Decision Date: 08/31/95 Archive Date: 01/16/96 DOCKET NO. 92-15 647 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a heart disorder. 2. Entitlement to service connection for a left shoulder disorder. 3. Entitlement to service connection for sinusitis. 4. Entitlement to service connection for residuals of thoracic strain. 5. Entitlement to service connection for a stomach disorder, including hiatal hernia. 6. Entitlement to an increased rating for diabetes mellitus, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD P. M. Lynch, Associate Counsel INTRODUCTION The veteran served on active duty from March 1979 to March 1983 and from September 1983 to December 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 1992 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, that granted service connection for diabetes mellitus with an assigned 20 disability evaluation and denied entitlement to service connection for a heart disorder, a right shoulder disorder, sinusitis, thoracic strain and a stomach disorder. The veteran originally filed a claim for entitlement to service connection for right shoulder trauma in December 1991. However, at the time of his VA examinations, he expressed only left shoulder complaints. He further reported that his statement that he injured his right shoulder during service was in error, and that he actually injured his left shoulder during service. The RO subsequently denied entitlement to service connection for left shoulder disorder (originally claimed as a right shoulder disorder) in February 1995, and changed the issue to service connection for left shoulder pain by history (originally claimed as a right shoulder condition) in the February 1995 supplemental statement of the case. Accordingly, I construe the issue on appeal to be entitlement to service connection for a left shoulder disorder, rather than a right shoulder disorder. The Board remanded the case in May 1994 for examination of the veteran and medical opinions. The RO completed the requested development and has returned the case to the Board for appellate review. In August 1992, the veteran’s representative observed that the veteran had been diagnosed as having a deviated nasal septum on VA examination, and characterized this as an “inferred issue.” The issue of service connection for a deviated nasal septum is not inextricably intertwined with the issues now on appeal, see Harris v. Derwinski, 1 Vet.App. 180 (1991), nor has it been developed or certified for appeal. 38 U.S.C.A. § 7105(c) (1994). It is referred to the RO for appropriate action. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that the RO committed error in denying his claims of entitlement to service connection for a heart disorder, a left shoulder disorder, sinusitis, thoracic strain and a stomach disorder. He alleges that these conditions are recurring in nature and were initially manifest during active service. He also contends that the RO committed error in denying his claim of entitlement to an increased rating for his diabetes mellitus, currently evaluated as 20 percent disabling. Specifically, he maintains that his diabetes mellitus is more severely disabling than currently evaluated in that he requires large dosages of insulin and that his activities and diet are restricted. He further states that the Board should apply reasonable doubt in his favor. In a July 1995 statement, the veteran’s representative in Washington, D.C., contended that the Board must remand this case again because the RO did not accomplish the development ordered by the Board in its May 1994 remand. Specifically, the representative maintained that the VA examinations were inadequate and that the RO did not give the veteran’s field representative an opportunity to review the claims folder before it was returned to the Board. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran’s claims file(s). Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the veteran’s claims of entitlement to service connection for a heart disorder, a left shoulder disorder, sinusitis and residuals of thoracic strain are not well-grounded. It is also the decision of the Board that the evidence supports the veteran’s claim of entitlement to an increased rating of 40 percent, and not in excess thereof, for diabetes mellitus and that the preponderance of the evidence supports entitlement to service connection for a stomach disorder, diagnosed as erosive esophagitis. FINDINGS OF FACT 1. There is no competent evidence of record showing that the veteran suffered from a heart disorder or sinusitis during active service. 2. There is no competent evidence of record showing that the veteran suffered from a heart disorder within one year following his discharge from active service. 3. There is no competent medical evidence of record showing that the veteran currently suffers from a heart disorder, a left shoulder disorder, sinusitis or residuals of thoracic strain. 4. There is no competent medical evidence of record showing a nexus between a disease or injury during the veteran’s service and any current heart, left shoulder, sinus or thoracic disability. 5. The veteran complained of indigestion manifested by heartburn of six months’ duration during active service. 6. The indigestion reported on recent VA examination, diagnosed as erosive esophagitis, has not been medically disassociated from the indigestion documented while the veteran was in active service. 7. The veteran’s service-connected diabetes mellitus is manifested by subjective complaints of hypoglycemic episodes occurring about once a month. 8. Objective evidence concerning the veteran’s service- connected diabetes mellitus consists of the use of 92 units of insulin per day and a restricted American Diabetes Association (ADA) diet of 1800 calories per day. 9. The veteran’s service-connected diabetes mellitus approximates, but does not exceed, a moderately severe disability. 10. The veteran’s service-connected diabetes mellitus does not present an exceptional or unusual disability picture rendering impracticable the application of the regular schedular standards that would have warranted referral of the case to the Director of the Compensation and Pension Service. CONCLUSIONS OF LAW 1. The veteran’s claims for service connection for a heart disorder, a left shoulder disorder, sinusitis and residuals of thoracic strain are not well-grounded and there is no statutory duty to assist the veteran in developing facts pertinent to these claims. 38 U.S.C.A. §§ 5107(a) (West 1991). 2. The veteran’s stomach disorder, diagnosed as erosive esophagitis, was incurred in active service. 38 U.S.C.A. §§ 1110 (West 1991); 38 C.F.R. §§ 3.303(a), (b) (1994). 3. The criteria for a disability rating of 40 percent, but not in excess thereof, for diabetes mellitus have been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.7, Part 4, Diagnostic Code 7913 (1994). 4. Failure of the RO to consider or document its consideration of an extraschedular rating and the failure to refer the case to the Director of the Compensation and Pension Service is no more than harmless error. 38 C.F.R. § 3.321(b)(1) (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With regard to the contention of the veteran’s representative in Washington, D.C. that this case must be remanded because the veteran’s local representative did not have an opportunity to review the claims folder prior to its return to the Board, I note that the RO essentially followed the procedures in VA Manual M21-1, Part IV, Chapter 8. VA Manual M21-1, Part IV, Change 13, Paragraphs 8.23, 8.40 (October 3, 1992); see also VA Manual M21-1, Part IV, Change 64, Paragraphs 8.31-8.34, 8.45 (October 11, 1994). Paragraph 8.23a provides that the RO should give the representative an opportunity to execute VA Form 1-646 in all instances except as noted in paragraph 8.23b, which provides that if an appeal was remanded by the Board solely for assembly of records for forwarding to the Board without further consideration by the agency of original jurisdiction, VA Form 1-646 is not required. As this appeal was not remanded by the Board in May 1994 solely for assembly of records, the RO did provide the veteran’s representative an opportunity to execute VA Form 1- 646. A review of the claims folder reveals that both the veteran and his representative were furnished with a copy of the supplemental statement of the case dated in February 1995. In a cover letter, the RO advised the veteran and his representative that they had 60 days in which to make comments concerning the additional information contained in the supplemental statement of the case. The RO further notified them that if no response was received within that period, the case would be returned to the Board. As no response was received, including a VA Form 1-646, the RO returned the case to the Board in June 1995. I also note that the Washington-based representative was given an opportunity to review the claims folder before submitting it to the Board. He has submitted additional argument on behalf of the appellant. He has offered no explanation for the requirement that the local representative, rather than the Washington-based representative of the same service organization, review the claims folder on the appellant’s behalf. I conclude that a remand is not warranted solely for solicitation of argument by the local representative merely because that procedure is usually followed. See Soyini v. Derwinski, 1 Vet.App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet.App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided); cf. Brady v. Brown, 4 Vet.App. 203, 207 (1993) (a remand is unnecessary even where there is error on the part of VA, where such error was not ultimately prejudicial to the veteran’s claim). I. Heart disorder, left shoulder disorder, sinusitis and residuals of thoracic strain In making a claim for service connection, the veteran has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well- grounded. 38 U.S.C.A. § 5107(a) (West 1991). A well- grounded claim is “a plausible claim, one which is meritorious on its own or capable of substantiation.” See Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). Establishing a well-grounded claim for service connection for a particular disability requires more than an allegation that the particular disability had its onset in service. It requires evidence relevant to the requirements for service connection and of sufficient weight to make the claim plausible and capable of substantiation. See Tirpak v. Derwinski, 2 Vet.App. 609, 610 (1992); Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). The kind of evidence needed to make a claim well grounded depends upon the types of issues presented by a claim. Grottveit v. Brown, 5 Vet.App. 91, 92-93 (1993). For some factual issues, competent lay evidence may be sufficient. However, where the claim involves issues of medical fact, such as medical causation or medical diagnoses, competent medical evidence is required. Id. at 93. Generally, entitlement to service connection for a particular disability requires evidence of the existence of a current disability and evidence that the disability resulted from a disease or injury incurred in or aggravated during service. See 38 U.S.C.A. §§ 101(16), 1110 (West 1991). Service connection for coronary heart disease may be established on a presumptive basis by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (1994). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1994). Therefore, in this case the determinative issues are: (1) whether the veteran has presented evidence of a current heart disorder, left shoulder disorder, sinusitis and residuals of thoracic strain as provided by a medical diagnosis; (2) whether the veteran has presented evidence of incurrence or aggravation of these disorders in service as provided by either lay or medical evidence, as the situation dictates; and (3) whether the veteran has presented evidence of a nexus, or link, between the in-service disorders and the current disorders as provided by competent medical evidence. See Caluza v. Brown, 7 Vet.App. 498 (1995); see also 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1994); Layno v. Brown, 6 Vet.App. 465, 470 (1994); Espiritu v. Derwinski, 2 Vet.App. 492, 494-95 (1992). I have carefully reviewed the evidence of record to determine if there are well-grounded claims. The veteran has presented no competent evidence of a current heart disorder, left shoulder disorder, sinusitis or chronic back disorder. Consequently, these claims are not well grounded. Regarding a heart disorder, the veteran complained of heart palpitations on several occasions during active service. Electrocardiograms demonstrated sinus bradycardia with sinus arrhythmia in May 1985, and sinus tachycardia with sinus arrhythmia in May 1991. No other heart abnormalities were noted in service. Following service the veteran was given a VA examination in January 1992. Examination of his heart was entirely normal. The examiner diagnosed history of sinus bradycardia. The veteran was also afforded VA cardiovascular examinations in June and December 1994. He complained of a history of heart palpitations. The examiner in June diagnosed palpitation with normal 24 hour Holter monitor, and no chest pain or shortness of breath with normal echocardiogram, exercise stress test and electrocardiogram. He added that the palpitation was not cardiac in origin, with normal stress test, echocardiogram and 24-hour Holter monitor. In December, the examiner diagnosed the veteran’s palpitation as of benign etiology and not cardiac in origin, in light of the normal examination findings, stress test, and echocardiogram. The veteran has never been diagnosed as having a heart disorder. He has been diagnosed as having sinus bradycardia with sinus arrhythmia, sinus tachycardia with sinus arrhythmia, and palpitation, but these findings constitute symptoms and are not acceptable diagnoses of a heart disorder for which service connection is warranted. See 38 C.F.R. § 4.100 (1994). Sinus bradycardia is a slow sinus rhythm, with a heart rate less than 60. Dorland’s Illustrated Medical Dictionary at 187 (26th ed. 1981). An arrhythmia is any variation from the normal rhythm of the heart beat, and sinus arrhythmia is the physiologic, or normal, cyclic variation in heart rate related to vagal impulses to the sinoatrial node, occurring commonly in children and the aged, and requiring no treatment. Id. at 112, 1016. Tachycardia is excessive rapidity in the action of the heart, usually applied to a heart rate above 100. Sinus tachycardia is simple tachycardia with origin in the sinus node. Id. at 1307. The cardiac rhythm normally takes its origin in the sinoatrial or sinus node, which is also known, for this reason, as the pacemaker of the heart. Id. at 897. Palpitation is a subjective sensation of an unduly rapid or irregular heartbeat. Id. at 956. In short, the veteran has a subjective sensation of rapid or irregular heartbeat, which the VA examiners in 1994 concluded was of benign etiology and not of cardiac origin. Lacking competent evidence of current disability, inservice heart disease or injury, or a nexus between the two, this claim is not well grounded. Concerning a left shoulder disorder, the veteran was afforded VA examinations in January 1992 and June 1994. In 1992, he reported that he injured this shoulder in service, and that it would be sore at times. In 1994, he complained of intermittent left shoulder pain increased by activities such as lifting and reaching. He had normal range of motion of the left shoulder in January 1992 and in June 1994. In 1994, he also had 5/5 strength and no crepitus of the acromioclavicular (AC) joint. Despite his subjective complaints of discomfort on extremes of abduction and tenderness to palpation directly over the AC joint, xrays of the left shoulder were essentially normal. The examiner diagnosed left shoulder trauma by history. Significantly, the veteran subsequently denied any problems with his left shoulder on examination in December 1994, adding that he had not been doing carpentry work, with associated lifting and working overhead. Examination findings were consistent with those noted above, but no pain was reported on movement. The examiner diagnosed history of left shoulder pain by history, now asymptomatic, without significant abnormal findings. The veteran has not been diagnosed as having a current left shoulder disability. Even assuming, for the sake of argument, that he has a current left shoulder disability, there is no medical evidence of a nexus between any current left shoulder disability and service. I note that his service medical records are completely negative for any left shoulder complaints or findings. Although, for the purpose of establishing a well-grounded claim, the veteran is competent to report that he sustained an injury in service, even without corroborating contemporaneous service medical records, he is not competent to establish a nexus between any inservice injury and any current disability. Lacking competent evidence of current left shoulder disability or of a nexus between an inservice left shoulder injury and current disability, this claim is not well grounded. Concerning sinusitis, the veteran complained of nasal drainage and congestion on several occasions during active service. However, he was not diagnosed as having sinusitis. Rather, diagnoses included viral upper respiratory infections, upper respiratory infection with bronchitis, sinus congestion and pharyngitis. In fact, in May 1991, sinus x-rays were ordered to rule out sinusitis. Although the veteran complained of chronic sinus congestion in June 1991, examination was within normal limits. X-rays showed only asymmetry in the maxillary sinuses, which was described as probably developmental rather than produced by inflammatory disease. The remainder of the sinuses were noted to be entirely normal. The impression was probably normal examination with smaller left maxillary sinus than right. The record also does not contain competent medical evidence of current sinusitis. Although the examiner diagnosed chronic sinusitis on VA examination in January 1992, examination of the veteran’s nose, sinuses, mouth and throat was normal. This diagnosis, therefore, was not supported by the objective examination findings. On a subsequent ear, nose and throat examination, a few days later, the examiner found only a deviated nasal septum with obstruction on the right. The remainder of the examination was described as normal. Lacking competent evidence of sinusitis in service, current disability due to sinusitis, or a nexus between the two, this claim is not well grounded. Finally, concerning the veteran’s claim of entitlement to residuals of thoracic strain, the veteran was treated in service for thoracic strain on one occasion in February 1987. He reported a sudden onset of back pain; no trauma was reported. On the separation examination conducted in September 1991, he reported no recurrent back pain. On VA examination in January 1992 the veteran complained of only some occasional low back pain associated with “a lot” of lifting. He denied taking medication or seeing a physician; it did not bother him to that extent. No abnormalities were reported on physical examination. Specifically, range of motion of the back was normal. Deep tendon reflexes were present and there was no abnormal sensory loss or radiculopathy. Straight leg raising was negative. The veteran had no difficulty going from a sitting to a lying or from a lying to a sitting position. The examiner did not diagnose a back disorder. Although the evidence in the claims file shows a thoracic strain in February 1987, this apparently resolved without identifiable residual disability before the veteran’s final separation from active military service. No current thoracic disability is shown, and there is no competent evidence of a nexus between the episode of thoracic strain in service and a current disability. This claim is not well grounded. I note that the veteran’s representative has alleged that the VA examinations were sparse and not in accordance with the most recent edition of the VA’s Physician’s Guide for Disability Evaluation Examinations. However, on review of the examination reports, I observe that all required testing was completed, including x-rays, an electrocardiogram, an echocardiogram, an exercise stress test and a Holter monitor. The reports of examination also included the veteran’s history and subjective complaints, as well as adequate objective findings, including range of motion measurements. I find that the representative’s contentions concerning the adequacy of the VA examinations are without merit. In any event, where the veteran has not met this burden of submitting a well-grounded claim, VA has no duty to assist him in developing facts pertinent to his claim, including no duty to provide him with another medical examination. 38 U.S.C.A. § 5107(a) (West 1991); Rabideau, 2 Vet.App. at 144 (where the claim was not well-grounded, VA was under no duty to provide the veteran with an examination). Nonetheless, where a claim is not well grounded it is incomplete, and, depending on the particular facts of the case, VA is obliged under 38 U.S.C.A. § 5103(a) to advise the claimant of the evidence needed to complete his application. Robinette v. Brown, No. 93-985 (U.S. Vet. App. July 14, 1995). In this case, the RO substantially complied with this obligation in an April 1992 letter to the veteran, a June 1992 statement of the case, and a February 1995 supplemental statement of the case. The veteran was specifically advised of the reasons for the RO’s denial of service connection for his claimed disabilities and notified that he could reopen his claims at any time by submitting evidence that was not previously submitted and which supported his claims. Moreover, this Board decision informs the veteran of the evidence that is lacking to make his claims well grounded. Unlike the situation in Robinette, he has not put VA on notice of the existence of any specific, particular piece of evidence that, if submitted, could make his claims well grounded. Although the RO did not specifically state that it denied the veteran’s claims on the basis that they were not well- grounded, I conclude that this error was harmless. See Edenfield v. Brown, 6 Vet.App. 432 (1994) (per curiam order) (requesting briefing on whether remedy for deciding on the merits a claim that is not well-grounded should be affirmance, on the basis of nonprejudicial error, or vacating of the decision). Accordingly, the Board dismisses the veteran’s claims for service connection for a heart disorder, a left shoulder disorder, sinusitis and residuals of thoracic strain as not well-grounded. See Boeck v. Brown, 6 Vet.App. 14, 17 (1993) (if a claim is not well-grounded, the Board does not have jurisdiction to adjudicate it). The RO denied the claims on the merits, rather than on the basis that the claims were not well-grounded. I conclude that dismissing the appeal because the claims are not well- grounded is not prejudicial to the appellant, as the appellant’s arguments concerning the merits of the claim include, at least by inference, the argument that sufficient evidence to establish well-grounded claims is of record. Moreover, the veteran may file additional claims for service connection for these disabilities in the future without the additional burden of filing new and material evidence to reopen his claims. Therefore, I conclude that it is not necessary to remand the matter for the issuance of a supplemental statement of the case concerning whether the claims are or are not well-grounded. See Bernard v. Brown, 4 Vet.App. 384 (1993). II. Stomach disorder, including a hiatal hernia In reviewing the evidence relevant to a claim for service connection for a stomach disorder, I conclude that not only has the veteran presented a well-grounded claim for service connection, but that the preponderance of the evidence is in favor of service connection for a stomach disorder as being directly incurred in service. The evidence of record reflects that the veteran complained of indigestion while in service. Specifically, at his separation examination in September 1991, the examiner noted his complaints of frequent indigestion manifested by heartburn of six months’ duration. The veteran stated that he treated this condition with medication with fair results. There are also VA examination reports documenting complaints of indigestion since service. On examination in January 1992, shortly after his discharge from service, the veteran once again complained of frequent indigestion for which he took medication. No hernias were noted. The examiner diagnosed indigestion, etiology undetermined. The veteran underwent another VA examination in June 1994. He complained of intermittent heartburn and indigestion staying 40 to 50 percent of the time during the day. He further stated that these symptoms had persisted for four years. A gastrointestinal endoscopy showed linear streaks of erythema with erosions suggestive of esophagitis anteriorly, with few erosions posteriorly. There was no hernia. The examiner diagnosed erosive esophagitis. The evidence in the service medical records of complaints of indigestion in 1991, together with the medical evidence since 1991 showing complaints of persistent indigestion, eventually diagnosed as erosive esophagitis, constitutes a sufficient basis to conclude that this disorder had its onset in service, in the absence of evidence to the contrary. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. §§ 3.303(a), (b) (1994). Accordingly, I conclude that the clear preponderance of the evidence weighs in favor of the veteran’s claim. Service connection is warranted for a “stomach disorder,” diagnosed as erosive esophagitis. III. Diabetes mellitus By a rating decision in March 1992, the RO granted the veteran’s claim of entitlement to service connection for diabetes mellitus and assigned a 20 percent disability rating, effective December 1991. In reaching its decision, the RO considered the veteran’s service medical records and a VA report of examination dated in January 1992. The veteran expressed disagreement with the RO’s assignment of a 20 percent disability evaluation. I find that the veteran’s expression of disagreement with the March 1992 rating decision establishes a well-grounded claim for an increased disability evaluation for his service-connected diabetes mellitus within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). When a claimant is awarded service connection for a disability and subsequently appeals the RO’s initial assignment of a rating for that disability the claim continues to be well-grounded as long as the rating schedule provides for a higher rating and the claim remains open. Shipwash v. Brown, No. 94-21 (U.S. Vet. App. May 10, 1995), slip op. at 8. The veteran has been examined by VA on three occasions during the course of his claim. The RO has also obtained the veteran’s service medical records and VA medical records. I conclude that the statutory duty to assist the veteran mandated by 38 U.S.C.A. § 5107(a) (West 1991) has been met. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1994). The veteran’s diabetes mellitus has been evaluated under 38 C.F.R. Part 4, Diagnostic Code 7913 (1994). Under this Diagnostic Code, a 20 percent evaluation is assigned when diabetes mellitus is moderate with moderate insulin or hypoglycemic agent dosage, and restricted (maintenance) diet, without impairment of health or vigor or limitation of activity. A 40 percent rating is warranted when the evidence demonstrates a moderately severe condition, requiring large insulin dosage, restricted diet, and careful regulation of activities, i.e., avoidance of strenuous occupational and recreational activities. 38 C.F.R. Part 4, Code 7913 (1994). 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 (1994). The veteran’s recent medical records show the severity of disability required for an evaluation of 40 percent, but not higher, for a diabetes mellitus pursuant to Code 7913. The record includes the veteran’s service medical records, VA reports of examination dated in January 1992 and in July and December 1994, and VA outpatient treatment records dated from August to September 1992. The veteran has been treated for diabetes mellitus since June 1984. Significantly, recent medical records demonstrate that he has consistently required large dosages of insulin. For example, on VA examination in January 1992 he was taking 90 units of insulin per day. On VA examination in July and December 1994, he was reportedly taking 92 units of insulin per day. The veteran has also been shown to be on a restricted diet. Outpatient treatment notes dated in August 1992 noted that his diabetes mellitus was poorly controlled. He was advised to eat at regular intervals and not to miss meals. On VA examination in July and December 1994, the examiner noted that the veteran was on a 2000 and 1800 calorie ADA diet, respectively. Concerning regulation of the veteran’s activities, the December 1994 VA examiner reported no restrictions on his activities. However, on VA examination in July 1994 the veteran reported hypoglycemic episodes occurring about once a month. He stated that he only lost consciousness on one occasion approximately one year earlier. Although the examiner reported that he did not get accurate information from the veteran with respect to interference with his ability to work, he noted that monthly hypoglycemic reactions certainly had potential for interfering with his work. Offsetting these findings are reports of essentially stable weight on examination in July and December 1994. In July 1994, neurologic examination was also normal and pedal pulses were intact. The veteran further reported that his vision was normal and that he had no problems with his speech. Moreover, inservice ophthalmology examinations showed no signs of diabetic retinopathy in June 1990 and October 1991. The July 1994 examiner also noted that a November 1993 eye examination was normal. In addition, the December 1994 examiner reported no vascular deficiencies and no diabetic ocular disturbances. The veteran was diagnosed as having diabetes mellitus, no end organ damage. The veteran’s representative has alleged that the VA diabetic examinations were inadequate as no eye examination was conducted and no comment was made pertaining to the veteran’s inservice complaints of numbing and loss of sensation in his extremities. The Board’s May 1994 remand did not require that the veteran undergo a special eye examination. In any event, the veteran’s eyes were examined on VA examinations in July and December 1994. As examination findings were essentially normal and the veteran specifically denied any problems with his vision, a special eye examination is not warranted. Moreover, concerning the veteran’s inservice neurological complaints, neurologic examination was conducted in July 1994. Examination findings were normal, including intact knee and ankle reflexes, normal vibratory sense and normal sense to pinprick. Weighing the reported findings, I conclude that the veteran’s disability picture more closely approximates a moderately severe disability required for a 40 percent evaluation. 38 C.F.R. § 4.7 and Part 4, Diagnostic Code 7913 (1994). However, the record in this case shows a disability well within the parameters of the criteria for a 40 percent rating. As noted above, there is no evidence of considerable loss of weight, vascular deficiencies or diabetic ocular disturbances as required for a 60 percent rating under Code 7913 38 C.F.R. Part 4, Code 7913 (1994). I have also considered assigning an extraschedular rating. However, this case does not present an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. §§ 3.321(b)(1) (1994). In July 1994, the examiner noted that the veteran was currently working as a nurse’s assistant, and in December 1994, it was reported that he had been going to school for six months to become a registered nurse. Marked interference with his employment has not been demonstrated. He has not been hospitalized for treatment of his diabetes mellitus. Therefore, any failure of the RO to refer the case to the Director of the Compensation and Pension Service for extraschedular consideration was harmless error. ORDER Because they are not well-grounded, the veteran’s claims of entitlement to service connection for a heart disorder, a left shoulder disorder, sinusitis and residuals of thoracic strain are dismissed. Entitlement to service connection for a stomach disorder, diagnosed as erosive esophagitis, is granted. A 40 percent rating for diabetes mellitus is granted, as indicated above, subject to the laws and regulations governing the payment of monetary awards. MARY GALLAGHER Member, Board of Veterans’ Appeals The Board of Veterans’ Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans’ Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans’ Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans’ Appeals. - 2 -