Citation Nr: 1123422 Decision Date: 06/21/11 Archive Date: 06/28/11 DOCKET NO. 08-09 667A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus, type II. 3. Entitlement to an initial disability rating in excess of 10 percent for diabetic neuropathy of the left lower extremity. 4. Entitlement to an initial compensable disability rating for diabetic nephropathy. REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs ATTORNEY FOR THE BOARD David Gratz, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1965 to December 1967. This matter comes before the Board of Veterans' Appeals (Board) from a March 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico, which increased the Veteran's disability rating for his service-connected PTSD from 30 to 50 percent as of December 18, 2006, the date of his claim for an increased rating; continued his 20 percent disability rating for his service-connected diabetes mellitus, type II; granted his January 2007 claim for entitlement to service connection for diabetic neuropathy of the left lower extremity, and assigned a disability rating of 10 percent; and granted his January 2007 claim for entitlement to service connection for diabetic nephropathy, and assigned a noncompensable disability rating. As these ratings do not represent the highest possible benefits, the issues have remained in appellate status. AB v. Brown, 6 Vet. App. 35, 38 (1993). The issue of entitlement to service connection for diabetic neuropathy of the right lower extremity has been raised by the record-see, the September 2009 VA peripheral nerves examination report-but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The Veteran's PTSD has manifested with occupational and social impairment with reduced reliability and productivity due to symptoms such as: being angry with himself; hearing voices that question him, feeling irritated, being unable to sleep for more than 3.5 hours per night, having nightmares about combat, hearing noises and explosions when alone, losing his concentration easily, becoming disoriented, having a poor memory for reading material, names of acquaintances, and driving directions; becoming verbally aggressive even in minor situations, having occasional suicidal thoughts without plans, having a somewhat depressed and anxious mood and a constricted affect, having limited social relationships because others make fun of or do not believe his descriptions of his service in Vietnam, persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, and persistent symptoms of increased arousal, and having angry outbursts with increased irritability related to his vivid memories of combat, feeling misunderstood, and feeling different from others who had not experienced combat. 2. The Veteran's service-connected PTSD has not manifested occupational and social impairment with deficiencies in most areas and does not affect his ability to function independently, appropriately, and effectively, with no evidence of suicidal or homicidal ideation, speech intermittently illogical, obscure, or irrelevant, near continuous panic or depression, or obssessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant, or near-continuous panic. 3. The Veteran's service-connected diabetes mellitus, type 2, requires insulin and a restricted diet, but not regulation of activities. Additionally, his episodes of ketoacidosis or hypoglycemic reactions do not require hospitalizations or visits to a diabetic care provider. 4. The Veteran's left lower extremity symptoms of diabetic neuropathy are equivalent to mild incomplete paralysis of the sciatic nerve. 5. The Veteran's diabetic nephropathy is manifested by micro-albuminuria, with no history of hospitalization or surgery, no urinary symptoms, no renal dysfunction or failure, no acute nephritis, no hydronephrosis, and no cardiovascular symptoms; the Veteran had a creatinine level of 0.93, and a blood, urea and nitrogen (BUN) level of 14.3. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7; 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). 2. The criteria for a rating in excess of 20 percent for diabetes mellitus, type II, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7; 38 C.F.R. § 4.119, Diagnostic Code 7913 (2010). 3. The criteria for a rating in excess of 10 percent for diabetic neuropathy of the left lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.14, 4.124; 38 C.F.R. § 4.124a, Diagnostic Code 8720 (2010). 4. The criteria for a compensable rating for diabetic nephropathy have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.124; 38 C.F.R. § 4.115a, Diagnostic Code 7599 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist the Veteran Review of the claims folder reveals compliance with the Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. § 5100 et seq. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b)(1). Such notice should be provided to a claimant before the initial unfavorable AOJ decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Letters dated January 2007 and March 2007, provided to the Veteran before the March 2007 rating decision, satisfied VA's duty to notify under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159, since they informed the Veteran of what evidence was needed to establish his claims, what VA would do and had done, and what evidence he should provide. The letters also informed the Veteran that it was his responsibility to help VA obtain medical evidence or other non-government records necessary to support his claims. The Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim, including the degree of disability and the effective date of an award. The Veteran was provided with such notice in January 2007 and March 2007. The Federal Circuit has held that VA's duty to notify, codified at 38 U.S.C.A. § 5103(a), does not require it to provide notice of alternative diagnostic codes, or to solicit evidence of the impact of the Veteran's claimed disability on his daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (2009). With respect to VA's duty to assist, the RO has obtained, or made reasonable attempts to obtain, all relevant evidence identified by the Veteran. The Veteran's service treatment records, VA treatment records, and available private treatment records have been obtained. The Veteran has not reported, and neither does the evidence of record show, that he is in receipt of Social Security Administration (SSA) disability benefits for his claimed disability. Therefore, it is not necessary for VA to have requested such records. Golz v. Shinseki, 590 F.3d 1317, 1323 (2010). Thus, the Board considers the VA's duty to assist satisfied. Accordingly, the Board finds that no further assistance to the Veteran in acquiring evidence is required by statute. 38 U.S.C.A. § 5103A. Laws and Regulations Pertaining to Claims for Increased Ratings Disability evaluations are determined by the application of a schedule of ratings that is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.7 provides that, where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. While the Veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. An evaluation of the level of disability present also includes consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. Analysis: A Disability Rating in Excess of 50 Percent for PTSD The RO granted service connection for the Veteran's PTSD and assigned an initial disability rating of 30 percent under Diagnostic Code 9411 as of March 17, 1989. In a March 2007 rating decision, the RO increased the Veteran's rating to 50 percent as of December 18, 2006, the date of his claim for an increased rating. PTSD is rated under the "General Rating Formula for Mental Disorders," Diagnostic Code 9411. 38 C.F.R. § 4.130. A 50 percent evaluation is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. A 100 percent evaluation is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. The Global Assessment of Functioning (GAF) is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FOURTH ED, American Psychiatric Association (1994) (DSM-IV), p.32; 38 C.F.R. §§ 4.125(a), 4.130 (2008). GAF scores of 61 to 70 are indicative of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. Scores of 51-60 involve moderate symptoms, such as flat affect and circumstantial speech, occasional panic attacks, or moderate difficulty in social or occupational functioning (e.g., few friends or conflicts with peers or co-workers.) Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Id. Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood, (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). Id. According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126; Mauerhan v. Principi, 16 Vet. App. 436 (2002). VA provided the Veteran with a compensation and pension (C&P) examination of his PTSD in January 2007. The examiner, a physician, reviewed the Veteran's Computerized Patient Record System (CPRS) medical records, and noted that the Veteran has been prescribed medication for this disorder. The Veteran reported that his psychiatric symptoms have been continuous and severe since service. He also stated that he was able to engage in productive activity until he retired. The Veteran reported that he receives all of his treatment at VA clinics, and that he has had a fairly good response to his treatment. The Veteran characterized his symptoms as including being angry with himself; hearing voices that question him; feeling irritated; being unable to sleep for more than 3.5 hours per night; having nightmares about combat; hearing noises and explosions when alone; losing his concentration easily; becoming disoriented; having a poor memory for reading material, names of acquaintances, and driving directions; and becoming verbally aggressive even in minor situations. He also reported having had occasional suicidal thoughts without plans. The Veteran reported that he retired from his job in May 2003 after 32 years of work. He further reported that he is married and has a good or fair relationship with his wife, and sometimes socializes with his relatives. The examiner found that the Veteran was alert and oriented, with a somewhat depressed and anxious mood, and a constricted affect. The Veteran's attention, concentration, memory, insight, and judgment were fair. He was not hallucinating, suicidal, or homicidal at the time of the examination. The VA examiner characterized the Veteran's impairment in social interactions and behavior as moderate, and characterized his impairment of social, marital, and interpersonal functioning as moderately severe. The examiner diagnosed the Veteran with PTSD, and assigned a GAF score of 50. A VA physician again diagnosed the Veteran with PTSD in August 2007, and assigned a GAF score of 48. The VA physician again diagnosed the Veteran with PTSD in May 2008, and assigned a GAF score of 50. In his April 2008 substantive appeal, the Veteran asserted that his GAF scores show serious impairment in social, occupational or school functioning. The Veteran also asserted that he is unable to keep a job, and that "there is nothing like moderately severe impairment in psychiatry." In a June 2009 letter, the Veteran again asserted that his PTSD makes him unable to secure or follow a substantially gainful occupation. VA provided the Veteran with a second C&P examination of his PTSD in September 2009. The examiner, a physician, reviewed the Veteran's medical records, and noted that the Veteran has been prescribed medication for this disorder. The clinician noted that the Veteran had no history of psychiatric hospitalizations. The Veteran reported that he was married, and that his grandchildren stay at their house after school until their mothers pick them up. He also noted that he was in communication with his children from a previous marriage. The Veteran reported that he was limited in his social relationships and basically remains at home. He noted that he does not communicate with others because they make fun of or do not believe his descriptions of his service in Vietnam, which in turn angers him. The Veteran reported having no history of suicide attempts or assaultiveness. The examiner found that the Veteran had an appropriate affect, somewhat apprehensive and guarded mood, unremarkable thought process, preoccupation with one or two topics, and no delusions. The Veteran reported that he has nightmares related to his combat experiences, and is awakened by sounds from his time in combat. On examination, the Veteran did not have inappropriate behavior, obsessive or ritualistic behavior, panic attacks, homicidal or suicidal thoughts, episodes of violence, or problems with activities of daily living. The Veteran had good impulse control, and his memory was normal. The Veteran had persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, and persistent symptoms of increased arousal-particularly with such stimuli as helicopter sounds, rain, and fog, and also during the month of May, when he was involved in traumatic combat in Vietnam. He also reported having angry outbursts with increased irritability related to his vivid memories of combat, feeling misunderstood, and feeling different from others who had not experienced combat. The Veteran reported that he remained retired. The VA examiner diagnosed the Veteran with chronic PTSD, and assigned a GAF score of 55. The examiner further opined that the Veteran has reduced reliability and productivity due to his PTSD symptoms. The examiner found that the Veteran does not have total occupational and social impairment due to PTSD signs and symptoms, or PTSD signs and symptoms that result in deficiencies in judgment thinking, family relations, work, or mood. A VA psychiatrist diagnosed the Veteran with PTSD and assigned GAF scores of 60 in February 2009 and August 2009, and 55 in July 2010. Based on a review of the foregoing, the Board finds that the evidence supports a continuation of the 50 percent rating for the Veteran's PTSD symptoms for the entire appellate period. The most probative evidence of record shows that the Veteran's symptoms include being angry with himself, hearing voices that question him, feeling irritated, being unable to sleep for more than 3.5 hours per night, having nightmares about combat, hearing noises and explosions when alone, losing his concentration easily, becoming disoriented, having a poor memory for reading material, names of acquaintances, and driving directions, becoming verbally aggressive even in minor situations, having occasional suicidal thoughts without plans, having a somewhat depressed and anxious mood and a constricted affect, having limited social relationships because others make fun of or do not believe his descriptions of his service in Vietnam, persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, and persistent symptoms of increased arousal, and having angry outbursts with increased irritability related to his vivid memories of combat, feeling misunderstood, and feeling different from others who had not experienced combat. The Veteran's GAF scores ranged from 48, by a VA physician in August 2007; to 60, by a VA psychiatrist in February 2009 and August 2009. These scores indicate moderate to serious symptoms due to PTSD. A 70 percent evaluation is not for application because the Veteran does not have obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or an inability to establish and maintain effective relationships. Although the Veteran, by his own report, has experienced some suicidal ideation without plans and near-continuous depression, the Board finds that those characteristics are outweighed by the more numerous characteristics associated with a 50 percent disability rating. 