Citation Nr: 1125050 Decision Date: 07/01/11 Archive Date: 07/14/11 DOCKET NO. 08-33 907A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased evaluation for post-traumatic stress disorder, currently rated as 50 percent disabling. 2. Entitlement to a higher initial rating for peripheral neuropathy of the right lower extremity, rated as 0 percent disabling prior to August 31, 2007 and 10 percent disabling from August 31, 2007. 3. Entitlement to a higher initial rating for peripheral neuropathy of the left lower extremity, rated as 0 percent disabling prior to August 31, 2007 and 10 percent disabling from August 31, 2007. ATTORNEY FOR THE BOARD Carolyn Wiggins, Counsel INTRODUCTION The Veteran served on active duty from February 1966 to January 1969 and from August 1969 to August 1972. This appeal arises from a January 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. FINDINGS OF FACT 1. The Veteran's PTSD produces impairment in social and occupational functioning with deficiencies in most areas, due to near continuous depression, suicidal and homicidal ideation, and difficulty adapting to stressful circumstances. 2. Prior to February 24, 2006, VA evaluation of the peripheral nerves of the lower extremities was normal. 3. From February 24, 2006, the Veteran's peripheral neuropathy of the right and left lower extremities produced sensory impairment consistent with mild incomplete paralysis of the peripheral nerve. CONCLUSIONS OF LAW 1. The criteria for a 70 percent rating, but no more, for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). 2. Prior to February 24, 2006 the criteria for a compensable rating for peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8721 (2010). 3. Prior to February 24, 2006 the criteria for a compensable rating for peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8721 (2010). 4. From February 24, 2006 the criteria for a 10 percent rating, but no more, for peripheral neuropathy of the right lower extremity have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8721 (2010). 5. From February 24, 2006 the criteria for a 10 percent rating, but no more, for peripheral neuropathy of the left lower extremity have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8721 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board must first address VA's duty to notify and assist claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010). The Veteran submitted his claims for an increased rating for PTSD and service connection for peripheral neuropathy in August 2007. The RO sent him a letter in 2007 which notified him of the evidence necessary to support his claims, how he could help, how VA could help him and how VA assigns disability ratings and effective dates. The issue of higher ratings for right and left lower extremity peripheral neuropathy arose from the decision granting service connection and assigning initial ratings. In Dingess v. Nicholson, 19 Vet. App. 473 (2006) the United States Court of Appeals for Veterans Claims (hereinafter, "the Court") held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated-it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. The Veteran's VA records of treatment were obtained. The Veteran was afforded VA examinations. The Veteran withdrew his request for a hearing before a Veterans Law Judge at the RO. No further notice to the Veteran or assistance with his claims is necessary. PTSD An August 2004 rating decision granted service connection for PTSD and assigned a 50 percent rating. The Veteran asserts his PTSD has gotten worse. His symptoms require more therapy and increasing use of medications. The Veteran submitted his claim for an increased rating for PTSD in August 2007. Factual Background. VA records dated in July 2006, indicate the Veteran had continued symptoms of depression, but his sleep and anxiety had improved somewhat, though he still had some distressing nightmares and he became tearful when recounting the attack that had killed his best friend. In September 2006, he was seen for medication management as he had to stop some of his medications due to his coronary artery bypass grafting. He was sleeping very poorly and getting only one to two hours of sleep at night. During the day he might sleep for an hour. He felt as if he was always on guard. He was getting depressed about the current war. He had broken down crying in Wal-Mart after a stranger approached him to say thank you when he was wearing a Vietnam shirt. He was still having crying spells and passive suicidal ideation. Mental status evaluation revealed he was depressed and his affect was restricted and mood congruent. A GAF of 50 was assigned. In November 2006 a VA examination was conducted. The information recorded in the report included the following. The Veteran was able to take care of himself. His social and interpersonal relationships were poor. Mental status examination found no impairment of his thought processes or communication. He was able to interact with the examiner appropriately. He did not have any suicidal thoughts. He was oriented in all spheres. He did not display any loss of memory. There was no obsessive or ritualistic behavior. He did not have panic attacks. There was no evidence of impaired impulse control. His symptoms of PTSD included hypervigilance, avoidance, social isolation, a flat affect and irritability. He was re-experiencing trauma daily. His physiological response was heightened. The symptoms were of moderate severity. A GAF of 60 was assigned. In January 2007 the Veteran reported having difficulty with his family during the holidays. He reduced the times he took Klonopin to only those occasions when he was leaving his house. He was able to sleep several hours a night with another medication, but did not want anymore since his nightmares would increase. He reported chronic passive suicidal ideation, depression and his mood was constricted. A GAF of 45 was assigned. There had been minimal improvement of his depressive and PTSD symptoms. A March 2007 letter from the business manager of the Veteran's union was submitted. He described the Veteran's tendency to quit a job when there was stress or conflict. The Veteran had a history of leaving jobs when his work routine was disrupted or quitting to avoid conflict or confrontation. April 2007 VA records indicate the Veteran was venting his anger over being mistreated by the government and the VA system. He complained that his family did not understand his PTSD. His sleep was worse and he wanted to try a new medication. He reported passive suicidal ideation, but denied having any plan or intent to harm himself. He was casually dressed with adequate grooming. He was depressed and his affect constricted. A GAF of 45 was diagnosed. August 2007 VA records indicate the Veteran was focused on his VA claim for service connection. He was interested in pursuing further evaluation with the hope of increasing his ratings. The Veteran reported feeling worthless due to his inability to work and support his family. He had difficulty in the past controlling his irritability and felt it was not safe for him to work. He spent most of the day at home and often went several days without showering or leaving the house. He was married but said they often wonder why they are still together. Minimal improvement of depressive and PTSD symptoms was the assessment. The examiner thought further medication changes were unlikely to help. A GAF of 45 was assigned. In September 2007 the Veteran was seen for medical management. He was casually dressed with fair grooming. His mood was depressed and his affect constricted, but he was capable of a smile or a laugh. A GAF of 48 was assigned. In December 2007 the Veteran was examined in conjunction with his claim for an increased rating. The Veteran reported his therapy had somewhat reduced his anxiety. He reported having marital problems for the last five years. (According to the November 2006 VA examination he reported his marriage in very positive terms.) There was no history of suicide attempts or assaultive behavior. Objective findings on mental status examination revealed he was clean, neatly groomed, and appropriately and casually dressed. There was no remarkable psychomotor activity. His speech was unremarkable, spontaneous, clear and coherent. His attitude toward the examiner was attentive, but hostile and irritable. His affect was constricted. He was unable to perform serial sevens, or spell world backwards. It was unclear to the examiner whether his difficulties were due to his education level or to poor concentration. He was oriented to person, place and time. There were no delusions present and his thought processes were unremarkable. He reported having no hallucinations, inappropriate behavior, obsessive or ritualistic behavior, panic attacks, homicidal or suicidal thoughts. Tests of remote, recent and immediate memory were normal. The Veteran had chronic symptoms of PTSD such as intrusive memories of Vietnam, significant distress in response to reminders of traumatic events, and tearfulness in response to trauma. He avoided thinking about his traumatic experiences. Watching television triggered upsetting memories. He reported anhedonia and a moderate degree of detachment. He slept poorly, only three to four hours per night; had problems with anger, difficulty concentrating, and hypervigilance. He also felt unsafe in public places. The examiner also noted the Veteran was an iron worker for thirty years, but had retired due to his heart condition and a transient ischemic attack. The Veteran also reported his unemployment was caused in part by his anger and irritability. Chronic PTSD was diagnosed and a GAF of 50 was assigned. In the opinion of the examiner the Veteran was not unemployable due to his PTSD, but that PTSD produced symptoms that resulted in reduced reliability and productivity. The Veteran was seen by his VA treating psychiatrist in December 2007. He had been taking Trazodone for his insomnia but did not feel it was helping. He did not appear in acute distress and was in a good mood. His mental status was unremarkable. The Veteran's daughter prepared his February 2008 notice of disagreement. She had observed him have panic attacks more than twice per week. She also remarked he had very poor impulse control, exploded into a rage of anger without warning and for no apparent reason, had problems functioning at work, was never able to maintain a friendship, and had serious family issues as he had threatened to kill his brothers and refused to speak to his sister. She also reported she had seen him grab people by the neck and sling them down, and described him as paranoid, and abusive toward her mother, but dependent on her to feed and dress him. She likewise noted he lacked the motivation to get out of bed most days. In July 2009, the Veteran was seen by his primary care physician at VA. He reported being under stress, as he had recently moved and was upset about his VA compensation claims, depressed and had frequent crying spells. He also had homicidal thoughts about the examiners who performed his VA examinations for compensation, and when he tried to get those ideas out of his head he thought about suicide. After breaking down and crying in the physician's office, he was referred to the emergency psychiatric service and was hospitalized. However, twenty four hours after admission and medication changes, the Veteran reported feeling much better. He denied having any homicidal or suicidal ideation, and mental status examination found his speech was normal in rate, volume and tone. Likewise, his mood was much better and more stable, with an affect that was full range and appropriate. GAF scores of 30 was assigned at admission and 60 at discharge. November 2009 VA records reveal the Veteran remained irritable and was afraid of going out due to fear of confrontations with people, though he was free of thought disorder and suicidal ideation. The Veteran was seen for VA compensation and pension examination for PTSD in January 2010. The report from it included the following information. The Veteran had been married for forty years. He described his relationship with his wife as fair. He had only one friend who died four years ago. There was one friend from the Army that he talked to every couple of months on the telephone. He was clean, neatly groomed and appropriately and casually dressed. His speech was unremarkable. He was cooperative, relaxed, attentive and friendly. His affect was normal and his mood was good. He was oriented to person, place and time. His thought processes were unremarkable without evidence of delusions or hallucinations. There was no evidence of inappropriate behavior, obsessive or ritualistic behavior, panic attacks, or homicidal or suicidal ideation. Sleep was unimpaired. Impulse control was good. The examiner observed no indication to suggest the Veteran was having any problems with hypervigilance or startle response. He sat with his back to an open door during testing. At one point the light went off in the room and the examiner entered from behind him and turned the light back on, the Veteran did not even turn around to investigate. He sat in a very relaxed manner. His remote, recent and immediate memory were normal. The Veteran reported the following symptoms: He had daily recurrent or intrusive thoughts. Nearly every night he had distressing dreams which woke him up. He cried when thinking about distressing events. His interest in participating in activities was diminished. His affect was restricted pretty much all the time. He had difficulty sleeping nightly. He reported being irritable when he was around others than his wife and children. He said they did not let him go anywhere by himself. (He was unaccompanied for that appointment.) He reported daily hypervigilance and that his startle response varied with his environment. He described his symptoms of PTSD as severe. In interpreting the results of psychological testing the examiner found it quite likely that there was some intentional exaggeration of his current symptoms, possibly for secondary gain. He found the results were invalid for interpretation. Chronic PTSD and alcohol dependence in remission were diagnosed. A GAF score of 65 was assigned. As to the Veteran's current level of functioning the examiner indicated there was significant evidence to suggest the Veteran was over reporting the frequency and severity of his claimed symptoms. The Veteran's PTSD did not result in total occupational or social impairment. The examiner concluded that his PTSD was not severe enough to interfere with occupational or social functioning. Applicable Regulations. The Schedule for Rating Disabilities provides the following criteria for rating disability due to PTSD: 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; memory loss for names of close relatives, own occupation, or own name 100 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); inability to establish and maintain effective relationships 70 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; difficulty in establishing and maintaining effective work and social relationships 50 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). Analysis. As set forth above, a 70 percent rating contemplates deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. Here, the Veteran claims he had difficulty at work due to inability to control his irritability. That is consistent with the statement of the manager of his union who noted the Veteran would quit jobs to avoid conflict. The evidence as to the nature of his family relations varies. He reported it was good, but later stated it was only fair. In December 2007 he reported having marital problems for the past five years. His daughter described him as abusive toward her mother and estranged from his brothers and sisters. There is no evidence of record which indicates he has any impairment of judgment or thinking, and there is no evidence of any thought disorder. The symptoms listed in the criteria for a 70 percent rating include suicidal ideation and the Veteran has a history of suicidal ideation. In September 2006, he reported having passive suicidal ideation. Again in January 2007, he reported chronic