Citation Nr: 1316575 Decision Date: 05/21/13 Archive Date: 05/29/13 DOCKET NO. 10-36 136 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Whether new and material evidence was received to reopen service connection for proteinuria. 2. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 3. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right upper extremity. 4. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left upper extremity. 5. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the left lower extremity. REPRESENTATION Appellant represented by: Timothy White, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. R. Fletcher, Counsel INTRODUCTION The Veteran served on active duty from June 1969 to January 1972. This case is before the Board of Veterans' Appeals (Board) on appeal of rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In March 2012 the Veteran testified at a Travel Board hearing at the RO before the undersigned Veterans Law Judge. A transcript of that hearing is of record. In addition to the paper claims file, there is a Virtual VA (VVA) electronic claims file associated with the Veteran's claim. Both the Board and originating agency (see November 2011 Supplemental Statement of the Case) have reviewed the VVA file, which includes VA treatment records and examination reports dated from December 2010 to November 2011. The other documents in the VVA file are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. The issue of entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right upper extremity is addressed in the REMAND that follows the order section of this decision. FINDINGS OF FACT 1. An unappealed June 2008 rating decision denied the Veteran's claim of entitlement to service connection for proteinuria on the basis that proteinuria was a laboratory finding and that an underlying disease/disability of the kidneys had not been demonstrated. 2. Evidence received subsequent to the June 2008 rating decision does not, by itself or when considered with previous evidence of record, relate to an unestablished fact necessary to substantiate the Veteran's claim of entitlement to service connection for proteinuria. 3. For the period of the appeal, the evidence fails to demonstrate that the Veteran's PTSD results in occupational and social impairment with reduced reliability and productivity and difficulty in establishing and maintaining effective work and social relationships. 4. For the period of the appeal, the Veteran's peripheral neuropathy of the left upper extremity has been manifested by no more than mild incomplete paralysis or neuritis of the median nerve. 5. For the period of the appeal, the Veteran's peripheral neuropathy of the left lower extremity has been manifested by no more than moderate incomplete paralysis or neuritis of the sciatic nerve. CONCLUSIONS OF LAW 1. The June 2008 rating decision which denied the Veteran's claim of entitlement to service connection for a kidney disorder, diagnosed as proteinuria, is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2012). 2. Evidence received since the June 2008 rating decision is not new and material, and the Veteran's claim of entitlement to service connection for proteinuria is not reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 3. The criteria for an initial rating in excess of 30 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.7, 4.130, Diagnostic Code 9411 (2012). 4. The criteria for an initial rating in excess of 10 percent for peripheral neuropathy of the left upper extremity are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.7, 4.124a, Diagnostic Code 8615 (2012). 5. The criteria for a 20 rating, but no greater, for peripheral neuropathy of the left lower extremity have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.7, 4.124a, Diagnostic Code 8520 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duty to notify and assist claimants in substantiating a claim 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, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). 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. 38 C.F.R. § 3.159(b)(1) (including as amended effective May 30, 2008, 73 Fed. Reg. 23353 (Apr. 30, 2008)). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Regarding the claim to reopen, by correspondence dated in November 2009 the Veteran was informed of the evidence and information necessary to substantiate the claim, the information required of the Veteran to enable VA to obtain evidence in support of the claim, the assistance that VA would provide to obtain evidence and information in support of the claim, and the evidence that should be submitted if there was no desire for VA to obtain such evidence. Notice regarding the assignment of a disability rating and effective date in the event of an award of VA benefits was included as well. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The November 2009 VCAA letter contained the information required by Kent v. Nicholson, 20 Vet. App. 1 (2006), regarding reopening new and material claims. Specifically, that letter explained to the Veteran that to reopen the claim he needed to provide evidence that he had a kidney disability that was incurred or aggravated by service, or due to service-connected disability. Such clearly conveyed that the Veteran had to establish the presence of a current disability of the kidneys, which had been the basis of the prior final decision. Complete VCAA notice was completed prior to the initial AOJ adjudication of the claim. Pelegrini, supra. Regarding the initial rating claims, as the September 2010 rating decision granted service connection for PTSD and the October 2010 rating decision granted service connection for peripheral neuropathy of the left upper extremity, those claims are now substantiated. VA's General Counsel has clarified that no additional VCAA notice is required in this circumstance concerning a "downstream" issue, such as the rating or effective date assigned for a service-connected disability and that a Court decision suggesting otherwise is not binding precedent. VAOPGCPREC 8-2003. The filing of a notice of disagreement as to the disability ratings assigned does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(3). Instead of issuing an additional VCAA notice letter in this situation concerning the "downstream" disability-rating and/or earlier-effective-date elements of the claim, the provisions of 38 U.S.C.A. § 7105(d) require VA to instead issue a Statement of the Case (SOC) if the disagreement concerning the downstream issue is not resolved. And since the RO issued the appropriate SOCs in October 2011 addressing the downstream increased rating claims, which included citation to the applicable statutes and regulations and a discussion of the reasons and bases for not assigning higher ratings, no further notice is required. See Goodwin v. Peake, 22 Vet. App. 128 (2008) and Huston v. Principi, 17 Vet. App. 195 (2003). Regarding the increased rating claim (peripheral neuropathy of the left lower extremity), the record reflects that the Veteran was provided all required notice in a letter mailed in October 2007, prior to the initial adjudication of the claim in June 2008. Regarding VA's duty to assist, all appropriate development to obtain the Veteran's pertinent medical records, to include service treatment records and pertinent, available post-service treatment records, has been completed. The Veteran has not identified any pertinent, outstanding records that could be obtained to substantiate his claim. The Board is also unaware of any such records. The Veteran has been afforded the appropriate VA examinations. The September 2010 PTSD examination and the November 2007, May 2009 and October 2010 neurological examinations were adequate as the examiners reviewed the relevant medical history and provided opinions with supporting rationale and citation to the evidence. Recognition is given to the fact that the reports of the Veteran's psychiatric and neurological examinations are now, at a minimum, in excess of two years old. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. VAOPGCPREC 11-95. Here, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's PTSD or peripheral neuropathy disabilities since he was last examined. The Veteran does not contend otherwise. Discussion of the Veteran's March 2012 Travel Board hearing finally is necessary. The individual presiding over a hearing must comply with the duties set forth in 38 C.F.R. § 3.103(c)(2). Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. They were met here. The issues as listed above were identified at the hearing. Information was elicited from the Veteran concerning the nature and severity of his PTSD and peripheral neuropathy disabilities. The Veteran was also asked as to whether he had any evidence that he had a chronic kidney disability that could be related to his active service or diabetes mellitus. Sources of evidence relevant in this regard were identified during this process. VA's duties to notify and assist are met. Accordingly, the Board will address the merits of the claims. II. Claim to Reopen Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection also may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1. See also Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995). A symptom, without a diagnosed or identifiable underlying malady or condition, does not, in and of itself, constitute a "disability" for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). Generally, a claim which has been denied in an unappealed RO decision or an unappealed Board decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c). An exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. Moreover, new and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed, will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). New evidence is defined as evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court has interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which, "does not require new and material evidence as to each previously unproven element of a claim." Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Here, a June 2008 rating decision denied service connection for proteinuria. The RO essentially concluded that the Veteran's proteinuria, which was documented in laboratory studies, was a laboratory finding of increased protein in the urine rather than a disability. Emphasis was placed on the finding that a chronic disability of the kidneys manifested by proteinuria was not established. See 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (laboratory results such as hyperlipidemia, elevated triglycerides, and elevated cholesterol are not, in and of themselves, disabilities and are, therefore, not appropriate entities for the rating schedule). The Veteran submitted a notice of disagreement in January 2009 and the RO issued an SOC in June 2009. The Veteran did not perfect his appeal by submitting a substantive appeal by August 5, 2009. The June 2008 rating decision thereby became final. At the time of the June 2008 rating decision, the record included STRs, which note no complaints or findings of a kidney disability. The record also included a November 2007 QTC examination report, which notes the Veteran's reported history of protein in the urine for eight months, current urinalysis which showed protein in the urine, and physical examination which showed no kidney disability. VA treatment records dated from 2001 to 2007 likewise showed no diagnosed kidney disability. In a January 2009 statement, the Veteran maintained that his proteinuria was secondary to his service-connected diabetes mellitus. In November 2009, the Veteran submitted a claim (in pertinent part) seeking service connection for proteinuria. Evidence received subsequent to the June 2008 decision includes VA treatment records and examination reports dated from 2008 to 2011 which note no diagnosis of any kidney disability. Also of record is the Veteran's March 2012 Travel Board hearing testimony, wherein the Veteran's representative stated that the Veteran has excessive amounts of protein in his urine. The Veteran and his representative essentially stated that the Veteran has a kidney disability secondary to service-connected diabetes mellitus. Although the additional medical evidence submitted is new, it is not material as it does not show that the Veteran has been diagnosed with a kidney disability related to service or service-connected disability. There is again only a reference to the Veteran having laboratory tests that are positive for proteinuria. An underlying disability of the kidneys or any other body system has not been shown. The Board notes that the Veteran is competent to provide statements concerning factual matters of which he has firsthand knowledge. Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). However, his assertion that his proteinuria represents a kidney disorder or any other chronic disability is not new evidence as this statement is essentially duplicative of those made in support of his claim when it was denied 2008. CFR Bostain v. West, 11 Vet. App. 124 (1998) (lay hearing testimony that is cumulative of previous contentions considered by decision maker at time of prior final disallowance of the claim is not new evidence). See also Reid v. Derwinski, 2 Vet. App. 312, 315 (1992). In sum, the newly received evidence does not, by itself or when considered with previous evidence of record, relate to an unestablished fact necessary to substantiate the claim. Accordingly, the evidence received since the denial of the claim in June 2008 is not new and material, and reopening of service connection for proteinuria is not warranted. The Board has been mindful of the "benefit-of-the-doubt" rule, but, in this case, there is not such an approximate balance of the positive and negative evidence to permit a favorable determination. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As the preponderance of the evidence is against the claim, the appeal is denied. III. Increased Ratings Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The Court has held that "staged" ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board has reviewed all of the evidence in the Veteran's claims files, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, and 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. A. PTSD Under the General Rating Formula for Mental Disorders, 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 warrants a 100 percent rating. Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships warrants a 70 percent rating. 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- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships warrants a 50 percent rating. Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) warrants a 30 percent rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). GAF Scale Consider psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Do not include impairment in functioning due to physical (or environmental) limitations. 100 - 91 Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his/her many positive qualities. No symptoms. 90 - 81 Absent of minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). 80 - 71 If symptoms are present, they are transient and expectable reactions to psycho-social stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). 70 - 61 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful relationships. 60 - 51 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). 50 - 41 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). 40 - 31 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). The symptoms listed in 38 C.F.R. § 4.130 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). In July 2010, the Veteran submitted a claim seeking service connection for PTSD. A September 2010 QTC examination report notes the Veteran reported a history of military service in a war zone during the war in Vietnam. He indicated that he had received treatment for PTSD since 2004. He complained of current symptoms of flashbacks, nightmares, depression, anxiety, insomnia, being easily startled, mood swings, poor short term memory, and worrying, which was described as severe. He reported initial and middle insomnia, averaging three to four hours every night. He denied any history of violent behavior, suicide attempts, or any other psychiatric disorder. He denied any psychiatric hospitalizations. The Veteran reported a fair relationship with his mother and a good relationship with his seven siblings. He reported that he was married, and had a very good relationship with his (third) wife of 18 years. He stated that he did not have any children. The Veteran also reported being involved in church activities; he indicated that his relationship with other church members was good. He participated in wrestling and stated that his relationship with the others involved was good. The Veteran indicated that he has worked with the mentally ill for 22 years and at times his clients are physically aggressive. This causes him stress and exacerbates his PTSD symptoms. Specifically, he becomes hypervigilant, is easily startled, isolates to home, has difficulty dealing with people, gets depressed and chooses to stay at home. His relationship with his supervisor is good and his relationship with his co-workers is good. He denied any lost time from work. On mental status examination, orientation was within normal limits. Appearance and hygiene were appropriate. Behavior was appropriate. The Veteran maintained good eye contact during the exam. Affect and mood showed anxiety, findings of anhedonia, worthlessness, hopelessness and depressed mood. Communication was grossly impaired due to hearing loss and tinnitus. Speech was within normal limits. Claimant showed impaired attention and/or focus. Panic attacks were present and occurred less than once per week. There were signs of suspiciousness. For example, the Veteran worried that people have a hidden agenda and are talking behind his back. There was no history of delusions or hallucinations, and no delusions or hallucinations observed on examination. Obsessive-compulsive behavior was absent. Thought processes were appropriate. The Veteran was able to understand directions. He did not have slowness of thought, nor did he appear confused. Judgment was mildly impaired. Abstract thinking was normal. Memory was mildly impaired (forgetting names, directions, recent events). Suicidal and homicidal ideation was absent. The diagnosis was PTSD secondary to hostile military activity. The examiner noted a GAF score of 65. The examiner stated that the effects of PTSD symptoms on the Veteran's employment and overall quality of life include an exacerbation of his PTSD symptoms - nightmares, flashbacks, intrusive thoughts, avoidance of others, and severe depression. The examiner further stated that the best description of the Veteran's current psychiatric impairment is: psychiatric symptoms are mild or transient but cause occupational and social impairment with decrease in work efficiency and occupational tasks only during periods of significant stress. A September 2010 rating decision granted service connection for PTSD, and assigned a 30 percent rating effective July 16, 2010. The Veteran appealed the rating assigned. A December 2010 VA outpatient treatment record notes the Veteran's reports that his medication was helping his depression and PTSD. A May 2011 VA outpatient treatment record notes that the Veteran had mild depression and problems sleeping. He denied suicidal ideation. The Veteran testified during the March 2012 Travel Board hearing that he has frequent nightmares about Vietnam. He stated that he has no friends as he lives in a remote area. He does not like crowds. However, he described his marriage of 28 years as "good" and reported getting along with his step-daughters, grandchildren and co-workers. The Veteran denied any episodes of violent behavior. He stated that because his wife is disabled, he does all the grocery shopping and cares for his wife. He hired someone to help with the cleaning and cooking. He denied any changes in his overall psychiatric condition. For the period of the appeal, the Veteran's PTSD has been rated 30 percent. The medical evidence for this period shows that the Veteran's service-connected PTSD has been manifested by no more than occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to symptoms of depressed mood, chronic sleep impairment and mild memory loss. While not outcome determinative, some focus is placed on the finding that the symptom warranting a 50 percent rating - flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships - were not shown. Further, although the Veteran reported some memory impairment on QTC examination in September 2010, this was characterized by the examiner as mild and (forgetting names, directions, recent events). There is also no indication that memory problems interfered with the Veteran's ability to attend to the activities of daily living or in the care that he provided for his disabled wife. Indeed, the Board does provide a great deal of emphasis that the Veteran reports a strong and fulfilling marital relationship, which includes positive relationships with his step-children and grandchildren. He reports that his limitation on going and being more social is due to his wife's disability rather than his PTSD. The fact that the Veteran works and endorses a positive working relationship with his superiors and co-workers also tends to refute the finding that his PTSD causes difficulty in establishing and maintaining effective work and social relationships. At no time during the period at issue did the evidence show that the Veteran has exhibited abnormal speech, panic attacks more than once a week, difficulty in understanding complex commands, impaired judgment, or impaired abstract thinking. No aberrant psychological features have been noted. Consequently, the assignment of a 50 percent rating (or higher) period during this appeal is not warranted under 38 C.F.R. § 4.130. A GAF score of 65 was listed on the QTC examination report dated during the period at issue. The Board finds that the Veteran's symptoms correspond to GAF scores ranging from 61 to 70, reflecting some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. The GAF scores ranging from 61 to 70, reflecting mild to moderate symptomatology and functional impairment, are generally consistent with the objective findings and a 30 percent rating. For all the foregoing reasons, the Veteran's claim for an initial schedular rating in excess of 30 percent for PTSD must be denied. See Fenderson, supra. B. Peripheral Neuropathy Disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. The term incomplete paralysis indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. The term incomplete paralysis indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. When there is complete paralysis, the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or very rarely lost. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement, when bilateral combine with application of the bilateral factor. 38 C.F.R. § 4.124a. Left Upper Extremity Diagnostic Code 8615 pertains to paralysis of the median nerve. Under Diagnostic Code 8615, a 10 percent rating is warranted for mild incomplete paralysis of the major or minor extremity. A 20 percent rating is warranted for moderate incomplete paralysis of the minor extremity. A 30 percent rating is warranted for moderate incomplete paralysis of the median nerve in the major extremity. A 40 percent rating is warranted for severe incomplete paralysis of the median nerve in the minor extremity. A 50 percent rating is warranted for severe incomplete paralysis of the median nerve in the major extremity. During an October 2010 QTC examination the examiner noted the Veteran's history of neuropathy of the left lower extremity associated with type II diabetes mellitus. On neurological examination, the sensory function for the radial ulnar and median nerves was noted to be decreased based on the modality of touch. Peripheral nerve examination revealed neuritis. There was sensory dysfunction demonstrated by diminished sensation in the hands. There was no motor dysfunction. The upper extremity reflexes revealed biceps jerk 2+, triceps jerk 2+, brachioradialis 2+ and the finger jerk 2+ on the left. The diagnoses included neuropathy of the left upper extremity, manifested by diminished sensation and pain, secondary to diabetes mellitus. An October 2010 rating decision (in pertinent part) granted service connection for peripheral neuropathy of the left upper extremity secondary to service-connected diabetes mellitus, and assigned a 10 percent rating effective October 7, 2010. The Veteran appealed the rating assigned. VA outpatient treatment records September 2011 to November 2011 note that the Veteran was taking medication for pain and neuropathy in the upper extremities. The Veteran testified at the March 2012 Travel Board hearing that he had numbness in his left hand. He indicated that he is right handed, but used his left arm for heavy lifting because his right arm was weak. The Board concludes that the evidence does not demonstrate that the Veteran's peripheral neuropathy of the left upper extremity approximates moderate incomplete paralysis such that a higher rating would be warranted under Diagnostic Code 8615. The evidence, including the October 2010 QTC examination, demonstrates that the Veteran has some decreased sensation with no decreased motor function in the left upper extremity and normal reflexes. Moreover, the Veteran testified in March 2012 that he was able to lift heavy objects with his left arm. The manifestations of the peripheral neuropathy have been completely sensory. Such is clearly contemplated in the current finding that the Veteran has mild peripheral neuropathy. In sum, the Board finds that throughout the appeal period, the evidence of record does not support a scheduler rating higher than 10 percent for left upper extremity neuropathy. Left Lower Extremity Diagnostic Code 8520 pertains to paralysis of the sciatic nerve. Under Diagnostic Code 8520, a 10 percent rating is warranted for mild incomplete paralysis of the sciatic nerve. A 20 percent rating requires moderate incomplete paralysis, and a 40 percent rating requires moderately severe incomplete paralysis. A 60 percent rating requires severe incomplete paralysis with marked muscular atrophy. An 80 percent rating requires complete paralysis. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Historically, a December 2004 rating decision awarded service connection for peripheral neuropathy of the left lower extremity associated with diabetes mellitus type II. A noncompensable rating was assigned. The Veteran submitted a claim seeking an increased rating in September 2007. In an October 2007 statement, the Veteran reported having pain in his leg, foot and toes. He also reported occasional numbness in his foot. A November 2007 QTC examination report notes the Veteran's complaints of tingling, numbness and pain in his leg and foot. He denied anesthesia, weakness, or paralysis. He reported pain and numbness when walking. On neurological examination, motor function was within normal limits. Sensory function was abnormal with findings of diminished sensation. Knee jerk was 1+ and ankle jerk was 1+ in the left lower extremity. By rating decision in June 2008 the RO granted an increased 10 percent rating for peripheral neuropathy of the left lower extremity, effective September 25, 2007. The Veteran continued his appeal. A May 2009 QTC examination report notes the Veteran's complaints of pain, numbness and weakness in his left leg, foot and toes. He denied abnormal sensation and paralysis. The Veteran reported intermittent attacks about two or three times a week. If these attacks occurred at work he had to get off his feet until the flare-ups stopped. Neurological examination of the left lower extremity revealed that coordination and motor function were within normal limits. Sensory function was abnormal with findings of diminished sensation in the left foot per pin prick and filament tests. Knee jerk was 2+ and ankle jerk was 2+ in the left leg. Peripheral nerve examination revealed neuritis in the sciatic nerve. The examiner noted that the Veteran's neuropathy was characterized by pain and diminished sensation. An October 2010 QTC examination report notes the Veteran's history of neuropathy of the left lower extremity associated with diabetes mellitus type II. The Veteran complained of tingling and numbness (severity level is 8), pain (severity level is 8) and anesthesia (severity level is 8) in his left leg, foot and toes. There was no abnormal sensation, weakness of the affected parts, or paralysis of the affected parts. The Veteran reported that during flare ups he was unable to perform his duties at work, and had to stay off his feet. On examination, the Veteran was well developed, well nourished and in no acute distress. The examiner noted that the Veteran's peripheral neuropathy did not cause generalized muscle weakness, generalized muscle wasting, or muscle atrophy. Or, to put it another way, there were no organic changes. On neurological examination coordination was within normal limits. Motor function of the left lower extremity was within normal limits. The left sensory function for the sciatic foot nerve was decreased based on the modality of the pinprick, touch, temperature and vibration. The left lower extremity reflexes were: knee jerk 2+ and ankle jerk 2+. Peripheral nerve examination revealed neuritis. There was sensory dysfunction demonstrated by diminished sensation in the left foot; the most likely peripheral nerve involved was diabetes mellitus stocking. The examiner stated that the Veteran's peripheral neuropathy was characterized by pain and diminished sensation. A December 2010 VA outpatient treatment record notes that the Veteran reported that the medication he was taking for his peripheral neuropathy was helping. The Veteran testified during the March 2012 Travel Board hearing that he has "deadness" in his left thigh and tingling and pain in his left ankle, foot and toes. He reported that he had worked with mentally challenged individuals in a woodshop for 23 years. He stated that his employer is understanding of his physical problems and allows him to sit down as needed (usually four hours out of an eight hour shift) at work. He indicated that he is "his own boss" so he is able to sit and continue supervising and working. He said he calls in sick about three days each month because he is unable to stand or walk. Given the above findings, and resolving all doubt in his favor, the Board finds that the criteria for a 20 percent rating for peripheral neuropathy of the left lower extremity have been met. The Veteran's sensory complaints along with the pain he experiences and the need to take sick leave more nearly approximates moderate incomplete paralysis such that a higher rating would be warranted under Diagnostic Code 8620. However, as the evidence, including the QTC examinations, does not document decreased motor or reflex function in the left lower extremity or any organic changes such as muscle atrophy, the assignment of a higher (40 percent) rating is not warranted. In sum, the Board finds that throughout the appeal period, the evidence of record supports the assignment of a scheduler rating of 20 percent for left lower extremity neuropathy but not higher. See Hart, supra. D Extra-schedular As for extra-schedular consideration, the threshold determination is whether the disability picture presented in the record is adequately contemplated by the rating schedule. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Court clarified the analytical steps necessary to determine whether referral for extra-schedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If so, then the assigned schedular evaluation is adequate, referral for extra-schedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation fails to reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment or frequent periods of hospitalization. Id. at 116. If additional factors are found, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether justice requires assignment of an extra-schedular rating. Id. The evidence of record does not reveal that the Veteran's PTSD or peripheral neuropathy disability picture is so unusual or exceptional in nature as to render his schedular ratings inadequate. The Veteran's disabilities on appeal have been evaluated under the applicable Diagnostic Codes that have specifically contemplated the level of occupational and social impairment caused by service-connected PTSD and peripheral neuropathy. The Veteran's symptoms such as depressed mood, sleep impairment, mild memory loss and mild incomplete paralysis are specifically enumerated under Diagnostic Codes 9411, 8615 and 8520. Therefore, referral for assignment of an extra-schedular evaluation in this case is not in order. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). Finally, although the Veteran has submitted evidence of medical disabilities, and made a claim for the highest rating possible, he has not submitted evidence of unemployability, or claimed to be unemployable. He has repeatedly indicated that he works on a full-time basis and that, as noted, he has missed only a minimal amount of work due to his service connected disabilities. The question of entitlement to a total disability rating based on individual unemployability due to a service-connected disability has not been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). ORDER New and material evidence was not received and, therefore, the request to reopen the claim of entitlement to service connection for proteinuria is denied. Entitlement to an initial rating in excess of 30 percent for PTSD is denied. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left upper extremity is denied. Entitlement to a 20 percent disability rating, but not higher, for peripheral neuropathy of the left lower extremity is granted, subject to the law and regulations governing the payment of monetary benefits. REMAND The Board is of the opinion that additional development is required before the Veteran's remaining rating claim is decided. The most recent VA examination to determine the degree of severity of the Veteran's service-connected right upper extremity peripheral neuropathy was in October 2010. At that time, examination revealed no complaints or findings of muscle weakness in the right upper extremity. Thereafter, during the March 2012 Travel Board hearing, the Veteran essentially testified that this disability had gotten worse since the 2010 QTC examination. Specifically, he testified that he was experiencing weakness in his right arm and was unable to use that arm for heavy lifting. He also testified that he had difficulty reaching with his right arm. When a veteran claims that his condition is worse than when originally rated, and when the available evidence is too old for an evaluation of the claimant's current condition, VA's duty to assist includes providing him with a new examination. Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). The Veteran should accordingly be scheduled for an examination to determine the current severity of this disability. Prior to scheduling any examinations, the RO or the AMC should obtain and associate with the claims files all outstanding treatment records pertinent to the issue on appeal. Accordingly, the case is REMANDED for the following actions: 1. The RO or the AMC should undertake appropriate development to obtain a copy of any outstanding records pertaining to treatment of the Veteran's peripheral neuropathy of the right upper extremity during the appeal period. All attempts to procure records should be documented in the claims file. If the RO or the AMC cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow the Veteran the opportunity to obtain and submit those records for VA review. 2. Then, the RO or the AMC should arrange for the Veteran to be scheduled for a VA examination by an examiner or examiners with the sufficient expertise to ascertain the current severity and manifestations of his service-connected peripheral neuropathy of the right upper extremity. The claims folders and any pertinent evidence in Virtual VA not included in the claims folders must be made available to and reviewed by the examiner, and any indicated studies should be performed. The RO or the AMC should ensure that the all information required for rating purposes is provided by the examiner. The supporting rationale for all opinions expressed must be provided. 3. The Veteran must be given adequate notice of the date and place of any requested examination. A copy of all notifications, including the address where the notice was sent, must be associated with the claims file if the Veteran fails to report for the examination. The Veteran is to be advised that failure to report for a scheduled VA examination without good cause may have adverse effects on his claim. 4. Thereafter, the RO or the AMC should review the claims file and ensure that the requested development has been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. 5. Then, the RO or the AMC should readjudicate the issue of entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right upper extremity based on a de novo review of the record. If the benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran and his representative should be furnished a supplemental statement of the case and provided an appropriate opportunity to respond before the case is returned to the Board for further appellate action. By this remand the Board intimates no opinion as to any final outcome warranted. The appellant need take no action until he is otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This REMAND must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs