Citation Nr: 1307967 Decision Date: 03/11/13 Archive Date: 03/20/13 DOCKET NO. 09-46 432 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy, right upper extremity. 2. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy, left upper extremity. 3. Entitlement to a rating in excess of 10 percent for peripheral neuropathy, right lower extremity. 4. Entitlement to a rating in excess of 10 percent for peripheral neuropathy, left lower extremity. 5. Entitlement to a rating in excess of 20 percent for diabetes mellitus type II. 6. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Michael D. J. Eisenberg, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Turner, Counsel INTRODUCTION The Veteran served on active duty from June 1968 to August 1971. These matters come before the Board of Veterans' Appeals (Board) on an appeal from a March 2009 rating decision issued by the Regional Office (RO) in Huntington, West Virginia. In that decision, the RO, among other things, granted entitlement to service connection for peripheral neuropathy of the upper extremities and assigned separate 10 percent ratings. The RO also denied increased ratings for diabetes (rated 20 percent), PTSD (rated 30 percent), and bilateral peripheral neuropathy of the lower extremities. Jurisdiction over this case was subsequently transferred to the VARO in Roanoke, Virginia, and that office forwarded the appeal to the Board. The Veteran timely appealed the initial ratings assigned as well as the denials of increased ratings. In October 2009, the RO granted an increased, 50 percent rating for PTSD, effective the date of claim. The Veteran testified before a Decision Review Officer at the RO in September 2009. The Veteran also requested a Board hearing and one was scheduled for August 20, 2012. The hearing was rescheduled at the Veteran's request, for November 6, 2012. The Veterans Appeal Control and Locator System (VACOLS) reflects that the hearing was cancelled by the Veteran. In any event, the Veteran did not appear for the hearing and his hearing request will therefore be considered withdrawn. 38 C.F.R. § 20.704(d) (2012). The Board notes that the RO also denied entitlement to a total disability rating based on individual unemployability (TDIU) in its March 2009 decision, the Veteran appealed this decision separately from the other claims on appeal herein (in his VA Form 9 filed in connection with the other claims), and the RO issued an April 2012 statement of the case in which it informed the Veteran that he would have to submit an additional VA Form 9 in order to perfect his appeal of the denial of entitlement to a TDIU. As the Veteran has not filed a VA Form 9 in connection with the claim for a TDIU, the denial of entitlement to a TDIU is not before the Board. The Board notes that the issue of entitlement to a TDIU is deemed to have been submitted as part of any claim for a higher initial rating or an increased rating when evidence of unemployability is submitted at the same time as the claim and the Veteran seeks the highest rating possible. See Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); Rice v. Shinseki, 22 Vet. App. 447 (2009). Whether the issue of entitlement to a TDIU has been raised in this manner and is before the Board at this time is addressed below. FINDINGS OF FACT 1. The evidence does not show symptoms more nearly approximating moderate incomplete paralysis of the median nerve of the right upper extremity. 2. The evidence does not show symptoms more nearly approximating moderate incomplete paralysis of the median nerve of the left upper extremity. 3. The evidence does not show symptoms more nearly approximating severe incomplete paralysis of the tibial nerve of the right lower extremity. 4. The evidence does not show symptoms more nearly approximating severe incomplete paralysis of the tibial nerve of the left lower extremity. 5. The Veteran was not shown to need to regulate his activities for diabetic control. 6. The overall level of impairment caused by the symptoms of the Veteran's PTSD most nearly approximates occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for peripheral neuropathy of the right upper extremity were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.124a, Diagnostic Code (DC) 8515 (2012). 2. The criteria for a rating in excess of 10 percent for peripheral neuropathy of the left upper extremity were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.124a, DC 8515. 3. The criteria for a rating in excess of 10 percent for peripheral neuropathy of the right lower extremity were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.124a, DC 8525 (2012). 4. The criteria for a rating in excess of 10 percent for peripheral neuropathy of the left lower extremity were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.124a, DC 8525. 5. The criteria for a rating in excess of 20 percent for diabetes were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.119, DC 7913 (2012). 6. The criteria for a rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.130, DC 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims and Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants with substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. § 3.102, 3.156(a), 3.159. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of any information, and any medical or lay evidence, that is necessary to substantiate his or her claim. 38 U.S.C.A. § 5103(a), 38 C.F.R § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183, 186-187 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. The Board notes that 38 C.F.R. § 3.159 was revised in part, effective May 30, 2008. See 73 Fed. Reg. 23,353-23,356. The third sentence of 38 C.F.R. § 3.159(b)(1), which stated that "VA will also request that the claimant provide any evidence in the claimant's possession that pertains to the claim," was removed. This amendment applies to all applications pending on, or filed after, the regulation's effective date. VCAA notice should be provided to a claimant before the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Pelegrini v. Principi, 18 Vet. App. 112, 115 (2004). However, the VCAA notice requirements may be satisfied notwithstanding errors in the timing or content of the notice if such errors are not prejudicial to the claimant. Id at 121. Further, a defect in the timing of the notice may be cured by sending proper notice prior to a re-adjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333-1334 (Fed. Cir. 2006). The VA General Counsel issued a precedential opinion interpreting Pelegrini as requiring the Board to ensure that proper notice is provided unless it makes findings regarding the completeness of the record or other facts that would permit the conclusion that the notice error was harmless. See VAOGCPREC 7-2004. The United States Court of Appeals for the Federal Circuit reaffirmed the importance of proper VCAA notice in Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Mayfield and its progeny instruct that a comprehensive VCAA letter, as opposed to a patchwork of other post-decisional documents, is required to meet the VCAA's notification requirements. Id at 1320. However, VCAA notification does not require a pre-adjudicatory analysis of the evidence already contained in the record. See, e.g., Mayfield v. Nicholson, 20 Vet. App. 537, 541 (2006). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice requirements are applicable to all five elements of a service connection claim. Thus, the Veteran must be notified that a disability rating and effective date for the award of benefits will be assigned if service connection for a claimed disability is awarded. Id at 486. In this case, the Veteran was sent a letter in November 2008, prior to the appealed from rating decision, which explained how VA could assist him with developing evidence in support of his claims. It also explained that in order to receive higher ratings for his service connected disabilities, he needed to show that they got worse. The November 2008 letter also explained how VA assigns ratings and effective dates for service connected disabilities. In May 2009 the Veteran was sent another letter which explained the criteria for rating his disabilities. VA also must make reasonable efforts to assist the claimant with 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. In connection with the current appeal, VA has of record evidence including VA treatment records, employment information submitted by the Veteran, and a transcript of the Veteran's testimony at the September 2009 hearing. The Veteran was also afforded adequate VA examinations in connection with his claims. Initial and Increased Ratings The Veteran contends that the symptoms of his peripheral neuropathy of all extremities, diabetes, and PTSD are worse than indicated by the ratings that are currently assigned for those disabilities. Disability ratings are determined by applying criteria that are set forth in the VA's Schedule for Rating Disabilities (38 C.F.R. Part 4). Ratings are based on average impairments of earning capacity resulting from particular diseases and injuries and the residuals thereof in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities are described utilizing diagnostic codes set forth in 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Where entitlement to compensation for a service-connected disease or injury already has been established and entitlement to an increase in the disability rating is at issue, the present level of disability is of primary importance. See, e.g., Franciso v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). 1. Peripheral neuropathy of the upper extremities. The Veteran's peripheral neuropathy of the upper extremities is rated by analogy to 38 C.F.R. § 4.124a, DC 8515, applicable to the median nerve. Pursuant to this diagnostic code, a 10 percent rating applies for mild incomplete paralysis of either the dominant or the non-dominant extremity. A 20 percent rating applies for moderate incomplete paralysis of the non-dominant extremity. A 30 percent rating applies for moderate incomplete paralysis of the dominant extremity. A 40 percent rating applies for severe incomplete paralysis of the non-dominant extremity. A 50 percent rating applies for severe incomplete paralysis of the dominant extremity. A 60 percent rating applies for complete paralysis of the non-dominant extremity and a 70 percent rating applies for complete paralysis of the dominant extremity. Complete paralysis entails the hand being inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand, pronation incomplete and defective, absence of flexion of the index finger and feeble flexion of the middle finger, inability to make a fist, index and middle fingers remain extended, cannot flex the distal phalanx of the thumb, defective opposition and abduction of the thumb at right angles to the palm, flexion of wrist weakened, and pain with trophic disturbances. The term incomplete paralysis indicates 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 in wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. The Veteran was afforded a VA contract examination in November 2008. At that time, no specific complaints applicable to the upper extremities were documented. Neurological examination of the upper extremities showed motor function within normal limits. Sensory function was abnormal with findings of decreased sensation to pinprick bilaterally from the arms distal to the elbows. Reflexes were normal. There were no VA treatment records showing any bilateral upper extremity symptoms. At his hearing, the Veteran did not testify to symptoms in either of his upper extremities. The evidence shows that the peripheral neuropathy in both of the Veteran's upper extremities is no more than mild, characterized by reduced sensation to pinprick. There is no indication of any other symptoms or functional effects due to the Veteran's peripheral neuropathy of the right and left upper extremities. The Board therefore finds that the symptoms of peripheral neuropathy of the Veteran's upper extremities do not more nearly approximate the moderate incomplete paralysis of the median nerve required for higher ratings for right and left upper extremity peripheral neuropathy, and no higher rating is warranted under any other potentially applicable diagnostic code. The Board finds that the Veteran's symptoms do not present such an exceptional disability picture as to render the schedular rating inadequate. 38 C.F.R. § 3.321(b). See also Thun v. Peake, 22 Vet. App. 111, 115 (2008) (the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the schedular evaluation is inadequate). Decreased sensation in the upper extremities is contemplated by the rating schedule. There is no evidence of unusual circumstances such as material interference with employment or repeated periods of hospitalization due to peripheral neuropathy of the upper extremities. 2. Peripheral neuropathy of the lower extremities The Veteran's peripheral neuropathy of the lower extremities is rated pursuant to 38 C.F.R. § 4.124a, DC 8525, applicable to the posterior tibial nerve. A 10 percent rating applies for mild or moderate paralysis of the posterior tibial nerve. A 20 percent rating applies for severe incomplete paralysis of the posterior tibial nerve. A 30 percent rating applies for complete paralysis of the posterior tibial nerve, encompassing paralysis of all muscles of the sole of the foot, frequently with painful paralysis of a causalgic nature, toes unable to be flexed, adduction is weakened, and plantar flexion is impaired. At the time of his November 2008 VA contract examination, the Veteran complained of tingling and numbness of the legs. Examination showed motor function was within normal limits. Sensory function was abnormal with findings of decreased sensation to pinprick in the bilateral lower extremities distal to mid thigh. Reflexes were normal. VA treatment records do not show treatment specifically for peripheral neuropathy of the lower extremities. At his September 2009 hearing, the Veteran did not testify about symptoms of his peripheral neuropathy of either lower extremity. Symptoms of peripheral neuropathy of the bilateral lower extremities are no more than mild, with only sensory impairments. There are no motor or reflex impairments and no indication of impaired function of either lower extremity. The Board therefore finds that the symptoms of the Veteran's peripheral neuropathy did not more nearly approximate the severe incomplete paralysis required for a higher rating under DC 8525, and no higher rating is warranted under any other potentially applicable diagnostic code. The Board finds that the Veteran's symptoms do not present such an exceptional disability picture as to render the schedular rating inadequate. 38 C.F.R. § 3.321(b). See also Thun, 22 Vet. App. at 115. The symptoms described by the Veteran, including sensory impairment is specifically contemplated by the rating schedule. There is no evidence of unusual factors such as marked interference with employment or repeated hospitalizations due to peripheral neuropathy of the lower extremities. No functional impairment from peripheral neuropathy of the bilateral lower extremities was shown. 3. Diabetes mellitus Diabetes is rated pursuant to 38 C.F.R. § 4.119, diagnostic code 7913. A 20 percent rating applies when insulin and restricted diet or an oral hypoglycemic agent and restricted diet are necessary for diabetic control. A 40 percent rating applies when insulin, restricted diet, and regulation of activities is required for diabetic control. A 60 percent rating applies when insulin, restricted diet, and regulation of activities are necessary and there are 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 evaluated separately. A 100 percent rating applies when 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 hypoglycemia requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss or weight and strength or complications that would be compensable if separately evaluated. The definition of "regulation of activities" in the criteria for a 100 percent rating, i.e., "the avoidance of strenuous occupational and recreational activities," applies to the "regulation of activities" criterion for a 40 percent rating under DC 7913. Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). Moreover, because of the successive nature of the rating criteria, such that the evaluation for each higher disability rating includes the criteria of each lower disability rating, each of the three criteria listed in the 40 percent rating must be met in order to warrant such a rating. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). In addition, a 40 percent rating under DC 7913 requires medical evidence that occupational and recreational activities have been restricted by the diabetes. Camacho, 21 Vet. App. at 363-365. At the Veteran's VA contract examination in November 2008, he denied a history of diabetic ketoacidosis or hypoglycemia. He never visited a diabetic care provider for ketoacidosis or a hypoglycemic reaction. There was no progressive loss of weight or strength. His treatment for diabetes was oral medication. The examiner noted that diabetes did not cause any restriction of activities. There were no diabetic complications related to the eye, heart, skin, kidneys, or peripheral arteries. VA treatment records show that the Veteran is diagnosed with diabetes and prescribed medication for diabetes. No other treatment for diabetes is documented. At his September 2009 hearing, the Veteran did not testify about his symptoms of diabetes. A rating in excess of 20 percent is not warranted because no need for regulation of activities was shown. Diabetes was shown to be managed by medication alone. The Board finds that the Veteran's symptoms do not present such an exceptional disability picture as to render the schedular rating inadequate. 38 C.F.R. § 3.321(b). See also Thun 22 Vet. App. at 115 (2008). The requirement to take medication to treat diabetes is specifically contemplated in the rating schedule. The Veteran is separately rated for peripheral neuropathy of the extremities due to his diabetes. Diabetes was not shown to materially interfere with employment or require repeated hospitalizations. 4. PTSD The Veteran's PTSD is evaluated under 38 C.F.R. 4.130, Diagnostic Code 9411. A rating of 50 percent is assigned where the Veteran exhibits 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-term or 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. A rating of 70 percent is assigned where the Veteran exhibits 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; obessional 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); inability to establish and maintain successful relationships. A rating of 100 percent is assigned where the Veteran exhibits 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. The GAF (Global Assessment of Functioning) scale reflects psychological, social, and occupational functioning of a hypothetical continuum of mental health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). A GAF score of 41-50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). A score of 51-60 indicates 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 peer or coworkers). At his February 2008 VA contract examination, the Veteran complained of a chronic low mood and sometimes feeling like life is not worth living. He oftentimes felt that he is living on borrowed time and should have died in Vietnam or as a young man. He felt that he did not sleep well and was tired all the time. He had symptoms of decreased energy and decreased motivation. He complained of a significantly low mood and apathy towards work and home. He felt that he had problems with irritability. He had trouble at work getting along with people and taking direction. He felt that his symptoms got worse over the past couple of years due to his declining physical health. The examiner felt that the Veteran also had major depressive disorder, with symptoms of decreased energy, decreased motivation, low mood, difficulty sleeping, decreased appetite, decreased libido, feelings of hopelessness, helplessness, worthlessness, guilt, irritability, and significant isolation. The Veteran currently took medication for his psychiatric disorder. Upon examination, the Veteran was fully oriented. Appearance and hygiene were acceptable. Behavior was for the most part within normal limits. Eye contact was decreased at times. The Veteran's affect appeared blunted and sometimes blank. He did at times seem to have an inappropriate or incongruent affect with respect to the subjects he was discussing. Communication was normal except for the Veteran raising his voice at times and using expletives. Speech was mostly normal with a mild amount of circumstantiality from time to time. Concentration appeared low normal. There was no history of panic attacks although the Veteran reported high anxiety in crowds. The Veteran was suspicious but not delusional and did not have hallucinations. The Veteran was not suicidal although he sometimes felt it would be easier if he was not alive; he denied that he would harm himself due to his family. He was not homicidal. His thought process, judgment, abstract thinking, and memory appeared intact although it was noted that in the past the Veteran's judgment was suspect. The Veteran was assigned a GAF score of 60. The Veteran was mentally capable of handling his own benefits and had no difficulties performing activities of daily living. He had difficulty with appropriate work relationships and felt that he should be left alone at work. He sometimes isolated himself from family members at home. He intermittently was unable to engage in recreational or leisure activities. He could not manage being around large crowds and tried to avoid this. He had no difficulty understanding simple or complex commands. The Veteran felt that his psychiatric symptoms were worse due to his chronic pain and sleep impairment. VA treatment records show treatment for PTSD and depression. The most severe problem was noted as sleep disturbance. The Veteran apparently was thought to possibly be suicidal at one point, but upon evaluation it was determined that he was not suicidal. He was referred for counseling and medication. A June 2009 letter from the Veteran's psychiatrist indicated that stress could reduce the Veteran's concentration and ability to interact with others. He has reexperiencing symptoms when he has to work around many people or loud noises. He has nightmares and flashbacks. His ability to work was limited by his stress level and working conditions, but the psychiatrist felt that with reasonable accommodations the Veteran could still effectively carry out most of his work duties. The Veteran submitted documentation that he was provided with reasonable accommodations for his physical and mental disabilities, but he still failed to perform his work in an appropriate manner. At his hearing, the Veteran testified to his opinion that all of his myriad of work problems were due to PTSD and that his supervisors attributed his poor performance to PTSD. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Id. at 443. The Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). While the Veteran has not had most of the symptoms listed in the criteria for a 70 percent rating, the Board finds that the lay and medical evidence discussed above, reflecting a significant impact of the Veteran's PTSD on his occupational and social functioning, reflects that the overall level of impairment has more nearly approximated occupational and social impairment with deficiencies in most areas. A 70 percent rating is therefore warranted. The Veteran is not, however, entitled to a higher, 100 percent rating because his occupational and social impairment have not more nearly approximated total occupational and social impairment. There was no suicidal ideation except in the very remote past, there were no obsessional rituals, the Veteran was fully oriented, his personal appearance and hygiene were normal, and he was able to perform his activities of daily living without difficulty. The Board finds that the Veteran's symptoms do not present such an exceptional disability picture as to render the schedular rating inadequate. 38 C.F.R. § 3.321(b). See also Thun 22 Vet. App. at 115 (2008). The Veteran's symptoms are contemplated by the rating schedule. There is no evidence of any hospitalization for a mental disorder within the applicable period. While the Veteran had some problems with work, this was not shown to be entirely due to PTSD, and the 70 percent rating that the Board has granted recognizes significant occupational impairment both as a general matter of the Rating Schedule, see 38 C.F.R. § 4.1 ("Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability") and the level of occupational impairment indicated in the criteria for a 70 percent rating for PTSD. As to entitlement to a TDIU, as noted above, although the Veteran disagreed with the denial of a TDIU that was made in the same March 2009 decision that denied entitlement to an increased rating for PTSD, he did not perfect his appeal on this issue. Consequently, the Board finds that the issue of entitlement to a TDIU, including as part of a claim for an increased rating for PTSD, is not before it at this time. Conclusion For the foregoing reasons, the preponderance of the evidence reflects that the Veteran's symptoms have not more nearly approximated the criteria for higher ratings for bilateral upper and lower extremity peripheral neuropathy of diabetes, but have more nearly approximated the criteria for a 70 percent rating for PTSD. The benefit-of-the-doubt doctrine is therefore not for application. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). ORDER A rating in excess of 10 percent for peripheral neuropathy of the right upper extremity is denied. A rating in excess of 10 percent for peripheral neuropathy of the left upper extremity is denied. A rating in excess of 10 percent for peripheral neuropathy of the right lower extremity is denied. A rating in excess of 10 percent for peripheral neuropathy of the left lower extremity is denied. A rating in excess of 20 percent for diabetes mellitus is denied. A rating of 70 percent, but no higher, for PTSD is granted, subject to controlling regulations governing the payment of monetary awards. ____________________________________________ J. HAGER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs