Citation Nr: 1317410 Decision Date: 05/29/13 Archive Date: 06/06/13 DOCKET NO. 09-15 132A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial rating in excess of 20 percent for type II diabetes mellitus. 2. Entitlement to an initial compensable rating for peripheral neuropathy of the left lower extremity. 3. Entitlement to an initial compensable rating for peripheral neuropathy of the right lower extremity. 4. Entitlement to an initial compensable rating for hypertension with diabetic nephropathy. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Adams, Counsel INTRODUCTION The Veteran served on active duty from February 1971 to April 1972. This case is before the Board of Veterans' Appeals (Board) on appeal from January 2006 and May 2007 rating decisions of the Department of Veterans Affairs (VA) Regional Offices (ROs) in Decatur, Georgia, and Columbia, South Carolina. The January 2006 rating decision, in pertinent part, granted service connection and assigned a 20 percent rating for diabetes mellitus, effective July 18, 2005. The May 2007 decision continued the 20 percent rating for diabetes mellitus and granted service connection and assigned noncompensable ratings for peripheral neuropathy of the feet and hypertension with diabetic nephropathy, effective March 21, 2007. During this appeal, jurisdiction of these claims was transferred to the RO in Atlanta, Georgia. The Board has reviewed the Veteran's claims file and the record maintained in the Virtual VA paperless claims processing system. FINDINGS OF FACT 1. The Veteran's type II diabetes mellitus has been manifested by the need for oral hypoglycemic agents and a restricted diet. 2. Resolving any doubt in the Veteran's favor, his service-connected peripheral neuropathy of both the left and right lower extremities demonstrates mild incomplete paralysis of the external popliteal nerve, for the entire period of appeal. 3. The Veteran's diabetic nephropathy has been manifested by diastolic pressure of no more than 95 and systolic pressure of no more than 145. There is no evidence of renal dysfunction with constant albumin or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C.A. § 1155, 5103(a), 5103A, 5107 (West 2002); 38 C.F.R. § 4.119, Diagnostic Code (DC) 7913 (2012). 2. The criteria for an initial rating of 10 percent, but no greater, for peripheral neuropathy of the left lower extremity, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1-4.7, 4.124a, DC 8521 (2012). 3. The criteria for an initial rating of 10 percent, but no greater, for peripheral neuropathy of the right lower extremity, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1-4.7, 4.124a, DC 8521 (2012). 4. The criteria for an initial compensable rating for diabetic nephropathy have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002); 38 C.F.R. § 4.124a , DCs 7101, 7541 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before addressing the merits of the issues on appeal, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. This appeal arises from disagreement with the initial evaluations following the grants of service connection for Type II diabetes mellitus, peripheral neuropathy of the lower extremities, and hypertension with diabetic nephropathy. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Regardless, the RO provided notice as to how VA assigns disability ratings in a letter sent to the Veteran in January 2007. Under the VCAA, VA also has a duty to assist the Veteran in the development of a claim. This includes assisting the Veteran in procuring service treatment records (STRs) and other relevant treatment records and providing a VA examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, VA obtained the Veteran's STRs. Also on file are pertinent outpatient treatment records. The file also contains statements and contentions made by the Veteran and his representative. VA examinations were conducted during the course of the appeal period in November 2005, March 2007, and May 2010. The VA examination reports were quite comprehensive and adequately addressed the Veteran's complaints of memory loss. The Board notes that the Veteran's claims file was unavailable at the time of the examinations. However, since the emphasis is on the current level of the Veteran's disabilities, the Board finds that the appellant is not prejudiced by such error. Accordingly, the Board concludes that during the administrative appeal process, the Veteran was provided the information necessary such that the purposes of the notification have been met. Under these circumstances, the Board finds that VA has complied with all duties to notify and assist required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159. Increased Ratings Generally Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (2002). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). In cases in which a reasonable doubt arises as to the appropriate degree of disability to be assigned, such doubt shall be resolved in favor of the Veteran. See 38 C.F.R. § 4.3 (2012). VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). In this case, the evidence of record does not establish additional, distinct time periods in which the issue on appeal resulted in symptoms that would warrant staged ratings. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2012) The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). A. Type II Diabetes Mellitus The Veteran's type II diabetes mellitus has been rated 20 percent disabling under Diagnostic Code 7913. Under Diagnostic Code 7913, a 20 percent rating is warranted for diabetes mellitus requiring insulin and restricted diet; or oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). Complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are deemed part of the diabetic process. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1) (2012). Turning to the merits of the claim, VA treatment records include an August 2005 report which reflects a recent diagnosis of type II diabetes mellitus and an increased dose of Metformin. In October 2005, the Veteran's diabetes was poorly controlled and he underwent nutritional counseling and was informed of the benefits of exercise. His Metformin was increased from 500 mg twice daily to 1000 mg twice daily. On VA diabetes mellitus examination in November 2005, the Veteran denied any major systemic problems, except that he had excessive thirst, polyuria, and polydipsia. He denied any evidence of hypoglycemic reactions or ketoacidosis. He denied any hospitalization for diabetes or diabetic-related conditions. The Veteran was on a restricted diet and was not restricted to any activity due to his diabetes. On examination, he was diagnosed with type II diabetes mellitus, on oral medications, diet, and exercise; mild hypertension unrelated to diabetes; and non-specific edema of the left leg. VA treatment records include January 2006 reports which show that the Veteran reported that his diabetes mellitus was well-controlled. The Veteran met with a dietitian to develop a meal plan and was advised of the importance of exercise. A May 2006 report shows that he was eating less, exercising regularly, and lost 10 ten pounds. He was prescribed Glyburide 5 mg twice daily. The assessment was poorly controlled diabetes mellitus. In October 2006, he was provided nutrition counseling and reported that was doing good with checks of his blood sugar home averaging in the 130s. In March 2007, the assessment was better controlled diabetes, but the Veteran had not reached his goal. He was again advised of the importance of a low calorie diet, regular exercise, and weight loss. On VA diabetes mellitus examination in March 2007, the examiner noted that the Veteran had been taking Metformin and Glyburide 10 mg twice daily for treatment of his diabetes. He denied having any hypoglycemic reactions or ketoacidosis and had not been hospitalized for diabetes or a diabetes-related condition. However, he was having difficulty tolerating the medications. He did not take insulin and had not lost or gained any significant amount of weight since his last examination. He was not restricted to any activity on account of diabetes. He had a history of hypertension six months after developing diabetes, but denied heart attack, coronary artery disease, deep venous thrombosis, arterial, or venous disease. The examiner diagnosed type II diabetes mellitus, controlled with a combination of oral medications. VA treatment records include an April 2007 report which shows that diabetes was not "at goal." He was taking the maximum dose of Metformin and Glyburide, but did not want to take insulin. In December 2007, he received additional nutritional counseling. In August 2008, the assessment was uncontrolled diabetes. An October 2009 report shows that he had poorly controlled diabetes and did not want to be on insulin. A July 2010 report shows that the Veteran's diabetes was poorly controlled and he admitted that he missed doses and did not follow a diet. The Veteran was encouraged to take medications regularly, follow a diet, and increase exercise. On review of the evidence, the Board finds that a rating in excess of 20 percent for the Veteran's service-connected diabetes mellitus is not warranted at any time during the pendency of the appeal. The threshold requirement for a 40 percent rating is regulation of activities. Camacho v. Nicholson, 21 Vet. App. 360 (2007). In order to meet a higher rating of 40 percent, the Veteran must have been told to avoid any strenuous occupational or recreational activities. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2012). While the evidence shows that the Veteran was prescribed insulin and placed on a restricted diet, the evidence does not indicate that the Veteran has been prescribed or advised to avoid strenuous occupational and recreational activities, as is required in order to merit a higher rating of 40 percent. Rather, the evidence tends to indicate that physical activity and exercise were encouraged. Specifically, on VA examination in March 2007 and on VA treatment in October 2009 June 2009, the Veteran was not restricted in his ability to perform strenuous activities. In addition, there were no periods of ketoacidosis or hospitalization for treatment of his diabetes mellitus. Therefore, the Board finds that the medical evidence does not support a rating greater than 20 percent for the Veteran's service-connected diabetes mellitus at any time during the pendency of the appeal, as his overall symptomatology more nearly approximates the criteria for a rating of 20 percent. The Board now turns to whether the Veteran is entitled to an increased rating based upon erectile dysfunction. The Veteran's erectile dysfunction has been rated as noncompensable pursuant to 38 C.F.R. § 4.120, DC 7913. While no diagnostic code specifically addresses the diagnosis of erectile dysfunction, DC 7522 does address loss of erectile power, which is precisely the symptomatology described by the Veteran. Moreover, that is the only diagnostic code that specifically addresses erectile function. The Board can identify no more appropriate diagnostic code and the Veteran has not identified one. Butts v. Brown, 5 Vet. App. 532 (1993). Accordingly, the Board will proceed with an analysis of the Veteran's disability under this diagnostic code. Diagnostic Code 7522 provides for a single 20 percent rating where the evidence shows deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115(b), DC 7522. The provisions of 38 C.F.R. § 4.31 indicate that where the criteria for a compensable rating under a diagnostic code are not met, and the schedule does not provide for a zero percent evaluation, a zero percent rating will be assigned when the required symptomatology is not shown. 38 C.F.R. § 4.31 (2012). Therefore, where both loss of erectile power and deformity are not demonstrated, a zero percent rating will be assigned. On VA diabetes mellitus examination in March 2007, it was noted that the Veteran was able to achieve a full erection with Levitra and was able to have intercourse. On VA genitourinary examination in May 2010, the Veteran was diagnosed with erectile dysfunction, but vaginal penetration was possible. The Veteran declined genital examination. Since the evidence of record does not document any penile deformity, the Veteran is not entitled to a compensable rating for erectile dysfunction under DC 7522. 38 C.F.R. § 4.20. The Board also notes that the Veteran is already in receipt of special monthly compensation based on loss of use of a creative organ. Finally, the Board also finds that the Veteran is not entitled to a separate rating for diabetic retinopathy, as none is shown by the evidence of record. Specifically, on VA eye examination in August 2010, no evidence of diabetic retinopathy was found. Rather, the Veteran was diagnosed with amblyopia OS refractive. The evidence of record is void of any visual disorders related to the Veteran's diabetes mellitus. Accordingly, the Veteran is not entitled to a separate compensable rating for any diabetic retinopathy under DC 6006. B. Peripheral Neuropathy of the Left and Right Lower Extremities The Veteran maintains that his service-connected neuropathy of the left and right lower extremities is more severe than what is reflected by the currently assigned disability ratings. He has been assigned noncompensable ratings under Diagnostic Code 8521 for peripheral neuropathy of both legs associated as neurological complications of his service-connected diabetes mellitus disability. Diagnostic Code 8521 pertains to paralysis of the external popliteal nerve (common peroneal), and provides for a 10 percent rating for mild incomplete paralysis. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. A rating of 20 percent is warranted for moderate incomplete paralysis. A rating of 30 percent is warranted for severe incomplete paralysis. A rating of 40 percent is warranted for paralysis involving foot drop and slight droop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes. See 38 C.F.R. § 4.124a, DC 8521. The Board notes that the rating schedule does not define the terms "mild," "moderate," or "severe." Therefore, the Board must evaluate the evidence of record and reach a decision that is equitable and just. See 38 C.F.R. § 4.6. Turning to the merits of the claims, on VA diabetes mellitus examination in March 2007, the Veteran complained of swelling in both the lower extremities and tingling in his feet. Neurological examination of the lower extremities was normal. The Veteran had only subjective symptoms of numbness and tingling in both lower extremities. He was diagnosed with mild symptomatic peripheral neuropathy in the lower extremities in the distribution of stockings. VA treatment records include an April 2007 report which reflects the Veteran's complaint of swelling in the legs. In May and August 2007, the Veteran complained of bilateral leg swelling. In December 2007 and August 2008, there was trace edema in the ankles. In his May 2009 substantive appeal, the Veteran complained of pain and swelling of both feet and ankles for which he stated his primary care physician prescribed medication. VA treatment records include an October 2009 report which reflects a complaint of swelling in the legs. A January 2010 EMG consultation note reflects complaint of occasional cramping in the feet and calves with paresthesias. However, the examination consisted of the upper extremities only. On VA peripheral nerves examination in May 2010, the Veteran presented with a history of chronic peripheral neuropathy of the lower extremities since 2005. He complained of paresthesias of the feet with tingling, soreness, and heaviness. Motor, sensory, and reflex examinations of the lower extremities were normal. There was no muscle atrophy, abnormal muscle tone or bulk, tremors, tics, or other abnormal movements. Gait and balance were normal. His diagnoses included diabetic sensory neuropathy of the lower extremities. On review of the evidence of record, the Board finds that the Board finds that the Veteran's bilateral foot disabilities are more severe than the current noncompensable ratings indicate. Rather, based on the above, the Board finds that a 10 percent rating should be assigned for each lower extremity. Again, a 10 percent rating is assigned for mild incomplete paralysis of the lower extremities under Diagnostic ode 8521. The Veteran has consistently reported subjective symptoms of swelling, pain and paresthesias in his legs and feet. On VA examination in March 2007, he was diagnosed with mild symptomatic peripheral neuropathy in the lower extremities, and on VA examination in May 2010, he was diagnosed with diabetic sensory neuropathy of the lower extremities. As such, the Veteran's reported symptomatology appeared to be wholly sensory and therefore his disabilities more closely approximate the criteria for mild incomplete paralysis of the external popliteal nerve for the bilateral lower extremities. The March 2007 and May 2010 VA examination reports include the Veteran subjective complaints of neurological symptomatology. Given these facts, the Board finds that the Veteran's lower extremities disabilities are, at most, mild in nature. As such, a 10 percent rating under Diagnostic Code 8521 is granted. However, the Board finds that higher ratings are not warranted under Diagnostic Code 8521 or any other applicable diagnostic code. With regards to Diagnostic Code 8521, the preponderance of the evidence does not indicate that the Veteran's bilateral lower extremities symptomatology more closely approximate moderate incomplete paralysis of the external popliteal nerve. Again, the Board highlights the March 2007 VA examiner's assessment of mild symptomatic peripheral neuropathy in the lower extremities and the May 2010 VA examiner's assessment of diabetic sensory neuropathy of the lower extremities. There is no evidence of record, even giving consideration to the Veteran's lay statements and the March 2007 and May 2010 VA examination reports, that the Veteran has experienced any additional symptomatology beyond that which has been described above that would rise to the level of moderate neurological impairments. Indeed, the Board finds it significant that there is scant medical evidence showing treatment or any additional assessments of the claimed disabilities. As such, 20 percent or higher ratings are not warranted for the disabilities under Diagnostic Code 8521. The Board has also considered whether higher ratings may be assigned for the Veteran's disabilities under any other diagnostic code during both of the identified times periods. In this regard, Diagnostic Codes 8524 (internal popliteal nerve) and 8526 (anterior crural nerve) also provide 20 percent for moderate incomplete paralysis. Diagnostic Code 8525 provides for a 10 percent rating for mild or moderate incomplete paralysis of the posterior tibial nerve and a 20 percent rating for severe incomplete paralysis of this nerve. However, as the Board finds that the Veteran's disabilities are of mild severity, higher ratings would not be warranted under these diagnostic codes. Nor is he entitled to increased ratings under Diagnostic Codes 8522 (musculocutaneous nerve) or 8523 (anterior tibial nerve) which both provide for a noncompensable rating for mild incomplete paralysis and a 10 percent rating for moderate incomplete paralysis of these nerves as the Veteran is now in receipt of a 10 percent rating for mild neurological impairment of each lower extremity. Finally, as Diagnostic Codes 8527 (internal saphenous nerve), 8528 (obturator nerve), 8529 (external cutaneous nerve of thigh), or 8530 (ilio-inguinal nerve) provide a maximum rating of 10 percent for severe to complete paralysis of the nerve, consideration of these diagnostic codes would be of no benefit to the Veteran. C. Hypertension with Diabetic Nephropathy The Veteran's service-connected diabetic nephropathy with hypertension is rated as noncompensable under Diagnostic Code 7541 as renal dysfunction due to diabetes mellitus. Renal dysfunction manifested by albumin and casts with history of acute nephritis; or, hypertension non-compensable under diagnostic code 7101, is rated noncompensable. Renal dysfunction with constant albumin or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under diagnostic code 7101 warrants a 30 percent rating. With constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under diagnostic code 7101, a 60 percent rating is warranted. Renal dysfunction with persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion warrants an 80 percent rating. Renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular warrants a 100 percent rating. 38 C.F.R. §§ 4.104, 4.115a, (Diagnostic Codes 7101, 7541). Separate ratings are not to be assigned for disability from disease of the heart and any form of nephritis, on account of the close interrelationships of cardiovascular disabilities. 38 C.F.R. § 4.115. Turning to the merits of the claim, on VA diabetes mellitus examination in March 2007, it was noted that diagnostic testing in March 2007 showed significant protein in the Veteran's urine. However, he had normal functioning kidneys and normal electrolytes and liver enzymes. Diagnoses included proteinuria and hypertension related to diabetic nephropathy. On VA genitourinary examination in May 2010, the Veteran presented with nephropathy that was stable. Diagnostic testing in January 2010 revealed the absence of blood in the Veteran's urine and the evaluation was normal. He had no history of hospitalization or surgery due to nephropathy. There was no history of renal dysfunction or renal failure and dialysis was not required. There was also no history of hydronephrosis or cardiovascular symptoms, lethargy, weakness, or anorexia. Blood pressure was 144/92. It was noted that there was peripheral edema in the legs. Dorsalis pedis and posterior pedis pulse in the lower extremities was normal. He was employed full-time as a detention officer. The diagnoses included nephropathy, without objective evidence of activity at present as microalbuminuria was controlled, no other residuals. On VA hypertension examination in May 2010, the Veteran had a history of microalbuminuria which was controlled with medication. There was no history of hospitalization or surgery. No renal dialysis was required, but continuous medication was required for control of hypertension. On examination, blood pressure was 144/92, 143/92 and 143/95. He was diagnosed with essential hypertension with no effects on usual daily activities. As regards hypertension, a review of VA treatment records dated from May 2006 to July 2010 and March 2007 and May 2010 VA examinations reflect blood pressure readings that reveal a systolic pressure of no more than 145 and a diastolic pressure of no more than 95. As the record does not reflect that the Veteran's diastolic pressure has predominantly been 100 or more or that his systolic pressure has predominantly been 160 or more, an initial compensable rating under DC 7101 is not warranted. As regards renal dysfunction, on VA diabetes mellitus examination in March 2007 the Veteran had normally functioning kidneys. While there is evidence of edema of the lower extremities (related to the Veteran's service-connected peripheral neuropathy of the lower extremities), the record is void of any findings of hyaline or granular casts or red blood cells. Accordingly, a compensable rating is not warranted under DC 7541. C. Additional Considerations In reaching the above conclusions, the Board has also not overlooked the Veteran's statements in support of his claims. In this regard, the Veteran is competent to report on factual matters of which he has first-hand knowledge, e.g. complaints of numbness and tingling in the lower extremities and high blood pressure. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, while the Board may consider the Veteran's subjective statements regarding the severity of the disabilities, the Board notes that with respect to the Rating Schedule, the criteria set forth therein generally require medical expertise which the Veteran has not been shown to have. See King v. Shinseki, 700 F.3d 1339, 1344 (Fed. Cir. 2012). Furthermore, the Board finds the objective medical findings and opinions provided by the expert of record should be accorded the greater probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the 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 the physician reaches . . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [Board as] adjudicators."). The above determination is based upon consideration of applicable rating provisions. It should also be noted that there is no showing that the Veteran's disabilities have reflected so exceptional or unusual a disability picture as to warrant the assignment of any higher evaluation on an extra-schedular basis. See 38 C.F.R. § 3.321(b) (1). In this case, there has been no showing that the Veteran's type II diabetes mellitus, peripheral neuropathy of the lower extremities, or hypertension with diabetic nephropathy could not be contemplated adequately by the applicable schedular criteria. Without sufficient evidence reflecting that the Veteran's disability picture is not contemplated by the rating schedule, referral for a determination of whether any disability on appeal requires the assignment of an extraschedular rating is not warranted. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). As the record reflects that the Veteran is gainfully employed, there is also no basis to find that the record has raised an implied claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009). In light of the foregoing, the Board finds that an initial higher rating of 10 percent for each lower extremity is warranted. However, the claims for an initial rating in excess of 20 percent for diabetes mellitus and an initial compensable rating for hypertension with diabetic nephropathy must be denied. Since the preponderance of the evidence is against these claims, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has considered additional staged ratings, under Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 21 Vet. App. 505 (2007), but concludes that they are not warranted. (CONTINUED ON NEXT PAGE) ORDER An initial rating in excess of 30 percent for diabetes mellitus, type II, is denied. A higher initial 10 percent, but not greater, rating is granted for the peripheral neuropathy of the left lower extremity, subject to the statutes and regulations governing the payment of VA compensation. A higher initial 10 percent, but not greater, rating is granted for the peripheral neuropathy of the right lower extremity, subject to the statutes and regulations governing the payment of VA compensation. An initial compensable rating for hypertension with diabetic nephropathy is denied. ____________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs