Citation Nr: 1313734 Decision Date: 04/24/13 Archive Date: 05/03/13 DOCKET NO. 06-36 532 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to an increased rating for Type II diabetes mellitus, to include nephropathy, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Rogers, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1968 to June 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. This case was previously before the Board in January 2010 and October 2012 when it was remanded for additional development on both occasions. The case is now before the Board for further appellate consideration. In a January 2013 rating decision, the Appeals Management Center (AMC) granted service connection for peripheral neuropathy of the bilateral upper extremities, and assigned separate noncompensable evaluations prior to December 28, 2012, and 20 percent evaluations for each upper extremity thereafter under Diagnostic Code 8512. Service connection was also granted for peripheral neuropathy of the bilateral lower extremities, and separate 10 percent disability ratings were assigned for each lower extremity, effective February 17, 2004, under Diagnostic Code 8520. To date, the Veteran has not submitted a notice of disagreement with the evaluations assigned for his service-connected peripheral neuropathy of the bilateral upper and lower extremities, thus, those issues are not currently before the Board for appellate consideration. A review of the Veteran's Virtual VA electronic claims file reveals additional VA treatment records pertinent to the claim on appeal. FINDINGS OF FACT 1. The Veteran's diabetes mellitus requires the daily use of insulin and a restricted diet, but the most probative evidence of record does not show that his diabetes requires regulation of activities. 2. The Veteran's diabetic nephropathy is not manifested by constant or recurring albumin with hyaline and granular casts or red blood cells, or edema, or hypertension at least 10 percent disabling. CONCLUSION OF LAW The criteria for a disability rating greater than 20 percent for diabetes mellitus with nephropathy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.104, 4.115a, 4.119, Diagnostic Codes 7101 and 7913 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Stegall Considerations As noted above, the Board remanded this matter for further development in January 2010 and October 2012. In January 2010, the Board instructed the RO/AMC to provide the Veteran with a VA examination to determine the current nature and severity of his service-connected Type II diabetes mellitus and all complications thereof, to include nephropathy and retinopathy. In September 2010, the April 2010 VA examiner provided an addendum opinion, however, physical examination of the Veteran was not performed. Thus, the claim was again remanded by the Board in October 2012 to afford the Veteran a VA examination and to obtain any ongoing treatment records pertinent to the Veteran's type II diabetes mellitus and any complications thereof. In December 2012, the Veteran was afforded a VA examination, which addressed the severity of his service-connected diabetes mellitus and complications thereof, to include nephropathy and retinopathy. Ongoing VA treatment records dating since February 2006 were also obtained in June and December 2012. The claim was most recently readjudicated in a January 2013 supplemental statement of the case. Thus, there is compliance with the Board's remand instruction. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Duties to Notify and Assist In correspondence dated August and November 2005, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2012). Specifically, the RO/AMC notified the Veteran of: information and evidence necessary to substantiate his claim for increase; information and evidence that VA would seek to provide; and information and evidence that he was expected to provide. The letters informed the Veteran that in order to establish a higher rating, the evidence would need to show that his disability had increased in severity. The letters informed the Veteran of the types of evidence that could be submitted to support his claim for an increased rating and of the types of evidence that could be submitted to support his claim. A September 2010 letter provided notice of the process by which disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The claim was last readjudicated in a January 2013 supplemental statement of the case. See Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (noting that VA cured its failure to afford statutory notice to the claimant prior to an initial rating decision by issuing a notification letter after the decision, readjudicating the claim, and notifying the claimant of such readjudication in the statement of the case). VA has done everything reasonably possible to assist the Veteran with respect to his claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). Evidence that has been obtained and associated with the claims file includes identified VA and private treatment records. All identified and available treatment records have been secured. Additionally, the Veteran was provided with VA examinations to determine the nature and severity of his diabetes mellitus and any complications thereof in January 2006, April 2010 with an addendum opinion dated in September 2010, February 2012, and December 2012. The aforementioned examination reports reflect that the examiners reviewed and recorded the Veteran's documented and/or reported past medical history and current complaints, conducted appropriate evaluations of the Veteran, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. Although the January 2006 VA examiner did not adequately address any related complications of diabetes mellitus, the Veteran was afforded additional VA examinations thereafter which addressed any related complications. As will be discussed in greater detail below, the Board notes that several findings contained in the December 2012 examination report regarding complications related to diabetes are being discounted n favor of more probative evidence of record. For this reason, the Board has considered whether these inaccuracies render the December 2012 VA examination inadequate so as to warrant further development. However, the Board finds that the remaining clinical findings in that report, in combination with the clinical findings contained in the other VA examination reports and treatment records, as well as the Veteran's own statements, provide a full and accurate picture of the Veteran's disability so as to allow the Board to render an informed decision. Thus, the Board concludes that the evidence of record is adequate for purposes of rendering a decision in the instant appeal and VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2012); Barr, 21 Vet. App. at 312. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2012). The Veteran has been accorded the opportunity to present evidence and argument in support of his claim. Statements received from the Veteran and his representative show that they have actual knowledge of the information and evidence necessary to substantiate the claim. Therefore, the duties to notify and assist have been met. Accordingly, the Board may proceed with adjudication of the claim. 38 C.F.R. § 20.1304(c) (2012). Law and Analysis Relevant Law Historically, service connection was granted for Type II diabetes mellitus associated with herbicide exposure in a January 2003 rating decision, which assigned a 20 percent disability rating under 38 C.F.R. § 4.119, Diagnostic Code 7913, effective January 27, 2002. The current appeal stems from a July 2005 claim for increase wherein the Veteran asserted that his diabetes mellitus has worsened. The Veteran and his representative essentially contend that symptoms associated with the Veteran's service connected diabetes mellitus with nephropathy present a greater degree of impairment than is reflected by the currently assigned 20 percent disability rating. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. § 4.1 (2012). Separate Diagnostic Codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). While the Veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The United States Court of Appeals for Veterans Claims (Court) has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings, i.e., disability ratings for separate periods of time based on the facts found. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Diagnostic Code 7913 provides disability evaluations for diabetes mellitus. Diabetes that is manageable by restricted diet only warrants a 10 percent rating. Diabetes that requires insulin and a restricted diet or oral hypoglycemic agents and restricted diet warrants a 20 percent evaluation. A 40 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent disability rating requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two complications that would not be compensable if separately rated. A 100 percent disability rating requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, DC 7913 (2012). Note (1) to Diagnostic Code 7913 instructs the rating board to rate compensable complications of diabetes separately unless they are part of the criteria used to support a 100 percent evaluation. It further instructs that noncompensable complications of diabetes are considered part of the diabetic process under Diagnostic Code 7913. The Board notes that restrictions of activities due to diabetes mellitus must be objectively confirmed. See Camacho v. Nicholson, 21 Vet. App. 360, 265 (2007). The pertinent inquiry, therefore, is whether there is objective and probative evidence that the Veteran's diabetes mellitus requires restricted activities warranting an increased rating. The Board concludes there is not. The claims file indicates that the Veteran was diagnosed with Type II diabetes mellitus in approximately 1993 or 1994. In connection with his July 2005 claim for an increased rating, the Veteran was afforded a VA examination in January 2006. The claimed file was reviewed. The Veteran indicated that the examination for an increased disability rating for his service-connected diabetes because he was started on insulin for treatment of his diabetes in May 2005. It was noted that insulin was prescribed for treatment of the Veteran's diabetes in an attempt to control his glucose and low A1C levels because he was noncompliant with diet restrictions. He remained on oral medications at breakfast, lunch and dinner in conjunction with insulin. His diet was as tolerated without restriction. A review of symptoms was significant for bilateral leg and plantar foot pain, weight gain, and intermittent chest pain that responded to nitroglycerine with myocardial infarctions in 1997 and 2005 requiring surgical treatment with a total of five stents. The Veteran denied any history of hypertension and the examiner noted that a review of his electronic treatment records showed that his blood pressure was normal. The Veteran was able to achieve an erection and he used medication as needed to potentiate an erection, which the examiner attributed to the Veteran's age (59 years old). There were no hypoglycemic or ketoacidotic reactions requiring hospitalization. On physical examination, the Veteran's blood pressure was read as 140/68. There were no findings of edema of the extremities or diabetic retinopathy. Lab reports dated in August 2005 showed elevated hemoglobin A1C (8.2%) and glucose (157 mg/dL) levels. Microalbumin (concentrated) and creatinine levels were normal. The examiner diagnosed Type II diabetes mellitus, uncontrolled, with poor compliance. Examination of the Veteran's heart condition during the January 2006 examination revealed symptoms of angina pain. A heavy smoking history of 1 to 2 packs a day for 49 years was noted and the Veteran continued to smoke at the time of the January 2006 examination. He was taking medication for treatment of peripheral vascular disease. He was able to walk but doing so for long distances caused leg and low back pain. Following physical examination of the Veteran and review of the claims file and electronic treatment records, the January 2006 VA examiner diagnosed (1) [two] myocardial infarction[s] status-post a total of five coronary artery bypass grafting stents; (2) coronary artery disease; (3) dyslipidemia, and; (4) Type II diabetes mellitus. She noted that presumptive service connection was in effect for diabetes mellitus associated with herbicide exposure. She opined that the Veteran's coronary artery disease, heart attacks, and stenting is less likely than not caused by or a result of his diabetes, rather, they are likely linked to his lifestyle of obesity and heavy tobacco use. Occupationally, the Veteran indicated that he had been unemployed since suffering from a heart attack in 1997. He denied that his diabetes mellitus had any effect on his activities of daily living. In January 2010, the Board remanded the claim for an increased rating for diabetes mellitus for obtainment of a new VA examination to determine the current nature and severity of the Veteran's service-connected diabetes mellitus and any complication thereof, to include diabetic retinopathy and nephropathy. Accordingly, in April 2010, the Veteran underwent an additional series of VA examinations. Treatment for his diabetes included insulin injections twice a day, and a salt restricted diet. Daily blood sugars consistently ran between 110 and 124. There had been no hypoglycemic or ketoacidotic reactions requiring hospitalization or a significant weight change since his last follow-up visit for diabetes 6 months prior. There had been no other visits for episodes of ketoacidosis or hypoglycemia. The Veteran gave a history of hypertension, dyslipidemia, and coronary artery disease. Hypertension was reportedly found in 1996, and the cardiac conditions were reportedly diagnosed in 1997. Two stents were placed in 1997 and three more were placed in 2002. Due to a slow pulse and/or an irregular heartbeat, a pacemaker/defibrillator was placed in February 2010. Physical examination was negative for significant pretibial or pedal edema. Urinalysis was negative for leukocyte esterase, nitrate, blood, bilirubin, ketones, glucose, and protein. Urine creatinine was 37.43 mg/dL, concentrated microalbumin was 1.9 mg/dL, and spot microalbumin was high at 50.8mcg/mg cr. Blood creatinine was normal at 1.25 mg/dL, and blood glucose (148 mg/dL), cholesterol (239mg/dL), triglycerides (672 mg/dL), LDL Direct (117 mg/dL), and hemoglobin A1C (7.4 percent) were high. Following a review of the claims file, VA treatment records, and examination of the Veteran, the examiner diagnosed diabetes mellitus, hypertension, dyslipidemia, and coronary artery disease. She opined that the Veteran's heart disease, hypertension, and dyslipidemia are most likely caused by or a result of diabetes. She reasoned that per up-to-date [medical literature], diabetes contributes to microvascular disease which is a contributing factor for the above listed complications. In a September 2010 addendum opinion, the April 2010 examiner clarified that the Veteran's mildly uncontrolled diabetes mellitus had not required hospitalization. Treatment for diabetes included moderate doses of insulin. Additionally, the examiner opined, in relevant part, that the Veteran's diagnosed hyperlipidemia is most likely caused by his diabetes. Specifically, she stated that controlled treatment of diabetes directly impacts triglyceride levels, which were currently and historically not under control at 672. Current treatment for hyperlipidemia include fish oil. Finally, she found that the Veteran's hypertension was adequately controlled with medications currently used. The Veteran was afforded an additional VA examination in February 2012. Treatment of his diabetes mellitus included more than one injection of prescribed insulin per day. Regulation of activities as part of medical management of diabetes, to include avoidance of strenuous occupational and recreational activities with the intention of avoiding hypoglycemic episodes, was not required. The Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than twice a month. He did not experience any episodes of ketoacidosis or hypoglycemic reactions requiring hospitalization over the past 12 months or progressive unintentional weight loss or loss of strength attributable to diabetes mellitus. The Veteran reported that his diabetes impacted his ability to work in that he could not sit, stand, or walk for any period of time. In this regard, the examiner noted that he is 100 percent service-connected for arteriosclerotic heart disease. The February 2012 examiner stated that complications of the Veteran's diabetes included mild diabetic nephropathy, erectile dysfunction, cardiac conditions, and hypertension (in the presence of diabetic renal disease). He opined that such complications are at least as likely as not due to the Veteran's diabetes. He further opined that the Veteran's diabetes mellitus is at least as likely as not permanently aggravated by his cardiac conditions, hypertension, and renal disease. In May and September 2011, fasting plasma glucose was greater than 126 mg/dL and A1C was 6.5 percent or greater. Random plasma glucose was greater than or equal to 200 mg/dL with classic symptoms of hyperglycemia in December 2010. His most recent A1C was 7.9 and his most recent fasting plasma glucose was 126 on September 12, 2011. During evaluation of the Veteran's now service-connected peripheral neuropathy in February 2012, the Veteran indicated that such condition impacted his ability to work in that he reportedly could not sit or stand for long periods of time due to leg numbness. During evaluation of the Veteran's diabetic erectile dysfunction at the February 2012 VA examination, the examiner noted that the Veteran was diagnosed with erectile dysfunction in 2001 and Peyronie's Disease (penis deformity) in 2000. The Veteran reportedly noticed gradual onset of erectile dysfunction in 2000. In February 2012, he the Veteran was unable to achieve an erection sufficient for penetration and/or ejaculation regardless of medication for treatment. Medication had been prescribed in the past without success. Physical examination confirmed a diagnosis of Peyronie's disease. There was no history of recurrent symptomatic urinary tract or kidney infections. The examiner diagnosed erectile dysfunction and opined that it is at least as likely as not a complication of the Veteran's chronic and poorly controlled diabetes mellitus. The Veteran's erectile dysfunction and Peyronie's disease did not impact his ability to work. During evaluation of the Veteran's diabetic nephropathy at the February 2012 VA examination, the examiner noted that such condition was diagnosed in 1999. At that time, the Veteran had a history of diabetes mellitus and BUN, creatinine, and microalbumin (spot) checks had not been done routinely. Elevation in urine microalbumin (spot) was initially noted in 2003 and it had increased over the last year. The Veteran denied experiencing renal symptoms of a renal condition. The examiner found that he did not have renal dysfunction, to include either persistent proteinuria, hematuria or GFR less than 60 cc/min/1.73m2. The examiner also found that the Veteran did not have hypertension and/or heart disease due to renal dysfunction or that was caused by any kidney condition. There was no history of kidney, ureteral or bladder calculi (urolithiasis). He did not have any signs or symptoms due to urolithiasis. Laboratory studies on September 12, 2011 revealed BUN of 20, Creatinine of 1.14, and EGFR of 64.9. A spot urine microalbumin/creatinine in May 2011 was 96.3. The Veteran's diabetic nephropathy did not impact his ability to work. During evaluation of the Veteran's hypertension during the February 2012 examination, the examiner noted diagnosis of hypertension or isolated systolic hypertension in 1997. The Veteran indicated that his blood pressure has fluctuated with his body weight. He denied any symptoms that he attributed to hypertension. He described his blood pressure control with his current treatment plan which included continuous medication (Losartan 50mg per day and Terazosin 10 mg per day). It was unknown whether the Veteran's initial diagnosis of hypertension was confirmed by blood pressure readings taken two or more times on at least three different days. There was no history of diastolic blood pressure elevation. During examination, blood pressure readings were 126/68, 126/66, and 126/66. Functionally, the Veteran's hypertension did not impact his ability to work. The Veteran was afforded an additional VA examination of his service-connected diabetes mellitus in December 2012. At the time of examination, diabetes was managed with restricted diet and prescribed insulin more than once a day. Regulation of activities as part of medical management of diabetes, to include avoidance of strenuous occupational and recreational activities with the intention of avoiding hypoglycemic episodes, was not required. The Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month. He did not experience any episodes of ketoacidosis or hypoglycemic reactions requiring hospitalization over the past 12 months or progressive unintentional weight loss or loss of strength attributable to diabetes mellitus. The examiner found that the only recognized complication of diabetes was peripheral neuropathy. The examiner opined that the Veteran did not have complications such as erectile dysfunction, a cardiac condition, hypertension, peripheral vascular disease, stroke, a skin condition, or an eye condition that is or are at least as likely as not due to his service-connected diabetes mellitus. He further opined that the Veteran's diabetes is at least as likely as not permanently aggravated his cardiac condition. It was noted that the Veteran's most recent test results showed an A1C level of 8.1. His fasting plasma glucose in December 2012 was 195. As to the Veteran's erectile dysfunction, the December 2012 examiner explained that the Veteran related his erectile dysfunction to a tick bite in his testicular area that swelled up and required treatment with cortisone shots. The Veteran denied any problem with erectile dysfunction when he had diabetes mellitus and he stated that his erectile dysfunction started after the described tick bite. In this regard, the Board notes that a May 1999 VA treatment record shows that the Veteran indicated that he was bitten by a tick in his genital area 5 years prior, which caused his penis to swell to the size of a 1 liter bottle. He indicated that he experienced curvature of his penis ever since that time. In support of this opinion, the examiner noted that a 1997 treatment record showed that the Veteran was reportedly able to achieve an erection easily at that time. In any event, during the December 2012 examination, the Veteran admittedly did not have any problems prior to the tick bite. As to diabetic retinopathy, the examiner noted that the Veteran was last seen by an ophthalmologist in July 2012 when it was noted that he did not have diabetic retinopathy at that time. The Board further notes that VA ophthalmology treatment records dating throughout the entirety of the claim are consistently negative for any finding or diagnosis of diabetic retinopathy or any other eye condition that may be related to the Veteran's diabetes mellitus. The December 2012 examiner also opined that the Veteran does have microalbuninuria, however, his documented BUN and creatinine levels have been in the normal range, thus, he does not have nephropathy. He stated that here is no diagnosis of such listed in the problem list and the Veteran's microalbumin was not checked on a regular basis. As to hypertension, the examiner stated that there is no diagnosis of hypertension and the Veteran's blood pressure has been controlled. He noted that the Veteran took no medication for blood pressure. He stated that the Veteran had a few isolated systolic blood pressures during 2010 with Dr. S who noted that the Veteran had hypertension, however, the examiner stated that such diagnosis was when the Veteran was having heart problems. Since then, the examiner stated that the Veteran's blood pressure had returned to normal as reflected by the 132/69 blood pressure reading during the December 2012 examination. It was noted that most recently, during a primary care physical, borderline systolic hypertension was noted with recommendation that the Veteran watch his diet and sale intake. The examiner stated that the Veteran was not on medication for hypertension and his blood sugar has not been under good control as evidenced by his consistently high HGA1C levels. In light of the foregoing, the examiner opined that the Veteran does not have hypertension that is caused or aggravated by his diabetes mellitus. Occupationally, the Veteran worked as a carpenter until the 1990s when he retired because he could not use is hands any longer. The examiner opined that the Veteran's diabetes mellitus and related complications did not impact his ability to work. VA and private treatment records show intermittent treatment for diabetes mellitus, with prescribed use of insulin and restricted diet. On review, the Board finds that the Veteran's diabetic condition alone does not warrant a rating greater than 20 percent pursuant to Diagnostic Code 7913. Although the Veteran's diabetes requires daily insulin and a restricted diet, the objective evidence does not indicate a restriction of activities or frequent hospitalizations due to hypoglycemic reaction. Indeed, the each of the January 2006, April 2010, and February and December 2012 VA examiners specifically noted the Veteran had no restriction of his activities on account of his diabetes and that he had never been hospitalized for his diabetes mellitus with the exception of a single occasion in 1994, many years prior to the rating period currently under consideration. The Veteran has not specifically argued that he has restricted activities as a result of his diabetes mellitus. Indeed, the Veteran's statement during the January 2006 VA examination to the effect that the purpose of that examination was due to a worsening of his diabetes as reflected by his prescribed use of insulin for treatment shortly prior to that examination, and his February 2006 statement, both appear to indicate a belief that the daily use of insulin or an increased dosage of insulin alone is sufficient to warrant a 40 percent rating. As discussed above, however, Diagnostic Code 7913 requires the use of insulin, a restricted diet, and regulation of activities (emphasis added). As discussed, there is no evidence of regulation of activities due to the Veteran's diabetes. As there is no evidence of restricted activity, ketoacidosis, any periods of hospitalization associated with hypoglycemic events or otherwise, or bimonthly treatment visits, a higher rating is not warranted. Evaluation of the Veteran's condition under any other Diagnostic Code would not warrant a higher rating in the absence of symptomatology demonstrating pertinent pathology or a more debilitating condition there under. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In regard to diabetic complications, the medical evidence indicates the Veteran's diabetes has caused additional disabilities, to include bilateral upper and lower extremity peripheral neuropathy. However, a review of the claims file shows that the Appeals Management Center granted service connection for peripheral neuropathy of the upper and lower extremities in a January 2013 rating decision. The Veteran has not filed a notice of disagreement with the separate ratings assigned for his peripheral neuropathy of the bilateral upper and lower extremities, thus, the Board will not discuss this aspect of the claim further. As to erectile dysfunction, the Board acknowledges that the February 2012 VA examiner found that such is at least as likely as not caused by the Veteran's service-connected diabetes mellitus. The February 2012 examiner, however, did not provide any supporting rationale for that opinion. To the contrary, as noted above, in concluding that the Veteran's erectile dysfunction is not caused or aggravated by his diabetes, the December 2012 examiner explained that the Veteran admittedly related his erectile dysfunction to a tick bite subsequent to being diagnosed with diabetes mellitus in 1993 or 1994. Accordingly, as to the etiology of the Veteran's erectile dysfunction, the Board finds the opinion of the December 2012 examiner to be of higher probative value and of greater weight in the analysis of the claim. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his [or her] opinion"). See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.); Elkins v. Brown, 5 Vet. App. 474, 478 (1993) (medical opinions as to a nexus may decline in probative value where the physician fails to discuss relevant medical history). Moreover, the Board observes that the Veteran underwent a VA genitourinary examination in 2003 fur symptoms of impotence, incomplete voiding, and urinary incontinence. As to impotence, following a review of the claims file and examination of the Veteran, the examiner at that time opined that the Veteran does not have true impotence, rather, he has Peyronie's disease, which she opined is not as likely as not related to his diabetes. Similarly, as noted above, the Veteran has not been shown to have a diagnosis of diabetic retinopathy at any time during his lifetime, to include since his claim for increase was received in July 2005. Annual VA ophthalmology evaluations performed in light of the Veteran's diabetes mellitus have consistently been negative for any finding or diagnosis of diabetic retinopathy or any other eye condition that may be caused or aggravated by diabetes mellitus. As to the Veteran's hypertension, the Board notes that contrary to findings of the December 2012 VA examiner that the Veteran does not have hypertension and that he is not or has not been taking medication for such, the Board notes that Virtual VA treatment records show that the Veteran was consistently prescribed medication (Metoprolol and/or Lisinopril) for treatment of "blood pressure or heart" from 2004 through at least 2007. Unfortunately, however, even if it were conceded that the Veteran does have hypertension that is caused or aggravated by his service-connected diabetes, blood pressure readings throughout the claim do not show that his hypertension does or has met the criteria necessary for the assignment of a compensable evaluation at any time during the claim. Disability ratings for hypertension are contained in 38 C.F.R. § 4.104. Diagnostic Code 7101, which pertains to disability ratings for hypertension and isolated systolic hypertension, states that a compensable 10 percent evaluation is warranted when diastolic pressure is predominantly 100mm. or more, or; systolic pressure is predominately 160 mm. or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100mm. or more who requires continuous medication for control. The Board has reviewed all of the blood pressure readings in the VA and private treatment records and found very few with a diastolic pressure of 100 or more or with systolic pressures anywhere near 160. Indeed, systolic pressure readings predominately ranged from 107 to 140mm and diastolic pressures predominately remained less than 100mm. Thus, hypertension has not been manifested to a level of 10 percent at any time during the course of appeal. Thus, the Veteran does not meet the criteria for a compensable rating for hypertension, and a separate rating for such is not warranted. As the Veteran's hypertension has not been shown to be compensable, it is deemed part of the underlying diabetic process. Similarly, the Veteran's nephropathy also has not been shown to a compensable degree at any time during the claim, thus, it too is deemed to be part of the underlying diabetic process. Specifically, the Board notes that contrary to the December 2012 VA examiner's conclusion that nephropathy is not currently diagnosed or present, the Board notes that VA treatment records show a diagnosis of such throughout the duration of the claim, to include as recently as May 2011 as noted in a July 2011 VA treatment note that shows "+ nephropathy" in light of a May 6, 2011, finding of microalbumin of 96.3 mcg/mr cr (H). Nevertheless, the Veteran consistently denied any systemic symptoms of nephropathy during the aforementioned VA examinations. Moreover, treatment records are negative for treatment for nephropathy and evidence of acute nephritis and the Veteran's blood pressure has consistently been found to be under good control throughout the claim. For the assignment of a compensable rating for renal dysfunction, the evidence must show 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. 38 C.F.R. § 4.115a (2012). In this case, lab findings during the claim are negative for any indication of constant or recurring albumin with hyaline and granular casts or red blood cells. Further review of the record reveals that there is no indication of edema at any time. Accordingly, to the extent that the Veteran does have nephropathy during the claim that may be related to his diabetes, symptoms of nephropathy are not shown to be compensable, thus, it is deemed part of the underlying diabetes mellitus process. Finally, as to the Veteran's heart condition, the Board notes that presumptive service connection was granted for ischemic heart disease due to herbicide exposure in a July 2011 Board decision. In the October 2011 rating decision that effectuated the grant of service connection, the RO assigned a 100 percent evaluation for a heart disability, to include coronary artery disease, effective March 7, 2003. As a 100 percent disability rating is currently in effect for the Veteran's heart disability, the same manifestations of such his heart disability under a different diagnosis is to be avoided. 38 C.F.R. § 4.14. To do so is to 'pyramid' the ratings. The Board has considered that Veteran's lay statements and his sincere belief that his service-connected diabetes mellitus has worsened warranting the assignment of a higher or additional disability rating. The Veteran is competent to report his current symptomatology and treatment as it pertains to his diabetes mellitus and the Board finds that the his statements are credible. With respect to the Rating Schedule, however, where the criteria set forth therein require medical expertise which the Veteran has not been shown to have or where these types of findings are not readily observable by a lay person, the Board has accorded greater probative weight to objective medical findings and opinions provided in the Veteran's treatment records and examination reports. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) ("[t]he probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . the credibility and weight to be attached to these opinions [are] within the province of the adjudicator."). The Board has considered the Veteran's reports with respect to experiencing symptoms in evaluating his disability rating in this decision. Accordingly, the preponderance of the evidence is against assignment of an increased disability rating for the Veteran's service-connected diabetes mellitus and complications thereof. As the greater weight of evidence is against the claim, there is no doubt on this matter that could be resolved in his favor. Extraschedular Considerations The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for diabetes mellitus are inadequate. A comparison between the level of severity and symptomatology of the Veteran's diabetes mellitus with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, the evidence shows that the Veteran's diabetes mellitus requires daily insulin and restricted diet, but not restricted activity, hospitalization, or bimonthly treatment for his diabetes. The current 20 percent rating under Diagnostic Code 7913 contemplates these treatment requirements. Thus, the Veteran's currently assigned schedular rating under Diagnostic Code 7913 is adequate to fully compensate him for his disability on appeal. In short, the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Board, therefore, has determined that referral of this case for extraschedular consideration is not warranted. ORDER Entitlement to an increased rating for diabetes mellitus, Type II, to include nephropathy, currently evaluated as 20 percent disabling, is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs