Citation Nr: 21075674 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 10-20 791 DATE: December 21, 2021 ORDER Entitlement to a compensable rating (evaluation) for diabetic retinopathy with cataracts from April 27, 2007, to March 8, 2021 is denied. Entitlement to a rating (evaluation) higher than 20 percent for diabetes mellitus, type II, from April 27, 2007, to February 3, 2021, and higher than 40 percent as of February 3, 2021, is denied. Entitlement to a separate 60 rating (evaluation) for diabetic nephropathy as of September 17, 2012, is granted. REMANDED Entitlement to a rating higher than 30 percent for diabetic retinopathy with cataracts as of March 8, 2021, is remanded. Entitlement to an effective date prior to April 27, 2017, for a total disability rating for compensation based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. From April 27, 2007, to March 8, 2021, the Veteran's diabetic retinopathy with cataracts manifested with blurred vision, floaters, and light sensitivity; the evidence does not indicate decreased visual acuity or other visual impairment, or incapacitating episodes. 2. From April 27, 2007, to February 3, 2021, the Veteran's service-connected diabetes mellitus type II required an oral hypoglycemic agent and a restricted diet; it did not require regulation of activities. 3. As of February 3, 2021, the Veteran's service-connected diabetes mellitus type II required an oral hypoglycemic agent, a restricted diet, and regulation of activities; it did not involve 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. 4. As of September 17, 2012, the Veteran had stage 3 chronic kidney disease and definite decrease in kidney function. CONCLUSIONS OF LAW 1. From April 27, 2007, to March 8, 2021, the criteria for a compensable rating for diabetic retinopathy with cataracts have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.79, DC 7913-6066. 2. From April 27, 2007, to February 3, 2021, the criteria for a rating higher than 20 percent for the service-connected diabetes mellitus type II have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 4.20, 4.40, 4.119, Diagnostic Code 7913. 3. From February 3, 2021, the criteria for a rating higher than 40 percent for the service-connected diabetes mellitus type II have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 4.20, 4.40, 4.119, Diagnostic Code 7913. 4. As of September 17, 2012, the criteria for a separate rating of 60 percent for diabetic nephropathy have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 4.20, 4.40, 4.115, Diagnostic Code 7541. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1970 to February 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2009 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared at hearings before two of the undersigned Veterans Law Judges (VLJs) in February 2013 and February 2020. As such, this appeal is now before a three-judge panel. See 38 U.S.C. § 7102; 38 C.F.R. § 20.707. At the February 2020 hearing, the Veteran was informed of the right to an additional hearing before a third VLJ but waived that right at the hearing. See Arneson v. Shinseki, 24 Vet. App. 379 (2011). Transcripts from both hearings are of record. In August 2013 and October 2020, the Board remanded the case for further development. The Board has now recharacterized the issue of an increased rating for diabetes mellitus as two, separate issues, to include a separate compensable rating for diabetic nephropathy. Diagnostic Code 7913 instructs the evaluator to rate compensable complications of diabetes separately. As the evidence indicates that diabetic nephropathy warrants a separate compensable rating, the Board has determined it should be considered a separate issue. Disability Ratings Disability ratings are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A claimant may experience multiple distinct degrees of disability that may result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The following analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The rating of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. That does not preclude the assignment of separate ratings for separate and distinct symptomatology where none of the symptomatology justifying a rating under one diagnostic code is duplicative of or overlapping with the symptomatology justifying a rating under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259 (1994). 1. Entitlement to a compensable rating for diabetic retinopathy with cataracts from April 27, 2007, to March 8, 2021 The Veteran's diabetic retinopathy with cataracts is rated noncompensable (0 percent) prior to March 8, 2021, under 38 C.F.R. § 4.79, Diagnostic Code (DC) 7913-6079. The Board notes the diagnostic code was changed to DC 6040, for diabetic retinopathy, as of March 8, 2021. During the pendency of the appeal, VA issued two final rules revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye in 2008 and 2018. 