suicidal ideation, and April 2007 VA records also include reports by the Veteran of passive suicidal ideation. In July 2009 the Veteran was admitted to the VA hospital due to his homicidal and suicidal ideation. There is no evidence of any obsessional rituals or illogical, obscure or irrelevant speech, as the Veteran's speech has consistently been described as unremarkable, linear and goal directed with only some evidence of circumstantiality. While the Veteran's daughter reported the Veteran had panic attacks, he consistently denied having panic attacks. The evidence does, however, document consistent symptoms of depression, and he has reported difficulties with his mood. In January 2006 he was dysphoric and tearful. March 2006 VA records again noted the Veteran was having crying spells. In July 2006, the examiner noted the Veteran became tearful when recounting the attack which killed his friend in service, and January 2007 VA records, noted the Veteran was depressed and his mood constricted. There had been only minimal improvement in his depressive and PTSD symptoms. September 2007 VA treatment records also reported the Veteran was depressed and his affect was constricted. In July 2009, the Veteran broke down and started crying in his VA physician's office and was hospitalized, although November 2009 outpatient records and the January 2010 examination report show the Veteran's mood was good and his affect normal. The Veteran's daughter described her father as having poor impulse control, as she described seeing him explode into anger and grab people, but no other evidence of poor impulse control is of record. The Veteran has consistently been oriented to person, place and time, and his grooming has been described as adequate, although the Veteran reported not showering for several days. It appears to the Board that the predominant difficulty of the Veteran is adapting to stressful circumstances. His reactions to set backs in the VA claims process document his inability to adapt to stress. He was hospitalized in July 2009 due to his reaction to stress caused by moving, and rejection of his VA claim. The manager of his union noted he would quit jobs to avoid confrontation or conflict. He frequently reports staying home to avoid any possible confrontations with other people. The Board notes the disparity between the level of impairment indicated in the VA outpatient treatment records and that seen by the VA examiner in January 2010, however, the Board will place greater weight on the symptoms observed in the VA outpatient treatment records. In this regard, at one point the Veteran was being seen every month at VA in an attempt to alleviate his symptoms. His depression, tearfulness and difficulty coping with the stress related to the VA claims process were all observed by VA care providers, and a GAF score as low as 30 was assigned. [A GAF is a global assessment of functioning scale reflecting psychological, social and occupational functioning on a hypothetical continuum of mental health-illness. A GAF of 50 is defined as serious symptoms, such as suicidal ideation, severe obsessional rituals, frequent shoplifting or any serious impairment in social, occupational or school functioning, such as having no friends or an inability to keep a job. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266 (1996) (citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed.), p. 32.] While Veteran clearly is seeking increased VA benefits, and thus has a motivation to appear more impaired than he actually might be, his VA outpatient treatment records support his reports of the severity of his PTSD, and his frustration with the claim's process which at the January 2010 examination was more than 2 years along, could reasonably account for any recent exaggeration, and may itself reflect a symptom of the disability. Further, the Veteran's work history as an iron worker illustrates his inability to form long lasting relationships. The list of his employers is long and varied, and the nature of his work allowed him to quit or change jobs when the job became stressful. Further, although the Veteran did not exhibit all the symptoms listed as being evidence of a 70 percent rating, he did consistently show near continuous depression, suicidal and homicidal ideation and difficulty adapting to stressful circumstances. In determining the level of impairment it is not the specific symptoms listed but the level of occupational impairment which is critical. In Mauerhan v. Principi, 16 Vet. App. 436 (2002) the United States Court of Appeals for Veterans Claims (hereinafter, "the Court") held that requiring the presence of all, most, or even some, of the enumerated symptoms is unsupported by reading of the plain language of the regulation. The Court stated that if the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by symptoms listed in the diagnostic code, the appropriate, equivalent rating will assigned. Under the circumstances of this case, the Board has concluded the Veteran's symptoms of PTSD cause impairment in occupational and social impairment with deficiencies in most areas. Thus, the evidence supports the grant of a 70 percent rating for PTSD. A higher rating than 70 percent requires total occupational and social impairment. After reviewing the claims folder the Board concludes the Veteran's PTSD does not result in total occupational or social impairment. He does not exhibit the symptoms noted to be indicative of total impairment listed in the Diagnostic Code. There is no evidence of hallucinations or persistent delusions. No grossly inappropriate behavior has been described. While the Veteran reported homicidal ideation in July 2009, there is no indication the Veteran has posed a threat to anyone. [While his daughter reported seeing him grab someone by the neck and "sling him down," such a cartoon-like image does not appear plausible.] The Veteran also has consistently been appropriately groomed, even when hospitalized, and the daughter's reports that he relies on his wife even to dress is not consistent with his appearances alone at VA treatment appointments and most VA examinations. The Veteran has demonstrated he is oriented to person, place and time. There is no indication he has memory loss. In December 2007 the VA examiner found his PTSD did not cause him to be unemployable. A higher evaluation than 70 percent for PTSD is not warranted. Peripheral Neuropathy of the Right and Left Lower Extremities A January 2008 rating decision granted service connection for peripheral neuropathy of the right and left lower extremities effective October 5, 2005. The RO assigned a noncompensable rating. See 38 C.F.R. § 4.119, Diagnostic Code 7913 (2010). The Veteran appealed the initial rating assigned. In February 2010 the RO granted separate 10 percent ratings for each lower extremity effective August 31, 2007. Applicable Regulations. Note (1) following the rating criteria for Diabetes Mellitus states that VA is to evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. See 38 C.F.R. § 4.119, Diagnostic Code 7913 (2010). The VA examiner in December 2007 indicated the Veteran's symptoms of lower extremity peripheral neuropathy were consistent with neuralgia. Neuralgia, is to be rated with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124 (2010). The external popliteal nerve (common peroneal) is the nerve involved in this instance. The Schedule for Rating Disabilities provides the following criteria for rating neuralgia of the external popliteal nerve: Paralysis of: Complete; foot drop and slight droop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes is rated as 40 percent disabling. Incomplete: Severe 30 Moderate 20 Mild 10 See 38 C.F.R. § 4.124a, Diagnostic Code 8721 (2010). Factual Background. November 2005 VA record reveal the Veteran had a transient ischemic attack in 2003. Neurological evaluation of the lower extremities found they were normal to light touch, vibration, position sense and temperature. In February 2006, the Veteran complained of bilateral hand and foot numbness, tingling, and burning. He reported having it for a few years, and had recently worsened. Objective examination revealed decreased sensation to 10 gram monofilament in a stocking glove distribution. Peripheral neuropathy was diagnosed as possibly due to diabetes mellitus, and the dosage of Gabapentin was increased. An undated VA record indicates his Gabapentin was stopped due to fatigue with no worsening of his neuropathy, although it was still present. The Veteran was seen in September 2007 for medication management. Switching medication to address his neuropathic pain was discussed. In December 2007, a VA examination was conducted to determine the severity of the Veteran's diabetes mellitus and to identify any complications of diabetes. The Veteran reported having numbness and tingling from his waist down to his toes for the past two years. Early diabetic peripheral neuropathy was diagnosed. Physical examination found no motor or sensory losses. Examination found no paralysis or neuritis. Neuralgia, however, was present. In the opinion of the examiner there were no significant effects caused by peripheral neuropathy on the Veteran's occupation or usual daily activities. In July 2009, the Veteran reported persistent lower extremity neuropathic pain. Diabetes mellitus Type II with neuropathy was diagnosed. December 2009 VA records reveal the Veteran had complaints of peripheral neuropathy. Sensory examination of the feet was abnormal, with the feet found to be partially insensate. The dosage of Lyrica was increased for persistent neuropathic pain. VA examination of the peripheral nerves was conducted in December 2009. The Veteran reported having symptoms of peripheral neuropathy beginning in 2005. The onset had been gradual and chronic. It had gotten progressively worse. He had numbness and tingling in both hands with a burning sensation from mid forearm distally. His symptoms of neuropathy were similar in the lower extremities. He described his pain as a sunburn or frostbite feeling. Objective examination revealed motor strength was normal with no functional impairment of any affected nerve. Sensory examination revealed the right and left lower extremities were normal to vibration sense. Pain sensation and light touch were decreased in a stocking distribution. Position sense was normal. There was no muscle atrophy or abnormal movement. Gait and balance were normal. Analysis. In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Prior to August 31, 2007 the Veteran's peripheral neuropathy is rated as noncompensably disabling for both lower extremities and from August 31, 2007 separate 10 percent ratings were assigned by the RO. After reviewing the claims folder the Board has concluded the evidence supports assigning a compensable rating from February 24, 2006, with a non-compensable evaluation warranted prior to that time. Prior to February 24, 2006 A compensable rating is assigned with evidence of mild incomplete paralysis of the peripheral nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8721 (2010) Examination in November 2005 found the lower extremities were normal. The Veteran has not offered any description of his symptoms of lower extremity peripheral neuropathy prior to February 24, 2006. In this regard, the Board notes the history given by the Veteran in later VA records of having numbness and tingling dating back to 2005. While the Board does not doubt the Veteran's reports of the onset of his symptoms, the severity of his neuropathy prior to February 24, 2006 is not consistent with assignment of a compensable rating as there is no objective evidence of any sensory impairment. Based on the normal sensory evaluation in November 2005 to light touch, vibration, position sense and temperature, the Board has concluded the preponderance of the evidence is against the claim for a compensable rating prior to February 24, 2006. From February 24, 2006 to August 31, 2007 On February 24, 2006 the Veteran was found to have decreased sensation in a stocking distribution in the lower extremities. The Veteran described having numbness, tingling and a burning sensation in his lower extremities. A compensable rating for peripheral neuropathy requires evidence of mild symptoms, consistent with mild incomplete paralysis of the peripheral nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8721 (2011). The Board considers the Veteran symptoms of peripheral neuropathy of both lower extremities reported on February 24, 2006, to be consistent with mild incomplete paralysis; i.e., the numbness, tingling, and burning sensation. Mild incomplete paralysis is rated as 10 percent disabling, and therefore, separate 10 percent ratings for each lower extremity based on bilateral peripheral neuropathy are warranted. In the absence of any other symptoms of loss of function, decrease in position sense, and only sensory symptoms such as pain, tingling, and numbness, a higher rating as for moderate impairment is not warranted. 38 C.F.R. § 4.124a, Diagnostic Code 8721 (2011). From August 31, 2007 In February 2010, the RO assigned separate 10 percent ratings for right and left lower extremity peripheral neuropathy effective August 31, 2007. Higher ratings of 20 percent require evidence of moderate incomplete paralysis of the nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8721 (2010). As explained above, there is no evidence of anything other than sensory symptoms. In December 2009, there was no evidence of loss of motor strength. Vibration sense was normal in both lower extremities, position sense was normal, and there was no evidence of abnormal movement, gait abnormality or imbalance. The Veteran's symptoms were only sensory in nature, with the feet described as only partially insensate. From August 31, 2007, a higher initial rating than 10 percent for right and left lower extremity peripheral neuropathy is not warranted. In conclusion prior to February 24, 2006, noncompensable ratings for right and left peripheral neuropathy of the lower extremities are assigned in combination with the evaluation for diabetes mellitus. From February 24, 2006, separate 10 percent ratings are assigned for right and left peripheral neuropathy of the lower extremities. Extraschedular The Board does not have the authority to assign an extraschedular rating in the first instance, nor does this case present an exceptional or unusual disability picture which would warrant referral to appropriate VA officials for consideration of an extraschedular rating under 38 C.F.R. § 3.321(b)(1). Bagwell v. Brown, 9 Vet. App. 337 (1996). In this regard, the Board notes a February 2010 rating decision granted entitlement to total disability rating based on individual unemployability due to service-connected disability. Neither the Veteran's PTSD or his peripheral neuropathy of the lower extremities has caused marked interference with employment (i.e., beyond that already contemplated in the assigned schedular evaluation), has necessitated recent frequent periods of hospitalization, or is attended by other such factors as would render impracticable the application of the regular schedular rating standards. The symptoms reported by the Veteran are specifically included in the rating criteria. He has not identified or described any symptoms which are not contemplated by the rating schedule. Referral for consideration of an extraschedular rating is not warranted. ORDER An increased rating to 70 percent for PTSD is granted, subject to regulations governing the award of monetary benefits. Prior to February 24, 2006 a compensable rating for peripheral neuropathy of the right lower extremity is denied. Prior to February 24, 2006 a compensable rating for peripheral neuropathy of the left lower extremity is denied. From February 24, 2006, a 10 percent rating and no more, for peripheral neuropathy of the right lower extremity is granted, subject to regulations governing the award of monetary benefits. From February 24, 2006, a 10 percent rating and no more, for peripheral neuropathy of the left lower extremity is granted, subject to regulations governing the award of monetary benefits. ____________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs