Citation Nr: 21006796 Decision Date: 02/05/21 Archive Date: 02/05/21 DOCKET NO. 08-20 857 DATE: February 5, 2021 ORDER Entitlement to service connection for stomach and esophageal cancer is denied. Entitlement to an increased rating in excess of 30 percent for diabetic nephropathy with hypertension is denied. Entitlement to a TDIU is denied. Entitlement to an increased rating in excess of 10 percent for diabetic retinopathy (previously rated as intra-ocular hemorrhage) from December 2, 2004 to May 15, 2005 is denied; entitlement to an increased rating of 20 percent from May 16, 2005 to March 18, 2007 is granted; and entitlement to an increased rating of 30 percent from March 19, 2007 is granted. Entitlement to a 100 percent rating for coronary artery disease (CAD) prior to May 26, 2012 is granted. Entitlement to an increased rating in excess of 40 percent from July 6, 2007 to April 28, 2009 for diabetes with erectile dysfunction is denied. Entitlement to an increased rating in excess of 20 percent from April 29, 2009 for diabetes with erectile dysfunction, to include whether reduction was proper, is denied. FINDINGS OF FACT 1. Stomach and esophageal cancers are not shown to be causally or etiologically related to any disease, injury, or incident in service, to include exposure to herbicides in Vietnam or contaminated water at Camp Lejeune. 2. The Veteran’s diabetic nephropathy was not shown to produce constant albuminuria with edema, a definite decrease in kidney function, or hypertension at least 40 percent disabling. 3. From July 6, 2007, the Veteran has a schedular rating of 100 percent for service-connected diabetes and secondary complications rendering his TDIU claim moot as of that date because his TDIU claim is largely premised on his diabetes manifestations. 4. The Veteran’s diabetic retinopathy did not result in impaired visual acuity or incapacitating episodes to warrant a rating in excess of 10 percent from December 2, 2004 to May 15, 2005; from May 16, 2005 to March 18, 2007, the Veteran’s reduced visual acuity warranted a 20 percent rating; from March 19, 2007, the Veteran’s reduced visual acuity warranted a 30 percent rating. 5. The Veteran experienced the equivalent of 3 METs resulting in dyspnea and angina throughout the appeal period. 6. From July 6, 2007 to April 28, 2009, the Veteran’s diabetes with erectile dysfunction manifested in insulin injections, restricted diet, and regulation of activities. 7. From April 29, 2009, the evidence reflects that the Veteran no longer required insulin or the regulation of activities as part of his diabetes treatment regimen. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for stomach and esophageal cancer have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for an increased rating in excess of 30 percent for diabetic nephropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.115, Diagnostic Code 7541. 3. The criteria for a TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 4.16. 4. The criteria for an increased rating in excess of 10 percent from December 2, 2004 to May 15, 2005 have not been met; the criteria for an increased rating of 20 percent from May 16, 2005 to March 18, 2007 have been met; and the criteria for an increased rating of 30 percent from March 19, 2007 have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.75-4.79, Diagnostic Code 6040. 5. The criteria for a 100 percent rating throughout the appeal period for the Veteran’s CAD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.104, Diagnostic Code 7005. 6. The criteria for an increased rating in excess of 40 percent from July 6, 2007 to April 28, 2009 for diabetes with erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, Diagnostic Codes 7522 and 7913. 7. Reduction from 40 percent to 20 percent for diabetes with erectile dysfunction was proper; the criteria for an increased rating in excess of 20 percent have not been met. 38 U.S.C. §§ 1155, 5107, 5112 (b)(6); 38 C.F.R. §§ 3.105 (e), 4.1, 4.2, 4.3, 4.7, 4.10, Diagnostic Codes 7522 and 7913. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1966 to December 1967. These matters are on appeal to the Board of Veterans’ Appeals (Board) from a November 2007 rating decision. The Veteran appealed and the claims were remanded by the Board in December 2011. The Veteran passed away in September 2012 during the pendency of the appeal. His surviving spouse is the Appellant; she has been accepted as the Veteran’s substitute for purposes of processing this appeal to completion. The claims were subsequently remanded again by the Board in June 2017 with instructions to comply with the December 2011 remand directives to the extent possible given the Veteran’s death in the interim. The Board finds the remand directives have been substantially complied with. Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for stomach and esophageal cancer The Appellant contends the Veteran’s esophageal and stomach cancers, diagnosed and treated in 2007, are due to herbicide exposure in Vietnam, or, alternatively, exposure to contaminated water at Camp Lejeune. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). a) Herbicide Exposure Relevant laws and regulations provide that absent affirmative evidence to the contrary, there is a presumption of exposure to herbicides agents (to include Agent Orange) for all veterans who served in Vietnam or in or near the Korean Demilitarized Zone (DMZ) during specified periods of time. See 38 U.S.C. § 1116 (f); 38 C.F.R. § 3.307 (a)(6)(iii). In the instant case, the Veteran served in the Republic of Vietnam during the required time period, therefore, in-service exposure to herbicide agents has been conceded. If a veteran was exposed to an herbicide agent, such as Agent Orange, during active service, service connection will be presumed for certain diseases if they become manifest to a degree of 10 percent or more at any time after service. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309 (e). Neither stomach nor esophageal cancer are among the enumerated diseases listed in 38 C.F.R. § 3.309 as presumptively due to such exposure. Therefore, the presumptive provisions do not apply. Notwithstanding the presumption, service connection for a disability claimed as due to exposure to herbicides may be established by showing that a disorder resulting in disability or death was in fact causally linked to such exposure. See Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994), citing 38 U.S.C. § 1113 (b) and 1116 and 38 C.F.R. § 3.303. The Veteran explained in his March 2009 DRO hearing that he was a mine and demolition expert in Vietnam. In carrying out his duties, he was constantly digging out mines that were heavily sprayed with Agent Orange. In an August 2020 VA opinion with clarifying addendums in October and November 2020, the examiner determined the Veteran’s small cell carcinoma was less likely than not caused by exposure to Agent Orange in service. The examiner explained that the Veteran’s cancers are not on the list of conditions with sufficient evidence of an association, or even a limited or suggestive association with Agent Orange. The examiner concluded a causal relationship could not be established. In the October 2020 addendum, it was clarified that the two GI cancers (or small cell carcinoma) are not due to Agent Orange. The rationale was that GI cancers are not Agent Orange presumptives nor is there other independent evidence that suggests causation at a level of at least as likely as not. There is no other evidence of record suggesting a link between Agent Orange exposure and stomach and esophageal cancers. During the March 2009 DRO hearing, the Veteran’s representative stated that the claims file contains, in writing, an opinion from an outside physician at Oakwood Hospital stated that the Veteran’s related conditions “are all related to exposure to Agent Orange.” The Board finds no such opinion in the claims file. The Oakwood Hospital records in the claims file are all prior to the Veteran’s diagnosis of stomach and esophageal cancer in 2007. There is a 2004 letter of record written by an internal medicine physician which states “The patient was also exposed to agent orange while in the Vietnam War which may also be a contributing factor to his colon cancer.” As this opinion pertains to colon cancer, which is not an issue on appeal, the Board does not afford this opinion any probative weight. In sum, the evidence is against the Appellant’s claim of service connection due to Agent Orange exposure and the claim must be denied on that theory. b) Camp Lejeune 38 C.F.R. §§ 3.307 and 3.309 provide a presumption of service connection for certain diseases based on exposure to contaminants present in the water supply at Camp Lejeune. The amendment defines “contaminants in the water supply” as the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE), benzene and vinyl chloride that were in the on-base water-supply systems located at United States Marine Corps Base Camp Lejeune, during the period beginning on August 1, 1953, and ending on December 31, 1987. In order to qualify for presumptive service connection under these provisions, there must be evidence of: (1) a diagnosis of one of the enumerated diseases under 38 C.F.R. § 3.309 (f), (i.e., kidney cancer, liver cancer, non-Hodgkin's lymphoma, adult leukemia, multiple myeloma, Parkinson's disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer), if manifest to a degree of 10 percent or more at any time after service; and (2) service of at least 30 days (consecutive or nonconsecutive) at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987. 38 C.F.R. §§ 3.307 (a)(7), 3.309 (f). The Veteran had more than 90 days of service at Camp Lejeune. Neither stomach nor esophageal cancer are among the enumerated diseases listed in 38 C.F.R. § 3.309 as presumptively due to such exposure. Therefore, the presumptive provisions do not apply. However, as stated above, this is not necessarily fatal to the Appellant’s claim. See Combee, 34 F.3d at 1044. In an August 2010 VA opinion, the examiner acknowledged that the Veteran was diagnosed with stomach cancer involving the gastroesophageal junction in 2007. He was stationed at Camp LeJeune for 6 months in 1966 while attending mine and demolition school, during the time there was documented contamination of drinking water with PCE and TCE. The examiner concluded the Veteran was unlikely to have developed stomach cancer due to toxin exposure. Neither TCE, Benzene, nor PCE show any connection to stomach or esophageal cancer based on all available data. In addition, available information suggests higher levels of exposure for longer periods of time would be required for human cancers to occur. In July 2020, an opinion was obtained from a Camp Lejeune Water Contamination subject matter expert. The examiner noted that the Veteran filed his claim for small cell carcinoma, rather than adenocarcinoma of the esophagus and stomach for which he had a diagnosis. Thus, she concluded no causation could be made as there was no diagnosis of small cell carcinoma. Another opinion was obtained in August 2020. The examiner provided a thorough explanation of esophageal cancer and its risk factors as well as a description of a retrospective mortality study of servicemembers stationed at Camp Lejeune during 1975 to 1985. He stated that “citing meta-analyses and recent cohort studies for occupational exposure, ATSDR [Agency for Toxic Substances and Disease Registry] concluded that there is below equipoise evidence for causation for TCE, PCE, benzene or vinyl chloride and the development of esophageal cancer. The ATSDR is silent on any association between stomach cancer and the contaminants found in the Camp Lejeune drinking water.” Taking into consideration the Veteran’s military and medical history coupled with the medical literature, the examiner determined the Veteran had the risk factors of tobacco use, age, gender, and race for the development of esophageal cancer as well as exposure to contaminated water at Camp Lejeune. He also had a history of other cancers and a strong family history of cancer. In consideration of the above, the diagnosis of adenocarcinoma of the esophagus and stomach was less likely than not caused by or related to exposure to contaminated water at Camp Lejeune. The Board finds that the evidence is against the Appellant’s claim that the Veteran’s stomach and esophageal cancer was caused by contaminated water at Camp Lejeune. There is no positive evidence of record suggesting a link between the type of cancers suffered by the Veteran and the toxicants in the Camp Lejeune water. The August 2020 opinion is particularly probative, as it considers not only the available medical literature but the Veteran’s individual circumstances as well. As the evidence is against the Appellant’s claim, service connection based on this theory must be denied. As there is no other theory of service connection has been raised, the Appellant’s claim for service connection for esophageal and stomach cancer is denied. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran’s service-connected disability. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Therefore, the Board will only consider evidence submitted one year prior to the filing of the claim for an increased rating, rather than from the initial assignment. The Veteran filed his increased rating claims for diabetes and CAD on July 6, 2007. Therefore, the appeal period begins July 6, 2006. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, as in this case, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran was service connected for his diabetic retinopathy in a March 2005 rating decision effective December 2, 2004, the date of claim. The claim has remained on appeal since the grant of service connection; thus, the Board will consider the evidence for this claim as of December 2, 2004. For the Veteran’s diabetic nephropathy claim, he was granted service connection in a November 2007 rating decision effective July 6, 2007, the date of claim. Thus, the Board will consider the evidence for this claim as of July 6, 2007. 1. Entitlement to an increased rating in excess of 30 percent for diabetic nephropathy with hypertension The Veteran’s diabetic nephropathy is rated under Diagnostic Code 7541, which provides that the disability should be rated as renal dysfunction under the criteria of 38 C.F.R. § 4.115a. For renal dysfunction, a 0 percent rating is assigned where albumin and casts with history of acute nephritis; or, hypertension non-compensable under diagnostic code 7101. A 30 percent rating is assigned where 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 Diagnostic Code 7101. A 60 percent rating is assigned where constant albuminuria with some edema; or definite decrease in kidney function; or hypertension at least 40 percent disabling under Diagnostic Code 7101. An 80 percent rating is assigned where there is persistent edema and albuminuria with BUN 40 to 80mg%; or creatine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating is assigned where regular dialysis is required, precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. Diagnostic Code 7101 provides that a 10 percent rating is assigned for diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is assigned for diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. A 40 percent rating is assigned for diastolic pressure predominantly 120 or more. A 60 percent rating is assigned for diastolic pressure predominantly 130 or more. In a September 2007 VA examination, the Veteran was noted to have diabetic nephropathy evidenced by microalbuminuria in the past, now proteinuria. Labs conducted at that time revealed BUN 10, creatinine 1.0, and urinalysis abnormal with 1+ protein. The examiner noted that the Veteran’s blood pressure was adequately managed at the time. In an April 2009 VA examination, labs showed BUN 20, creatinine 0.7, and urinalysis negative for protein. The examiner remarked that the Veteran’s marked loss of muscle mass and low blood protein levels (due to recent GI surgery for stomach and esophageal cancer) may cause underestimation of severity of renal disease. He opined that an accurate estimate of renal status would require retesting in 6 months after the Veteran regained lost muscle mass and a stable weight. Unfortunately, retesting to ascertain a more accurate renal assessment was not conducted before the Veteran’s death in 2012. Thus, in August 2020, an opinion was sought to ascertain the Veteran’s renal status to the extent possible prior to his death. The examiner concluded that based on the evidence, the Veteran’s diabetic nephropathy was mild; however, this opinion was based on lab results outside the appeal period in the early 2000s. In an October 2020 addendum, the examiner made the following initial comment: “RO is attempting to re-evaluate ratings for multiple disabilities eight years post-mortem. Available information is limited and completion of the DBQs is impossible. Examiner has made a best effort to provide potential rating information as close as possible to time of death.” Regarding nephropathy, the examiner determined that the Veteran’s renal function remained normal, and it appeared to improve following the 2007 GI surgery. The most recent lab results were in June 2012; at that time, he had BUN 12, creatinine 0.7, and his urinalysis was negative for protein. Because renal function was never impaired, the examiner concluded there was no reason to believe the nephropathy aggravated hypertension. Because his renal function was essentially normal, there is no evidence that the Veteran suffered fatigue or other symptoms related to kidney disease. In a November 2020 addendum that included a completed Disability Benefits Questionnaire (DBQ), the examiner noted a March 2010 CT that reflected unremarkable kidneys. The Veteran was not on continuous medication for renal dysfunction and was not on dialysis. The examiner indicated there was no hypertension due to nephropathy. The evidence within the appeal period does not reflect constant albuminuria, a definite decrease of kidney function, or hypertension at least 40 percent disabling. In fact, the evidence of record reflects essentially normal kidney function, adequately controlled blood pressure, and there was no albuminuria following the September 2007 labs. Thus, an increased rating in excess of 30 percent for nephropathy with hypertension is denied. 2. Entitlement to an increased rating in excess of 10 percent for diabetic retinopathy (also rated as intra-ocular hemorrhage) The Veteran’s diabetic retinopathy has been rated under Diagnostic Code 6007 for intra-ocular hemorrhage; however, in May 2018, Diagnostic Code 6040 was added for diabetic retinopathy. Where a condition is specifically listed in the rating schedule, it should not be rated by analogy. Copeland v. McDonald, 27 Vet. App. 333, 336-37 (2015); see 38 C.F.R. § 4.20. Accordingly, the Veteran’s condition will be evaluated under Diagnostic Code 6040. However, both codes provide for rating based on visual impairment or incapacitating episodes in accordance with the General Rating Formula for Diseases of the Eye. During the pendency of the appeal, the Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye has been amended twice. One amendment went into effect on December 10, 2008. 73 Fed. Reg. 66543 (Nov. 10, 2008). The other amendment went into effect on May 13, 2018. 83 Fed. Reg. 15316 (Apr. 10, 2018). Accordingly, all three versions of the ratings schedule are applicable to this claim. VA will consider the claim in light of all three versions, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. In general, the mechanics of rating visual impairment remained consistent throughout the amendments. Evaluation of visual impairment is based on impairment of visual acuity, visual field, and muscle function. 38 C.F.R. § 4.75 (a). There is no evidence of impairment of visual field or muscle function throughout the appeal period. 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. 