38 C.F.R. § 4.1. The Board further finds that the most probative evidence of record shows that the Veteran is not unemployable as a result of his PTSD. The September 2009 VA examiner's determination that the Veteran does not have total occupational and social impairment due to PTSD signs and symptoms is entitled to greater probative weight than the Veteran's own assessment that his PTSD makes him unemployable, because the examiner's determinations are based on greater medical knowledge and experience. Winsett v. West, 11 Vet. App. 420 (1998), aff'd 217 F.3d 854 (Fed. Cir. 1999); Guerrieri v. Brown, 4 Vet. App. 467 (1993). Furthermore, the Veteran had reported in his January 2007 C&P examination that he had retired from his job in May 2003 after 32 years of work because of the duration of his employment. Separate consideration of a claim for entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disability under Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009) is inapplicable in this case because the September 2009 VA examiner found that the Veteran is not unemployable due to his PTSD. The Board also notes that the Veteran was denied service connection for TDIU in a December 2009 rating decision, and he did not file a notice of disagreement in response to that decision. Based upon the guidance of the Court in Hart, 21 Vet. App. 505 (2007), the Board has considered whether staged ratings are appropriate; however, in the present case, no staged ratings are warranted by the Veteran's symptomatology. The Board has considered the issue of whether the Veteran's PTSD, standing alone, presents an exceptional or unusual disability picture, as to render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular evaluation is appropriate. Thun v. Peake, 22 Vet. App. 111, 115-116. First, the threshold factor for extra-schedular consideration is that there must be a comparison between the level of severity and symptomatology of the Veteran'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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Id. at 115. However, if not adequately contemplated by the rating criteria, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. at 116. See also 38 C.F.R. § 3.321(b)(1). If either of the factors of step two is 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 extra-schedular rating. Id. at 116. In this case, because the rating criteria reasonably describe the claimant's disability level and symptomatology, the claimant's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is adequate. Analysis: A Disability Rating in Excess of 20 Percent for Diabetes Mellitus, Type II The RO granted service connection for the Veteran's diabetes mellitus, type II, and assigned an initial disability rating of 20 percent under Diagnostic Code 7913 as of March 12, 2001. In a March 2007 rating decision, the RO continued the Veteran's rating of 20 percent in response to his December 18, 2006 claim for an increased rating. Under 38 C.F.R. § 4.119, Diagnostic Code 7913, a 20 percent rating is assigned for diabetes mellitus controlled by insulin and restricted diet; or, oral hypoglycemic agent and restricted diet. A 40 percent rating is assigned where the diabetes mellitus requires insulin, restricted diet, and regulation of activities. A 60 percent disability rating is assigned where the diabetes mellitus requires 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 rated. A 100 percent rating is assigned where diabetes mellitus requires more than one daily insulin injection, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational 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. Diagnostic Code 7913, Note 1, provides that compensable complications of diabetes will be rated 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. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2010). The Veteran's claims for an initial disability rating in excess of 10 percent for diabetic neuropathy of the left lower extremity, and an initial compensable rating for diabetic nephropathy, are considered separately below. The Veteran has additional compensable complications of diabetes which have been found to be subject to service connection on a secondary basis. VA provided the Veteran with a C&P examination of his diabetes mellitus in February 2007. The examiner, a physician, reviewed the Veteran's medical records. The Veteran reported that he takes insulin and oral medication. The Veteran was instructed to follow a restricted diet. He is not restricted in his ability to perform strenuous activities. The Veteran had no hospitalizations or surgery associated with his diabetes. He had no episodes of ketoacidosis or hypoglycemic reactions. The examiner noted that the Veteran reported having retired in May 2003 because he was eligible by age or duration of work. The examiner diagnosed the Veteran with diabetes. In May 2007, a VA clinician noted that the Veteran's diabetes was uncontrolled, and recommended increased insulin, reinforced his diet, and recommended weight loss. A VA clinician found that the Veteran's diabetes was better controlled with insulin in March 2008. A VA clinician again found the Veteran's diabetes to be better controlled in November 2008. VA provided the Veteran with a second C&P examination of his diabetes mellitus in September 2009, by the same examiner. The examiner reviewed the Veteran's medical records, and noted that he is on insulin and other medication. The Veteran reported that he was retired based on eligibility due to his age or duration of work. The Veteran also reported that his diabetes had a severe effect on his chores, exercise, and sports; a moderate effect on his shopping, recreation, traveling, and driving; a mild effect on his bathing and dressing, and no effect on his feeding, toileting, or grooming. The Veteran had episodes of hypoglycemia reactions or ketoacidosis which did not require hospitalization or visits to a diabetic care provider; he explained that his episodes of hypoglycemia, which occur at least twice per month, are usually related to his skipping a meal. The Veteran was instructed to follow a restricted diet. The Veteran was not restricted in his ability to perform strenuous activities. The examiner diagnosed the Veteran with diabetes. In December 2009, a VA clinician found that the Veteran's diabetes was uncontrolled and that he was not compliant with his diet. Competent medical evidence includes statements from a person qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). Because the VA examiner is so qualified, her medical findings constitute competent medical evidence. Based on the facts outlined above, the Board finds that the Veteran is not entitled to a disability rating in excess of 20 percent for his diabetes mellitus, type 2, under 38 C.F.R. § 4.119, Diagnostic Code 7913. Although the Veteran has reported that his diabetes had a severe effect on his chores, exercise, and sports, he has not established this prevents all strenuous recreational activities. Moreover, no VA or private clinician has made a finding contrary to the February 2007 and September 2009 VA examiner's opinion that the Veteran is not restricted in his ability to perform strenuous activities. Additionally, the Veteran's own determination regarding regulation of activities is outweighed by the more probative findings of the February 2007 and September 2009 VA examiner, because her determination is based on greater medical knowledge and experience. Winsett v. West, 11 Vet. App. 420 (1998), aff'd 217 F.3d 854 (Fed. Cir. 1999); Guerrieri v. Brown, 4 Vet. App. 467 (1993). A higher evaluation is not warranted because the Veteran does not have regulation of activities. Additionally, the Veteran does not have episodes of ketoacidosis or hypoglycemic reactions that require hospitalizations or visits to a diabetic care provider. Based upon the guidance of the Court in Hart, 21 Vet. App. 505 (2007), the Board has considered whether staged ratings are appropriate; however, in the present case, no staged ratings are warranted by the Veteran's symptomatology. The Board has considered the issue of whether the Veteran's diabetes mellitus, type II, standing alone, presents an exceptional or unusual disability picture, as to render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular evaluation is appropriate. Thun v. Peake, 22 Vet. App. 111, 115-116. First, the threshold factor for extra-schedular consideration is that there must be a comparison between the level of severity and symptomatology of the Veteran'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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Id. at 115. However, if not adequately contemplated by the rating criteria, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. at 116. See also 38 C.F.R. § 3.321(b)(1). If either of the factors of step two is 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 extra-schedular rating. Id. at 116. In this case, because the rating criteria reasonably describe the claimant's disability level and symptomatology, the claimant's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is adequate. Laws and Regulations Pertaining to Initial Disability Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, 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. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. If there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). See AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original or an increased rating remains in controversy when less than the maximum available benefit is awarded). Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Since the present appeal arises from an initial rating decision, which established service connection and assigned the initial disability rating, it is not the present level of disability which is of primary importance; the entire period is to be considered to ensure that consideration is given to the possibility of separate ratings for separate periods of time based on the facts found. See Fenderson, supra. Evaluation of a disability includes consideration of the Veteran's ability to engage in ordinary activities, including employment, and the effect of symptoms on functional abilities. 38 C.F.R. § 4.10. Analysis: An Initial Disability Rating in Excess of 10 Percent for Diabetic Neuropathy of the Left Lower Extremity Paralysis of the sciatic nerve warrants a disability rating of 80 percent where there is complete paralysis, the foot dangles and drops, no active movement is possible of muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. A 60 percent disability rating applies where there is severe incomplete paralysis with marked muscular atrophy. A 40 percent disability rating applies where there is moderately severe incomplete paralysis. A 20 percent disability rating applies where there is moderate incomplete paralysis. A 10 percent disability rating applies where there is mild incomplete paralysis. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Neuritis of the sciatic nerve-characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating-is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. In cases of sciatic nerve involvement, the maximum rating which may be assigned for neuritis not characterized by organic changes will be for moderately severe incomplete paralysis. 38 C.F.R. §§ 4.123, 4.124a, Diagnostic Code 8620. Neuralgia of the sciatic nerve-characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve-is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. §§ 4.124, 4.124a, Diagnostic Code 8720. In February 2007, a VA physiatrist found that the Veteran's lower extremity peripheral neuropathy bilaterally was mild to moderate. VA provided the Veteran with a C&P examination of his peripheral nerves in September 2009. The examiner, a physician, reviewed the Veteran's medical records. The Veteran noted that he had retired in 2003 due to his eligibility by age or duration of work. His peripheral neuropathy of his left lower extremity reportedly prevented exercise and sports; had a moderate effect on chores and travelling; had a mild effect on shopping and recreation; and had no effect on feeding, bathing, dressing, toileting, and grooming. The Veteran had no history of hospitalization or surgery for his diabetic neuropathy of the left lower extremity. He reported experiencing numbness, paresthesias (which he described as a crawling sensation), and pain in his left lower extremity. The Veteran had left knee reflex of +1, and left ankle reflex of +1. His left plantar flexion was normal. The Veteran had no muscle atrophy, abnormal muscle tone or bulk, or abnormal movements. His gait and balance were normal. The VA examiner diagnosed the Veteran with mild sensory diabetic peripheral neuropathy in the left lower extremity. The examiner further found that nerve dysfunction was present, paralysis was absent, and neuritis and neuralgia were present. The Board finds that the evidence of record supports a 10 percent rating for mild sensory diabetic peripheral neuropathy in the left lower extremity, based on the September 2009 VA examiner's assessment of the Veteran's disability. A higher rating is not for application because the Veteran's sensory diabetic peripheral neuropathy in the left lower extremity has not been characterized as moderate, moderately severe, severe, or as a completely paralyzed left lower extremity. Although a VA clinician found in February 2007 that the Veteran's lower extremity peripheral neuropathy bilaterally was mild to moderate, the clinician did not specify the extent to which the moderate neuropathy was attributable to the left lower extremity, or whether that characterization encompassed the combination of both extremities. Because the September 2009 VA examiner expressly found that the Veteran's diabetic peripheral neuropathy in the left lower extremity was moderate, that finding is entitled to greater probative weight. Additionally, the Veteran's own determination regarding the degree of disability is outweighed by the more probative findings of the September 2009 VA examiner, because his determination is based on greater medical knowledge and experience. Winsett v. West, 11 Vet. App. 420 (1998), aff'd 217 F.3d 854 (Fed. Cir. 1999); Guerrieri v. Brown, 4 Vet. App. 467 (1993). Consequently, a higher rating is not warranted in this case. 38 C.F.R. § 4.124a, Diagnostic Codes 8520, 8620, 8720. Finally, the Board emphasizes that Diagnostic Code 8720, under which the Veteran retains his 10 percent rating, incorporates all of the symptoms of his diabetic neuropathy of the left lower extremity. The Veteran is not entitled to receive a separate rating under Diagnostic Code 8620 in addition to his rating under Diagnostic Code 8720, because that would create a situation in which he was being compensated twice for the same left lower extremity neuropathy, in violation of the rule against pyramiding. 38 C.F.R. § 4.14 (2010). A rating under Diagnostic Code 8720 is most applicable in this case because the Veteran has no muscle atrophy, abnormal muscle tone or bulk, or abnormal movements, and his gait and balance are normal. 38 C.F.R. § 4.1 (2010). In reaching this determination, the Board has considered whether, under Fenderson, a higher rating might be warranted for any period of time during the pendency of this appeal. Fenderson, 12 Vet. App. 119. There is no evidence that the Veteran's diabetic neuropathy of the left lower extremity has been persistently more severe than the extent of disability contemplated under the assigned rating at any time during the period of this initial evaluation. Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). The Board has also considered the issue of whether the Veteran's diabetic neuropathy of the left lower extremity, standing alone, presents an exceptional or unusual disability picture, as to render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular evaluation is appropriate. Thun v. Peake, 22 Vet. App. 111, 115-116. First, the threshold factor for extra-schedular consideration is that there must be a comparison between the level of severity and symptomatology of the Veteran'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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Id. at 115. However, if not adequately contemplated by the rating criteria, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. at 116. See also 38 C.F.R. § 3.321(b)(1). If either of the factors of step two is 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 extra-schedular rating. Id. at 116. In this case, because the rating criteria reasonably describe the claimant's disability level and symptomatology, the claimant's disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is adequate. Analysis: An Initial Compensable Disability Rating for Diabetic Nephropathy Under 38 C.F.R. § 4.115a, regarding renal dysfunction, a noncompensable disability rating applies where the Veteran has albumin and casts with a history of acute nephritis; or, hypertension non-compensable under diagnostic code 7101. A disability rating of 30 applies where the Veteran has albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under diagnostic code 7101. A disability rating of 60 applies where the Veteran has constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under diagnostic code 7101. A disability rating of 80 applies where the Veteran has persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A disability rating of 100 applies where the disorder is requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. VA provided the Veteran with a C&P examination of his genitourinary system in September 2009. The examiner, a physician, reviewed the Veteran's medical records. The Veteran reported that he had retired on May 3, 2003, because he was eligible by age or duration of work. The Veteran reported no effects of his diabetic nephropathy on his usual daily activities. The examiner noted that the Veteran had a history of micro-albuminuria as a manifestation of diabetic nephropathy in the 1990's, for which the Veteran is on medication. The Veteran had no history of hospitalization or surgery, no urinary symptoms, no renal dysfunction or failure, no acute nephritis, no hydronephrosis, and no cardiovascular symptoms. The Veteran had a creatinine level of 0.93, and a BUN level of 14.3. The VA examiner diagnosed the Veteran with micro-albuminuria as a manifestation of diabetic nephropathy. The Board finds that the evidence of record supports a noncompensable rating for diabetic nephropathy, based on the September 2009 VA examiner's assessment of the Veteran's disability. A compensable rating is not for application because the Veteran's diabetic nephropathy has not been shown to meet the criteria therefor. In reaching this determination, the Board has considered whether, under Fenderson, a higher rating might be warranted for any period of time during the pendency of this appeal. Fenderson, 12 Vet. App. 119. There is no evidence that the Veteran's diabetic nephropathy has been persistently more severe than the extent of disability contemplated under the assigned noncompensable rating at any time during the period of this initial evaluation. Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). The Board has also considered the issue of whether the Veteran's diabetic nephropathy, standing alone, presents an exceptional or unusual disability picture, as to render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular evaluation is appropriate. Thun v. Peake, 22 Vet. App. 111, 115-116. First, the threshold factor for extra-schedular consideration is that there must be a comparison between the level of severity and symptomatology of the Veteran'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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Id. at 115. However, if not adequately contemplated by the rating criteria, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. at 116. See also 38 C.F.R. § 3.321(b)(1). If either of the factors of step two is 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 extra-schedular rating. Id. at 116. In this case, because the rating criteria reasonably describe the claimant's disability level and symptomatology, the claimant's disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is adequate. ORDER A disability rating in excess of 50 percent for PTSD is denied. A disability rating in excess of 20 percent for diabetes mellitus, type II, is denied. A disability rating in excess of 10 percent for diabetic neuropathy of the left lower extremity is denied. A compensable disability rating for diabetic nephropathy is denied. ____________________________________________ A. BRYANT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs