Citation Nr: 1125928 Decision Date: 07/11/11 Archive Date: 07/19/11 DOCKET NO. 10-01 335 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to an increase rating for diabetes mellitus type II with bilateral upper and lower peripheral neuropathy, currently rated as 20 percent disabling. 2. Evaluation of posttraumatic stress disorder (PTSD), currently rated as 50 percent disabling. REPRESENTATION Appellant represented by: Nevada Office of Veterans' Services ATTORNEY FOR THE BOARD J. Schulman, Associate Counsel INTRODUCTION The Veteran had active service from December 1968 until October 1989. This matter comes before the Board of Veterans' Appeals (BVA or Board) from an October 2008 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Reno, Nevada. The matter of entitlement to service connection for a disorder characterized by head sweating, nausea and altered mental state has been raised by the record, 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. PTSD has been productive of GAF scores from 60 to 45, restricted affect impaired impulse control, irritability, anger and violent behavior, but normal speech, judgment, and thinking. 2. Diabetes mellitus type II with bilateral upper and lower peripheral neuropathy requires the use of insulin and restricted diet. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 70 percent for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.130, Diagnostic Code 9411 (2010). 2. The criteria for a disability rating in excess of 20 percent for diabetes mellitus type II with bilateral upper and lower peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.119, Diagnostic Code 7913 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act The Veterans Claims Assistance Act of 2000 (VCAA) provides that VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). Proper notice from VA must inform the claimant of any information and medical or lay 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. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Veteran's claim relating to PTSD arises from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Rango v. Shinseki, No. 06-2723 (Vet. App. January 26, 2009). Therefore, no further notice is needed under VCAA with respect to this issue. For an increased-compensation claim, such as the Veteran's claim regarding diabetes, the Court of Appeals of Veterans Claims had held that § 5103(a) required, at a minimum, that VA notify the claimant that, to substantiate a claim, the medical or lay evidence must show a worsening or increase in severity of the disability. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009). Here, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in January 2008 that fully addressed all notice elements and was sent prior to the initial RO decision in this matter. The letter provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. The letter also informed the Veteran of what type of information and evidence was needed to establish a disability rating and effective date. Based on the foregoing, adequate notice was provided to the appellant prior to the transfer and certification of his case to the Board and complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist the Veteran in the development of the claim. To that end, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2010). Service records have been obtained, as have records of private and VA treatment. Furthermore, the Veteran was afforded VA examinations in September 2008 during which examiners took down the Veteran's history, considered the lay evidence presented, laid factual foundations for the conclusions reached, and reached conclusions based on their examinations that are consistent with the record. The Board is aware that although the Veteran's PTSD examination included a review of his claims file, his VA examination for diabetes did not. Nonetheless, the Board has reviewed the September 2008 diabetes examination and finds the examination to have been exceptionally thorough with respect to diagnostic testing and evaluation. The Board notes that it is "entitled to assume the competence of a VA examiner." Cox v. Nicholson, 20 Vet. App. 563, 596 (2007). See also, Hilkert v. West, 12 Vet. App. 145, 151 (1999). Here, examinations of the appellant are found to have been adequate. All necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See, Bernard v. Brown, 4 Vet. App. 384 (1993). In addition to the evidence discussed above, the Veteran's statements in support of the claim are also of record. The Board has carefully considered such statements and concludes that no available outstanding evidence has been identified. Additionally, the Board has reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Ratings On Appeal Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2010). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2010). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C.A. § 5107(a) (West 2002); 38 C.F.R. § 3.102 (2010); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). PTSD At the outset, the Board notes that the Veteran's claim of entitlement to higher rating for PTSD is an appeal from the initial assignment of a disability rating in October 2008. When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). In Hart v. Mansfield, the Court extended entitlement to staged ratings to claims for increased disability ratings where "the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings." Hart v. Mansfield, 21 Vet. App. 505, 511 (2007). Here, as discussed in greater detail below, the Veteran's level of symptomatology has not significantly changed during the period on appeal, and a uniform evaluation is warranted. In the rating decision on appeal, the Veteran was awarded service connection for PTSD and granted an evaluation of 30 percent, effective November 1, 2007. In a subsequent November 2009 rating decision, the Veteran's evaluation for PTSD was raised to 50 percent, effective the same date. PTSD is evaluated under the general rating formula for mental disorders. See 38 C.F.R. § 4.130, Diagnostic Code (Code or DC) 9411 (2010). Under this general rating formula, a 50 percent evaluation is provided for on evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as a 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; or difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411 (2010). A 70 percent rating requires 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 work like setting); or the inability to establish and maintain effective relationships. Id. A 100 percent rating may be awarded where there is 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; or memory loss for the names of close relatives, own occupation, or own name. Id. In evaluating the Veteran's level of disability, the Board has considered the Veteran's Global Assessment of Functioning (GAF) scores as one component of his overall disability picture. GAF is a scale used by mental health professional and reflects psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. The scale may be relevant in evaluating mental disability. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). Here, the record shows GAF scores from 45 to 60 during the period on appeal. Sores from 51 to 60 indicate moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores in the range of 41 to 50, however, indicate serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). The Secretary, acting within his authority to "adopt and apply a schedule of ratings," chose to create one general rating formula for mental disorders. 38 U.S.C. § 1155 (West 2002); see 38 U.S.C. § 501 (West 2002); 38 C.F.R. § 4.130 (2010). By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet. App. 128 (1997). The evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (1992). Psychological treatment notes from August 2007 indicate that the Veteran felt he was "losing control" of his emotions. He reported being short with his children and at work found that he had to "fight through stuff" and had difficulty concentrating. Sleep was for no more than an hour at a time, and he awoke with panic and sweating. The Veteran's wife reported that he was very vigilant when awakening. The Veteran had recurrent distressing dreams, and he experiencing triggered by smells. He became frustrated and angry when hearing the news. He exhibited persistent avoidance of stimuli associated with in-service trauma, had restricted range of affect, and a foreshortened sense of the future. The Veteran was hypervigilant, but did not have an exaggerated startle response. His level of anger was impacting his job, and avoidance behavior had an impact on his marriage. Mental status examination revealed that the Veteran was alert and oriented, well-groomed, and appeared stressed but over-controlled. Speech and language were within normal limits. He denied hallucinations, suicidal or homicidal ideation, and his through process was logical and goal-directed. Insight was very good, but guarded and memory was good. His GAF score was 60. In a February 2008 letter, the Veteran's wife indicate that he was both verbally and physically aggressive and had started carrying a baseball bat in his vehicle. She reported aggression towards herself as well as their children. The Veteran's wife noted that he often woke in the middle of the night in a heavy sweat. On VA examination in September 2008, the Veteran reported that he did not socialize but did occasionally take his children to community activities like the 4th of July, and that he and his wife went out to dinner once every three weeks. No impairment of thought process or communication was noted, and the Veteran had no delusions or hallucinations. He was neatly and cleanly dressed, and both mood and thought content were appropriate. Long term memory was good, but the Veteran reported that his short term memory was poor. He had no history of obsessive or ritualistic behavior, and his speech was goal oriented. The Veteran had no impulse control, though did endorse anger. Sleep was impaired, and he had difficulty both falling asleep and staying asleep. There were symptoms of intrusive and distressing memories, avoidance, and restricted affect. The Veteran had no friends and was estranged from family members; he also had symptoms of hyperarousal. Social impairment was described as significant, and his GAF score was assessed as 45. In a statement of January 2010, the Veteran indicated that he difficulties with memory and isolated himself and his family within his home. He endorsed panic and anxiety that interfered with his daily activities, and was fearful that he was unable to maintain control of his anger. After a careful review of the record, the Board finds the Veteran's PTSD is been 70 percent disabling. As stated above, the current 50 percent evaluation contemplates occupational and social impairment with reduced reliability and productivity due to such symptoms as a 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; or difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411 (2010). In order to warrant a 70 percent evaluation, there must be evidence of 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 work like setting); or the inability to establish and maintain effective relationships. Id. A 100 percent rating is called for where there is 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; or memory loss for the names of close relatives, own occupation, or own name. Id. Here the Board notes indications that the Veteran has a restricted affect and impaired impulse control to the extent that he is prone to irritability, anger and violent behavior. In addition, the Veteran's symptoms have impacted his family and social relationships and have caused some limitation in the tasks which he performs at work. In spite of the severity of such symptoms, however, the Veteran's speech, judgment, and thinking have been largely within normal limits. He does have sleep disturbance and interference with daily activities, however the evidence shows that he is able to function independently and appropriately. A number of practitioners have observed that in clinical settings the Veteran appears to be intentionally diminishing his symptoms. Given GAF scores as low as 45, indicating serious symptoms, the Board finds that the Veteran's overall disability picture is most closely reflects the criteria for a 70 percent evaluation. A 100 percent evaluation cannot be awarded in view of the facts that the Veteran is still capable of working, maintaining relationships with his immediate family, and does not appear to have impairment such as gross impairment in thought processes or communication, any delusions or hallucinations, or inappropriate behavior as contemplated under DC 9411. Mauerhan v. Principi, 16 Vet. App. 436 (1992). The Board finds the Veteran's statements to be highly internally consistent, and his endorsed levels of symptomatology are confirmed by objective medical evidence as well as statements by his wife. The Veteran's testimony is both credible and probative. Based on the foregoing, the Board concludes that the Veteran's PTSD has been 70 percent disabling throughout the period on appeal. All evidence has been considered and there is no doubt to be resolved. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Diabetes Mellitus When a claimant is awarded service connection and assigned a disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). In Hart v. Mansfield, the Court extended entitlement to staged ratings to claims for increased disability ratings where "the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings." Hart v. Mansfield, 21 Vet. App. 505, 511 (2007). Here, the Veteran's diabetes has not significantly changed and a uniform evaluation is warranted for the period on appeal. In the rating decision on appeal, the Veteran's 20 percent evaluation for diabetes mellitus type II was confirmed as effective June 22, 2004. Additionally, service connection was established for peripheral neuropathy of the upper and lower extremities, effective November 1, 2007. The Veteran's peripheral neuropathy was evaluated as noncompensably disabling and as such separate ratings were not assigned. The Veteran's diabetes mellitus is rated under 38 C.F.R. § 4.119 DC 7913 (2010). Under this Code, a 20 percent rating is warranted for diabetes mellitus requiring insulin and a restricted diet, or oral hypoglycemic agents and a restricted diet. A 40 percent rating is indicated by evidence of diabetes requiring insulin, restricted diet, and regulation of activities. A 60 percent rating is assigned where the diabetes 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 evaluated. In order to warrant a 100 percent rating, evidence must show that diabetes requires more than one daily injection of insulin, 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. 38 C.F.R. § 4.119, DC 7913 (2010). In August 2006 the Veteran reported a history of brittle diabetes with difficulty controlling his blood sugar levels. He was indicated to be a good candidate for an insulin pump. On evaluation in January 2008, the Veteran was alert and oriented with intact motor and sensory system. The assessments were of inadequately controlled diabetes mellitus and diabetic peripheral neuropathy. In March 2008 the Veteran reported an episode of altered level of awareness, but denied any loss of consciousness. He reported a single episode of low blood sugars, however his insulin dosage had been adjusted to correct the issue. He was using 75 units of Lantus insulin once a day. In September 2008 the Veteran complained of occasional numbness and tingling of the hands and feet, with intermittent pain in the feet. He denied joint pain and swelling, as well as decreased joint mobility. He also denied headaches, seizures, dizziness, weakness, and loss of consciousness. The Veteran did not have diabetic complications requiring hospitalization, and saw a diabetic care provider monthly or less. He was instructed to follow a restricted diet, but was not restricted in his ability to perform strenuous activities. Diagnostic evaluation showed cranial nerves were intact, muscle strength was normal, and sensory was normal to pinprick and light touch. Electromyography indicated normal insertional resting and exertional potentials of both upper and lower extremities and paraspinal muscles. There was no evidence of neuropathy, myopathy or radiculopathy and no evidence of diabetic neuropathy. On VA examination in September 2008, there were no signs of cardiac, visual, or neurovascular symptoms. Paresthesias and pain were present as were symptoms of peripheral neuropathy related to diabetes. These symptoms manifest in the hands and feet. The examiner noted, however, that there was no diabetic nephropathy, skin symptomatology, gastrointestinal symptoms, genitourinary symptoms, or other complications resulting from diabetes. All extremities were of normal temperature and color, with no trophic changes and normal radial pulse. There was no motor or sensory loss, and Babinski signs were negative. Nerve examination indicated numbness and tingling with pain in the feet and hands since 2005. Symptoms included paresthesias, dysesthesia, and burning. Paralysis and neuritis were not present. Neuralgia was present; however there were no effects on daily activities. After a careful review of the evidence above, the Board finds the Veteran's diabetes mellitus to be not more than 20 percent disabling. As previously indicated, the current 20 percent evaluation contemplates that diabetes mellitus requires insulin and a restricted diet, or oral hypoglycemic agents and a restricted diet. 38 C.F.R. § 4.119 DC 7913 (2010). In order to warrant a 40 percent evaluation, there must be evidence of diabetes requiring insulin, restricted diet, and regulation of activities. Id. Here the Veteran takes insulin daily to control his disease, and has been placed on a doctor-recommended restricted diet. However, the appellant's diabetes does not require a restriction of regular activities, and thus a 60 percent rating is not warranted. The Veteran has asserted that his service-connected diabetes warrants a rating of higher than 20 percent. While the Board finds his testimony to be credible, the evidence nonetheless indicates that a higher rating cannot be assigned in view of his current level of symptomatology. The Board finds that separate compensable evaluations are not warranted for either the upper or lower extremity neuropathy. Again, the Veteran's reports of symptoms are credible, but less probative than the clinical findings of record. The more probative evidence establishes that strength, sensation, reflexes, electromyography, and nerve conduction studies have been normal. Even when considering the guidance established in 38 C.F.R. §§ 4.120, 4.123, 4.124, and 4.124(a), the Veteran's manifestations do not rise to the level of mild neuropathy of any nerve. 38 C.F.R. § 4.123 provides that neuritis, 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. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.124 provides that neuralgia, 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. Tic douloureux, or trifacial neuralgia, may be rated up to complete paralysis of the affected nerve. 38 C.F.R. § 4.124a defines the term "incomplete paralysis" as indicating a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, DC 8515 provides a 10 percent rating for mild incomplete paralysis of the median nerve in either the major or minor upper extremity, a 20 percent rating for moderate incomplete paralysis of the median nerve in the minor upper extremity, a 30 percent rating for moderate incomplete paralysis of the median nerve in the major upper extremity, a 40 percent rating for severe incomplete paralysis of the median nerve in the minor upper extremity, and a 50 percent rating for severe incomplete paralysis of the median nerve in the major upper extremity. Similarly, 38 C.F.R. § 4.124a, Diagnostic Code 8520 provides a 10 percent rating for mild incomplete paralysis of the sciatic nerve in either lower extremity, a 20 percent rating for moderate incomplete paralysis of the sciatic nerve in either lower extremity, a 40 percent rating for moderately severe incomplete paralysis of the sciatic nerve in either lower extremity, and a 60 percent rating for severe incomplete paralysis of the sciatic nerve with marked musculature atrophy in either lower extremity. The Board also notes that where the Rating Schedule does not provide for a noncompensable rating for a diagnostic code, a noncompensable rating shall be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31 (2010). Given the above criteria, the board finds that the more probative evidence establishes that a separate evaluation is not warranted. 38 C.F.R. § 4.119, DC 7913, Note 1 (2010). Based on the foregoing, the Board concludes that the Veteran's diabetes mellitus has been 20 percent disabling throughout the period on appeal. As the preponderance of the evidence is against the claim, there is no doubt to be resolved. 38 U.S.C.A. § 5107(b), Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Extraschedular Consideration Consideration of referral for an extraschedular rating requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. 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. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. Having reviewed the evidence, the Board finds that referral to Under Secretary for Benefits or the Director of the Compensation and Pension Service for determination and assignment of extraschedular ratings is not warranted, as the schedular evaluations assigned adequately contemplate the claimant's levels of disability and symptomatology. ORDER An evaluation of 70 percent for PTSD is granted subject to the controlling regulations applicable to payment of monetary benefit. An evaluation in excess of 20 percent for diabetes mellitus is denied. ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs