Citation Nr: 1003000 Decision Date: 01/20/10 Archive Date: 02/01/10 DOCKET NO. 05-40 649 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial rating in excess of 20 percent for diabetes mellitus. 2. Entitlement to a separate rating in excess of 10 percent for peripheral neuropathy of the left lower extremity secondary to diabetes mellitus, from October 5, 2005 to August 5, 2009, and in excess of 20 percent thereafter. 3. Entitlement to a separate rating in excess of 10 percent for peripheral neuropathy of the right lower extremity secondary to diabetes mellitus, from October 5, 2005 to August 5, 2009, and in excess of 20 percent thereafter. 4. Entitlement to a separate compensable rating for peripheral neuropathy of the left upper extremity secondary to diabetes mellitus. 5. Entitlement to a separate compensable rating for peripheral neuropathy of the right upper extremity secondary to diabetes mellitus. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Timothy D. Rudy, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1968 to July 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2004 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which granted service connection for diabetes mellitus with nephropathy, retinopathy, and erectile dysfunction and awarded a 20 percent disability rating. Subsequently, the claims file was transferred to the jurisdiction of the RO in Atlanta, Georgia. The Board remanded this issue for additional development in September 2008. In June 2008, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge at the RO. A transcript of the hearing is of record. During the hearing, the Veteran withdrew any claims that his diabetic complications included retinopathy or cardiovascular difficulties (see transcript at pp. 9-11). Where, as is the case here, an award of service connection for a disability has been granted and the assignment of an initial rating for that disability is disputed, separate ratings may be assigned for separate periods of time based on the facts found. In other words, the ratings may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Further, the Veteran has been granted separate ratings for peripheral neuropathy of his lower extremities, has not withdrawn his claim for an increased initial rating for diabetes and its complications, and is presumed to be seeking the maximum benefits allowed by law and regulation. AB v. Brown, 6 Vet. App. 35, 38 (1993). Such consideration is reflected by the characterization of the claim as shown on the title page. FINDINGS OF FACT 1. The Veteran's diabetes mellitus is not manifested by a regulation of activities; the evidence of early nephropathy and of erectile dysfunction is not manifested to the level of separately compensable diabetic complications under the applicable schedular criteria. 2. From October 5, 2005 to August 4, 2009, the Veteran's peripheral neuropathy of the left lower extremity is not manifested by moderate incomplete paralysis of the external popliteal nerve. 3. From August 5, 2009, the Veteran's peripheral neuropathy of the left lower extremity is not manifested by severe incomplete paralysis of the external popliteal nerve. 4. From October 5, 2005 to August 4, 2009, the Veteran's peripheral neuropathy of the right lower extremity is not manifested by moderate incomplete paralysis of the external popliteal nerve. 5. From August 5, 2009, the Veteran's peripheral neuropathy of the right lower extremity is not manifested by severe incomplete paralysis of the external popliteal nerve. 6. The Veteran's peripheral neuropathy of the left upper extremity is not manifested by mild incomplete paralysis of the median nerve. 7. The Veteran's peripheral neuropathy of the right upper extremity is not manifested by mild incomplete paralysis of the median nerve. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.119, Diagnostic Code 7913 (2009). 2. The criteria for a rating in excess of 10 percent for peripheral neuropathy of the left lower extremity secondary to diabetes mellitus, from October 5, 2005 to August 5, 2009, and in excess of 20 percent thereafter, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Codes 8521, 8621 (2009). 3. The criteria for a rating in excess of 10 percent for peripheral neuropathy of the right lower extremity secondary to diabetes mellitus, from October 5, 2005 to August 5, 2009, and in excess of 20 percent thereafter, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Codes 8521, 8621 (2009). 4. The criteria for a compensable rating for peripheral neuropathy of the left upper extremity secondary to diabetes mellitus have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8615 (2009). 