An initial rating in excess of 20 percent for right upper extremity peripheral neuropathy. 8. An initial rating in excess of 20 percent for left upper extremity peripheral neuropathy. 9. Service connection for leukemia. 10. Service connection for sleep apnea. FINDINGS OF FACT 1. From September 23, 2014 to April 14, 2015, the Veteran’s PTSD with MDD manifested in occupational and social impairment with reduced reliability and productivity, but not occupational and social impairment with deficiencies in most areas or total occupational and social impairment. 2. Since April 15, 2015, exclusive of the temporary total rating period from August 27, 2015 to September 30, 2015, the Veteran’s PTSD with MDD has resulted in occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. 3. The Veteran initially filed a claim of service connection for diabetes mellitus, type 2, on April 15, 2015. 4. The Veteran has experienced compensable right and left upper extremity peripheral neuropathy since September 29, 2016 as complications of diabetes. CONCLUSIONS OF LAW 1. From September 23, 2014 to April 14, 2015, the criteria for a 50 percent rating, but no higher, for PTSD with MDD are met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411. 2. Since April 15, 2015, exclusive of the temporary total rating period from August 27, 2015 to September 30, 2015, the criteria for a rating in excess of 70 percent for PTSD with MDD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, DC 9411. 3. The criteria for an effective date prior to April 15, 2015 for an award of service connection for diabetes mellitus, type 2, have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400. 4. The criteria for an effective date of September 29, 2016, but no earlier, for service connection for right upper extremity peripheral neuropathy are met. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.400, 4.119, DC 7913. 5. The criteria for an effective date of September 29, 2016, but no earlier, for service connection for left upper extremity peripheral neuropathy are met. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.400, 4.119, DC 7913. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1996 to February 2009, from July 2007 to January 2008, and from February 2011 to June 2013. The case is on appeal from January 2016, July 2017, and October 2017 rating decisions. In September 2019, the Veteran’s representative requested a 90 day extension to submit additional evidence, which the Board granted in December 2019. Thereafter, the Veteran’s representative submitted additional evidence and argument later in December 2019. The Veteran’s representative also submitted additional evidence in September 2020. Waiver of RO consideration of the additional evidence is presumed given the date of the substantive appeal. See 38 U.S.C. § 7105(e). The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). I. New and Material Evidence 1. Whether new and material evidence has been submitted to reopen a claim of service connection for sleep apnea. By a January 2015 rating decision, a claim of service connection for sleep apnea was denied. The Veteran was notified of the decision by letter later that month, which was mailed to the then current mailing address of record. Thereafter, nothing further regarding the claim was received until the present claim to reopen in September 2017. No new evidence or notice of disagreement was received by VA within one year of the issuance of the January 2015 rating decision. As the Veteran did not appeal the decision, that rating decision is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. The Board finds that new and material evidence has been submitted so that the previously denied claim of service connection for sleep apnea is reopened. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). See also Journal Article submitted in September 2020. II. Increased Rating Claim 2. A higher rating for PTSD with MDD, exclusive of the prior grant of a temporary total rating from August 27, 2015 to September 30, 2015. Legal Criteria Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Under 38 C.F.R. § 4.130, PTSD is rated pursuant to the General Rating Formula for Mental Disorders. Evaluation of a mental disorder requires consideration of the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission. Evaluations will be assigned based on all evidence of record that bears on occupational and social impairment, rather than solely on an examiner’s assessment of the level of disability at the moment of the examination. The extent of social impairment shall also be considered, but an evaluation may not be assigned based solely on the basis of social impairment. 38 C.F.R. § 4.126. A 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The Board notes that the records contain various global assessment of functioning (GAF) scores. However, GAF scores have been found to be unreliable and not sufficient evidence for rating a psychiatric disorder. See Golden v. Shulkin, 29 Vet. App. 221, 226 (2018). Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In addition, an effective date for an increased rating should not be assigned mechanically based on the date of a diagnosis. Rather, all of the facts should be examined to determine the date that the disability first manifested. Accordingly, the effective date for an increased rating-as well as for an initial rating or for staged ratings-is predicated on when the increase in the level of disability can be ascertained. Swain v. McDonald, 27 Vet. App. 219, 224 (2015); DeLisio v. Shinseki, 25 Vet. App. 45, 56 (2011). In determining when an increase is “factually ascertainable,” all of the evidence must be looked to, including testimonial evidence and expert medical opinions, and an effective date must be assigned based on that evidence. See McGrath v. Gober, 14 Vet. App. 28, 35-36 (2000); VAOPGCPREC 12-98. Thus, “it is the information in a medical opinion, and not the date the medical opinion [that] was provided that is relevant when assigning an effective date.” Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010); see also Young v. McDonald, 766 F.3d 1348 (Fed. Cir. 2014). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Analysis In April 2015, the Veteran filed a claim for a rating in excess of 30 percent for PTSD. Within one year of present claim, he was afforded a psychiatric examination on September 23, 2014. The Veteran reported maintaining good relationships with his sisters. He also reported a history of working as an emergency medical technician. The examiner diagnosed the Veteran with PTSD with symptoms of depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. The examiner denied the presence of psychosis and suicidal and homicidal ideation. The examiner found that the Veteran’s PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran’s VA treatment records include a psychiatric assessment from October 2, 2015. The treatment provider reported that the Veteran was anxious, but found that his thought content was relevant, and his thought processes were logical and coherent. The treatment provider denied evidence of suicidal ideation, homicidal ideation, and violent thoughts. The Veteran submitted a PTSD disabilities benefits questionnaire (DBQ) completed by a VA psychologist in October 2015. The Veteran reported living with his mother, stepfather, and stepsister. He also reported being close to one of his sisters. The psychologist reported that the Veteran has a history of psychiatric hospitalizations and substance abuse and diagnosed him with PTSD, MDD, and substance abuse disorders in remission. He reported symptoms of depressed mood, anxiety, panic attacks more than once a week, sleep impairment, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, impaired impulse control, persistent danger of hurting self or others, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living. The psychologist found that the Veteran is able to manage his financial affairs. He concluded that the Veteran experiences occupational and social impairment, with deficiencies in most areas. In a January 2016 rating decision, the RO granted the Veteran a temporary total evaluation from August 27, 2015 to September 30, 2015 based on psychiatric hospitalization and assigned a 70 percent rating effective October 1, 2015. After engaging in a holistic analysis assessing the severity, frequency and duration of the signs and symptoms of the Veteran’s PTSD with MDD, recognizing that the symptoms listed in the rating criteria are non-exhaustive examples and when looking at the effects determining the impairment level, the Board finds that a 50 percent rating is factually ascertainable as early as September 23, 2014; a rating in excess of 50 percent is not warranted prior to April 15, 2015; and a rating in excess of 70 percent is not warranted outside of the temporary rating period from August 27, 2015 to September 30, 2015. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013); Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); Mauerhan v. Principi, 16 Vet. App. 436 442 (2002); see also Swain, 27 Vet. App. at 219. In this regard, the September 2014 VA examination occurred within one year of the present claim and included a report of disturbances of motivation and mood, indicating impairment at the 50 percent level. However, a rating in excess of 50 percent is not warranted prior to April 15, 2015. The September 2014 examiner did not report the presence of occupational and social impairment with deficiencies in most areas. In addition, the September 2014 examination and the Veteran’s treatment records do not show symptoms indicative of a rating in excess of 50 percent prior to April 15, 2015. Furthermore, since April 15, 2015, the evidence does not show the presence of total occupational and social impairment outside of the temporary total rating period. The Board notes that the October 2015 VA psychologist DBQ reported the presence of persistent danger of hurting self or others, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living. However, the psychologist also reported that the Veteran is living with family and has a good relationship with his sister. He further reported that the Veteran is able to manage his finances and found that he experiences occupational and social impairment with deficiencies in most areas rather than total occupational and social impairment. The Veteran has also consistently reported having good relationships with some family members, which indicates that he has not experienced total social impairment. The preponderance of the evidence shows that, from September 23, 2014 to April 14, 2015, the Veteran’s PTSD with MDD manifested in occupational and social impairment with reduced reliability and productivity, but not occupational and social impairment with deficiencies in most areas or total occupational and social impairment and that, since April 15, 2015, exclusive of the temporary total rating period from August 27, 2015 to September 30, 2015, the Veteran’s PTSD with MDD has resulted in occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. Therefore, while a 50 percent rating is warranted from September 23, 2014 to April 14, 2015, the benefit of the doubt doctrine is not further applicable and a rating in excess of 70 percent outside of the temporary total rating period is not warranted since April 15, 2015. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Although the Board is remanding other claims for additional development, remand is not necessary for this issue, as there is no reasonable possibility that further assistance would substantiate the claim. See 38 C.F.R. § 3.159(d). III. Earlier Effective Dates 3. An effective date prior to April 15, 2015 for service connection for diabetes mellitus, type 2. 4. An effective date prior to August 31, 2016 for service connection for right upper extremity peripheral neuropathy. 5. An effective date prior to August 31, 2016 for service connection for left upper extremity peripheral neuropathy. Legal Criteria The effective date of an original award of direct service connection is the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service; otherwise, date of receipt of claim, or date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400(b)(2)(i). Generally, except as otherwise provided, the effective date of an evaluation and award of pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim, or the date entitlement arose, whichever is later. See 38 U.S.C. § 5110; 38 C.F.R. § 3.400. For increases in disability, the effective date will generally be the date of receipt of claim or date entitlement arose, whichever is later. 38 C.F.R. § 3.400(o)(1). However, an effective date for an increased rating should not be assigned mechanically based on the date of a diagnosis. Rather, all of the facts should be examined to determine the date that the disability first manifested. Accordingly, the effective date for an increased rating-as well as for an initial rating or for staged ratings-is predicated on when the increase in the level of disability can be ascertained. Swain, 27 Vet. App. at 224. Furthermore, the effective date may be assigned beginning from the earliest date as of which it is factually ascertainable based on all evidence of record that an increase in disability had occurred if a complete claim or intent to file a claim is received within one year from such date. 38 C.F.R. § 3.400(o)(2); Gaston v. Shinseki, 605 F.3d 979, 980 (Fed. Cir. 2010). Analysis The Veteran initially filed a claim of service connection for diabetes mellitus, type 2, on April 15, 2015. In a January 2016 rating decision, the Veteran was granted service connection for diabetes mellitus, type 2, effective April 15, 2015. Thereafter, the Veteran submitted an intent to file a claim on August 31, 2016. In a December 2016 notice of disagreement (NOD), the Veteran disagreed with the assigned diabetes rating. Then, in April 2017, he filed a claim for bilateral upper extremity peripheral neuropathies as complications of diabetes. The Veteran was afforded an examination in November 2015 for diabetic sensory motor peripheral neuropathy. The examiner denied the presence of right and left upper extremity symptoms and found that the Veteran did not have upper extremity peripheral neuropathy. Subsequently, on September 29, 2016, the Veteran’s VA treatment records show that he called into a VA medical center and requested treatment for neuropathy in his fingers. The Veteran was seen by a VA physician in November 2016 in regard to such symptoms. The physician reported a history of neuropathy in the legs and the onset of neuropathy in both hands that results in difficulty writing and hand cramps. The physician diagnosed the Veteran with bilateral hand neuropathies related to diabetes mellitus, type 2. In June 2017, the Veteran was afforded another diabetic sensory motor peripheral neuropathy examination. The examiner reported the presence of bilateral upper extremity peripheral neuropathies. In a July 2017 rating decision, the RO granted service connection for right and left upper extremity peripheral neuropathies associated with diabetes, effective August 31, 2016. In this case, the effective date for service connection for diabetes is the date of receipt of the claim or the date entitlement to service connection arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400(b)(2)(i). No formal or informal communication requesting a determination of entitlement, or evidencing a belief in entitlement, to this condition was submitted prior to April 15, 2015. In addition, the claim was submitted more than one year after the Veteran’s discharge from service, so the exception allowing for earlier effective dates for claims filed within one year of discharge is not applicable. Therefore, an effective date for service connection for diabetes mellitus, type 2, is not warranted prior to April 15, 2015. However, Note 1 to the DC 7913 for diabetes mellitus states to evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100-percent evaluation and that noncompensable complications are considered part of the diabetic process under DC 7913. 38 C.F.R. § 4.119, DC 7913. In this case, the Veteran’s right and left upper extremity peripheral neuropathies are first shown to be present during the pendency of the increased diabetes rating claim addressed herein. Therefore, the proper effective date for these disabilities is September 29, 2016, which is the first date these separately compensable diabetes complications are shown to have been present. 38 C.F.R. § 3.400(o)(1); Swain, 27 Vet. App. at 224. The preponderance of the evidence shows that the Veteran submitted an initial claim of service connection for diabetes mellitus, type 2, on April 15, 2015, and that the onset of the diabetic complications of compensable bilateral upper extremity peripheral neuropathies is factually ascertainable as of September 29, 2016. Therefore, while an effective date of September 29, 2016 is warranted for the bilateral upper extremity peripheral neuropathies, the benefit of the doubt doctrine is not further applicable, and an earlier effective date for diabetes or even earlier effective dates for the peripheral neuropathies are not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Although the Board is remanding other claims for additional development, remand is not necessary for these issues, as there is no reasonable possibility that further assistance would substantiate the claims. See 38 C.F.R. § 3.159(d). REASONS FOR REMAND 1. A rating in excess of 30 percent for pancreatitis. The Veteran is seeking a rating in excess of 30 percent for pancreatitis that resulted in development of diabetes. In a December 2019 correspondence, the Veteran’s representative reported that this condition resulted in severe, disabling abdominal pain 3 times in the prior 12 months with few remissions. He also reported symptoms of steatorrhea, diarrhea, weight loss, and multiple hospitalizations resulting in limitation in the ability to work. The Board notes that the Veteran’s representative indicated in a December 2016 NOD that the Veteran is requesting an earlier effective date for an award of benefits related to pancreatitis. However, as no benefits have been awarded in regard to the increased rating claim for this disability, there is no earlier effective date claim presently before the Board. In October 2015, the Veteran submitted a DBQ completed by a private treatment provider. He reported that the Veteran has pancreatitis that is treated by insulin. He also reported severe, disabling episodes of abdominal pain 3 times in the prior 12 months with few pain-free intermissions between attacks. The treatment provider explained that hospitalizations have limited the Veteran’s ability to work, most recently in July 2015. He further reported symptoms of steatorrhea, diarrhea, and weight loss. He also stated that the Veteran’s weight was down to 115 pounds during an attack of diabetes in March 2015. A VA assessment of the Veteran’s pancreatitis based on his treatment records was obtained in October 2018. The examiner reported a diagnosis of pancreatitis with steatorrhea. The examiner noted no documentation of recent attacks. On remand, the Veteran should be afforded an examination to determine the severity of his pancreatitis. 2. An initial rating in excess of 20 percent for diabetes mellitus, type 2. The Veteran is seeking an initial rating in excess of 20 percent for diabetes. In a December 2019 correspondence, the Veteran’s representative reported that this condition results in the need for an insulin pump and regulation of activities. The Veteran was afforded a VA examination in November 2015. The examiner reported a diagnosis of diabetes mellitus, type 2, treated by restricted diet and more than one insulin injection per day. The examiner denied the need for regulation of activities due to diabetes. The Veteran was afforded another examination in October 2018. The examiner reported a diagnosis of diabetes mellitus, type 2, treated by restricted diet, oral hypoglycemic agent, one insulin injection per day, and use of an insulin pump. The examiner also reported the need for required regulation of activities, but listed as an example the need to count carbohydrates due to the insulin pump. While the October 2018 examiner found that the Veteran is required to regulate his activities, the only regulation he lists is related to restriction of diet. However, the term “regulation of activities” means that a claimant must have a medical need to avoid strenuous occupational and recreational activities and medical evidence is needed to show such activities have been restricted. See 38 C.F.R. § 4.119, DC 7913; Camacho v. Nicholson, 21 Vet. App. 360, 363-64 (2007). Therefore, a remand is necessary for another examination to determine if the Veteran’s diabetes results in required regulation of activities in terms of avoiding strenuous work or recreation. 3. A rating in excess of 10 percent for right lower extremity sciatic nerve peripheral neuropathy. 4. A rating in excess of 10 percent for left lower extremity sciatic nerve peripheral neuropathy. 5. A rating in excess of 10 percent for right lower extremity femoral nerve peripheral neuropathy. 6. A rating in excess of 10 percent for left lower extremity femoral nerve peripheral neuropathy. 7. An initial rating in excess of 20 percent for right upper extremity peripheral neuropathy. 8. An initial rating in excess of 20 percent for left upper extremity peripheral neuropathy. The Veteran is also seeking higher ratings for bilateral lower and upper extremity peripheral neuropathies. In a December 2019 correspondence, the Veteran’s representative reported that the Veteran’s lower extremity conditions result in moderate incomplete paralysis. He also reported that a June 2017 examiner reported the conditions are moderate to severe. The Board notes that the Veteran’s representative submitted an August 2017 NOD requesting earlier effective dates related to the Veteran’s bilateral sciatic nerve and femoral nerve disabilities. The Veteran was granted service connection for these conditions and assigned 10 percent ratings in a January 2016 rating decision. No NOD or new and material evidence was received within one year of notification of such decision, thus, the January 2016 decision became final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 20.302, 20.1103. The Veteran then submitted an intent to file a claim in August 2016 and requested increased ratings for his lower extremity disabilities in April 2017. To the extent that the Veteran is seeking an earlier date for service connection for such conditions, VA claimants may not properly file, and VA has no authority to adjudicate, a freestanding claim for an earlier effective date in an attempt to overcome the finality of an unappealed RO decision. See 38 U.S.C. § 7105; Rudd v. Nicholson, 20 Vet. App. 296 (2006). In addition, there have been no benefits awarded in regard to the present higher rating claims for the lower extremity disabilities. Therefore, as no benefits have been awarded in regard to such disabilities, there are no earlier effective date claims presently before the Board for the lower extremity conditions. The Veteran was afforded a VA peripheral neuropathy examination in November 2015. The examiner denied the presence of upper extremity symptoms and rated the lower extremity symptoms moderate in severity. Thereafter, he was afforded another VA peripheral neuropathy examination in June 2017. The Veteran reported experiencing ongoing numbness and tingling in the hands and being unable to write with a pen or pick up small objects. He also reported always feeling like he is walking on rocks and being unable to feel the water in the shower. The examiner reported bilateral lower and upper extremity moderate pain, paresthesias, and numbness. The examiner also reported decreased sensation to light touch in the hands, fingers, lower legs, feet, and toes. The examiner further reported decreased vibration sensation in the bilateral lower and upper extremities. She denied the presence of muscle atrophy and reduced muscle strength and reflexes. The examiner concluded that the Veteran has moderate to severe lower and upper extremity neuropathies. She found the Veteran’s bilateral femoral nerve and upper extremity neuropathies result in moderate incomplete paralysis and his bilateral lower sciatic nerve neuropathies result in moderately severe incomplete paralysis. The Board finds that another examination to assess the severity of these conditions is required. In this regard, the June 2017 examiner reported that the neuropathies are moderate to severe without explaining which neuropathies are moderate and which are severe. The examiner also did not report any individual symptoms to be severe or sensitivities to be absent, but also found that the sciatic nerve neuropathies were moderately severe. 9. Service connection for leukemia. The Veteran filed a claim for service connection for chronic myeloid leukemia in April 2017, but did not explain why he believes this condition is related to service. In an April 2013 memorandum, the Department of the Army found that the Veteran’s service treatment records (STRs) for the period of service from 1996 to 2002 are unavailable. The Veteran’s file includes some STRs for his periods of service from July 2007 to January 2008 and from February 2011 to June 2013. However, a remand is required to try to locate additional STRs from such periods of service, to include enlistment and separation examinations. 10. Service connection for sleep apnea. The Veteran is seeking service connection for sleep apnea. In September 2020, the Veteran’s representative submitted a journal article regarding a possible relationship between psychiatric disorders and sleep apnea. The Veteran’s STRs include November 2012 treatment for difficulty falling asleep and staying asleep. The RO scheduled the Veteran for an examination in November 2019, however, he did not attend. In a January 2020 statement, the Veteran reported that he did not know about the examination. On remand, the Veteran should be afforded an examination to determine the nature and etiology of his sleep apnea. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). These claims are REMANDED for the following actions: 1. Contact the appropriate service department and/or records custodian(s), such as the National Personnel Records Center, to request copies of the Veteran’s complete STRs and SPRs for his periods of service from July 2007 to January 2008 and from February 2011 to June 2013, to include all entrance and separation examinations. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc. if an in person examination is not feasible) to assess the severity of the service-connected pancreatitis. The examiner should list all hospitalizations for this condition since April 2015. 3. Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc. if an in person examination is not feasible) to assess the severity of the service-connected diabetes mellitus, type 2. If required regulation of activities is found, the examiner should list all restrictions of activities required due to diabetes. 4. Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc. if an in person examination is not feasible) to assess the severity of the service-connected bilateral sciatic nerve, femoral nerve, and upper extremity peripheral neuropathies. 5. Schedule the Veteran for an examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) by an appropriate medical professional to determine the nature and etiology of the sleep disorders. The entire claims file should be reviewed by the examiner. Thereafter, the examiner is asked to: (a.) Identify all of the Veteran’s sleep disorders experienced since September 2017. (b.) State whether it is at least as likely as not that each disorder had its onset during service or is otherwise related to an in-service event, disease, or injury. (c.) State whether it is at least as likely as not that each disorder is caused or aggravated by PTSD with MDD. Aggravation means an increase in severity beyond the natural progress of the disease. A rationale should be provided for opinions expressed. E. BLOWERS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Jimerfield 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.