73 Fed. Reg. 66543; 83 Fed. Reg. 15316. The final rules went into effect November 10, 2008, and May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim using the former and revised schedular rating criteria, although an increased rating based on the revised criteria cannot predate the effective date of the amendments. The Veteran was previously rated under DC 6079 for decreased visual impairment of 20/40 in both eyes. DC 6079 no longer exists and was changed to DC 6066. However, retinopathy was evaluated under DC 6006. Cataracts are evaluated under DC 6027. As DC 6079 was changed to DC 6066 in the 2008 revisions, the Board has updated the Veteran's diagnostic code to DC 6066. Under the former criteria, Diagnostic Code 6006 was evaluated from 10 percent to 100 percent for impairment of visual acuity or field loss, pain, rest-requirements, or episodic incapacity, combining an additional rating of 10 percent during continuance of active pathology. A minimum rating of 10 percent was assigned during active pathology. Under the 2008 revised criteria, DC 6006 instructed to evaluate pursuant to the General Rating Formula for DCs 6000 through 6009 instructs to evaluate on the basis of either visual impairment due to the particular condition or on incapacitating episodes, whichever results in a higher evaluation. Where incapacitating episodes have a total duration of at least 1 week, but less than 2 weeks, during the past 12 months, a 10 percent rating is warranted. Where incapacitating episodes have a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months, a 20 percent rating is warranted. Where incapacitating episodes have a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months, a 40 percent rating is warranted. Where incapacitating episodes have a total duration of at least 6 weeks during the past 12 months, a 60 percent rating is warranted. A Note following the General Rating Formula indicates that, for VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. Under the 2018 revised criteria, the General Rating Formula for Diseases of the Eye instructs to evaluate on the basis of either visual impairment due to a particular condition or on incapacitating episodes, whichever results in a higher evaluation. Where there are documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months, a 10 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months, a 20 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months, a 40 percent rating is warranted. Where there are documented incapacitating episodes requiring 7 or more treatment visits for an eye condition during the past 12 months, a 60 percent rating is warranted. Note (1) indicates that, for the purposes of evaluations under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Note (2) indicates that examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. Note (3) indicates that, for the purposes of evaluating visual impairment due to a particular condition, refer to 38 C.F.R. § 4.75-4.78 and to § 4.79, DCs 6061-6091. Regarding cataracts, the former criteria and revised criteria distinguish preoperative and postoperative cataracts. Under the former criteria, DC 6027 instructed evaluation of preoperative cataracts under impairment of vision and postoperative cataracts under impairment of vision or aphakia. Under the 2008 revised criteria, DC 6027 instructed evaluation of preoperative cataracts on visual impairment. For postoperative cataracts, when a replacement lens present (pseudophakia), then evaluate based on visual impairment. When there is no replacement lens, then evaluate based on aphakia, which is DC 6029. Under the 2018 revised criteria for preoperative cataracts, the criteria instruct to evaluate under the General Rating Formula for Diseases of the Eye. For postoperative cataracts, both the former and revised rating criteria distinguish between pseudophakia and aphakia. If there is a replacement lens present (pseudophakia), then the former criteria instructed to evaluate based on visual impairment whereas the revised criteria instruct to evaluate under the General Rating Formula for Diseases of the Eye. If there is no replacement lens (aphakia), both the former and revised criteria instruct to evaluate based on aphakia, which is DC 6029. The evaluation of visual impairment is based on impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. § 4.75(a). Evaluation of visual acuity is based on corrected distance vision with central fixation. 38 C.F.R. § 4.76(b)(1). The measurements for each eye are applied to the table for Impairment of Central Visual Acuity. Generally, the table is divided into steps corresponding to different levels of visual acuity for one eye, and each step is further divided into subsections of visual acuity for the other eye, with corresponding ratings. Where a reported visual acuity is between two sequentially listed visual acuities, the visual acuity which permits the higher evaluation will be used. 38 C.F.R. § 4.76(c). Under the former criteria for decreased visual acuity, DC 6079 provided ratings where vision in one eye (the poorer eye) is 10/200 or better. Where the visual acuity in both eyes is 20/40, a 0 percent rating is warranted. Where the visual acuity in the poorer eye is 20/50, a 10 percent rating is warranted where vision in the other eye is 20/50. Where the visual acuity in the poorer eye is 20/100, a 10 percent rating is warranted where vision in the other eye is 20/40. Under the 2008 revised criteria, DC 6066 provides ratings where vision in one eye (the poorer eye) is 10/200 or better. Where the visual acuity in both eyes is 20/40, a 0 percent rating is warranted. Where the visual acuity in the poorer eye is 20/50, a 10 percent rating is warranted where vision in the other eye is either 20/50 or 20/40. The competent evidence does not indicate any visual field or muscle function impairments, or any incapacitating episodes prior to March 8, 2021. The Veteran had cataract surgery on the right eye in 2008 and the left eye in 2010, and had a replacement lens in each eye. At the May 2009 VA examination, the Veteran reported fluctuating vision and floaters. Corrected distance measured 20/40 in the right eye and 20/20 in the left eye. The examiner diagnosed mild non-proliferative diabetic retinopathy, a preoperative cataract in the left eye, and pseudophakia in the right eye. At the November 2013 VA examination, the Veteran reported floaters once a month. Corrected distance measured 20/40 bilaterally. The postoperative bilateral cataracts did not result in aphakia or dislocation of the crystalline lens. The examiner noted the cataracts and retinopathy did not cause a decrease in visual acuity or other visual impairment. There was no visual field defect, and there were no incapacitating episodes. At the April 2017 VA examination, the Veteran reported recent light sensitivity. Corrected distance measured 20/40 bilaterally. The examiner noted that the cataracts and retinopathy did not cause a decrease in visual acuity or other visual impairment. A visual field defect and incapacitating episodes were not shown. At the February 2020 Board hearing, the Veteran reported that he ruptured blood vessels in both eyes and had to wear dark glasses. VA treatment records show complaints of blurred vision, floaters, and light sensitivity. After review of the record, prior to March 8, 2021, the Board finds that a compensable rating for the Veteran's eye disability is not warranted. Visual acuity remained normal throughout this portion of the appeal period. While the Board acknowledges the reports of floaters and sensitivity to light, these statements did not constitute incapacitating episodes supporting a higher rating under the rating criteria. The bilateral eye disability was not shown to manifest in decreased visual acuity or other visual impairment, or to involve any incapacitating episodes, sufficient to support an increased rating; therefore, the Board finds that the evidence does not demonstrate that the service-connected disability met or more nearly approximated the criteria for a higher rating under Diagnostic Code 6006, 6027, 6040, 6066 or any other potentially applicable diagnostic code during this portion of the appeal period. Accordingly, the Board finds that the preponderance of the evidence is against a compensable rating for the Veteran's service-connected diabetic retinopathy with cataracts prior to March 8, 2021; therefore, the appeal for a higher (compensable) rating for this stage is denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7. For reasons detailed below, the rating for the period beginning March 8, 2021 will be addressed on remand. 2. Entitlement to a rating higher than 20 percent for diabetes mellitus, type II, from April 27, 2007, to February 3, 2021, and higher than 40 percent for diabetes mellitus, type II, as of February 3, 2021 The Veteran has a 20 percent rating for service-connected diabetes mellitus, type II, from April 27, 2007, to February 3, 2021, and a 40 percent rating as of February 3, 2021. He seeks a higher rating for the condition for the entire period of the appeal. The 20 percent evaluation was awarded pursuant to 38 C.F.R. § 4.119, Diagnostic Code 7913. Under this code section, diabetes mellitus type II requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet, is rated 20 percent disabling. Diabetes mellitus. type II requiring insulin, restricted diet, and regulation of activities, is rated 40 percent disabling. Id. Diabetes mellitus type II 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, is rated 60 percent disabling. Id. Diabetes mellitus type II requiring insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational 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, is rated 100 percent disabling. Id. The Board notes that, in revisions effectuated December 10, 2017, the insulin requirement was specified to include one or more daily injection(s), but this change is not material to the case at hand because an evaluation of at least 20 percent, contemplating such insulin use, has been assigned throughout the appeal period. 82 Fed. Reg. 50802. The rating schedule in Note 1 also instructs to evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process. In this Veteran's case, separate ratings have been assigned for diabetic complications of bilateral upper and lower extremity radiculopathy, retinopathy, and erectile dysfunction. Retinopathy is the only existing complication rating presently on appeal, and was addressed above. As noted below, a separate rating is being assigned in this Board decision for the diabetic nephropathy. From April 27, 2007, to February 3, 2021 The Veteran's diabetes mellitus type II has required the use of insulin and a restricted diet for control, but did not require regulation of activities; thus, a rating in excess of 20 percent is not met for the period from April 27, 2007 to February 3, 2021. At the August 2007 VA examination, the Veteran reported taking insulin twice a day. He had not experienced any hypoglycemic reactions or ketoacidosis in the last year. His weight was stable. The Veteran had been exercising but stopped because his knees started to bother him. The examiner specifically noted that the Veteran did not have any restriction of activities due to diabetes. At the May 2009 and June 2009 VA examinations, the diabetes was treated with insulin once a day and a restricted diet. The Veteran reported that he lost 8 pounds in the past six months due to a hospitalization for a left knee infection. However, his weight was stable. There was no renal disease, dialysis, or treatment for a urinary disorder. The examiner noted that there were no hypoglycemic reactions or ketoacidosis requiring hospitalization in the past 12 months. Although the Veteran had hypertension, the examiner found that it was not due to or aggravated by the diabetes. Both disabilities occurred around the same time. At the February 2013 Board hearing, the Veteran testified that the diabetes had worsened and required a regulation of activities. Specifically, he stated that his doctor informed him that he could no longer be a part of the Move Program, a VA program for weight loss. Similarly, during the February 2020 hearing, the Veteran reported that his treating physician restricted his activities as due to his diabetes mellitus. He also stated that physical exertion caused shaking and lightheadedness. Notwithstanding the Veteran's assertion of required regulation of activities during testimony at Board hearings, the weight of the other lay and medical evidence of record, including histories and assessments for treatment purposes and when being examined by a VA examiner, shows that regulation of activities was not required. For example, at the April 2017 VA examination, the Veteran's diabetes was treated with a restricted diet and insulin more than once a day, with no regulation of activity, similar to previous conclusions at three VA examinations in 2007 and 2009. For these reasons, for the period from April 27, 2007, to February 3, 2021, the Board finds that a rating in excess of 20 percent rating is not warranted. The competent evidence indicates that the diabetes mellitus required regular insulin treatment and a restricted diet, but it did not require regulation of activity during this period. The Board acknowledges the Veteran's reports that he required a regulation of activities; however, such assertion is outweighed by the other lay and medical evidence or record that does not show that the diabetes mellitus required regulation of activities. The competent evidence of record, notably the April 2017 VA examination report, is specifically against a finding that regulation of activities was required; therefore, prior to February 3, 2021, a rating higher than 20 percent is not warranted. From February 3, 2021 For the rating period from February 3, 2021, the Board finds that the weight of the evidence shows that a rating in excess of 40 percent rating is not warranted. At the time of the February 2021 VA examination, diabetes was being treated with a restricted diet, insulin, and regulation of activities. The Veteran reported he could not play sports or perform physical labor due to the service-connected diabetic peripheral neuropathy (although this was not shown to be prescribed by a medical professional). The evidence shows fewer than two visits to a diabetic care provider per month due to ketoacidosis and hypoglycemia episodes, and shows no required hospitalizations in a 12 month period for ketoacidosis or hypoglycemic reactions. The February 2021 VA examiner indicated the Veteran required a regulation of activities based on the Veteran's own report. Although the evidence showed the Veteran had increased difficulty with mobility, there were no episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider. In a March 2021 opinion, the examiner indicated that the regulation of activity was due to the diabetic neuropathy. For these reasons, as of February 3, 2021, the Board finds a rating higher than 40 percent is not warranted for diabetes mellitus type II. 3. A separate 60 rating for diabetic nephropathy as of September 17, 2012 The Board finds that the evidence is at least in equipoise on the question of whether a separate 60 percent rating for diabetic nephropathy is warranted from September 17, 2012. Prior to November 14, 2021, DC 7541 evaluates renal involvement in diabetes mellitus and instructs rating the disability as renal dysfunction. A noncompensable rating is warranted for renal dysfunction with albumin and casts with history of acute nephritis; or, hypertension non-compensable under DC 7101. A 30 percent rating is warranted for renal dysfunction with albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under DC 7101. A 60 percent rating is warranted for renal dysfunction with constant albuminuria with some edema; or definite decrease in kidney function; or, hypertension at least 40 percent disabling under DC 7101. An 80 percent rating is warranted for renal dysfunction with persistent edema and albuminuria with blood urea nitrogen (BUN) 40 to 80 mg%; or creatinine 4 to 8 mg%; or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating is warranted for a renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or BUN more than 80 mg%; or, creatinine more than 8 mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. The criteria for rating renal dysfunction were substantively revised and effectuated only from November 14, 2021. 86 Fed. Reg. 54081. Under the new criteria, effective only from that date, a zero percent evaluation is assigned for glomerular filtration rate (GFR) from 60 to 89 mL/min/1.73 m2 and either recurrent red blood cell (RBC) casts, white blood cell (WBC) casts, or granular casts for at least 3 consecutive months during the past 12 months; or, GFR from 60 to 89 mL/min/1.73 m2 and structural kidney abnormalities (cystic, obstructive, or glomerular) for at least 3 consecutive months during the past 12 months; or, GFR from 60 to 89 mL/min/1.73 m2 and albumin/creatinine ratio (ACR) 30 mg/g for at least 3 consecutive months during the past 12 months. A 30 percent evaluation is assigned for chronic kidney disease with GFR from 45 to 59 mL/min/1.73 m2 for at least 3 consecutive months during the past 12 months. A 60 percent evaluation is assigned for chronic kidney disease with GFR from 30 to 44 mL/min/1.73 m2 for at least 3 consecutive months during the past 12 months. An 80 percent evaluation is assigned for chronic kidney disease with GFR from 15 to 29 mL/min/1.73 m2 for at least 3 consecutive months during the past 12 months. A 100 percent evaluation is assigned for chronic kidney disease with GFR less than 15 mL/min/1.73 m2 for at least 3 consecutive months during the past 12 months; or requiring regular routine dialysis; or eligible kidney transplant recipient. An accompanying Note indicates that GFR, estimated GFR (eGFR), and creatinine-based approximations of GFR will be accepted for evaluation purposes under this section when determined to be appropriate and calculated by a medical professional. VA treatment records show kidney disease throughout the appeal period. Diabetic nephropathy was first noted in May 2002, and has been as an active problem since December 2015. Prior to September 17, 2012, the treatment records showed decreased kidney function as indicated by elevated creatinine and microalbumin. At the May 2009 and June 2009 VA examinations, however, the Veteran was not aware of any diabetic nephropathy. There was no renal disease, dialysis, or treatment for a urinary disorder. However, on September 17, 2012, a VA treatment record indicated stage 3 chronic kidney disease. At a February 2021 VA examination, the Veteran reported kidney disease since the 2000s. VA treatment records showed elevated creatinine and elevated urine microalbumin since 2006. The VA examiner assessed the Veteran had renal dysfunction. In a March 2021 addendum opinion, the examiner noted the Veteran was taking medication for renal insufficiency. His GFR was abnormally low at 44, and creatinine was abnormally elevated to 1.84. The BUN was normal on examination. There were no signs or symptoms due to renal disease, but the Veteran had a decrease in renal function. There was also evidence of elevated microalbumin. Based on the evidence, prior to September 17, 2012, the Board finds that a separate compensable disability rating for diabetic nephropathy is not warranted. Although there were elevated creatinine and elevated urine microalbumin, the evidence does not reflect albumin constant or recurring with hyaline and granular casts or red blood cells or transient or slight edema or hypertension at least 10 percent disabling under DC 7101. Accordingly, the Board finds that the preponderance of the evidence is against a separate compensable disability rating for diabetic nephropathy prior to September 17, 2012. Based on the above evidence, and resolving reasonable doubt in the Veteran's favor, the Board finds a 60 percent rating is warranted as of September 17, 2012. The evidence shows a stage 3 chronic kidney disease in September 2012, which is a strong indication of a definite decrease in kidney function. Although the April 2017 VA examiner did not report diabetic nephropathy as a complication, VA treatment records show decreased kidney function as a result of the chronic kidney disease from diabetes mellitus. However, the evidence does not indicate persistent edema and albuminuria with BUN 40 to 80 mg%; or creatinine 4 to 8 mg%; or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. Similarly, when applying the revised criteria (again, effective only from November 14, 2021), there is no evidence of chronic kidney disease with GFR from 15 to 29 mL/min/1.73 m2 for at least 3 consecutive months during the past 12 months. As such, the Board finds a 60 percent rating, but not higher, is warranted as of September 17, 2012. REASONS FOR REMAND 4. Entitlement to a rating higher than 30 percent for diabetic retinopathy with cataracts as of March 8, 2021, is remanded. The October 2020 remand directed the RO to provide an updated VA examination and obtain all outstanding VA treatment records and missing visual field testing results, specifically, the results stored in the VistA imaging system. The record does not show if these actions were taken; therefore, the Board will remand the case for compliance with the October 2020 Remand directives. The Veteran is service connected for diabetic retinopathy with cataracts. While the March 2021 examiner noted the presence of a PCIOL or posterior chamber intraocular lens, which is used during cataract surgery, the examiner did not complete the lens condition section of the examination report, which assesses cataracts. For this reason, an updated and complete examination is being requested. 5. Entitlement to an effective date prior to April 27, 2017 for TDIU is remanded. As noted above, a separate 60 rating for diabetic nephropathy as of September 17, 2012 has been granted in this decision. This is a significant grant that will affect the analysis of the TDIU effective date claim, as the severity and functional impairment of the diabetic nephropathy will need to be considered, along with other service-connected disabilities, in regard to the ability to secure and follow a substantially gainful occupation during this earlier time period. The issues of higher rating for diabetic retinopathy and TDIU prior to April 27, 2017 are REMANDED for the following action: 1. Obtain VA treatment records for the period from March 2021 to the present. (Continued on the next page) 2. Schedule a VA eye examination to help determine the current severity of the service-connected diabetic retinopathy with cataracts. The examiner should elicit information about the nature of the eye disability and all symptoms or manifestations of the disability when present, even if not present at the time of the examination, including blurred vision. 3. Adjudicate the issue of TDIU prior to April 27, 2017 based on impairment from all disabilities, specifically including the now separately rated diabetic nephropathy. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals J. PARKER Veterans Law Judge Board of Veterans' Appeals A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Kass, 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.