5. The criteria for a compensable rating for peripheral neuropathy of the right upper extremity secondary to diabetes mellitus have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8615 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) and as interpreted by the United States Court of Appeals for Veterans Claims (the Court), have been fulfilled by information provided to the Veteran in letters from the RO dated in October 2003, January 2006, April 2006, and November 2008. These letters notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing his claim, and identified the Veteran's duties in obtaining information and evidence to substantiate his claim. (See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006), Dingess/Hartman v. Nicholson, 20 Vet. App. 473 (2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006)). During the pendency of this appeal, the Court in Dingess/Hartman found that the VCAA notice requirements applied to all elements of a claim. An additional notice as to these matters was provided in the April 2006 and November 2008 correspondence. The Board notes that on remand the RO requested the Veteran to complete and sign a VA Form 21-4142 (Authorization to Release Information to the VA) in order to obtain medical records from his private physician, Dr. B.W., including those dated after March 2005, which have not been previously secured, but that the Veteran did not respond. The Court has held that VA's "duty to assist is not always a one-way street." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). If a Veteran wishes help he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining relevant evidence. The Board finds that the notice requirements pertinent to the issue on appeal have been met. The duty to assist also has been fulfilled as all identified and authorized VA and private medical records relevant to this matter have been requested and the Veteran was provided with multiple VA examinations. The Board finds that the available medical evidence is sufficient for an adequate determination. There has been substantial compliance with all pertinent VA laws and regulations and to move forward with this claim would not cause any prejudice to the appellant. Increased Ratings - Laws and Regulations Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2009). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The Court has held that a claim for a higher rating when placed in appellate status by disagreement with the original or initial rating award (service connection having been allowed, but not yet ultimately resolved), remains an "original claim" and is not a new claim for an increased rating. See Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the pendency of the appeal, a practice known as "staged" ratings. Id. at 126. It is the responsibility of the rating specialist to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2009). Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses are prohibited. 38 C.F.R. § 4.14 (2009). When there is a question as to which of two evaluations to apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7 (2009). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3 (2009). By way of the March 2004 rating decision under appeal, the Veteran was granted service connection for diabetes mellitus with nephropathy, retinopathy and erectile dysfunction and awarded a 20 percent rating, effective October 14, 2003, the date he filed his claim for service connection. The disability rating was awarded pursuant to the provisions of 38 C.F.R. § 4.119, Diagnostic Code 7913 (2009). Under the applicable criteria, a 20 percent rating is warranted if diabetes mellitus requires insulin and a restricted diet, or an oral hypoglycemic agent and a restricted diet. A 40 percent rating requires insulin, a restricted diet, and regulation of the Veteran's activities (avoidance of strenuous occupational and recreational activities). A 60 percent rating requires insulin, a 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, and complications that would not be compensable if separately evaluated. Finally, a 100 percent rating requires more than one injection of insulin daily, a restricted diet, 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, and either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, Diagnostic Code 7913. A note to the rating criteria instructs that compensable complications of diabetes should be evaluated separately unless they are part of the criteria used to support a 100 percent rating and that noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note 1 (2009). Service connection and separate ratings for peripheral neuropathy of the Veteran's lower extremities were granted in a March 2006 RO rating decision wherein the Veteran was awarded separate 10 percent disability ratings for the left and for the right lower extremity. In an October 2009 rating decision, the RO increased these disability ratings from 10 percent to 20 percent under the provisions of Diagnostic Code 7913-8521. Under the provisions of Diagnostic Code 8521, for incomplete paralysis of the external popliteal nerve in the lower extremities, and the like Diagnostic Code 8621 for neuritis, a rating of 10 percent is for mild incomplete paralysis, a 20 percent rating is for moderate incomplete paralysis, and a 30 percent rating is for severe incomplete paralysis of the external popliteal nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8521 and 8621 (2009). The criteria for evaluating the severity or impairment of the median nerve in the upper extremities is set forth under Diagnostic Codes 8515, and the like Diagnostic Code 8615 for neuritis of the same. Under these codes, a 10 percent rating is warranted for mild incomplete paralysis of the median nerve. A 20 percent rating is warranted for moderate incomplete paralysis of the minor extremity and a 30 percent rating is warranted for moderate incomplete paralysis of the median nerve in the major extremity. A 40 percent rating requires severe incomplete paralysis of the median nerve in the minor extremity, and a 50 percent rating is warranted for severe incomplete paralysis of the median nerve in the major extremity. 38 C.F.R. § 4.124a, Diagnostic Codes 8515 and 8615 (2009). The words such as "moderate" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2009). 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. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. Factual Background and Analysis In a November 2003 Physician's Statement from B.W., D.O., the Veteran's private physician checked boxes indicating the following: that the Veteran had been diagnosed with adult onset diabetes mellitus, type II; that his diabetes required insulin and restricted diet or oral hypoglycemic agent and restricted diet; and that peripheral atherosclerosis with bypass was a complication directly due to diabetes. Assessments in private medical records from Dr. B.W., dated from January 2004 to February 2005, indicated a diagnosis of diabetes mellitus, type II, and peripheral vascular disease. The Veteran underwent a fee-basis VA examination in January 2004. It was noted that he had been diagnosed with diabetes mellitus about 6 years before during an evaluation for peripheral vascular disease of the left leg and had been on medication since. He was currently taking Actos twice a day and Amaryl twice a day. There was no history of diabetic ketoacidosis and he did not have a problem with hypoglycemia. On average he visited a doctor four times a year for diabetes. During the day the Veteran urinated six times at intervals of two hours and during the night he urinated once every four hours. He did not have any urinary incontinence. He complained of tingling and numbness of the feet, but stated that the diabetes did not affect the eyes, the skin, the heart, or the kidneys. It had affected the arteries for six years resulting in intermittent claudication. He experienced leg pain after walking 200 feet. The artery problem was treated with surgery in 1998 and Plavix. The Veteran complained of no functional impairment from his condition or any lost time from work. He did complain of impotence which began six years before. He said that he could not achieve and maintain an erection and that vaginal penetration with ejaculation was not possible. Treatment with Viagra helped to some extent. On examination, the Veteran stood 73 inches and weighed 248 pounds. He was well-developed, well-nourished and in no acute distress. Retinopathy was present in both eyes with findings of small exudates. Peripheral pulses bilaterally were normal. Motor and sensory functions of the extremities were within normal limits. Reflexes of the bilateral lower and upper extremities were normal. Examination revealed normal arterial pulsations of the lower extremities and no evidence of an obstructive peripheral vascular disease of the lower extremities. Diagnostic tests showed elevated glucose at 237 mg/dl and urinalysis showed protein present. Diagnosis was diabetes mellitus, type II with diabetic nephropathy, diabetic retinopathy and impotence. A fee basis VA examination of the eyes in February 2004 found no diagnosis of diabetic retinopathy because the examiner found no pathology with which to render a diagnosis. Keratoconus was not present and the Veteran did not have diplopia. The Veteran reported no symptoms of distorted vision, enlarged images, pain, or incapacitation. An additional fee basis VA examination of the eyes in September 2005 found none of the ocular complications of diabetes mellitus. The examiner diagnosed hyperopia and presbyopia. VA medical records dated from November 2004 to May 2009 reveal the Veteran's treatment for his diabetes and complications from the disease, including occasional medication adjustments and diet counseling, and his start on insulin in November 2006. The Veteran underwent a fee-basis VA examination in October 2005. It was noted that the Veteran did not have a history of diabetic ketoacidosis or problems with hypoglycemia. He was treated with medication: Actos once per day and Amaryl twice per day. On average he visited a doctor four times a year for diabetes. During the day he urinated 12 times at one hour intervals and during the night he urinated twice at three-hour intervals. The Veteran complained of tingling and numbness in his fingers and toes, but said that the diabetes did not affect his eyes, skin, or heart. He complained of an effect on the arteries for seven years causing intermittent claudication, calf pain at rest and persistent coldness of the extremities. There was no functional impairment of the kidneys or time lost from work, but the Veteran complained of impotence beginning eight years before. He could not achieve and maintain an erection and vaginal penetration with ejaculation was not possible. On examination, the Veteran stood five feet, 11 inches and weighed 246 pounds. He was well developed, well nourished and in no acute distress. Examination of the eyes, including the funduscope, was within normal limits. Examination of the extremities did not reveal atrophic skin changes, ulceration, gangrene, ischemic limb pain or persistent coldness. Bilateral peripheral pulses were normal. Peripheral nerve examination was within normal limits. Motor and sensory functions of the bilateral upper extremities were normal. Motor functions of the lower extremities also were normal, but sensory function was abnormal with findings of decreased vibratory sensation in both feet. Bilateral knee jerk and ankle jerk were measured at 1+. Diagnostic tests showed a glucose level of 193 and the urinalysis showed the presence of sugar and the absence of protein. Diagnosis was diabetes mellitus, type II, and peripheral neuropathy of the lower extremities secondary to diabetes with the neurological condition resulting in neuritis. The diabetes did not cause any restriction of activities and the Veteran did not have a non-diabetic condition aggravated by diabetes. The examiner failed to diagnose nephropathy because he found there was no pathology with which to render a diagnosis. A Physician's Statement dated in February 2006 from Dr. B.W. indicated that the Veteran required insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet for his diabetes and that he suffered cardiovascular and neurological complications directly due to his diabetes. During his June 2008 Board hearing, the Veteran, a baggage handler for Delta Airlines, testified that he had no problem with his eyes and was not claiming any cardiovascular difficulties as a result of his diabetes. He said that he thought that a doctor had told him that his erectile dysfunction and kidney problems were related to his diabetes. He testified that he was constantly urinating and that his doctor had given him pills for an enlarged prostate, but that they made him dizzy and he did not like the way they made him feel. He also said his doctor refused his request for Levitra for his erectile dysfunction because she did not know if he was healthy enough for sex. After further testing he was put on an Ace inhibitor. The Veteran also testified that his fingertips and part of his hand become numb and his fingers tingled, worse in the winter, and that it was difficult to keep his hands warm. (See transcript at pp. 4- 5, 9-13). A Physician's Statement form completed by a VA physician in June 2008 reflected that the Veteran's diabetes mellitus required insulin, restricted diet, and regulation of activities. The VA physician did not provide further information on the form, however, regarding the regulation of activities. The Veteran underwent a VA examination in March 2009. He told the examiner that he had no episodes of ketoacidosis, hyperglycemia or hypoglycemic reactions and had not been hospitalized for his diabetes. He said that he did not check his blood glucose levels on a regular basis and tried to follow a carbohydrate restricted diet. He reported weight loss which he believed was stress related to his father's illness. It was noted that the Veteran faced no restriction on his activities on account of his diabetes. He was seen by his VA primary provider every three months and was currently treated with NPH insulin and Glipizide. He did not report a history of retinopathy, cataracts, glaucoma or other eye conditions. He reported erectile dysfunction for 13 years, that he was unable to achieve or maintain an erection for successful vaginal intercourse, that he and his wife were last able to have successful sexual vaginal intercourse 2 or 3 years before, and that he had used Levitra in the past but was unable to maintain an erection for intercourse. The Veteran did not report a history of nephropathy, but said that he urinated every 30 minutes and had done so for years during the day and is up 2 to 3 times at night. He also reported he did not exercise and smoked cigarettes. The Veteran complained of burning in his fingertips and in his feet as well as numbness in his hands and feet with cold weather. He reported no edema, achiness or fatigue in the legs, he had no vericose veins and did not report wearing compression stockings. On physical examination, the Veteran appeared well developed, well nourished and in no apparent distress. Diminished pinprick was noted on both the examination of the hands and fingertips and both feet. Feet reflexes were brachial 1+ bilaterally, downgoing; plantar reflexes and Achilles reflexes bilaterally were normal; and dorsalis pedis and posterior tibial pulses were 1+ bilaterally. Diagnostic tests showed a glucose level of 302. Diagnosis was diabetes mellitus without any cardiovascular, eye, skin, or bowel complications. Evidence of erectile dysfunction was more likely than not multifactorial based on a combination of age, stress, depression and diabetes. Bilateral upper and lower extremity peripheral neuropathy was at least as likely as not related to diabetes. The examiner noted the diminished pinprick sensation in all extremities and that the Veteran had failed the monofilament test and was prescribed Neurontin for his symptoms. The VA examiner also diagnosed early nephropathy that was at least as likely as not related to his diabetes. The nephropathy was manifested by urine microalbuminuria in the presence of a normal creatinine level. The examiner also found that the Veteran's peripheral vascular disease, with the prior left leg bypass surgery, was at least as likely as not related to his diabetes. The Veteran underwent a VA peripheral nerves examination in August 2009. Motor and sensory findings were consistent with moderate to severe chronic mixed sensory motor polyneuropathy affecting bilateral lower extremities, most likely due to diabetes. The VA examiner noted that peripheral neuropathy was limited to the lower extremities and that upper extremity studies were normal. Progression of peripheral neuropathy to the upper extremities, however, could occur at a later stage. The examiner recommended preventive foot care, diabetic shoes, weight control, and a daily exercise program. Based upon the evidence of record, the Board finds the Veteran's service-connected diabetes is manifested by no more than the required use of an oral hypoglycemic agent, insulin, and a restricted diet. There is no probative and competent evidence of the regulation of activities because of diabetes. The competent medical evidence of record does not reflect that the Veteran's diabetes requires medically directed "regulation of activities," defined in Diagnostic Code 7913 as "avoidance of strenuous occupational and recreational activities". The June 2008 Physician's Statement completed by a VA physician is the only evidence that the Veteran's activities had to be regulated due to diabetes. Moreover, this physician failed to provide further information as VA had requested on the form. Further, VA medical records dated from November 2004 to May 2009 reveal no evidence of regulation of activities due to diabetes. Nor is there any evidence of episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, or a progressive loss of weight and strength because of this disorder. Therefore, the Board finds that an initial rating in excess of 20 percent for the Veteran's service-connected diabetes mellitus is not warranted. The Board also notes that the June 2005 VA examiner failed to diagnose diabetic nephropathy and the March 2009 VA examiner diagnosed only early nephropathy. Both opinions suggest that the Veteran's nephropathy is part of the Veteran's diabetic process and not, as yet, at the level of a separate rating for a diabetic complication. See 38 C.F.R. § 4.119, Diagnostic Code 7913, Note 1. There was no evidence in these VA examinations that the Veteran's early nephropathy satisfied the criteria for a compensable rating for renal dysfunction pursuant to 38 C.F.R. § 4.115a, 4.115b, Diagnostic Code 7541 (2009). Specifically, under the schedule criteria for renal dysfunction, it is not shown that the Veteran suffers from criteria for the minimal 30 percent rating. As noted above, the Veteran withdrew his request to have his diabetes evaluated for retinopathy and any evidence of diabetic retinopathy found in the January 2004 VA examination was contradicted in all succeeding VA examinations beginning in February 2004. Further, as regards the Veteran's erectile dysfunction which evidence links to his diabetes, a review of the claims file discloses that the Veteran is receiving special monthly compensation under 38 U.S.C.A. § 1114 for loss of use of a creative organ; and the evidence of record does not otherwise rise to the level of schedular compensation for his erectile dysfunction because there is no evidence of deformity of the penis. See 38 C.F.R. § 4.115b, Diagnostic Code 7522 (2009). Therefore, the Board finds that nephropathy and erectile dysfunction are noncompensable schedular complications of diabetes and that their consideration as part of the Veteran's diabetic process under Diagnostic Code 7913 does not warrant an initial rating in excess of 20 percent for the Veteran's service-connected diabetes mellitus Based upon the evidence of record, the Board finds that the Veteran is entitled to separate ratings for the peripheral neuropathy of his lower extremities. As noted above, the RO awarded 10 percent disability ratings for each extremity for the period from October 5, 2005 to August 5, 2009, and 20 percent for the period thereafter. Under the provisions of Diagnostic Code 8521 and 8621, for incomplete paralysis of the external popliteal nerve in the lower extremities representing neuritis, a rating not in excess of 10 percent for mild incomplete paralysis of the nerve is warranted for the period from the October 5, 2005 VA examination to the August 5, 2009 VA examination. The October 2005 VA examiner found that peripheral neuropathy of the lower extremities was secondary to diabetes and that the resulting neurological condition represented neuritis. This examiner noted, however, that bilateral peripheral pulses were normal, the bilateral peripheral nerve examination also was within normal limits, and that motor functions of the lower extremities also were normal. Only the Veteran's sensory functions were abnormal with findings of decreased vibratory sensation in both feet. Under the provisions of Diagnostic Code 8521 and Diagnostic Code 8621, a rating not in excess of 20 percent for moderate incomplete paralysis is warranted for the period from October 5, 2005 to the present. The August 2009 VA peripheral nerves examination found greater sensory deprivation in the lower extremities than was found in the October 2005 examination. Tests conducted by the August 2009 VA examiner found moderate to severe chronic mixed sensory motor polyneuropathy affecting both of the lower extremities. As most of the negative testing reflected sensory deficits rather than sensory and motor function losses, the Board finds a 20 percent rating for moderate incomplete paralysis is appropriate rather than the 30 percent rating available for severe incomplete paralysis. See 38 C.F.R. § 4.124a, Diagnostic Codes 8521 and 8621 (2009). The Veteran also sought separate ratings and an increased initial rating based on peripheral neuropathy in his upper extremities. As noted above, however, the medical evidence has never shown motor and sensory deficits of the upper extremities, although the March 2009 VA examiner found bilateral peripheral neuropathy of the upper and lower extremities. However, the August 2009 VA peripheral nerves examination found after testing that upper extremity studies were normal. The August 2009 VA examiner did note, however, that the Veteran could face the progression of his peripheral neuropathy to his upper extremities in the future. Therefore, under the criteria of Diagnostic Codes 8515 and 8615 for impairment or neuritis of the median nerve in the upper extremities, a compensable rating for peripheral neuropathy of either the left or right upper extremity is not warranted in this appeal at this time as the medical evidence of record does not even show mild incomplete paralysis of the nerve, or the criteria for a 10 percent disability rating. In addition, competent medical evidence reflects that the Veteran does not have any additional compensable diabetic complications. Consequently, the assignment of a separate disability rating for any other condition, but peripheral neuropathy of the lower extremities, is not warranted under 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1). The Board has considered whether the application of "staged ratings" would be in order. See Fenderson, 12 Vet. App. at 125-26. However, there appears to be no identifiable period of time since the effective date of service connection during which the Veteran's service-connected diabetes mellitus was shown to be in excess of the assigned 20 percent rating. The Board has carefully considered the Veteran's personal report of his symptoms and finds he is competent to testify regarding what he is able to experience through his senses. However, while the Veteran is competent to report what comes to him through his senses, he does not have medical expertise. See Layno v. Brown, 6 Vet. App. 465 (1994). As the Veteran does not have medical expertise, the Board finds his statements to be less persuasive than the medical evidence noted above. The Board acknowledges the Veteran's contentions that his diabetes mellitus is more severely disabling. However, the Veteran is not a licensed medical practitioner and is not competent to offer opinions on questions of medical causation or diagnosis. See Grottveit v. Brown, 5 Vet. App. 91 (1993); see also Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The Board also finds that the evidence of record does not support submission of the file for extraschedular consideration of the disability ratings at issue. There is a three-step analysis for determining whether an extraschedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111, 115 (2008). First, there must be a comparison between the level of severity and symptomatology of the claimant's service- connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id. at 115-16; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalizations). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. at 116. After a thorough review of the record, the Board is convinced that the Veteran has not met the first step of Thun as the Board believes that the rating criteria noted within this decision reasonably describes the Veteran's disability levels and the symptomatology of his diabetes and its complications during the time period of this appeal; moreover, he has not argued that exceptional factors, such as interference with employment or hospitalizations, are involved in his case. Therefore, no referral for extraschedular consideration is required in this case. When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The preponderance of the evidence is against awarding an initial disability rating in excess of 20 percent for diabetes mellitus with nephropathy, retinopathy and erectile dysfunction, and against granting separate ratings for peripheral neuropathy of both upper extremities. In addition, the preponderance of the evidence is against separate ratings in excess of 10 percent for peripheral neuropathy of both lower extremities, for the period from October 5, 2005 to August 5, 2009, and in excess of 20 percent thereafter. See Fenderson, supra. ORDER Entitlement to an initial rating in excess of 20 percent for diabetes mellitus is denied. Entitlement to a separate rating in excess of 10 percent for peripheral neuropathy of the left lower extremity secondary to diabetes mellitus, from October 5, 2005 to August 5, 2009, and in excess of 20 percent thereafter, is denied. Entitlement to a separate rating in excess of 10 percent for peripheral neuropathy of the right lower extremity secondary to diabetes mellitus, from October 5, 2005 to August 5, 2009, and in excess of 20 percent thereafter, is denied. Entitlement to a separate compensable rating for peripheral neuropathy of the left upper extremity secondary to diabetes mellitus is denied. Entitlement to a separate compensable rating for peripheral neuropathy of the right upper extremity secondary to diabetes mellitus is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs