Citation Nr: 21011704 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 16-01 594 DATE: March 2, 2021 ORDER Entitlement to a rating greater than 20 percent for type 2 diabetes with erectile dysfunction is denied. Entitlement to a rating greater than 40 percent for peripheral neuropathy of the right lower extremity (sciatic nerve) is denied. Entitlement to a rating greater than 40 percent for peripheral neuropathy of the left lower extremity (sciatic nerve) is denied. Entitlement to an initial 30 percent rating for peripheral neuropathy of the right lower extremity (femoral nerve) is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to an initial 30 percent rating for peripheral neuropathy of the left lower extremity (femoral nerve) is granted, subject to the laws and regulations governing the award of monetary benefits. For the period from August 16, 2017 to March 24, 2019, entitlement to an initial 20 percent rating for left leg scars (left thigh and left lower inner thigh) is granted, subject to the laws and regulations governing the award of monetary benefits. For the period from March 25, 2019, entitlement to a rating greater than 20 percent for left thigh scar is denied. For the period from March 25, 2019, entitlement to a rating greater than 20 percent for left lower inner thigh scar is denied. For the period from August 16, 2017, entitlement to a 10 percent rating for left leg scars based on limitation of motion of the left hip is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted effective July 22, 2016, subject to the laws and regulations governing the award of monetary benefits. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for peripheral vascular disease of the right and left lower extremities is remanded. FINDINGS OF FACT 1. The Veteran’s diabetes does not require one or more daily injections of insulin; there is no evidence of penile deformity and a separate compensable rating for erectile dysfunction is not warranted. 2. The Veteran’s right lower extremity peripheral neuropathy is not manifested by severe incomplete paralysis of the sciatic nerve with marked muscular atrophy. 3. The Veteran’s left lower extremity peripheral neuropathy is not manifested by severe incomplete paralysis of the sciatic nerve with marked muscular atrophy. 4. Resolving reasonable doubt in the Veteran’s favor, his right lower extremity peripheral neuropathy is manifested by severe incomplete paralysis of the femoral nerve. 5. Resolving reasonable doubt in the Veteran’s favor, his left lower extremity peripheral neuropathy is manifested by severe incomplete paralysis of the femoral nerve. 6. For the period from August 16, 2017 to March 24, 2019, the Veteran is shown to have two scars of the left lower extremity that are both painful and unstable. 7. For the period from March 25, 2019, the Veteran is not shown to have three or four scars of the left lower extremity that are painful or unstable with one or more being both painful and unstable; or, five or more scars that are painful or unstable. 8. Resolving reasonable doubt in the Veteran’s favor, his left leg scars are productive of painful motion of the left hip. 9. The Veteran meets the schedular requirements for TDIU during the entirety of the appeal period beginning July 22, 2016, and the evidence is at least in equipoise as to whether his service-connected disabilities are so severe as to preclude all forms of substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a rating greater than 20 percent for type 2 diabetes with erectile dysfunction are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.119, Diagnostic Code 7913; 38 C.F.R. § 4.115b, Diagnostic Code 7522. 2. The criteria for a rating greater than 40 percent for right lower extremity peripheral neuropathy (sciatic nerve) have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.124a, Diagnostic Code 8520. 3. The criteria for a rating greater than 40 percent for left lower extremity peripheral neuropathy (sciatic nerve) have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.124a, Diagnostic Code 8520. 4. The criteria for an initial 30 percent rating for right lower extremity peripheral neuropathy (femoral nerve) have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.124a, Diagnostic Code 8526. 5. The criteria for an initial 30 percent rating for left lower extremity peripheral neuropathy (femoral nerve) have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.124a, Diagnostic Code 8526. 6. For the period from August 16, 2017 to March 24, 2019, the criteria for an initial 20 percent rating for left leg scars (left thigh and left lower inner thigh) have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Code 7804. 7. For the period from March 25, 2019, the criteria for a rating greater than 20 percent for left thigh scar are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Code 7804. 8. For the period from March 25, 2019, the criteria for a rating greater than 20 percent for left lower inner thigh scar are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Code 7804. 9. For the period from August 16, 2017, the criteria for a separate 10 percent rating for left leg scars based on limitation of motion of the left hip are met. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Codes 5251-5253, § 4.118, Diagnostic Code 7805. 10. The criteria for TDIU have been met effective July 22, 2016. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1966 to January 1968. In October 2020, a virtual hearing was held before the undersigned Veterans Law Judge. The record was held open for 90 days and additional evidence was timely received. Automatic waiver applies. 38 U.S.C. § 7105(e). Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. The Board acknowledges that in the May 2020 informal hearing presentation, the Veteran generally asserted worsening of his service-connected disorders and suggested they were not adequately reflected in the previous examination results. At the subsequent hearing, he argued entitlement to TDIU due to the severity of his disabilities. On review, the Board finds the record adequate to address the increased rating claims and as discussed below, various increases are granted herein, to include TDIU. Remanding for additional examinations on the claims for increase would only serve to delay the claim. Entitlement to a rating greater than 20 percent for type 2 diabetes with erectile dysfunction In January 2017, VA continued a 20 percent rating for type 2 diabetes with erectile dysfunction. The Veteran disagreed with the rating and perfected this appeal. Diagnostic Code 7913 provides a structured scheme of specific, successive, cumulative criteria. Each higher rating includes the same criteria as the lower rating plus distinct new criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). A 10 percent rating is warranted when diabetes is manageable by restricted diet only. A 20 percent rating is warranted when diabetes requires one or more daily injection of insulin and restricted diet, or an oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted when it requires one or more daily injection of insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. Compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100-percent evaluation. Noncompensable complications of diabetes are considered part of the diabetic process. 38 C.F.R. § 4.119, Diagnostic Code 7913 (Note 1). Because Diagnostic Code 7913 contains successive criteria, the criteria for the lower rating must be met before a higher disability rating may be awarded. A higher rating cannot be granted based on a finding that the Veteran’s disability picture more nearly approximates the criteria for the next higher rating. However, reasonable doubt regarding the presence of a criterion may be resolved in the Veteran’ favor. Johnson v. Wilkie, 30 Vet. App. 245 (2018). The question in this appeal is whether the Veteran’s diabetes requires one or more daily injections of insulin, restricted diet, and regulation of activities. VA examination in December 2016 indicates that the Veteran’s diabetes was treated with prescribed oral hypoglycemic agents. He did not require insulin or regulation of activities as part of medical management. The examiner stated that the diabetes was relatively controlled according to his last A1c result at 6.7. VA and private outpatient records do not indicate that insulin has been prescribed to treat the Veteran’s diabetes. A June 2020 VA record indicates that insulin therapy was reviewed but patient declined to consider. At the October 2020 hearing, the Veteran reported that he takes 4 oral medications to control his diabetes. He also argued that regulation of activities was required. On review, evidence of record indicates that the Veteran’s diabetes is treated with restricted diet and oral hypoglycemic agents. While insulin therapy may have been suggested, there is no evidence showing that he requires or uses one or more daily injections of insulin. The Veteran’s testimony and contentions concerning the need for regulation of activities is acknowledged. As above, however, the criteria are successive and absent the need for insulin, it is not necessary to discuss whether regulation of activities is required. The criteria for a rating greater than 20 percent for type 2 diabetes are not met at any time during the appeal period and the claim is denied. Regarding erectile dysfunction, the Veteran has not provided specific argument or testimony. VA male reproductive system examination dated in December 2016 indicates that the Veteran’s penis was normal without evidence of deformity. Accordingly, a separate compensable rating is not warranted. See 38 C.F.R. § 4.115b, Diagnostic Code 7522. Finally, the Board acknowledges that in December 2017, VA granted service connection for diabetic nephropathy as another noncompensable complication of diabetes. The Veteran did not appeal the rating assigned for nephropathy and this issue is not for consideration at this time. Entitlement to increased ratings for peripheral neuropathy of the right and left lower extremities In September 2016, VA increased the ratings for peripheral neuropathy (impairment of the sciatic nerve) of the right and left lower extremities to 40 percent effective July 22, 2016. VA also granted service connection for impairment of the femoral nerve and assigned separate 20 percent ratings for the lower extremities also effective as of that date. Additional relevant evidence (VA examination) was added within the one-year appeal period and in January 2017, VA continued the assigned ratings. The Veteran disagreed with the ratings and perfected this appeal. Thus, the appeal is considered to stem from the July 2016 claim for increase. Paralysis of the sciatic nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8520. (Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8620 and 8720.). Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Moderately severe incomplete paralysis is rated as 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy is rated as 60 percent disabling. Complete paralysis, the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R § 4.124a. Paralysis of the femoral nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8526. (Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8626 and 8726). Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Severe incomplete paralysis is rated as 30 percent disabling. Complete paralysis of the quadriceps extensor muscles is rated as 40 percent disabling. 38 C.F.R § 4.124a. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based on the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). On VA examination in September 2016, the Veteran reported an inability to sense the position of his feet when descending stairs. He reported moderate intermittent pain, severe paresthesias and/or dysesthesias, and severe numbness in both lower extremities. He also described a neuropathic gait. On neurologic examination, strength was 5/5 in bilateral knee flexion and extension, and 4/5 in bilateral ankle plantar flexion and dorsiflexion. Deep tendon reflexes were 2+ in the knees and 1+ in the ankles. Light touch/monofilament testing was decreased at the knees/thighs and absent at the ankles and feet/toes. Position sense and vibration sensation were absent in the lower extremities. Cold sensation was decreased in the right and left lower extremities. The Veteran did not have muscle atrophy but did have trophic changes. The examiner indicated that the Veteran had moderately severe incomplete paralysis of the sciatic nerve on the right and the left. He also had severe incomplete paralysis of the femoral nerve on both sides. EMG testing of the lower extremities in March 2016 revealed diffuse sensory neuropathy in the lower extremities. On VA examination in December 2016, the Veteran reported progressive worsening of his neuropathies with increased bilateral lower extremity numbness, tingling, restless legs, pins and needles sensation, and burning sensation. He takes medication but could not remember the name. Regarding lower extremity symptoms, he reported moderate intermittent pain, mild paresthesias and/or dysesthesias; and moderate numbness. On neurologic examination, strength was 4/5 in bilateral knee extension; 5/5 in right knee flexion; 4/5 in left knee flexion; 5/5 in right ankle plantar flexion; 4/5 in left ankle plantar flexion; 5/5 in right ankle dorsiflexion; and 4/5 in left ankle dorsiflexion. Deep tendon reflexes were 2+ at the right knee; 1+ at the left knee; 0 at the right ankle; and 1+ at the left ankle. Light touch/monofilament testing was decreased at the bilateral ankle/lower leg and absent at the bilateral foot/toes. Position sense was decreased, vibration sensation was absent, and cold sensation was decreased in both lower extremities. There was no muscle atrophy but there were trophic changes described as extreme hair loss and skin appears shinier. The examiner described the level of severity as mild incomplete paralysis of the sciatic nerve on the left. The right sciatic nerve and bilateral femoral nerves were all described as normal. The examiner, however, went on to state that the Veteran’s severe lower extremity neuropathy makes him more prone to avoidable accidents, such as tripping over objects or stepping on sharp objects. In a September 2020 statement, the Veteran’s physician, Dr. J.C., indicated that he has diabetic peripheral neuropathy which makes it difficult to walk for extended periods of time. At the hearing, the Veteran testified that due to his neuropathy, he cannot really determine where his feet are at and so his ankle and foot are locked at rigid positions resulting in him walking differently. When he drives, he has one foot at the brake pedal and the other foot on the accelerator because he cannot switch from one pedal to the other. He also reported that his feet were cold all the time and sometimes he feels like they are being stuck with needles or are on fire. When questioned regarding atrophy, the Veteran stated that his doctor has not mentioned this to him, and he was not aware of any decrease in size. As set forth, the Veteran reports severe symptoms related to his lower extremity neuropathies. Review of objective evidence, however, does not show findings of any muscle atrophy, much less to the “marked” degree. By his own testimony, the Veteran was unaware of any muscle atrophy. Thus, the disability picture does not more nearly approximate severe incomplete paralysis of the sciatic nerve with marked muscular atrophy of the right or left lower extremity. A rating greater than 40 percent is not warranted at any time during the appeal period. Regarding the femoral nerve, the September 2016 VA examiner indicated that there was severe incomplete paralysis of the femoral nerve on both the right and the left. The December 2016 examiner indicated that the femoral nerve was normal on both sides yet went on to describe severe neuropathy. Resolving reasonable doubt in the Veteran’s favor, the Board finds that the disability picture more nearly approximates severe incomplete paralysis of the femoral nerve in the right and left lower extremities and initial 30 percent ratings are warranted. 38 C.F.R. § 4.3. A rating in excess of 30 percent, however, is not warranted at any time during the appeal period as there is simply no evidence to support a finding of complete paralysis of the quadriceps extensor muscles on either side. Entitlement to initial increased ratings for left leg scars In December 2017, VA granted service connection for two left leg scars and assigned noncompensable ratings effective August 16, 2017. The Veteran disagreed with the ratings and perfected this appeal. In April 2019, VA increased the ratings for the scars now described as left thigh and left lower inner thigh to 20 percent each effective March 25, 2019. This action resulted in staged ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). A 10 percent rating is assigned for burn scars or scars due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage and involve an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.). 38 C.F.R. § 4.118, Diagnostic Code 7801. A 10 percent rating is assigned for burn scars or scars due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage and involve an area or areas of 144 square inches (929 sq. cm. or greater). 38 C.F.R. § 4.118, Diagnostic Code 7802. A 10 percent rating is assigned when there are one or two scars that are unstable or painful. A 20 percent rating is assigned for three or four scars that are unstable or painful. A 30 percent rating is assigned for five or more scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic Code 7804. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. at Note (1). If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Id. at Note (2). Scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 maybe also receive an evaluation under this diagnostic code, when applicable. Id. at Note (3). Any disabling effects not considered in a rating under Diagnostic Codes 7800-04 should be rated under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. The November 2017 VA examination indicates that none of the scars on the extremities are painful. There was one unstable scar on the left leg. The examiner described two scars on the left lower extremity. The first was located at the left thigh and was superficial and non-linear measuring 3 x .3 cm. The second was located at the left inner medial leg thigh/buttock and was deep and non-linear measuring 5 x 1 cm. The approximate area of superficial scars on the left lower extremity was .9 cm squared. The approximate area of deep scars on the left lower extremity was 5 cm squared. The examiner stated that there was limitation of function due to the scar on the left thigh buttock which is unstable and affects the ability to sit and walk as he has constant rubbing in the area. In a January 2018 statement, Dr. J.C. indicated that the Veteran has been suffering from reoccurring cysts on his back, neck and extremities which are painful. He has approximately 40 cm of linear scars all over his body. The physician did not report the specific locations or dimensions of the scars. In his January 2019 Form 9, the Veteran reported that he experiences daily pain from the scar on his left leg below the buttock. It hurts to sit on the toilet or a hard chair, or to lay down, or do anything. It also oozes when his sugar gets high. In January 2019, Dr. J.C. stated that the Veteran has been suffering from a reoccurring cyst on his left leg below the buttock. It gets infected and it is painful for the Veteran to sit and walk. He had removal procedures in July 2017 and August 2018. On VA examination in March 2019, the examiner stated that there were two painful scars on the left lower extremity. Per the Veteran there was intense pain with walking and sitting especially on hard surfaces. Both scars were also unstable. Scar #1 measured 5 cm x 1 cm and scar #2 measured 3 cm by .2 cm. Both scars were tender to palpation and both had underlying soft tissue damage. The approximate total area was 5.6 cm squared. At the hearing, the Veteran testified that he has a scar directly below the buttock on the left leg and it causes functional limitations with sitting. He also reported that the scars were both painful and unstable following the surgeries in 2017. The Board notes that in addition to the scars of the left lower extremity, the Veteran is service connected for scars on the neck, back and right hip. The Veteran only perfected an appeal as to the ratings assigned for the left leg scars and the Board’s discussion will be limited to same. The Veteran’s left leg scars do not encompass an area sufficient to warrant compensable ratings under either Diagnostic Codes 7801 or 7802 and they are more appropriately evaluated under Diagnostic Code 7804. For the period from August 16, 2017 to March 24, 2019 The October 2017 VA examination showed two scars on the left lower extremity and the examiner noted that the thigh buttock scar was unstable. The Veteran also testified that his left leg scars were painful. The Board has no reason to doubt his testimony and thus, an initial 20 percent rating is warranted for the left leg scars together. This is based on 10 percent for 2 scars that are unstable or painful plus an additional 10 percent because one or more scars are both unstable and painful. For the period from March 25, 2019 The March 2019 examination indicates that both scars were painful and unstable, and the Veteran was assigned two 20 percent ratings effective March 25, 2019. As set forth above, one or two scars that are unstable or painful warrants a 10 percent evaluation and an additional 10 percent can be added if one or more scars are both unstable and painful. There is no provision for separate 20 percent ratings in this case. Notwithstanding, the Board will not disturb the ratings assigned but notes that there is simply no legal basis for assigning higher ratings under Diagnostic Code 7804. As concerns the left lower extremity there is no indication of three or four scars that are unstable or painful with one or more being both unstable and painful; or, five or more scars that are unstable or painful. In March 2019, the Veteran also underwent a VA left hip examination. Left hip range of motion was abnormal with flexion 0 to 100 degrees; extension 0 to 25 degrees; abduction 0 to 40 degrees; adduction 0 to 20 degrees; external rotation 0 to 50 degrees; and internal rotation 0 to 30 degrees. Adduction was not limited such that the Veteran cannot cross his legs. The examiner stated that there was pain noted on examination which caused functional loss and that the decreased range of motion due to pain was related to his left thigh scars. The limitation of motion reflected on examination is not compensable under either the former or current applicable rating criteria pertaining to the hip and thigh. See 38 C.F.R. § 4.71a, Diagnostic Codes 5251-5253. Objective evidence, however, shows painful motion of the left hip related to the scars. Resolving reasonable doubt in the Veteran’s favor as to whether this functional limitation of the joint is distinct from the pain caused by the scars, a separate 10 percent rating is warranted based on left hip painful motion. Considering the Veteran’s testimony concerning pain and functional limitations since the procedures resulting in the scarring, the rating is assigned effective August 16, 2017, the date service connection was established for left leg scars. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Codes 5251-5253, § 4.118, Diagnostic Code 7805. There is no basis for a separate rating in excess of 10 percent. Entitlement to TDIU On July 22, 2016, VA received a claim for increase for peripheral neuropathy. In October 2016, the Veteran submitted a claim for individual unemployability. As the Veteran argues he is unemployable as a result of peripheral neuropathy, the Board considers the claim for TDIU as part of the pending appeal for increase. Rice v. Shinseki, 22 Vet. App. 447 (2009). In January 2017, VA denied entitlement to TDIU. The Veteran disagreed with the decision and perfected this appeal. The Veteran contends that he is unemployable due to service-connected disabilities, mainly diabetes and associated peripheral neuropathy. In his Form 9, he stated that had to leave work because he could not walk and stand on his feet all day. At the hearing, he testified that he left his last job because he could no longer keep up with the walking requirements. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities: provided that, if there is only one such disability, such disability shall be ratable as 60 percent or more and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). In considering entitlement to individual unemployability, the pertinent inquiry is whether service-connected disabilities individually or in combination are of sufficient severity to produce unemployability - not whether a Veteran is unemployable solely due to his service-connected disabilities. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The Veteran is service connected for the following disorders: diabetes with erectile dysfunction and diabetic nephropathy; peripheral neuropathy of the lower extremities (sciatic and femoral nerve impairment); scars of the left leg, neck, back, and right hip; and subcutaneous cysts. He meets the schedular requirements for TDIU during the entirety of the appeal period beginning July 22, 2016. In his VA Form 21-8940, the Veteran reported that he last worked full time in December 2014. He reported that he had a high school diploma and an associate degree. Information from his former employer shows long-term employment as an application engineer until he retired in December 2014. In a February 2017 statement, a private physician indicated that the Veteran’s job required a lot of walking in customer’s plants and he was no longer able to do the job he was trained for due to his diabetes and neuropathy. In March 2017 and September 2020, the Veteran’s former employer indicated that his job required walking several miles while inside customer’s facilities. He was unable to do so at the end of his employment, from 2010 until retirement in 2014. The employer provided accommodations to include allowing him to work indoors in the office and he was not able to perform his original duties. The employer further stated that the Veteran was unable to make sales calls because of his inability to walk long distances. As discussed above, the Veteran is shown to have diabetic neuropathy which causes significant impairment in his lower extremities, to include difficulty walking and standing. The Veteran also testified that he was unable to work in a sedentary capacity as he had difficulty sitting due to his service-connected left leg scars. On review, the evidence is at least in equipoise as to whether the Veteran’s service-connected disabilities are so severe as to preclude all forms of substantially gainful employment when considering his educational and occupational history. Resolving reasonable doubt in his favor, TDIU is granted. 38 C.F.R. § 4.7. The Board notes that considering the increased ratings granted above, the Veteran’s combined schedular rating should be 100 percent effective August 16, 2017. See 38 C.F.R. § 4.25. At that time, the TDIU issue becomes moot. In this regard, the Board notes that even if the TDIU is based on a single disability (i.e., type 2 diabetes with associated peripheral neuropathy), the Veteran is not shown to have additional disability independently ratable at 60 percent so as to support special monthly compensation (SMC) at the housebound rate. See Bradley v. Peake, 22 Vet. App. 280 (2008). Thus, the SMC issue is not inferred herein. REASONS FOR REMAND Entitlement to service connection for hypertension In March 2014, VA denied service connection for hypertension. The Veteran disagreed with the decision and perfected this appeal. He generally contends that his hypertension is related to service-connected diabetes. In September 2013, the Veteran submitted a diabetes mellitus disability benefits questionnaire completed by his private physician. The questionnaire indicates that the Veteran has hypertension at least as likely as not related to diabetes. In April 2014, the same physician, Dr. J.C., submitted a statement indicating that the Veteran had hypertension. He further stated that diabetes is a disease that can be linked to hypertension and that he believed this to be true in the Veteran’s case. The Veteran underwent a VA examination in December 2015. The examiner provided a negative etiology opinion noting that the Veteran’s hypertension was diagnosed at about the same time as diabetes or possibly even slightly earlier. Further, there was no evidence at that time of diabetic renal involvement. In January 2016, Dr. J.C. submitted a statement indicating that the Veteran was diagnosed with diabetes in April 2012 and hypertension in February 2014. He further stated that diabetes can be linked to making hypertension worse and he believed this to be true in the Veteran’s case. In December 2017, VA granted service connection for nephropathy as a noncompensable complication of diabetes. At the hearing, the Veteran argued that his hypertension was linked to diabetes and he stated that he had submitted a medical statement to this effect. The VLJ noted that there appeared to now be renal involvement (diabetic nephropathy) which might affect the medical opinions. Thereafter, the Veteran submitted another statement from his private physician. Dr. J.C. again stated that the Veteran was diagnosed with diabetes in April 2012 and hypertension in February 2014. He further indicated that there was not any renal impairment and the hypertension was well-controlled with medication. On review, the positive nexus statements from Dr. J.C. are not supported by adequate rationale and the VA opinion did not address secondary aggravation. Further, the record appears to contain conflicting information regarding whether the Veteran has renal impairment. Considering this, the Board finds that additional examination and opinion are needed. 38 C.F.R. § 3.159(c)(4). Entitlement to service connection for peripheral vascular disease of the right and left lower extremities In March 2014, VA denied entitlement to service connection for peripheral vascular disease of the right and left lower extremities. The Veteran disagreed with the decision and perfected this appeal. At the hearing, the representative argued that there was a causal link between peripheral vascular disease, hypertension, and diabetes. In September 2013, the Veteran submitted a diabetes mellitus disability benefits questionnaire completed by his private physician. The questionnaire indicates that the Veteran had peripheral vascular disease at least as likely as not related to diabetes. In April 2014, the same physician, Dr. J.C., submitted a statement indicating that the Veteran had peripheral vascular disease. He further stated that diabetes is a disease that can be linked to peripheral vascular disease and that he believed this to be true in the Veteran’s case. The Veteran underwent a VA arteries and veins examination in December 2015. The examiner stated that the Veteran never had a vascular disease (arterial or venous) but indicated that he has been diagnosed with peripheral vascular disease. He then remarked that as per his examination and result of lower extremity doppler dated in June 2014, there is no evidence of peripheral vascular disease involving bilateral lower extremities. Both ankle-brachial indices were greater than 1 and the study was interpreted as normal. In a January 2016 statement, Dr. J.C. indicated that the Veteran had been diagnosed with peripheral vascular disease in September 2013 and that diabetes can be linked to this disorder making it worse. In September 2016, the Veteran underwent a lower extremity arterial study which was normal. On review, it is unclear whether the Veteran has a confirmed diagnosis of peripheral vascular disease. Further, to the extent the private physician provided positive opinions, they were not supported by adequate rationale. Additional examination and opinion are needed to appropriately address the secondary service connection claim. 38 C.F.R. § 3.159(c)(4). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of hypertension. The examiner must review the claims file and provide an opinion as to the following: (a) Is the Veteran’s hypertension at least as likely as not proximately due to or the result of service-connected diabetes? (b) If the answer to (a) is no, is the Veteran’s hypertension at least as likely as not aggravated, i.e., worsened beyond its natural progression, by service-connected diabetes? In making this determination, the examiner should discuss whether the Veteran has renal impairment and if so, describe its impact on hypertension. The examiner is advised that the Veteran is service-connected for diabetic nephropathy but in October 2020, his private physician indicated there was no renal impairment. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), or by a deficiency in the record (additional facts are required) or the examiner (does not have the needed knowledge or training). 2. Schedule the Veteran for a VA examination to determine the nature and etiology of claimed peripheral vascular disorder. The examiner is requested to review the claims file and state whether the Veteran has had peripheral vascular disease at any time during the appeal period (from September 2013 to the present). If the Veteran is shown to have peripheral vascular disease, the examiner should provide an opinion as to the following: (a) Is the Veteran’s peripheral vascular disease at least as likely as not proximately due to or the result of service-connected diabetes? (b) If the answer to (a) is no, is the Veteran’s peripheral vascular disease at least as likely as not aggravated, i.e., worsened beyond its natural progression, by service-connected diabetes? A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), or by a deficiency in the record (additional facts are required) or the examiner (does not have the needed knowledge or training). LAURA E. COLLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Carsten, 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.