Citation Nr: 1312779 Decision Date: 04/17/13 Archive Date: 05/02/13 DOCKET NO. 07-32 866 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus, prior to June 21, 2011, and a rating in excess of 40 percent thereafter. 2. Entitlement to service connection for a visual disability, to include as secondary to the service connected diabetes mellitus. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Tiffany Berry, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1987 to July 1991 and from May 1999 to August 2003. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2006 rating decision of the Department of Veterans Affairs Regional Office (RO) that confirmed and continued the 20 percent evaluation in effect for diabetes mellitus and denied service connection for glaucoma, claimed as vision problems. In April 2011, the Board remanded these claims for additional development and consideration. During the pendency of this appeal, a May 2012 rating decision increased the Veteran's disability rating for his diabetes mellitus to 40 percent, effective from June 21, 2011. The case has now been returned to the Board for further appellate action. The Board also notes that, in addition to the paper claims file, there is a paperless, electronic claims file associated with the Veteran's claim. A review of the documents in such file reveals these records are relevant to the issues on appeal. As such, these records have been properly considered in the adjudication of the Veteran's claims. FINDINGS OF FACT 1. The most probative evidence indicates that the Veteran does not currently suffer from a diagnosed vision disability. 2. Prior to June 21, 2011, the Veteran's diabetes mellitus was controlled by diet restriction and use of insulin; regulation of activities was not shown. 3. Since June 21, 2011, the Veteran's diabetes mellitus is controlled by diet restriction, use of insulin, and regulation of activities. However, the competent and credible evidence does not demonstrate episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetes care provider. CONCLUSIONS OF LAW 1. The requirements for establishing service connection for a vision disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. The criteria for a disability rating in excess of 20 percent for diabetes mellitus prior to June 21, 2011 and in excess of 40 percent thereafter are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, November 2005 and April 2006 letters advised the Veteran of the evidence and information necessary to substantiate his increased rating claim and his service connection claim, as well as his and VA's respective responsibilities in obtaining such evidence and information. The claims were last readjudicated in May 2012. Relevant to the duty to assist, the Veteran's service treatment records as well as post-service VA treatment records have been obtained and considered. The Veteran was also afforded VA examinations in August 2006 and June 2011 in conjunction with the claims on appeal. All of the actions previously sought by the Board through its prior remand have been completed. Indeed, VA treatment records were obtained and a VA examination was conducted. A supplemental statement of the case (SSOC) was issued May 2012. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate the claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran was an active participant in the claims process by submitting evidence and argument. Therefore, he was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication or to cause injury to the Veteran. See Pelegrini, 18 Vet. App. at 121. Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits. See Conway, 353 F.3d at 1374; Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (2012). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Similarly, in order to establish entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. §§ 1110; 1131. In the absence of proof of present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328 (1997) (38 U.S.C.A. § 1131 requires existence of present disability for VA compensation purposes); see also Wamhoff v. Brown, 8 Vet. App. 517, 521 (1996). The determination as to whether the requirements for entitlement to service connection are met is based on an analysis of all of the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a) (West 2002); Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a) (2012). When there is an approximate balance of positive and negative evidence regarding a material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102, 4.3 (2012). If the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran claims that he suffers from a vision disability that is secondary to his service-connected type II diabetes mellitus. Specifically, he asserts that he has fluctuating vision when his blood sugar level drops. Upon consideration of the evidence of record, the Board concludes that the Veteran is not entitled to service connection for a vision disability. The Veteran's service treatment records reveal that he was assessed with and treated for conjunctivitis of the right eye in October 2001. Additionally, when the Veteran was first diagnosed with diabetes mellitus in September 2002, his complaints included blurry vision. During the March 2003 Medical Board examination, the Veteran reported a history of eye disorder or trouble, which he indicated was due to diabetes. However, upon clinical evaluation, the eyes were found to be normal. During a September 2003 VA eye examination, conducted in accordance with the Veteran's initial claim of entitlement to service connection for diabetes mellitus, the assessment was that the Veteran had dry eye of both eyes, but that there was no diabetic retinopathy or other retinal pathology for either eye. Thereafter, during a May 2005 temporary disability retirement evaluation, the impression was of pigment dispersion syndrome with glaucomatous defect and no diabetic retinopathy. During an August 2005 temporary disability retirement evaluation, the assessment included glaucoma/intraocular pressure. The Veteran filed his claim for service connection for a visual disability in September 2005. The Veteran was provided a VA eye examination in August 2006, and the examiner again stated there was no diabetic retinopathy or other retinal pathology for either eye. The examiner further stated that if glaucoma is present, it is not secondary to his diabetes. The Veteran was diagnosed with premature presbyopia. In September 2007, the Veteran reported that he has blurred vision that fluctuates with his blood sugar. It was noted that the Veteran should be watched for diabetic retinopathy, but he was taken off of Timolol, which is used for glaucoma. In June 2011, in compliance with the Board's April 2011 remand directives, the Veteran was again scheduled for a VA eye examination to specifically determine whether the Veteran suffers from any current eye disability that may be related to active service or his service-connected disabilities. During the examination, the examiner, an ophthalmologist, noted the Veteran had no current visual complaints. This examiner also noted the Veteran's prior use of Timolol and its discontinuation upon a determination that he does not have glaucoma. Upon physical examination, the examiner determined there were no physical findings of abnormal lacrimal duct function, abnormal eyelids, chronic conjunctivitis, residuals of an eye injury, lagophthalmos, symblepharon, ptosis, nystagmus, and eyelash or eyebrow loss. Ultimately, the examiner determined the Veteran suffers from diabetes mellitus without diabetic macular edema or diabetic retinopathy and that he does not have glaucoma. In rendering his opinion, the examiner stated that the Veteran's fluctuating vision is at least as likely as not caused by or the result of his diabetes mellitus. However, it was also determined the Veteran's visual acuity and visual fields were normal. The examiner stated that the Veteran does not have glaucoma or diabetic changes in the eye, but that the Veteran's glucose is poorly controlled and can result in fluctuations in vision. Upon review of the record, the Board notes that while the Veteran was thought to have glaucoma in early 2005, ultimately he has been found not to suffer from such disorder. The 2011 VA examiner confirmed such after examination of the Veteran and review of the claims file. Such conclusion is supported by the fact that medication to treat glaucoma was discontinued. Accordingly, the Board finds this opinion highly probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Additionally, although the Veteran was noted to have presbyopia on the August 2006 examination and on the 2011 VA examination, such condition is a refractive error of the eye and is not a disability for VA purposes. In this regard, pursuant to 38 C.F.R. § 3.303(c), refractive error of the eye is not a disease or injury for VA purposes. "[R]efractive errors of the eye, such as presbyopia, are recognized in medical literature as being constitutional or developmental abnormalities . . . Presbyopia is described as 'hyperopia and impairment of vision due to advancing years or to old age; it is dependent on diminution of the power of accommodation from loss of elasticity of the crystalline lens, causing the near point of distinct vision to be removed farther from the eye.'" Terry v. Principi, 340 F.3d 1378, 1384 (Fed. Cir. 2003), citing Dorland's Illustrated Medical Dictionary 1453 (29th ed.2000)). Thus, to the extent the Veteran suffers from presbyopia, such is not a disability within the meaning of the law. The Board also notes the Veteran was noted to have dry eyes on the 2003 VA examination, but such was not noted during the examinations conducted during the course of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 323 (2007). In short, during the course of this claim, the medical evidence does not include a clinical diagnosis of a vision disability for which service connection can be established. VA treatment records and VA examinations in August 2006 and June 2011 fail to provide a clinical diagnosis of a vision disability related to his diabetes. Both VA examiners noted there is no diabetic retinopathy or other retinal pathology present. The Board acknowledges the Veteran's assertion that he suffers from blurry and fluctuating vision; indeed, the June 2011 VA examiner also noted that the Veteran's blood sugar fluctuations can result in fluctuations in vision. However, the examiner also determined the Veteran's visual acuity is 20/20 in both eyes, a clinical examination of the Veteran's eyes was within normal limits and the Veteran does not have diabetic changes in the eyes or glaucoma. In the absence of a currently diagnosed vision disability, there is no reasonable basis to establish service connection. See Degmetich, 104 F.3d 1328 (38 U.S.C.A. § 1131 requires existence of present disability for VA compensation purposes). In short, while the Veteran has visual symptoms associated with fluctuating blood sugar levels, he has not been diagnosed with a vision disability. Subjective symptomatology, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute disability for which service connection may be granted. See Sanchez Benitez v. West, 13 Vet. App. 282, 285 (1999) appeal dismissed in part, and vacated and remanded in part, Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). In the absence of a diagnosed vision disability, service connection is not warranted. However, as will be discussed below, the Board will consider the Veteran's fluctuating vision symptoms when evaluating his diabetes disability. To the extent the Veteran himself believes that he suffers from a vision disability, the Veteran has not shown that he has specialized training sufficient to render a diagnosis for his eye complaints, as such matter requires medical expertise. Accordingly, his opinion as to the diagnosis or etiology of any vision problems is not competent medical evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). The Board finds the medical evidence to be of greater probative value than the Veteran's lay contentions. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). The preponderance is against the Veteran's claim, and therefore, his claim for service connection must be denied. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2012); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2012); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2012); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2012). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. 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 based on the facts found - a practice known as "staged" ratings. The Board has reviewed all of the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Historically, the Veteran was granted service connection for diabetes mellitus in an October 2003 rating decision, with an initial 20 percent disability rating assigned. In September 2005, he filed a claim for an increased rating for this disability. The August 2006 rating decision on appeal denied a disability rating in excess of 20 percent; however, the May 2012 rating decision issued during the pendency of the appeal increased his rating to 40 percent, effective from June 21, 2011, the date of a VA compensation examination. Therefore, the question before the Board is whether the Veteran is entitled to a disability rating in excess of 20 percent prior to June 21, 2011, and a rating higher than 40 percent thereafter for his diabetes mellitus. Under 38 C.F.R. § 4.119, Diagnostic Code 7913, a 20 percent evaluation is assigned for diabetes mellitus that requires insulin and restricted diet or oral hypoglycemic agent and a restricted diet. For an increase to the 40 percent evaluation, the evidence must show that the Veteran's diabetes mellitus requires insulin, restricted diet, and regulation of activities. A 60 percent evaluation is warranted for diabetes mellitus that requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least one or 2 hospitalizations per year or twice a month visits to a diabetes care provider, plus complications that would not be compensable if separately evaluated. A 100 percent evaluation is assigned for diabetes mellitus that 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. Note (1) to Diagnostic Code 7913 instructs the rating board to evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). Prior to June 21, 2011 The evidence of record for the period prior to June 21, 2011, includes the report of an August 2006 VA compensation examination, and VA treatment records through June 2011. As an initial matter, a September 2004 VA treatment record indicates the Veteran's diabetes is uncontrolled and insulin dependent. There was no indication at that time that his activity was restricted. The August 2006 VA compensation examiner noted the Veteran was initially diagnosed with diabetes mellitus in 2003 and has required insulin treatment since that time. There were no episodes of ketoacidosis. The examiner stated the Veteran does have occasional low sugar condition with insulin treatment; however, he managed the hypoglycemic condition without hospitalization. The Veteran was on a low fat diabetic diet, without activity restrictions, but was taking Lantus insulin and occasionally Humulin. The examiner also stated there were no skin infections, cellutitis, and leg or foot ulcers, but the Veteran is taking Lisinopril merely for the prevention of diabetic nephropathy. Further, there are no complaints of tingling or numbness in the extremities, and no history of diabetes neuropathy. The examiner also stated the Veteran was employed at the time of the examination and was able to perform his job since his diabetes does not affect his daily activities. A microalbiumin test showed negative, BUN was 11, and creatinine 1.0, which is normal. The examiner ultimately concluded the Veteran's diabetes is under insulin control, with no evidence of diabetic nephropathy or peripheral neuropathy. A contemporaneous eye examination also showed no diabetic retinopathy or other retinal pathology for either eye. Following the August 2006 VA examination, the record reflects the Veteran continued to receive treatment at VA. A November 2006 VA treatment record notes the Veteran has been noncompliant and his diabetes is poorly controlled. A June 2007 record states the Veteran is continuing to use his insulin and exercising. In September 2007, the Veteran reported that he has blurred vision that fluctuates with his blood sugar. It was noted that the Veteran should be watched for diabetic retinopathy, but he was taken off of Timolol, which is used for glaucoma. A January 2009 treatment note indicates the Veteran's blood sugar has been better controlled, but no weight gain or appetite changes were reported, and he denied blurred vision. A May 2009 endocrine treatment notes shows the Veteran's diet was evaluated and an insulin pump was ordered. The insulin pump was installed in August 2009. A November 2009 note indicates the Veteran's insulin pump ran out of insulin for three weeks, but the Veteran was not taking his insulin. More recently, an April 2011 treatment record shows that the Veteran had higher than desirable blood sugars. The general picture presented by the clinical evidence with regard to the Veteran's diabetes mellitus prior to June 21, 2011, is one that more closely approximates the constellation of symptomatology contemplated in the rating criteria for a 20 percent evaluation on the basis of insulin-dependent diabetes with restricted diet. The evidence does not suggest restriction of the Veteran's activities, in fact, quite the opposite. The August 2006 VA examiner specifically determined the Veteran's diabetes did not interfere with his daily activities as he was able to maintain a job, and he was not under any activities restrictions. The evidence also does not support assigning an even higher 60 percent, much less a 100 percent rating, for this period since the requisite frequency of hospitalization for hypoglycemia or ketoacidosis, is not demonstrated by the clinical record. Therefore, the criteria for the assignment of a rating in excess of 20 percent for service-connected diabetes mellitus for this period on appeal have not been met. Since June 21, 2011 Following the Board's April 2011 remand, the Veteran was afforded a VA examination in June 2011 to reassess the severity of his diabetes. At that time, it was confirmed that he has had no episodes of ketoacidosis or hypoglycemic reactions. The examiner indicated the Veteran has been working for the last two months, with no time lost from work. He was noted as requiring insulin more than once a day, being on a restrictive diet, and regulations of activities to control his diabetes. The Veteran denied symptoms of peripheral vascular disease, visual disorders, neurovascular disease, diabetic neuropathy, skin disorders, gastrointestinal disorder, genitourinary disorders, and any other diabetic complications. The Veteran reported paresthesia in the lower legs and feet, but an examination of the lower extremities was normal. Also of record for this second period on appeal are VA treatment records. These records indicate the Veteran's diabetes is uncontrolled, but there is still no evidence of episodes of ketoacidosis or hypoglycemic reactions requiring hospitalizations. To summarize, at no time during this period on appeal was there any evidence the Veteran's diabetes mellitus was characterized by episodes of ketoacidosis or hypoglycemic reactions requiring hospitalizations. The evidence does reflect the Veteran's continued use of insulin, diet restrictions, and regulations of activities to control his diabetes. However, without episodes of ketoacidosis or hypoglycemic reactions requiring hospitalizations, the criteria for a 60 percent or even 100 percent rating for diabetes mellitus have not been met. 38 C.F.R. § 4.119. The 40 percent rating presently assigned most closely approximates the severity of the Veteran's diabetes as evidenced by the clinical records and VA examination reports. Again, Note (1) to Diagnostic Code 7913 instructs the rating board to separately rate compensable residuals of diabetes. The Veteran did have several ophthalmological consults during the pendency of this appeal. However, as indicated above, the Veteran has not been diagnosed with a visual disability resulting from his diabetes. Thus, a separate rating for a visual disability is not warranted during either period. Any vision fluctuations associated with his changes in blood sugar during the period on appeal have been considered as part of the rating for his diabetes. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1) (noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913). The Board additionally notes that the June 2011 VA examiner specifically determined there was no evidence of cardiovascular disease, kidney disease, neurological disease, amputation, or "other" diabetic conditions. There is no indication in the record showing a compensable level of disability as to any other potential residual to diabetes. Thus, the rating under Diagnostic Code 7913 is found to encompass all elements of this Veteran's diabetes process. There is no basis for finding that a separate rating is warranted. The Board has also considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extra-schedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology and provide for additional or more severe symptoms than currently shown by the evidence. Indeed, Diagnostic Code 7913 contemplates noncompensable complications of diabetes, which would include such symptom as fluctuating vision, for purposes of evaluating the disability, and contemplates the assignment of separate ratings for compensable complications. Consequently, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Thus, referral for extraschedular consideration is not warranted. In reaching the conclusions above the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Service connection for a visual disability is denied. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus prior to June 21, 2011 is denied. Entitlement to a disability rating in excess of 40 percent for diabetes mellitus from June 21, 2011 is denied. ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs