Citation Nr: 21026608 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 18-01 168 DATE: May 3, 2021 ORDER Entitlement to an initial evaluation in excess of 20 percent for diabetes mellitus (DM), type II is denied. Entitlement to an evaluation in excess of 20 percent for right lower extremity peripheral neuropathy is denied. Entitlement to an evaluation in excess of 20 percent for left lower extremity peripheral neuropathy is denied. Entitlement to an initial evaluation in excess of 60 percent for arteriosclerotic cardiovascular disease (ACD) is denied. REMANDED Entitlement to service connection for right upper extremity peripheral neuropathy is remanded. Entitlement to service connection for left upper extremity peripheral neuropathy is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. Entitlement to an initial evaluation in excess of 50 percent for bilateral hearing loss is remanded. FINDINGS OF FACT 1. The Veteran's DM, type II required only restricted diet and an oral glycemic agent during the period on appeal. 2. The Veteran's right lower extremity peripheral neuropathy is manifest by no more than moderate incomplete paralysis. 3. The Veteran's left lower extremity peripheral neuropathy is manifest by no more than moderate incomplete paralysis. 4. The Veteran's ACD is manifest by a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, or dizziness. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 20 percent for DM, type II have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.119, Diagnostic Code 7913 (2020). 2. The criteria for a disability rating in excess of 20 percent for right lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520 (2020). 3. The criteria for a disability rating in excess of 20 percent for left lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520 (2020). 4. The criteria for a rating in excess of 60 percent for ACD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.100, 4.104, Diagnostic Code 7017-7005 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1968 to February 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The case was previously before the Board in May 2019 when it was remanded for further development. The issue of a total disability evaluation based on individual unemployability (TDIU) was also remanded at that time. In a December 2020 rating decision, the RO awarded entitlement to TDIU effective December 9, 2013. As the Veteran did not have any service-connected disabilities prior to December 9, 2013, this is a full grant of the benefits sought on appeal and therefore the issue is no longer before the Board. The December 2020 rating decision also awarded an increased rating to 20 percent for the Veteran's right and left lower extremity peripheral neuropathy, effective December 9, 2014. However, as these issues were not granted in full, and the Veteran has not indicated that he is satisfied with these increased ratings, the issues remain on appeal. The Board's notes that the Veteran's attorney submitted a motion for withdrawal in February 2021, which indicated that withdrawal under 38 C.F.R. § 20.608 was requested because continuation of representation was impossible, impractical, or unethical. Disclosure of the specific reasons would be unethical and for this reason they were omitted. Pursuant to 38 C.F.R. § 20.608(b)(2), after an appeal has been certified to the Board, a representative may not withdraw services as a representative in the appeal unless good cause is shown on motion, and motion must be in writing and must comply with the criteria set forth in 38 C.F.R. § 20.608(b)(2). Here, the Veteran's attorney did not include a signed statement certifying that a copy of the motion was sent by first-class mail, postage prepaid, to the Veteran, setting forth the address to which the copy was mailed. Absent proper compliance with the directives set forth by 38 C.F.R. § 20.608(b)(2), the withdrawal of representation is not accepted as valid. The Veteran has not appointed a new representative therefore, the attorney remains the representative of record. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C. § 1155. Ratings of a service-connected disability require review of the entire medical history regarding the disability. 38 C.F.R. §§ 4.1, 4.2. If there is a question that arises as to which rating to apply, the higher rating is assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. DM, Type II The Veteran seeks an initial rating in excess of 20 percent for his service-connected DM, type II. The Veteran's DM, type II is rated under 38 C.F.R. § 4.119, Diagnostic Code 7913. 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). The rating criteria for the endocrine system, including diabetes, have been revised during the course of the Veteran's appeal, effective December 10, 2017. The criteria for Diagnostic Code 7913 effective prior to December 10, 2017 stated that "requiring insulin" was needed for a 20, 40 or 60 percent rating and the revisions merely clarified VA's interpretation that the previously used "requiring insulin" means "one or more daily injection of insulin." 80 Fed. Reg. 39,011, 39,016 (July 8, 2015). Therefore, as these amendments made no substantive change to the rating criteria, the Board will cite to and apply the rating criteria effective from December 10, 2017. Under Diagnostic Code 7913, 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. A 60 percent rating is warranted when diabetes requires one or more daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when diabetes 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. 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 mellitus required one or more daily injections of insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. This criterion requires medical evidence. Camacho v. Nicholson, 21 Vet. App. 360, 364-65 (2007). The Veteran underwent a VA examination in February 2015. The examiner indicated that the Veteran's treatment included management by restricted diet and prescription of an oral hypoglycemic agent. The Veteran did not require regulation of activities as part of medical management of DM. He visited his diabetic care provider less than two times a month for episodes of ketoacidosis or hypoglycemic reactions and there were no episodes requiring hospitalization over the past 12 months. The Veteran did not have progressive unintentional weight loss and loss of strength. Complications of DM were diabetic peripheral neuropathy. The examiner indicated that the Veteran's DM and complications did not impact his ability to work. VA treatment records from April 2017 indicate that the Veteran was followed by the move weight management clinic and that his blood sugar readings looked controlled. VA treatment records from October 2018, June 2019, December 2019, June 2020, and November 2020 indicate that the Veteran's DM was well controlled on metformin. The Veteran underwent another VA examination in August 2020. The examiner indicated that the Veteran's treatment was prescription of an oral hypoglycemic agent. The Veteran did not require regulation of activities as part of medical management of DM. He visited his diabetic care provider less than two times a month for episodes of ketoacidosis or hypoglycemic reactions and there were no episodes requiring hospitalization over the past 12 months. The Veteran did not have progressive unintentional weight loss and loss of strength. No complications of DM were noted. The examiner indicated that the Veteran's DM and complications did not impact his ability to work. The Board finds that for the period on appeal, the Veteran's DM, type II required only restricted diet and an oral glycemic agent. In order to establish a higher 40 percent evaluation, the record must also show that the Veteran has a regulation of daily activities. As indicated above, the term "regulation of activities" as applied in Diagnostic Code 7913 means that a claimant must have a medical need to avoid strenuous occupational or recreational activities and thus medical evidence of limitation of activities is required. The February 2015 and August 2020 VA examiners both indicated that the Veteran did not require regulation of activities as part of medical management of DM, and the VA treatment records indicate that the Veteran's DM was basically well controlled on medication. The Veteran is competent to report that his symptoms warrant a higher rating. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the medical evidence of record is against a finding that regulation of activities was required during the period on appeal. Regarding any compensable complications of diabetes, the Veteran is separately service-connected for peripheral neuropathy of the bilateral lower extremities as secondary to diabetes and these issues are addressed below. Accordingly, the preponderance of the evidence is against assigning a rating in excess of 20 percent during the period on appeal. In denying such ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Right Lower Extremity Peripheral Neuropathy and Left Lower Extremity Peripheral Neuropathy The Veteran is seeking ratings in excess of 20 percent for his service-connected right lower extremity peripheral neuropathy and left lower extremity peripheral neuropathy, which are rated under 38 C.F.R. § 4.124a, Diagnostic Code 8520. Paralysis of the sciatic nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8520. 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, with 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. 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 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). The maximum rating which may be assigned for neuritis not characterized by organic changes will be moderately severe incomplete paralysis for sciatic nerve involvement. See 38 C.F.R. § 4.123. The Veteran underwent a VA examination in February 2015. The Veteran stated that his condition began with numbness and burning in his feet. His symptoms were mild paresthesias and/or dysesthesias and mild numbness in the right and left lower extremities. Strength testing and deep tendon reflex testing were normal. Light touch was decreased in the foot/toes and vibration sensation and cold sensation was decreased in both lower extremities. There was no muscle atrophy and tropic changes. The Veteran did not have an upper extremity diabetic peripheral neuropathy. The Veteran did have mild incomplete paralysis in the right and left lower extremities. The Veteran's diabetic peripheral neuropathy did not impact his ability to work. VA treatment records from November 2015 note numbness and tingling in the feet and fingers. While February 2016 records indicate no numbness, weakness, and dizziness, he did complain of tingling in the feet in February 2017, October 2017, and May 2018. In June 2020 VA treatment records, it was noted that the Veteran was continuing gabapentin for his diabetic neuropathy. The Veteran underwent a VA examination in August 2020. The Veteran reported his condition since onset remained the same and indicated intermittent sensory loss to the toes and fingers. He indicated he was on medication but did not know the names. The Veteran's symptoms were mild paresthesias and/or dysesthesias and mild numbness. Strength testing, deep tendon reflex testing, position sense, light touch, and cold sensation were normal. Vibration sensation was decreased in the right and left lower extremities. There was no muscle atrophy and tropic changes. The Veteran did not have an upper extremity diabetic peripheral neuropathy. The Veteran did have mild incomplete paralysis in the right and left lower extremities. The Veteran's diabetic peripheral neuropathy did impact his ability to work in that the Veteran reported difficulty in feeling light sensation to his feet and occasionally in his fingers. Based on the above, the Board finds that the Veteran's right and left lower extremity peripheral neuropathy disability is primarily manifest by decreased vibration sensation, some decreased light touch sensation, and some decreased cold sensation, as well as the Veteran's subjective complaints of tingling in the feet. A higher rating of 40 percent for the Veteran's right and left lower extremity peripheral neuropathy would require symptoms of incomplete paralysis that are moderately severe or worse, or complete paralysis. The VA examiners found strength testing and deep tendon reflex testing to be normal, and there was no muscle atrophy and tropic changes. Furthermore, the VA examiners characterized the Veteran's symptoms as "mild" which is inconsistent with a finding that the Veteran suffered from moderately severe incomplete paralysis or worse. The Board thus finds that the level of impairment is most analogous to the already assigned moderate incomplete paralysis. The Board acknowledges that in February 2017, Dr. H.S. stated that due to pain, the Veteran had sleep problems due to pain and could not stand for 15 minutes without leaning and could sit for 15 minutes at a time. However, Dr. H.S. provided no explanation as to what symptoms were attributable to specific service-connected disabilities, only providing general conclusions as to the Veteran's employability. As such, the statements from Dr. H.S. lack probative weight as to the issue of the severity of the Veteran's service-connected right and left lower extremity peripheral neuropathy. The Board observes that the Veteran feels that his service-connected right and left lower extremity peripheral neuropathy are more severe than currently rated. However, the Board finds that as a lay person, the Veteran lacks the orthopedic training and medical prowess to render an opinion as to the severity of this respective service-connected disability. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Routen v. Brown, 10 Vet. App. 183, 186 (1997). As such the Board finds the medical of evidence of record to be more probative. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claims for ratings in excess of 20 percent for his service-connected right lower extremity peripheral neuropathy and left lower extremity peripheral neuropathy. In denying such ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. ACD The Veteran is seeking an initial rating in excess of 60 percent for his service-connected ACD, which is rated under 38 C.F.R. § 4.104, Diagnostic Code 7017-7005. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. The hyphenated diagnostic code in this case indicates that coronary bypass surgery is the service-connected disability, as reflected by the assignment of Diagnostic Code 7017, while ACD is the residual disability, to which the Veteran's disability is evaluated, under Diagnostic Code 7005. Under Diagnostic Code 7005, 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 results 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 results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. One MET 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 (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. Id. For the purposes of a 60 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of 30 to 50 percent. Otero-Castro v. Principi, 16 Vet. App. 375, 382 (2002). Additionally, the phrase "30 to 50 percent" means 30 percent through 50 percent. Id. at 380. For the purposes of a 100 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of less than 30 percent. See id. at 382. VA treatment records from November 2013 note that the Veteran would get occasional chest tingling once a month following some sort of activity. He denied associated diaphoresis and shortness of breath. He also indicated feeling fatigued easily, but it was typically back pain that limited activities. Echocardiography from October 2013 showed left ventricular ejection fraction of 55 percent. The Veteran underwent a VA examination in March 2015. The Veteran indicated that he experienced shortness of breath, fatigue, and angina. Continuous medication was required for control. The Veteran did not have congestive heart failure. An echocardiogram from February 2015 showed an left ventricular ejection fraction (LVEF) of 60-65 percent, and an interview based METs test indicated symptoms of dyspnea, fatigue, angina, and dizziness. The METs level was greater than 3-5 METs, which was consistent with activities such as light yard work, mowing lawn, and brisk walking. The METs level limitation was solely due to the heart condition. The Veteran's heart condition impacted his ability to work in that his fatigue limited his exertional capacity to less than or equal to 5 METs. He was able to do sedentary work. In June 2016 VA treatment records, it was noted that the Veteran was having trouble with dyspnea on exertion and diaphoresis with exertion. He would occasionally get diaphoretic while at rest. In August 2016 the Veteran underwent a cardiac catherization that showed patent grafts. In January 2017 records it was noted that he was doing better. It was also noted that an echocardiogram from September 2016 showed normal left ventricular function, ejection fraction of 55 percent, with no significant valvulopathy. In July 2017 the Veteran had an episode of sharp chest pain about three weeks ago, which occurred at rest and resolved spontaneously. It was noted that the pain was atypical and likely musculoskeletal. In a February 2017 letter, Dr. H.S. stated that due to pain, the Veteran had sleep problems due to pain, could not carry or lift more than 5 pounds, and could not stand for 15 minutes without leaning and could sit for 15 minutes at a time. He also did some chores but with frequent breaks. However, Dr. H.S. provided no explanation as to what symptoms were attributable to specific service-connected disabilities, only providing general conclusions as to the Veteran's employability. As such, the statements from Dr. H.S. lack probative weight as to the issue of the severity of the Veteran's service-connected ACD. VA treatment records from April 2018 indicate the Veteran was doing well but felt dyspneic after walking half a mile but improved with inhaler use. In October 2018 he indicated that he had spasms in his sternal area, and subsequent appointments including in June 2019 indicate that the Veteran was doing well apart from some chest pains. In December 2019 he indicated he was doing well but complained of less exertional stamina with advancing age. He indicated he could go up three flights of stairs without stopping. In June 2020 and November 2020 he indicated he was feeling well and it was noted that his condition was stable. The Veteran underwent a VA examination in August 2020. The Veteran reported dyspnea on exertion and was unable to perform physical activity for an extended period of time. The Veteran did not have congestive heart failure. A physical examination was normal. There was no evidence of cardiac hypertrophy and cardiac dilatation. An echocardiogram from March 2020 showed LVEF from 55-60 percent, with mild diastolic dysfunction and aortic valve mildly sclerotic without significant stenosis. An interview based METs test indicated symptoms of dyspnea. The METs level was greater than 3-5 METs, which was consistent with activities such as light yard work, mowing lawn, and brisk walking. The METs level limitation was solely due to the heart condition. The Veteran's heart condition impacted his ability to work in that the Veteran admitted to dyspnea on exertion when performing any physical activity. Considering all relevant evidence of record, the Board finds that the preponderance of the competent, credible evidence of record weighs against a finding that a higher, 100 percent disability rating is warranted for the Veteran's service-connected ACD. There is no evidence that the Veteran suffers from congestive heart failure. Further, there is no evidence that the Veteran's service-connected ACD alone results in a workload of less than 3 METs. Additionally, the medical evidence does not reflect left ventricular dysfunction with an ejection fraction of less than 30 percent. In fact, the Veteran's left ventricular dysfunction with an ejection fraction has consistently been within 55 to 65 percent. The Veteran has also indicated during treatment that his condition had been relatively stable, with some tingling, spasms, and dyspnea on exertion. Accordingly, the Board concludes that the symptoms and findings of the Veteran's ACD during the appeal period more closely correspond to the criteria for a 60 percent rating under Diagnostic Code 7005. A higher 100 percent rating is not warranted unless there is chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. Thus, the Board concludes that the Veteran's ACD did not meet the criteria corresponding to a higher 100 percent rating. The Board acknowledges the Veteran's claim that his service-connected ACD is more severe than is reflected in his current 60 percent disability rating. The Board also notes that the Veteran is competent to describe the symptoms of his disability, including dyspnea, fatigue, dizziness, and angina. Layno v. Brown, 6 Vet. App. 465 (1994). However, the Board finds that the medical evidence of record is of greater probative value as it resulted from physical examinations of the Veteran, diagnostic testing, and clinical evaluation of his functional capacity and ability. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 60 percent for his service-connected ACD. In denying such ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND Service connection for right upper extremity peripheral neuropathy and left upper extremity peripheral neuropathy In the Board's May 2019 remand, it was directed that the Veteran be afforded a new VA examination and medical opinion regarding the etiology of his claimed upper right and left extremity peripheral neuropathy. The Veteran was afforded a VA examination in August 2020. While the examiner found that the Veteran did not have bilateral upper extremity peripheral neuropathy on exam, the examiner indicated that the Veteran had symptoms attributable to diabetic peripheral neuropathy, including mild paresthesias and dysesthesias and mild numbness in the right and left upper extremities. Based on this conflicting evidence, the Board finds that remand for a new VA examination is needed in this case. Barr v. Nicholson, 21 Vet. App. 303 (2007). Entitlement to service connection for an acquired psychiatric disorder, claimed as PTSD Also in the Board's May 2019 remand, it was directed that the Veteran be afforded a VA examination and medical opinion to determine whether the Veteran had a psychiatric disability that was related to service or caused or aggravated by a service-connected disability. It was indicated that a rationale must be provided for any opinion, including consideration of all the evidence associated with the Veteran's claims file. The Veteran was afforded a VA examination in February 2020. The examiner indicated that the Veteran's electronic claims file was reviewed. The examiner found that the Veteran's symptoms did not meet the diagnostic criteria for PTSD under the DSM-5 criteria and did not have a mental disorder that conformed with the DSM-5 criteria. However, in making this determination, the examiner did not discuss the November 2016 diagnosis of "anxiety disorder due to another medical condition" by Dr. H.H.-G. in the claims file. A current disability is established for the purpose of service connection if demonstrated during the appeal even if it resolves prior to adjudication. See McClain v. Nicholson, 21 Vet. App. 319 (2007). The examiner did not reconcile her findings that the Veteran did not have a psychiatric diagnosis with the diagnosis that dr. H.H.-G. provided. The Board finds that remand is necessary to obtain an addendum medical opinion. Entitlement to an initial evaluation in excess of 50 percent for bilateral hearing loss The Veteran's claims file includes VA audiology treatment records from January 2017 and November 2017, which indicates that the Veteran underwent audiological testing during these appointments. Findings showed hearing loss in both ears; however, the actual results of the audiogram are not associated with the record. As audiometric test data are relevant to the claim for an increased rating for bilateral hearing loss, remand is required to obtain the VA audiometric results from January 2017 and November 2017. All Issues Finally, updated VA treatment records should be obtained and associated with the claims file. The matters are REMANDED for the following actions: 1. Obtain the Veteran's VA treatment records for the period from November 2020 to the present. 2. Obtain the audiometric and speech discrimination test results from the Veteran's VA audiology appointments in January 2017 and November 2017. **If it is unclear from any audiometry results whether speech discrimination testing was done using the Maryland CNC word list, please seek clarification regarding what type of speech discrimination testing was used. 3. Provide the Veteran an appropriate VA examination to determine the nature, extent, and etiology of the Veteran's right upper extremity peripheral neuropathy and left upper extremity peripheral neuropathy. The electronic claims file must be made available to the examiner for review in connection with the examination. All indicated tests should be conducted, including any diagnostic testing, and the reports of any such studies incorporated into the examination reports to be associated with the claims file. a) Following examination of the Veteran and review of the claims file, the examiner must indicate whether the Veteran has had right upper or left upper extremity peripheral neuropathy at any point on appeal. b) If so, then the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that right upper or left upper extremity peripheral neuropathy is related to the Veteran's active duty service. c) The examiner must also provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that right upper or left upper extremity peripheral neuropathy is caused by the Veteran's service-connected DM, type II. d) Also, provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that right upper or left upper extremity peripheral neuropathy is aggravated (any worsening of the condition beyond natural progression) by the Veteran's service-connected DM, type II. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 4. Return the claims file to the February 2020 VA psychiatric examiner for an addendum opinion. The examiner must review the entire claims file, including a copy of this remand. If the VA examiner who provided the February 2020 opinion is not available, then forward the Veteran's claims file to another appropriate specialist to obtain the below requested medical opinion. The Veteran should only be scheduled for another examination if it is deemed necessary by the clinician providing the opinion. Following a review of the Veteran's claims file, the examiner must answer the following: a) Based upon the examination results and review of the record, the examiner must identify the presence of all current mental health disabilities present. The Board notes that the record includes a past November 2016 diagnosis of "anxiety disorder due to another medical condition" by Dr. H.H.-G. This disorder must be considered and discussed, in addition to any other disorders that may be found. If any specific disorder is ruled out, a complete explanation must be provided. That explanation should include a discussion of all the pertinent evidence of record, to include lay evidence. The examiner is advised that even if a disability subsequently resolves during the appeal period, service connection may still be awarded if a disability is diagnosed at the time the claim was filed or during the pendency of the claim. McClain, 21 Vet. App. at 321. b) With respect to any diagnosed psychiatric disorder, the examiner should render an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that each diagnosed psychiatric disorder, is related to the Veteran's service. c) The examiner must also opine whether it at least as likely as not (a 50 percent probability or greater) that a diagnosed acquired psychiatric disability is proximately caused by any of the Veteran's service-connected disabilities. d) The examiner must also opine whether it at least as likely as not (a 50 percent probability or greater) that a diagnosed acquired psychiatric disability is aggravated by (where aggravation is any increase in severity beyond the natural progress of the disability) any of the Veteran's service-connected disabilities. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Bonnie Yoon, 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.