Citation Nr: 1304598 Decision Date: 02/08/13 Archive Date: 02/19/13 DOCKET NO. 09-07 002 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to a disability rating in excess of 20 percent for residuals of prostate cancer. 2. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus, type II, with erectile dysfunction. 3. Entitlement to a disability rating in excess of 20 percent for peripheral neuropathy of the right upper extremity. 4. Entitlement to a disability rating in excess of 20 percent for peripheral neuropathy of the left upper extremity. 5. Entitlement to a disability rating for peripheral neuropathy of the right lower extremity in excess of 10 percent prior to September 11, 2012, and in excess of 20 percent from September 11, 2012. 6. Entitlement to a disability rating for peripheral neuropathy of the left lower extremity in excess of 10 percent prior to September 11, 2012, and in excess of 20 percent from September 11, 2012. REPRESENTATION Appellant represented by: New Jersey Department of Military and Veterans' Affairs ATTORNEY FOR THE BOARD Patricia Veresink, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1965 to August 1967. This matter comes before the Board of Veterans' Appeals (Board) from October 2007 and February 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. The Veteran requested a videoconference Board hearing. A hearing was scheduled for December 2012, but prior to that hearing, the Veteran submitted a notice indicating his desire to withdraw his request for a Video-Conference hearing and requesting the RO to forward his appeal to the Board for a decision. Thus, his hearing request is considered withdrawn. FINDINGS OF FACT 1. The Veteran's residuals of prostate cancer have been manifested by urinary frequency of no more than three to four times per night; there is no showing of voiding intervals of less than one hour. 2. The Veteran's diabetes mellitus has been manifested by the need for medication and a restricted diet, but does not require regulation of activities. 3. The Veteran's peripheral neuropathy of the peripheral neuropathy of the right upper extremity was manifested by no more than mild incomplete paralysis of the median nerve prior to September 11, 2012. 4. The Veteran's peripheral neuropathy of the peripheral neuropathy of the right upper extremity has been manifested by no more than moderate incomplete paralysis of the median nerve from September 11, 2012. 5. The Veteran's peripheral neuropathy of the left upper extremity was manifested by no more than mild incomplete paralysis of the median nerve prior to September 11, 2012. 6. The Veteran's peripheral neuropathy of the left upper extremity has been manifested by no more than moderate incomplete paralysis of the median nerve from September 11, 2012. 7. Prior to September 2012, the Veteran's peripheral neuropathy of the right lower extremity was manifested by no more than mild incomplete paralysis of the sciatic nerve. 8. From September 11, 2012, the Veteran's peripheral neuropathy of the right lower extremity has been manifested by no more than moderate incomplete paralysis of the sciatic nerve. 9. Prior to September 2012, the Veteran's peripheral neuropathy of the left lower extremity was manifested by no more than mild incomplete paralysis of the sciatic nerve. 10. From September 11, 2012, the Veteran's peripheral neuropathy of the left lower extremity has been manifested by no more than moderate incomplete paralysis of the sciatic nerve. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for residuals of prostate cancer have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.119, Diagnostic Code 7528 (2012). 2. The criteria for a disability rating in excess of 20 percent for diabetes mellitus, type II, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.119, Diagnostic Code 7913 (2012). 3. The criteria for a disability rating of 40 percent for peripheral neuropathy of the right upper extremity have been met from September 11, 2012. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.119, Diagnostic Code 8512 (2012). 4. The criteria for a disability rating of 30 percent for peripheral neuropathy of the left upper extremity have been met from September 11, 2012. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.119, Diagnostic Code 8512 (2012). 5. The criteria for a disability rating for peripheral neuropathy of the left lower extremity in excess of 10 percent prior to September 11, 2012 and in excess of 20 percent from September 11, 2012 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.119, Diagnostic Code 8520 (2012). 6. The criteria for a disability rating for peripheral neuropathy of the right lower extremity in excess of 10 percent prior to September 11, 2012 and in excess of 20 percent from September 11, 2012 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.119, Diagnostic Code 8520 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126 (West 2002) and 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a) (2011), VA has a duty to notify a claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant, and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The record shows that through VCAA letters dated March 2006, August 2007, May 2008, September 2008, November 2008, March 2010, April 2011, and August 2012, the Veteran was informed of the information and evidence necessary to warrant entitlement to the benefit sought on appeal. The Veteran was also advised of the types of evidence VA would assist him in obtaining as well as his own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Charles v. Principi, 16 Vet.App. 370 (2002). He has received all essential notice, has had a meaningful opportunity to participate in the development of the claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Thus, no further development is required with respect to the duty to notify. The Board also finds that there has been compliance with the assistance provisions set forth in the law and regulations. The record in this case includes VA examination reports, VA treatment records, private treatment records, and lay evidence. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case, and no further action is necessary. See generally 38 C.F.R. § 3.159(c). No additional pertinent evidence has been identified by the Veteran. The Veteran was provided VA examinations in August 2007, December 2008, December 2009, April 2010, and September 2012. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The examiners were provided with an accurate history, the Veteran's history and complaints were recorded, the examination reports set forth detailed examination findings in a manner that allows for informed appellate review under applicable VA laws and regulations, and the examiners offered the necessary findings. Therefore, the Board finds the examinations to be sufficient and adequate for rating purposes. Increased Rating - Laws and Regulations Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet.App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet.App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Increased Rating - Residuals of Prostate Cancer The Veteran's residuals of prostate cancer are rated at 20 percent disabling under Diagnostic Code 7528. That regulation states that following the cessation of surgical, X-ray, antineo- plastic chemotherapy, or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105(e). If there has been no local reoccurrence or metastasis, then rate on residuals as voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. § 4.115(b) Diagnostic Code 7528. A December 2009 VA examination noted that the Veteran underwent 39 external beam radiation treatments from March to May of 2009. After six months he showed no local reoccurrence or metastasis. Therefore, the Board must rate on residuals such as voiding dysfunction or renal dysfunction. These dysfunctions are rated as follows: Renal dysfunction 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 warrants a 100 percent disability rating. Renal dysfunction with 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 warrants an 80 percent disability rating. Renal dysfunction with constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code 7101 warrants a 60 percent disability rating. Renal dysfunction with 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 warrants a 30 percent disability rating. Renal dysfunction with albumin and casts with history of acute nephritis; or, hypertension non-compensable under Diagnostic Code 7101 warrants a noncompensable disability rating. Voiding dysfunction should be rated as a particular condition as urine leakage, frequency, or obstructed voiding. Continual urine leakage, post surgical urinary diversion, urinary incontinence, or stress incontinence requiring the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day warrants a 60 percent disability rating. Continual urine leakage, post surgical urinary diversion, urinary incontinence, or stress incontinence requiring the wearing of absorbent materials which must be changed 2 to 4 times per day warrants a 40 percent disability rating. Continual urine leakage, post surgical urinary diversion, urinary incontinence, or stress incontinence requiring the wearing of absorbent materials which must be changed less than 2 times per day warrants a 20 percent disability rating. Urinary frequency with daytime voiding interval less than one hour, or; awakening to void five or more times per night warrants a 40 percent disability rating. Urinary frequency with daytime voiding interval between one and two hours, or; awakening to void three to four times per night warrants a 20 percent disability rating. Urinary frequency with daytime voiding interval between two and three hours, or; awakening to void two times per night warrants a 10 percent disability rating. Obstructed voiding with urinary retention requiring intermittent or continuous catherization warrants a 30 percent disability rating. 38 C.F.R. § 4.115a. The December 2009 VA examiner noted no renal dysfunction or urinary incontinence. The Veteran voided six to seven times during the day and one time at night. He was continent of urine. His recent PSA was 1.3. Examination revealed normal penis and scrotal contents. A May 2010 oncology follow-up showed a most recent PSA as 1.2. He noted ongoing daytime frequency and nocturia x 3. The Veteran reported occasional incomplete emptying, intermittency, and weak stream. He denied dysuria, hematuria, or incontinence. A November 2010 treatment record also noted daytime frequency and nocturia x 3. The Veteran again noted occasional incomplete emptying, intermittency, and weak stream without dysuria, hematuria, or incontinence. The Veteran was afforded a VA examination in September 2012. The examiner noted no further treatment since the radiation therapy in May 2009. The examiner noted no renal dysfunction and no urinary incontinence. He noted voiding frequency during the daytime of four times per day two to three hours apart and nighttime voiding frequency of three times, two hours apart. The examiner determined that the Veteran's activities of daily living are not affected by his genitourinary condition. Based on the evidence showing no renal dysfunction, continual urine leakage, post surgical urinary diversion, urinary incontinence, stress incontinence requiring the wearing of absorbent materials, or urinary frequency voiding at least once an hour and five or more times per night, the Board finds that a preponderance of the evidence is against the claim for a higher rating in excess of the 20 percent currently awarded. In making this determination, the Board has considered the Veteran's lay statements, which additionally do not show any of the above symptoms to the extent that would warrant a disability rating in excess of 20 percent. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Increased Rating - Diabetes Mellitus The Veteran's service-connected diabetes mellitus has been rated at 20 percent by the RO under the provisions of Diagnostic Code 7913. Under this regulatory provision: Diabetes mellitus requiring 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 warrants a 100 percent disability rating; Diabetes mellitus requiring 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 warrants a 60 percent disability rating; Diabetes mellitus requiring insulin, restricted diet, and regulation of activities warrants a 40 percent disability rating; Diabetes mellitus requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet, warrants a 20 percent disability rating; Diabetes mellitus manageable by restricted diet only warrants a 10 percent disability rating. 38 C.F.R. § 4.120, Diagnostic Code 7913. A March 2007 note from the Veteran's private physician showed a diagnosis of insulin dependent diabetes mellitus requiring a diabetic diet. The Veteran was afforded a VA examination in August 2007. At that time, the examiner noted that the Veteran had no history of ketoacidosis or hypoglycemia requiring treatment on an emergency basis. The examiner noted that any dietary and treatment prescriptions for the diabetes type II do not at all interfere with the Veteran's activities of daily living or employment. The Veteran had good exercise capacity with no difficulty with the ordinary strenuous activities of daily living. During a September 2008 treatment record, the examiner noted that the Veteran walked for exercise once per day. The Veteran was on insulin twice per day and used metformin twice per day. The Veteran was on a restricted diet, but the examiner encouraged the Veteran to increase his exercise through the day as possible getting at least thirty minutes total daily. In February 2009, the Veteran's VA physician noted his diabetes mellitus diagnosis and indicated that the Veteran needed to bear down on diet and exercise to drop weight. The examiner again suggested that the Veteran increase his exercise throughout the day. A February 2010 treatment record showed the use of insulin for seven years. The Veteran walked for exercise around thirty minutes every day. The examiner encouraged a strict diet, but requested that the Veteran increase his exercise to forty five minutes total per day. Again in August 2010, the examiner encouraged the Veteran's current exercise plan. The Veteran was afforded a VA examination in April 2010. He was on a sugar restricted diet. He reported no hypoglycemic or ketoacidosis reactions requiring hospitalization. The Veteran had no restrictions of his activities due to poorly controlled diabetes mellitus. The examiner noted that the Veteran was taking enalapril and three different types of insulin. The Veteran was afforded another VA examination in April 2011. He required the treatment of a diabetic care provided three to four times per year for management of his diabetes mellitus. He denied any severe hypoglycemic episodes, hyperglycemic episodes, or history of ketoacidosis. He has never been hospitalized for ketoacidosis or hypoglycemia. The Veteran was on insulin, novolin, and metformin to manage his diabetes. The examiner specifically noted that the Veteran's physical activities were not limited to maintain glycemic control. The Veteran was afforded a final examination in September 2012. The examiner noted oral medication and three injections of insulin daily. He found no ketoacidosis, but noted hypoglycemia requiring food related to activities about once per month. The Veteran had never been hospitalized for diabetes mellitus. In his lay statements, the Veteran asserts that he is on a strict diet and regulation of activities related to his diabetes mellitus. However, the Board notes that regulation of activity is defined as the avoidance of strenuous activities, which is inconsistent with the evidence here, showing that the Veteran was advised to increase his exercise frequency. The Veteran acknowledged in a March 2010 statement that he has been advised to watch his diet and to exercise. This statement is consistent with the treatment records and VA examination results. As he has been encouraged repeatedly to increase his activity, the Board finds that the overall evidence fails to demonstrate regulation of activities as defined under Diagnostic Code 7913. The Veteran has also been found to have peripheral vein occlusion of the left eye and bilateral mild cataracts related to his diabetes mellitus. Peripheral vein occlusion of the left eye and bilateral mild cataracts warrant separate disability ratings when they result in incapacitating episodes having a total duration of at least one week, but less than two weeks, during the past twelve months; when they result in visual acuity of 20/50 in one eye and at least 20/40 in the other eye; or, when they result in visual acuity of 20/70 in one eye and 20/40 in the other. The Veteran received a VA optometry examination. The examiner noted vision of 20/30 of the left eye and 20/25 of the right eye. The record is silent regarding any incapacitating episodes related to the eye. Therefore, the Board finds that the Veteran is not entitled to a separate compensable disability rating based on his peripheral vein occlusion of the eye. Thus, his eye symptoms attributable to diabetes mellitus remain encompassed with the rating already in effect for that disability. See Diagnostic Code 7913, Note (1). The Board also notes diagnoses of partial and complete erectile dysfunction related to the Veteran's diabetes mellitus. In this regard, he is currently receiving special monthly compensation under 38 U.S.C.A. § 1114(k) and 38 C.F.R. § 3.350(a) on account of loss of use of a creative organ. He is not entitled to additional compensation for erectile dysfunction. Increased Rating - Peripheral Neuropathy The Board will address peripheral neuropathy of all four extremities together, as they stem from the same factual background and applicable law. The Veteran's upper extremity peripheral neuropathy is rated at 20 percent bilaterally under Diagnostic Code 8512. Under that regulation, complete paralysis of the median nerve involving all intrinsic muscles of the hand and some or all flexors of the wrist and fingers, paralyzed (substantial loss of use of hand) warrants a 70 percent rating in the major side and a 60 percent rating in the minor side. Severe incomplete paralysis of the median nerve warrants a 50 percent rating in the major side and a 40 percent rating in the minor side. Moderate incomplete paralysis of the median nerve warrants a 40 percent rating in the major side and a 30 percent rating in the minor side. Mild incomplete paralysis of the median nerve warrants a 20 percent rating bilaterally. 38 C.F.R. § 4.124a. The Veteran's lower extremity peripheral neuropathy is rated at 10 percent bilaterally prior to September 11, 2012, and 20 percent bilaterally from September 11, 2012, under Diagnostic Code 8521. Under that regulation, complete paralysis of the external popliteal nerve with foot drop and slight droop of first phalanges of all toes, an inability to dorsiflex the foot, extension of proximal phalanges of toes lost, abduction of foot lost, adduction weakened, and anesthesia covers the entire dorsum of the foot and toes warrants a 40 percent disability rating. Severe incomplete paralysis of the external popliteal nerve warrants a 30 percent rating. Moderate incomplete paralysis of the external popliteal nerve warrants a 20 percent rating. Mild incomplete paralysis of the external popliteal nerve warrants a 10 percent rating. 38 C.F.R. § 4.124a. The Veteran's neuropathy has been diagnosed as incomplete paralysis of the sciatic nerve; however, his symptoms more nearly approximate those found under the regulation related to the external popliteal nerve. Therefore, the Board will apply Diagnostic Code 8521 in determining the current evaluation. In September 2008, a VA examiner noted some numbness or tingling in the feet and hands that is worse at night and occasionally awakens him. A February 2010 treatment record showed some neuropathic tingling of the feet at night that did not keep him awake. His feet had good pulses and perfusion and no loss of monofilament sensation in the toes. An April 2010 treatment record showed numbness and tingling in the feet and hands. During the April 2010 VA examination, the examiner noted a diagnosis of bilateral peripheral neuropathy of the feet. Neurological testing showed a decrease in sensation of both his feet consistent with peripheral nerve roots L4-5, S1. The Veteran was afforded another VA examination in April 2011. He complained of paresthesias in bother hands and in both feet. On examination, there was glove-type slight decrease in sensation to light touch and pinprick in both his upper extremities in the C6-C8 nerve root distribution. He also showed slight decrease to sensation to light touch and pinprick in both feet in the L4-L5, S1 nerve root distribution. The Veteran received no medication for his neuropathies. The examiner described mild bilateral peripheral neuropathy in the upper extremities and lower extremities. The Veteran was afforded a final VA examination in September 2012. The examiner noted a history of peripheral nerves. He complained of a moderate degree of paresthesias and numbness involving all four extremities. The examiner noted that it is constant in nature, with no history of pain. Physical examination revealed 5/5 strength in all major groups. Deep tendon reflexes revealed absent ankle reflexes but were otherwise normal. He had diminished sensation in glove and stocking distribution to fine touch monofilament sensation and temperature. The examiner diagnosed incomplete sciatic neuropathy involving both lower extremities, moderate in severity, and incomplete partial neuropathy of the median nerves in both upper extremities. Prior to September 2012, the Veteran's peripheral neuropathy of the upper extremities has been generally described as mild. He experienced some tingling and numbness that did not interfere with his activities of daily living. The Veteran maintained use of his hand. Based on the evidence showing mild symptoms with retained use of the hand and little to no functional impairment, the Board finds that a preponderance of the evidence is against the claim for a higher rating in excess of the 20 percent currently awarded for the Veteran's bilateral upper extremity peripheral neuropathy prior to September 11, 2012. During the September 2012 VA examination, the examiner described the Veteran's upper extremity peripheral neuropathy as moderate. He also noted sensitivity to temperature, which had not been indicated previously. Based on the Veteran's complaints and the September 2012 VA examiner's findings, the Board concludes that the Veteran's upper extremity peripheral neuropathy should be staged to reflect moderate incomplete paralysis from September 11, 2012 forward. Therefore, the Board finds that the Veteran is entitled to a 40 percent disability rating in his dominant right hand and a 30 percent disability rating in his minor left hand. Prior to September 11, 2012, the Veteran's lower extremity bilateral peripheral neuropathy manifested with tingling, numbness, and the occasional awakening from sleep. He did not experience loss of control of the feet or toes. Based on the evidence showing mild symptoms, to include occasional awakening from sleep, and little to no functional impairment, the Board finds no basis for assigning a rating in excess of the 10 percent currently awarded for the bilateral lower extremity peripheral neuropathy prior to September 11, 2012. In September 2012, the Veteran's lower extremity peripheral neuropathy increased in severity. The examiner noted a lack of sensitivity to temperature and absent deep tendon ankle reflexes. The examiner described these symptoms as moderate incomplete paralysis. The Board notes that the Veteran maintained his ability to ambulate and did not lose control of his knee, feet, or toes. Therefore, the Board agrees with the examiner that the Veteran's lower extremity peripheral neuropathy is moderate in nature and does not warrant a disability rating in excess of 20 percent. In making this determination, the Board has considered the Veteran's lay statements, which additionally do not show any symptoms to the extent that would warrant a disability rating in excess of the staged ratings assigned for the upper and lower peripheral neuropathy. Extraschedular Considerations In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria contemplate the Veteran's disability. His service-connected diabetes requires restriction of diet and medication, but does not otherwise cause any significant functional impairment. The Veteran's residuals of prostate cancer have resulted in urinary frequency awakening up to three times per night. His peripheral neuropathy manifests with mild incomplete paralysis. Theses manifestations are contemplated in the rating criteria. The rating criteria are therefore adequate to evaluate the residuals of prostate cancer, peripheral neuropathy, and diabetes mellitus and referral for consideration of extraschedular rating is not warranted. ORDER Entitlement to a disability rating in excess of 20 percent for residuals of prostate cancer is denied. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus, type II, with erectile dysfunction is denied. Entitlement to a disability rating of 40 percent for peripheral neuropathy of the right upper extremity from September 11, 2012, is granted. Entitlement to a disability rating of 30 percent for peripheral neuropathy of the left upper extremity from September 11, 2012, is granted. Entitlement to a disability rating for peripheral neuropathy of the right lower extremity in excess of 10 percent prior to September 11, 2012, and in excess of 20 percent from September 11, 2012, is denied. Entitlement to a disability rating for peripheral neuropathy of the left lower extremity in excess of 10 percent prior to September 11, 2012, and in excess of 20 percent from September 11, 2012, is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs