Citation Nr: 21010308 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 20-28 098 DATE: February 24, 2021 ORDER The appeal as to the claim of entitlement to service connection for aortic aneurysm (claimed as iliac aneurysm) is moot, and the claim is dismissed for lack of jurisdiction. The appeal as to the claim of entitlement to an initial evaluation in excess of 10 percent for service-connected coronary artery disease (CAD), prior to October 26, 2018, is denied. The appeal as to the claim of entitlement to an initial evaluation in excess of 60 percent for service-connected CAD, from October 26, 2018, to June 24, 2020, is denied. REMANDED The appeal as to the claim of entitlement to service connection for skin cancer, is remanded. The appeal as to the claim of entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to the service-connected coronary artery disease (CAD), and/or diabetes mellitus, type II, and/or service-connected acquired psychiatric disorder, is remanded. The appeal as to the claim of entitlement to an initial evaluation in excess of 20 percent for service-connected diabetes mellitus, type II, is remanded. The appeal as to the claim of entitlement to an initial evaluation in excess of 10 percent for service-connected right lower extremity peripheral neuropathy, prior to October 26, 2018, and in excess of 20 percent since October 26, 2018, is remanded. The appeal as to the claim of entitlement to an initial evaluation in excess of 10 percent for service-connected left lower extremity peripheral neuropathy, prior to October 26, 2018, and in excess of 20 percent since October 26, 2018, is remanded. The appeal as to the claim of entitlement to a total disability evaluation based upon individual unemployability (TDIU), due to service-connected disabilities, is remanded. FINDINGS OF FACT 1. The Veteran’s claim of entitlement to service connection for aortic aneurysm was granted in a rating decision issued by the Agency of Original Jurisdiction (AOJ) in September 2020, with an effective date of June 24, 2020. 2. Prior to October 26, 2018, the Veteran’s CAD was not manifested by a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or with evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray warrants a 30 percent disability. 3. From October 26, 2018, to June 24, 2020, the Veteran’s CAD was not manifested by evidence of chronic congestive heart failure; nor a workload of 3 METs (metabolic equivalents) or less resulting in dyspnea, fatigue, angina, dizziness or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. CONCLUSIONS OF LAW 1. The Board lacks jurisdiction over the claim of service connection for aortic aneurysm, because that claim has been granted and rendered moot. 38 U.S.C. § § 7104 (a), 7105(d)(5) (2012); 38 C.F.R. § § 19.7, 20.101, 20.200, 20.202 (2019). 2. The criteria for establishing entitlement to an initial evaluation in excess of 10 percent, prior to October 26, 2018, for CAD have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. § 4.104, Diagnostic Code 7005 (2019). 3. The criteria for establishing entitlement to an initial evaluation in excess of 60 percent from October 26, 2018, to June 24, 2020, for CAD have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. § 4.104, Diagnostic Code 7005 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Navy from August 1963 to December 1967. His service was under honorable conditions. The matters are on appeal from a January 2017 rating decision. In a November 2018 rating decision, the AOJ increased the evaluation for the service-connected CAD from 10 to 60 percent, right lower extremity peripheral neuropathy from 10 to 20 percent, and left lower extremity peripheral neuropathy from 10 to 20 percent, effective October 26, 2018. As this is not the maximum benefit available, the claim remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In multiple statements, the Veteran raised an informal claim of entitlement to a TDIU due to his service-connected disabilities. The issue of whether entitlement to a TDIU is warranted as a result of that disability is part and parcel of the increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, the issues are as noted on the title page. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion 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); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Dismissal as Moot 1. Entitlement to service connection for aortic aneurysm. In this case, the Veteran's claim of service connection for aortic aneurysm was granted in a rating decision issued by the AOJ in September 2020. As a general matter, the grant of a claim of service connection constitutes an award of full benefits sought on an appeal of the denial of a service connection claim. Seri v. Nicholson, 21 Vet. App. 441, 447 (2007); see also Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second Notice of Disagreement must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection). The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.202 (2019). Here, as a result of the AOJ's action, there no longer remains a case or controversy with respect to this claim. Therefore, the Board lacks jurisdiction over this issue because it has been granted and rendered moot on appeal. 38 U.S.C. § 7104, 7105 (2012); 38 C.F.R. § 19.7, 20.101, 20.200, 20.202 (2019). Therefore, dismissal of this claim is warranted. Increased Rating – General Legal Criteria Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2019). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321 (a), 4.1 (2019). 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. In accordance with 38 C.F.R. §§ 4.1, 4.2 (2019) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities at issue. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disability. In both initial rating claims and normal increased rating claims, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). VA must consider all favorable lay evidence of record. 38 U.S.C. § 5107 (b); Caluza v. Brown, 7 Vet. App. 498 (1995). The Veteran is competent to testify regarding the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 2. Entitlement to an initial evaluation in excess of 10 percent for service-connected CAD, prior to October 26, 2018, and in excess of 60 percent from October 26, 2018, to June 24, 2020. The Veteran contends that his service-connected CAD warrants an initial higher evaluation throughout. The preponderance of the evidence is against his claim. Pursuant to a January 2017 rating decision, the AOJ granted service connection for CAD and assigned a 10 percent rating under Diagnostic Code 7005. 38 C.F.R. § 4.104 (2019). An effective date of April 27, 2016 was noted. In a November 2018 rating decision, the assigned evaluation for the Veteran’s service-connected CAD was increased from 10 percent disabling to 60 percent disabling. An effective date of October 26, 2018 was noted. In an August 2020 rating decision, the assigned evaluation for the Veteran’s service-connected CAD was increased from 60 percent disabling to 100 disabling, effective June 24, 2020. Under Diagnostic Code 7005, CAD with a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or when continuous medication is required, a 10 percent disability rating is warranted. CAD with a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or with evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray warrants a 30 percent disability. CAD with more than one episode of acute congestive heart failure in the past year, a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or with left ventricular dysfunction with an ejection fraction of 30 to 50 percent warrants a 60 percent disability rating. CAD with chronic congestive heart failure, with a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or with left ventricular dysfunction with an ejection fraction of less than 30 percent warrants a 100 percent disability. 38 C.F.R. § 4.104 (2019); Diagnostic Code 7005. A December 2015 record demonstrates left ventricular ejection fraction (LVEF) testing of 45-50 percent. Wall motion abnormalities include moderate hypokinesis of the inferior wall. There was no evidence of valvular regurgitation. On VA examination in December 2016, valvular heart disease and CAD were diagnosed. The Veteran reported that he experienced a sudden episode of chest pain with left arm pain, and was treated with a stent in December 2015. In June 2016, the Veteran had another episode of CP, left arm pain, and he collapsed; an angiogram was performed. Since June 2015, the Veteran reported that he is easily tired. He reported that he is on multiple heart medications. Continuous medication is required to control the Veteran’s heart condition, to include ASA, Clopidogrel, Simvastatin, Metoprolol, and Lisinopril. The Veteran has not had myocardial infarction, congestive heart failure, or arrhythmia. The Veteran has not had infectious heart conditions. The Veteran has not had pericardial adhesions. The Veteran had heart valve conditions, to include mitral, tricuspid, and aortic conditions. The Veteran has had percutaneous coronary intervention (PCI) (angioplasty), in 2015. On examination, heart rate was 86 with regular rhythm. Point of maximum impact was not palpable. Heart sounds were normal. There was no evidence of jugular-venous distension. Auscultation of the lungs was clear. Peripheral pulses, dorsalis pedis and posterior tibial, were normal. There was no evidence of peripheral edema. Blood pressure was 149/71, 138/80, 140/87. There is no evidence of scars or complications. There was no evidence of cardiac hypertrophy or cardiac dilatation. EKG performed on December 19, 2016, shows junctional rhythm – no evidence of LVH. Chest x-ray was abnormal, showing possible calcified old granuloma, and atherosclerotic calcification in the arch of the aorta. Echocardiogram shows LVEF of 56 percent with abnormal wall motion; specifically, mild aortic valve stenosis by valve area/visualization, structurally normal mitral valve with mild to moderate regurgitation, structurally normal tricuspid valve with mild regurgitation, and doppler evidence of grade I (impaired) diastolic dysfunction. Wall thickness was normal. Stress testing was not performed. Interview-based METs test reflects the lowest activity level at which the Veteran reports dyspnea, and fatigue. This METs level, a workload of greater than 7, but not greater than 10 METs, has been found to be consistent with activities such as climbing stairs quickly, moderate bicycling, sawing wood, and jogging (6 mph). The Veteran did not have an exercise stress test. His METs level is due solely to his heart conditions. The examiner concluded that Veteran’s METs score was due solely to cardiac function. On subsequent VA examination, in November 2018, CAD was diagnosed. The examiner noted that continuous medication was required. The examiner noted a history of myocardial infarction in December 2015 and January 2016. There was no evidence of congestive heart failure or cardiac arrhythmia. There was no evidence of a heart valve condition, infectious heart conditions, or pericardial adhesions. There was a history of percutaneous coronary intervention (PCI) in December 2015 and January 2016. Physical exam revealed heart rate of 56, regular rhythm, normal heart sounds, clear auscultation of the lungs, normal peripheral pulses, and blood pressure of 140/90, 142/90, and 136/86. There was no evidence of jugular-venous distension or peripheral edema. Echocardiogram revealed evidence of cardiac hypertrophy. There was no evidence of cardiac dilatation. EKG and Chest x-ray were normal. Echocardiogram revealed LVEF of 60 percent, with abnormal mitral inflow and abnormal mild LVH. Interview based METs testing revealed dyspnea, and fatigue. METs level was greater than 5 but less than 7. The Veteran did not have both an exercise stress test and an interview-based METs test. The examiner concluded that Veteran’s METs score was due solely due to heart conditions. On VA examination in July 2020, atherosclerotic cardiovascular disease and CAD were diagnosed. The examiner noted that continuous medication was required. There was no evidence of congestive heart failure or cardiac arrhythmia. There was no evidence of a heart valve condition, infectious heart conditions, or pericardial adhesions. There was a history of percutaneous coronary intervention (PCI) in December 2015 and January 2016. Physical exam revealed heart rate of 80 regular rhythm, normal heart sounds, clear auscultation of the lungs, normal peripheral pulses, and blood pressure of 130/82, 132/82, and 132/82. Point of maximum impact was not palpable. There was no evidence of jugular-venous distension. There was evidence of peripheral edema of 1+, of the right and left lower extremities. There was no evidence of cardiac hypertrophy or cardiac dilatation. EKG and chest x-ray were normal. Echocardiogram revealed LVEF of 60 percent with abnormal mitral inflow and abnormal mild LVH. Interview based METs testing revealed dyspnea, fatigue, angina, and dizziness. METs level was greater than 1 but less than 3. The Veteran had both an exercise stress test and an interview-based METs test. The interview-based METs test most accurately reflects the Veteran’s current cardiac functional level. The examiner concluded that Veteran’s METs score was due solely due to heart conditions. Considering the forgoing, the Board finds that the preponderance of the evidence fails to show that the Veteran's symptoms worsened or warranted the next higher evaluation for any time during the appeal period. In making all determinations, the Board has fully considered all medical evidence and the lay assertions of record. It also acknowledges the Veteran's competence to report on observable symptoms and notes that such statements are generally deemed credible to the extent that they articulate the Veteran's belief that he is entitled to a higher rating. In this case, however, the Veteran's lay assertions are outweighed by competent and credible medical evidence which evaluated the true extent of his heart condition to include consideration of his contentions as to worsening symptoms. In this regard, the Board notes that the VA examiner possesses the training and expertise necessary to administer the appropriate tests to determine the type and degree of the Veteran's impairment and complaints of symptoms. For these reasons, greater evidentiary weight is placed on the examination findings. While the Board is sympathetic to the Veteran's complaints of worsening symptoms, to include dyspnea, fatigue, and dizziness on light exertion with increased risk of falls, difficulty with prolonged walking or standing, climbing stairs, and performing strenuous physical activity, the medical evidence does not show symptomology sufficient to warrant a higher evaluation. On VA examination in December 2016, there was no evidence of evidence of cardiac hypertrophy or dilatation, or a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope as required to establish a disability evaluation of 30 percent. Similarly, VA findings in November 2018 revealed symptomology no worse than a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. Further, there was no evidence of left ventricular dysfunction with an ejection fraction of less than 30 percent. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim and the benefit of the doubt provisions are inapplicable. 38 U.S.C. § 5107 (West 2012); 38 C.F.R. § 4.3 (2019); Gilbert, 1 Vet. App. at 56. The Veteran's claim of entitlement to an initial evaluation in excess of 10 percent for his service-connected CAD prior to October 26, 2018, and in excess of 60 percent from October 26, 2018, to June 24, 2020, must be denied. REASONS FOR REMAND 1. Entitlement to service connection for skin cancer. The Veteran contends that his current skin cancer disorder is due to exposure to herbicidal agents while serving in the Republic of Vietnam, during the Vietnam Era. Service treatment records are negative for complaints of, treatment for, or a diagnosis of skin cancer, to include soft tissue sarcoma. Post-service records include a July 2015 private treatment record that notes that the Veteran presented with a skin lesion over the right angle of his mouth. Examination revealed a raised 3 to 4mm skin lesion with a central punctum. The assessment was a skin neoplasm of the right lateral upper lip. A January 2016 record notes a biopsy of a skin lesion was performed. An April 2016 record notes a diagnosis of basal cell carcinoma of the lip. In December 2016, a VA examiner reviewed the record, and found there was no supporting medical records documenting skin cancer. Given the Veteran’s assertions, that his current skin cancer disorder is related to his active service, and the current diagnosis of record, the Board must remand this issue for VA a examination and medical opinion concerning this matter. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C. § 5103A (d) (West 2012); 38 C.F.R. § 3.159 (c)(4). 2. Entitlement to service connection for OSA, to include as secondary to the service-connected CAD, diabetes mellitus, type II, and/or service-connected acquired psychiatric disorder. The Veteran contends that his current sleeping disorder is due to his service-connected CAD, diabetes mellitus, type II, and/or his acquired psychiatric disorder. Service treatment records are negative for complaints of, treatment for, or a diagnosis of a respiratory disorder, to include OSA. Post-service VA outpatient treatment records dated in April 2016 and July 2020 note diagnoses of OSA. A March 2018 record notes the Veteran’s use of a CPAP machine for his OSA. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (2019). This includes any increase in severity of a nonservice-connected disease that is proximately due to or the result of a service-connected disability as set forth in 38 C.F.R. § 3.310(b). See also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). A claimant is also entitled to service connection on a secondary basis when it is shown that a service-connected disability aggravates a nonservice-connected disability. 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 439. Therefore, the issue is remanded for a VA examination and medical opinion regarding whether any respiratory disorder, to include OSA, is directly related to the Veteran’s active service or to his service-connected CAD, diabetes mellitus, type II, and/or acquired psychiatric disorder. 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). 3. Entitlement to an initial evaluation in excess of 20 percent for service-connected diabetes mellitus, type II. See argument Below at 5 4. Entitlement to an initial evaluation in excess of 10 percent for service-connected right lower extremity peripheral neuropathy, prior to October 26, 2018, and in excess of 20 percent since October 26, 2018. See argument Below at 5 5. Entitlement to an initial evaluation in excess of 10 percent for service-connected left lower extremity peripheral neuropathy, prior to October 26, 2018, and in excess of 20 percent since October 26, 2018. VA's duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. Peters v. Brown, 6 Vet. App. 540, 542 (1994). In this regard, the Board notes that the Veteran was most recently afforded a VA examination to assess the severity of his service-connected diabetes mellitus, type II, and bilateral lower extremity peripheral neuropathy disorders in November 2018, more than two years ago. In several statements, the Veteran asserted that symptoms of his diabetes and bilateral lower extremity peripheral neuropathy disabilities worsened; specifically, that he experienced increased eye symptoms associated with diabetes, and increased numbness of his bilateral lower extremities. VA outpatient treatment records dated in July 2020 note the examiner’s finding of glaucoma associated with diabetes, with increased symptoms since January 2020. Records dated in March 2018 note the Veteran’s increased peripheral neuropathy symptoms and use of Gabapentin to treat his symptoms. In light of the foregoing, more contemporaneous examinations are warranted in order to ensure that the record reflects the current severity of the Veteran's service-connected diabetes mellitus, type II, and bilateral lower extremity peripheral neuropathy disabilities. Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (holding that where the record does not adequately reveal the current state of that disability, the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination). 6. Entitlement to a TDIU due to service-connected disabilities. As the aforementioned claim of entitlement to service connection and increased evaluations are currently being developed by the AOJ, and they are directly applicable to the question of employability, the issue of TDIU is also remanded as inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two or more issues are inextricably intertwined if one claim could have significant impact on the other). Further, development to obtain any outstanding medical records pertinent to the Veteran’s claims should be completed. The matters are REMANDED for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran’s claims, to include VA outpatient treatment records from July 2020, to the present. If any requested records are unavailable, or the search for such records otherwise yields negative results, that fact should clearly be documented in the record and the Veteran so notified in accordance with 38 C.F.R. § 3.159(e). All steps taken to attempt to obtain the above records should clearly be documented in the record. 2. Schedule the Veteran for a VA examination before an appropriate physician to determine the etiology of any current skin cancer disorder present during the period on appeal. The examiner must review the record, to include service treatment records, VA and private treatment records, and the Veteran’s assertions. The examiner must also consideration the Veteran's documented medical history, assertions, and reported symptoms. All necessary tests and studies should be completed, and all clinical findings reported in detail. The examiner must provide an opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that any identified skin cancer disorder(s), manifested during, or as a result of, active military service to include his presumed herbicide exposure. (The Board stresses that the Veteran’s exposure to herbicidal agents such as Agent Orange is conceded). In providing the opinion, the examiner must discuss the contemporaneous private treatment records, which note diagnoses of basal cell carcinoma of the lip. For purposes of the opinions, the examiner should assume that the Veteran is a credible historian. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. 3. Schedule the Veteran for a VA examination before an appropriate physician to determine the etiology of any current respiratory disorder, to OSA, present during the period on appeal. The examiner must review the record, to include service treatment records, VA and private treatment records, and the Veteran’s assertions. The examiner must also consideration the Veteran's documented medical history, assertions, and reported symptoms. All necessary tests and studies should be completed, and all clinical findings reported in detail. The examiner must provide an opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that any respiratory disorder(s), to include OSA, manifested during, or as a result of, active military service. If not, the physician should state a medical opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that the OSA disorder was caused or permanently worsened by the service-connected CAD, diabetes mellitus, type II, and/or acquired psychiatric disability. If the physician believes that an OSA disorder was permanently worsened by the service-connected CAD, diabetes mellitus, type II, and/or acquired psychiatric disability, the physician should attempt to identify the baseline level of disability that existed prior to the onset of aggravation and the extent of disability that is attributable to aggravation. In providing the opinion, the examiner must discuss the contemporaneous VA and private diagnoses of OSA. For purposes of the opinions, the examiner should assume that the Veteran is a credible historian. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. 4. Schedule the Veteran for a VA examination by an appropriate physician to assess the nature and severity of his service-connected diabetes mellitus, type II disability. The examiner should thoroughly review the record and should note that review in the report. The examiner should also consider the Veteran's assertions, and complaints. All necessary tests and studies should be completed, and all clinical findings reported in detail. The examiner is requested to describe all manifestations and symptoms of the diabetes mellitus, type II disability, as well as information required for rating purposes. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he or she should be directed to clearly explain why that is so. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. 5. Schedule the Veteran for a VA examination by an appropriate physician to assess the nature and severity of his service-connected right and left lower extremity peripheral neuropathy disabilities. The examiner should thoroughly review the record and should note that review in the report. The examiner should also consider the Veteran's assertions, and complaints. All necessary tests and studies should be completed, and all clinical findings reported in detail. The examiner is requested to describe all manifestations and symptoms of the right and left lower extremity peripheral neuropathy disabilities, as well as information required for rating purposes. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he or she should be directed to clearly explain why that is so. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. 6. The AOJ should ensure that the Veteran is provided with adequate notice of the date and place of all scheduled examinations. A copy of all notifications, including the address where the notice was sent, must be associated with the record if the Veteran fails to report for any examination. The Veteran is to be advised that failure to report for a scheduled VA examination without good cause may have adverse effects on his claim. 7. Then, the AOJ should readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran’s satisfaction, he and his representative should be provided a supplemental statement of the case and an appropriate period of time for response before the case is returned to the Board for further appellate action B. MULLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sara Schinnerer, 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.