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). All versions of the rating criteria also allowed for rating based on incapacitating episodes. Prior to May 2018, incapacitating episodes were defined as a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. From May 2018 onward, incapacitating episodes are defined as an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. A 10 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) if corrected visual acuity is 20/100 in one eye and 20/40 in the other eye; (2) if corrected visual acuity is 20/70 in one eye and 20/40 in the other eye; (3) if corrected visual acuity is 20/50 in one eye and 20/40 in the other eye; (4) or when corrected visual acuity is 20/50 in both eyes. A 20 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) if corrected visual acuity is 15/200 in one eye and 20/40 in the other eye; (2) if corrected visual acuity is 20/200 in one eye and 20/40 in the other eye; (3) if corrected visual acuity is 20/100 in one eye and 20/50 in the other eye; or (4) corrected visual acuity of 20/70 in one eye and 20/50 in the other eye. A 30 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) corrected visual acuity in both eyes is 20/70; (2) corrected visual acuity in one eye is 20/100 and the other eye is 20/70; (3) corrected visual acuity in one eye is 20/200 in one eye and 20/50 in the other eye; (4) corrected visual acuity in one eye is 15/200 and 20/50 in the other eye; (5) corrected visual acuity in one eye is 10/200 and 20/40 in the other eye; (6) corrected visual acuity in one eye is 5/200 and 20/40 in the other eye; or (7) blindness of one eye and corrected vision to 20/40 in the other eye. For purposes of brevity, the criteria for higher ratings have not been included in this decision. Turning to the evidence of record, in the February 2005 VA examination, the examiner noted diabetic macular edema with a history of recent laser photocoagulation to the macula bilaterally in November 2004. The Veteran’s corrected distance visual acuity was 20/30 bilaterally. Dilated examination revealed multiple microaneurysms with dot-and-blot hemorrhages and thickening of the macula. The examiner concluded that the Veteran’s visual acuity was likely decreased secondary to diabetic eye disease. In a February 2005 treatment record, the Veteran’s best corrected visual acuity was 20/40 bilaterally. In his March 2005 NOD, the Veteran stated that following his laser surgery his visual acuity is now 20/30, whereas it used to be 20/20. In a May 2005 treatment record, the Veteran’s best corrected visual acuity was 20/60 in the right eye and 20/50 in the left. An October 2005 treatment record reflects best corrected visual acuity as 20/60 and 20/40. In March 2007, the Veteran presented for a retina consultation complaining of blurred vision bilaterally over the past two years. He reported difficulty with glare at night and endorsed symptoms of intermittent floaters, occasional sudden, sharp pains, and redness. The Veteran’s best corrected visual acuity was 20/70 in the right eye and 20/60 in the left. The retina specialist noted the macular edema was the main cause of the Veteran’s vision loss, and intravitreal injections were done at the visit. In a follow-up May 2007 visit, his visual acuity was 20/70 in the right eye and 20/40 in the left. In a May 2009 VA examination, the Veteran complained of progressive blurry vision bilaterally. His corrected distance visual acuity was 20/40 in the right eye and 20/30 in the left. In the August 2020 retrospective VA opinion, the examiner determined there were no incapacitating episodes of record and his visual acuity was 20/40 and 20/30. In the November 2020 addendum, the examiner determined the Veteran’s corrected distance visual acuity was 20/50 in the right eye and 20/40 in the left but noted that his acuity fluctuated between 20/40 and 20/70. There were no incapacitating episodes. As evidenced by the above, the Veteran’s visual acuity varied. Several of the visual acuity readings warrant a 10 percent rating under the criteria; however, the May 2005 record does indicate a visual acuity of 20/60 in the right eye and 20/50 in the left, which corresponds to a 20 percent rating. The March 2007 record indicates a visual acuity of 20/70 in the right eye and 20/60 in the left, which corresponds to a 30 percent rating. See 38 C.F.R. § 4.76 (b) (4) (to evaluate the impairment of visual acuity where a claimant has a reported visual acuity that is between two sequentially listed visual acuities, use the visual acuity which permits the higher evaluation). While improvement in the visual acuity is shown following the above visual acuity readings, in granting the benefit of the doubt to the Veteran, the Board finds that staged ratings is warranted. There is no other indication of visual impairment or incapacitating episodes throughout the record that would warrant a higher rating. While the Board acknowledges the March 2007 intravitreal injections, this does not constitute an incapacitating episode as the definition under the regulations in place at that time did not include an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. In sum, the Veteran is entitled to a 10 percent rating from December 2, 2004 to May 15, 2005; a 20 percent rating from May 16, 2005 to March 18, 2007; and a 30 percent rating from March 19, 2007. 3. Entitlement to a 100 percent rating for CAD prior to May 26, 2012 and after August 1, 2012 In a November 2020 rating decision, the Veteran’s CAD rating was increased to 100 percent disabling from May 26, 2012 to July 31, 2012 following implantation of a cardiac pacemaker in accordance with Diagnostic Code 7018. Prior to that date, and after the two months following hospital admission for implantation had ended, the rating was 60 percent. The Veteran’s CAD is rated under Diagnostic Code 7005. Under Diagnostic Code 7005, a 10 percent rating is warranted for a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is warranted for a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or x-ray. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for chronic congestive heart failure, or; workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2). When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. Id. In June 2007, the Veteran received treatment for shortness of breath (dyspnea) and chest pain. He underwent a stress test which was abnormal. His left ventricle ejection fraction was 63 percent. The METs level was not included as the test was terminated for reasons unknown. In a September 2007 VA examination, the examiner discussed the abnormal June 2007 cardiac stress test and noted that the Veteran’s recent GI surgery precluded additional cardiac intervention. Aggressive medical management was recommended, and the Veteran was put on additional medication until he could undergo additional cardiac work-up. At the time of the examination the Veteran reported no chest pain and only minimal shortness of breath but admitted his activity level was minimal. He stated he experiences chest pain on a weekly or monthly basis which persists until he rests. He reported shortness of breath with exertion. The examiner stated “[h]e states that slow walking causes him to feel shortness of breath and chest pain which corresponds to a clinically estimated METs level of 3-5.” In his March 2009 DRO hearing, the Veteran stated his cardiac condition was steady if he maintained proper exercise and diet. He could do some level of exercise but remained cautious; for example, going up a flight of more than 10 stairs would wear him out. In the August 2020 retrospective VA opinion, the examiner determined that the nature and extent of the Veteran’s CAD was mild. The examiner predominately relied on evidence outside the appeal period in the early 2000s, however, the examiner referenced the June 2007 stress test report that stated “mild to moderate severity apical and anterior significant partial reversibility defect c/w perfusion.” The examiner concluded that the partial reversible defect supported a mild condition. In the October 2020 addendum, the examiner made the following initial comment: “RO is attempting to re-evaluate ratings for multiple disabilities eight years post-mortem. Available information is limited and completion of the DBQs is impossible. Examiner has made a best effort to provide potential rating information as close as possible to time of death.” The examiner explained there is no information to permit estimate of METs and any such information would be limited by multiple other serious medical conditions. In the November 2020 addendum which included completion of a DBQ, the examiner indicated the Veteran was on continuous medication for his CAD. He had no congestive heart failure. The examiner estimated the METs level to be greater than 7 but less than 10. However, this was based on the last available METs level in May 2000, which is outside the appeal period. There is no METs level determined by exercise testing of record within the appeal period. There is, however, an estimation by medical examiner in September 2007. The September 2007 examiner considered the Veteran’s report of dyspnea and angina with slow walking and determined this corresponded to a METs level of 3-5. According to the November 2020 DBQ, a METs level of 1-3 has been found to be consistent with activities such as eating, dressing, taking a shower, or slow walking for 1-2 blocks. As the 60 percent rating criteria requires a METs level greater than 3, the Board finds a 100 percent rating is warranted for METs level of 1-3 throughout the entire appeal period. 4. Entitlement to an increased rating in excess of 40 percent from July 6, 2007 to April 28, 2009 for diabetes with erectile dysfunction The Veteran’s diabetes is rated under Diagnostic Code 7913, which provides for a 10 percent rating when diabetes is managed by restricted diet only; a 20 percent rating when it requires insulin and restricted diet, or oral hypoglycemic agent and restricted diet; a 40 percent rating when it requires insulin, restricted diet, and regulation of activities; a 60 percent rating when it requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice monthly visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated; and a maximum 100 percent rating if it requires 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. Significantly, “regulation of activities” is defined as “avoidance of strenuous occupational and recreational activities.” 38 C.F.R. § 4.119, Diagnostic Code 7913. With respect to a 40 percent rating, the United States Court of Appeals for Veterans Claims (Court) has held that all the criteria must be met given the clearly conjunctive structure of the language used in Diagnostic Code 7913. See Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007); see also Tatum v. Shinseki, 23 Vet. App. 152, 155-56 (2009) (comparing the successive nature of Diagnostic Code 7913 for diabetes mellitus with the non-successive Diagnostic Code 7903 for hypothyroidism). Moreover, a note following Diagnostic Code 7913 states that compensable complications of diabetes are to be separately evaluated unless those complications are part of the criteria used to support a 100 percent evaluation for diabetes mellitus; noncompensable complications, however, are considered part of the diabetic process under Diagnostic Code 7913. See 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1). In compliance with that provision, the Veteran’s noncompensable erectile dysfunction has been included with his diabetes evaluation. In a September 2007 VA examination, the Veteran denied any hospitalizations for diabetes, ketoacidosis, or hypoglycemic reactions. The Veteran stated that he meticulously regulated his diet, medication, and activity. He stated he was not on insulin at the time of examination because it was stopped after his recent GI surgery. The Veteran reported that his activities were restricted due to his diabetes and that his diabetic control was so tenuous that he avoided strenuous occupational and recreational activities. He was seeing his diabetic care provider every 3 months at the time of examination. In his March 2009 DRO hearing, the Veteran reported that his diabetes treatment regimen consisted of oral medication, diet control, and “exercise diet.” He stated he was not on insulin injections. The Board finds that the criteria for a rating in excess of 40 percent have not been met. The evidence does not reflect episodes of ketoacidosis or hypoglycemic reactions requiring hospitalization or twice monthly visits to a diabetic care provider. The Board further finds that the weight of the evidence is against finding that the Veteran’s erectile dysfunction warranted a compensable rating. See 38 C.F.R. § 4.115b, Diagnostic Code 7522 (penis, deformity, with loss of erectile power). Pursuant to Diagnostic Code 7522, a 20 percent rating is warranted for deformity of the penis with the loss of erectile power. This is the only schedular rating provided under this diagnostic code. Therefore, the evidence must demonstrate “deformity of the penis” to warrant an additional schedular rating under Diagnostic Code 7522. After a review of all the lay and medical evidence, the Board finds that, for the entire rating period on appeal, the Veteran’s erectile dysfunction manifested by loss of erectile power such that the Veteran was unable to achieve an erection sufficient for penetration and ejaculation, but without deformity of the penis. 5. Entitlement to an increased rating in excess of 20 percent from April 29, 2009, to include whether reduction was proper In a November 2009 rating decision, the Veteran’s 40 percent rating for diabetes with erectile dysfunction was reduced to 20 percent disabling. Thus, in addition to his increased rating claim, the Board must consider whether the reduction was proper. Regulations provide that where the reduction in evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, rating action will be taken. The reduction will be made effective the last day of the month in which a 60-day period from the date of notice to the payee expires. The Veteran will be notified of the proposed reduction, that he has 60 days to present evidence showing why the reduction should not be implemented, and that he may request a hearing. 38 C.F.R. § 3.105 (e). In the instant case, the Board observes that the AOJ complied with § 3.105 (e) in that the reduction did not result in a reduction or discontinuance of compensation payments, therefore no notification of the proposed reduction was required. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history. Furthermore, 38 C.F.R. § 4.13 provides that the rating agency should assure itself that there has been an actual change in the condition, for better or worse, and not merely a difference in the thoroughness of the examination or in use of descriptive terms. Additionally, in any rating reduction case, not only must it be determined that an improvement in a disability has actually occurred, but that such improvement reflects improvement in ability to function under ordinary conditions of life and work. Brown v. Brown, 5 Vet. App. 413, 420-421 (1993); see 38 C.F.R. §§ 4.2, 4.10. A claim as to whether a rating reduction was proper must be resolved in the veteran’s favor unless the Board concludes that a fair preponderance of evidence weighs against the claim. Brown, 5 Vet. App. at 421. In considering the propriety of a reduction, the Board must focus on the evidence of record available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered for the limited purpose of determining whether the condition had demonstrated actual improvement. Dofflemyer v. Derwinski, 2 Vet. App. 277, 279-80 (1992). In a September 2007 VA examination, the Veteran denied any hospitalizations for diabetes, ketoacidosis, or hypoglycemic reactions. The Veteran stated that he meticulously regulated his diet, medication, and activity. He stated he was not on insulin at the time of examination because it was stopped after his recent GI surgery, and this was corroborated by the discharge summary. The Veteran reported that his activities were restricted due to his diabetes and that his diabetic control was so tenuous that he avoided strenuous occupational and recreational activities. He was seeing his diabetic care provider every 3 months at the time of examination. In his March 2009 DRO hearing, the Veteran reported that his diabetes treatment regimen consisted of oral medication, diet control, and “exercise diet.” He stated he was not on insulin injection. In the April 2009 VA examination, the examiner indicated the Veteran was currently on oral medication and restricted diet, but no insulin or regulation of activities. It was noted that the Veteran had previously been on much more aggressive therapy but after his massive post-operative weight loss his therapy was cut back. In a May 2009 VA examination for diabetic retinopathy, the examiner remarked that the Veteran’s recent diagnosis and treatment of stomach cancer lead to a significant loss of weight and improvement in his diabetic control. In the August 2020 retrospective VA opinion, the examiner stated there was no evidence to indicate there were any episodes of ketoacidosis or hypoglycemic reactions or that the Veteran’s diabetes itself resulted in a progressive loss of weight and strength. The examiner concluded the Veteran’s diabetes was moderate. In the October 2020 addendum, the examiner noted that at one time the Veteran required insulin. After his GI surgery for cancer, however, he lost considerable weight and no longer required insulin. In his 2009 examination, he was off insulin and using oral medication. There was no known history of hypoglycemia or ketoacidosis. The examiner concluded “overall, diabetes improved after gastrointestinal surgery primarily due to dramatic weight loss.” In the November 2020 addendum with completed DBQ based on the evidence of record, the examiner indicated treatment of restricted diet, oral medication, and one insulin injection per day. Regulation of activities was not indicated. As stated above, the 40 percent rating criteria require one or more daily injection of insulin, restricted diet, and regulation of activities. The evidence, to include VA examination, medical records, and the Veteran’s own testimony, reflects that the Veteran was not on insulin as of April 29, 2009. Subsequent evidence of record confirms there was substantial improvement in the Veteran’s diabetic condition at the time. Thus, a reduction to 20 percent was proper. The evidence does not reflect an increased rating in excess of 20 percent from April 29, 2009. Medical records from 2012 in the months prior to the Veteran’s death do list insulin as a prescribed medication; however, there is no indication that a regulation of activities was part of the Veteran’s treatment regimen after April 29, 2009. 6. Entitlement to a TDIU The Veteran filed a claim for entitlement to a TDIU in 2005; the claim was denied in a January 2006 rating decision and the Veteran did not appeal. The Board subsequently deemed it raised by the record in its December 2011 decision. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). In this decision, the Appellant is granted a 100 percent rating for the Veteran’s CAD as of July 6, 2006, the entire period on appeal. The Board notes that the presence of a schedular 100 percent disability rating does not necessarily render the issue of TDIU moot.  See Bradley v. Peake, 22 Vet. App. 280, 293-94 (2008) (holding that 100 percent evaluation does not render a TDIU claim moot where there is a possibility that TDIU will impact entitlement to special monthly compensation (SMC) based on receipt of service connection for a disability with a 100 percent rating and another with a separate 60 percent rating). That is especially true if the Veteran is in receipt of a 100 percent disability rating, but his unemployability is alleged based on an entirely separate service-connected disability. See id. That is not the case here, as the Veteran’s TDIU claim is based on the manifestations of his service-connected diabetes and secondary disabilities, to include CAD. In fact, with the exception of hearing loss and tinnitus, each of the Veteran’s service-connected disabilities was secondary to his diabetes. Therefore, the 100 percent disability rating for CAD does render the TDIU claim moot, effective July 6, 2006. L.M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Carroll, 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.